Laparoscopic excision of the cystic stump

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Laparoscopic   excision   of   the   cystic   stump

Authors
J Leroy
Mots-clés
operation,biliary tract,Calot's triangle,cystic artery,cystic duct,gallbladder,lithiasis
Type de vidéo
Durée
14'00''
Publication
2004-09
Popularité
Favoris
Favorites Media
Audio
en
Sous-titres
en
E-publication
WeBSurg.com, Sept 2004;4(09).
URL: http://www.websurg.com/doi-vd01en1112e.htm

Laparoscopic   excision   of   the   cystic   stump

1. Case presentation 00'22''
This is an interesting patient who previously had a laparoscopic cholecystectomy performed and was well postoperatively. He now presents with episodic pain in the right upper quadrant, which raises the suspicion of a residual stone in the biliary tree. This was investigated with MRI cholangiography and this confirmed that he had a long cystic duct remnant with a stone near the clip. On the suspicion that the migration of this stone or other stones from this area could be causing the symptoms, an ERCP was performed in an effort to remove it. However, despite an adequate sphincterotomy, this stone could not be removed in this manner. After the patient had developed another episode of pain and because he was in a very good clinical condition, it was decided to perform laparoscopic exploration and to attempt to remove the cystic duct remnant. In addition to the previous laparoscopic cholecystectomy, the patient has also had an appendicectomy and exploration of the right kidney for a pelviureteric stone. Some of these adhesions can be seen here laterally. This is the area of the appendicectomy and a band like this is actually dangerous and can cause later small bowel obstruction. Therefore if one sees it, it should probably be broken down. The liver is suspended with an atraumatic suture, which is passed below the xiphoid and passed around the round ligament. This pulls up the liver and allows excellent exposure of the area below the liver; in this case, a very prominent left hepatic artery can be seen pulsating in the lower border of the field. Dissection will start by taking down these omental adhesions but first an additional trocar will be inserted below the costal angle for retraction of the liver and the adhesions. It is so important in laparoscopic surgery to have good exposure as 50% or more of all cases of conversions are probably due to inadequate exposure. Therefore it is no problem to insert one more trocar if this will aid in exposure of the operative field. We will now start dissecting these omental adhesions from the liver. Usually they strip away easily but diathermy and scissors can be used as needed. A good surgical plane is usually present near to the known anatomy, in this case near to the underside of the liver and that is probably the best plane of dissection. If there is bowel near to the liver as in this case or bowel near to the adhesions, one should obviously have prudent use of the diathermy. In cases like these where a lot of diathermy is used, one generates a fair amount of smoke and is opportune to open one of the ports slightly and this acts as a vent for the smoke and clears the operative field. Because of all these adhesions, it will be difficult to directly find the cystic duct stump and one will just dissect as much as is safely possible, where it is possibly the easiest to look for the hepatoduodenal ligament and dissect that out first because once again, it is a known structure. These are all adhesions and the hepatoduodenal ligament is now appearing in the surgical field. Staying close to these known organs, we have up to now known exactly where we are dissecting and there has been no danger to the patient or the structures. Going back now to the imaging, we know that there is a clip sitting right at the end of this long cystic duct and in this case, it is very helpful because as soon as we have identified the clip, we will know where the rest of the cystic duct is. Once again, there is a very prominent left hepatic artery bulging into the operative field and which appears slightly ectatic. It appears to be the cystic duct remnant in the centre of the operative field but at this stage one cannot be sure. Therefore, all dissection should be done carefully aiming to find the clip. Using this careful dissection technique, it appears as if the cystic duct remnant is now held in the left hand grasper and the clip is visible in the distance. What one cannot deduce at this stage from the dissection or from the preoperative imaging is whether a new connection has formed between the tip of the cystic duct remnant and the hepatobiliary tree. Therefore, dissection needs to continue carefully and one cannot just willy-nilly cut around the area of the clip. A connection is possible due to the inflammation around the residual stone and the clip. Here’s the clip and we will now carefully free the area around it. Here the clip is clearly visible and we will now start careful dissection around the clip. We know from the imaging that this is probably the cystic duct held here but what one does not know at this stage whether this is only cystic duct or whether there is a right hepatic artery crossing over it. Notice that we put a swab into the abdominal cavity previously and this is very useful to swab away small bleeders as in this case. There are now free structures and it is indeed a problem, which of those are cystic duct, which is common bile duct, and which is the artery. Therefore, dissection will continue in the plane between these vessels using traction and counter-traction as illustrated. Once again, the operative field is excellent due to the exposure given by the suture on the round ligament of the liver but also the other forceps. We can go back to the imaging again to check the exact position of the long cystic duct in relation to the common bile duct. Once we have now identified the cystic duct remnant with certainty, we can commence to inspecting it with cholangioscopy. The cystic duct is freed adequately and a 5th port is now inserted just below the costal angle for insertion of the choledochoscope. The position of this port is also important as it should be right above the area of dissection and parallel with the cystic duct to ease the insertion of the choledochoscope through it. Hereafter, an incision will now be made in the cystic duct to allow for insertion of the choledochoscope. A transverse incision is certainly the easiest as it opens up the cystic duct very nicely. This is confirmed by the release of bile on cutting. Another important point is to have the tip of the trocar as near as possible to this to minimize the movement of the choledochoscope inside the peritoneal cavity. In this case, no dilatation is needed and the scope passes easily into the common bile duct. One can then go distally, here is the pancreatic duct, the duct of Wirsung, and this is the site of the previous sphincterotomy and one can actually enter the small bowel as is illustrated here. This is very easy without applying any pressure. This obviously opens the possibility that any stone found can be pushed through the sphincterotomy into the small bowel and that would be the end of the problems. Some fibrin is also visible and here is the sphincterotomy clearly seen. Fortunately, it is away from the pancreatic duct and unlikely to have caused any damage in this patient. No stone is illustrated anywhere in the common bile duct, this is obviously distal to the attachment of the cystic duct. The rest of the cystic duct will now be inspected with the scope pushing retrograde into the remnant. As with all these procedures, the procedure is greatly simplified if the choledochoscope and the duct to be explored is pulled into the same axis as is shown here. Usually, one can flush out any stones found or any remnants found by simply opening up the irrigation channel of the scope as we will do now. The actual stone is not visible in this remnant but we know from the preoperative imaging that it is probably sitting in the distal end of the stump. There we go. There’s the distal end of the stump and there is no connection with the rest of the biliary tree. The choledochoscope can now be removed and we can safely divide the long cystic duct remnant from the clip and from the bile duct. The distal end of the long cystic duct remnant is now freed just distally to the clip. Taking care not to damage the artery, which can be seen to run quite near to it. We also know from the preoperative imaging that the common hepatic duct is running just below this area here. Therefore, dissection is done still carefully and with minimal application of the diathermy. This is actually a very long cystic duct and it is now ligated flush with the common bile duct using a loop suture. Hereafter, both the duct remnant and the suture will be cut and the duct remnant possibly containing the stone will be removed through one of the ports. That will be the end of the procedure.