Laparoscopic one-trocar cholecystectomy, vascular anomaly: interest of angled scope and liver retraction to expose Calot’s triangle

The objective of this film is to demonstrate how to perform a safe single trocar cholecystectomy in a female patient who had previously benefited from a xiphopubic laparotomy to manage several abdominal infections. This video underlines the importance of a good exposure in order to avoid dangerous lesions in case of anatomical anomalies.

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Laparoscopic one-trocar cholecystectomy, vascular anomaly: interest of angled scope and liver retraction to expose Calot’s triangle

Authors

F Costantino, J Leroy, J Marescaux

Abstract

The objective of this film is to demonstrate how to perform a safe single trocar cholecystectomy in a female patient who had previously benefited from a xiphopubic laparotomy to manage several abdominal infections. This video underlines the importance of a good exposure in order to avoid dangerous lesions in case of anatomical anomalies.

Mots-clés

SILS, Single port, cholecystectomy, vascular risk, vasculsr anomaly, cholelithiasis, CBD stone, 30-degree scope

Type de vidéo

Vidéo chirurgicale

Durée

07'49''

Publication

2011-01

Popularité

Favoris

Favorites Media

Audio

Sous-titres

E-publication

WeBSurg.com, Jan 2011;11(01).
URL: http://www.websurg.com/doi-vd01en3168.htm

Laparoscopic one-trocar cholecystectomy, vascular anomaly: interest of angled scope and liver retraction to expose Calot’s triangle

1. Introduction 00'21''

The objective of this film is to demonstrate how to perform a safe single trocar cholecystectomy in a female patient who had previously benefited from a xiphopubic laparotomy to manage several abdominal infections.

2. Freeing of adhesions 00'38''

The first step of the procedure is to free the adhesions at the supraumbilical median scar, to rule out the presence of adhesions in the upper portion of the abdominal cavity, and then to suspend the round ligament by means of a suture that is passed around it once it has been passed through the abdominal cavity in a subxiphoid position.

3. Liver suspension 01'12''

The round ligament of the liver is maintained in a cranial position with this ligation. The liver is maintained once the patient has been placed head up.

4. Dissection of gallbladder adhesions 01'37''

The adhesions at the gallbladder and those between the gallbladder and the first duodenum are taken down by means of the monopolar hook, as this is safer than the scissors, especially when they are long and sharp-tipped.

5. Exposure of the subhepatic region 02'12''

The exposure of the subhepatic region and of the gallbladder’s bed is rendered easier by exerting traction on the liver, as can be seen here. The left hand is used to introduce double-curved instruments through a flexible trocar in the supraumbilical region. This allows to exert traction while avoiding an external crossing of the hands and exposing the gallbladder’s bed in an appropriate fashion. The liver is kept in a cranial position.

6. Dissection of Calot’s triangle 02'52''

The use of a 5mm, 30-degree angled scope proves efficacious in this case. This scope allows to have an almost anterior-posterior view, contrarily to the 0-degree scope.

7. Vascular anomaly identification 03'10''

In this case, one can realize that the gallbladder’s bed hosts a large vessel, which could be thought to be a cystic artery. However, it turns out to be a hepatic artery. The skeletonization of the structures of Calot’s triangle is of high importance here, as this allows to identify the cystic duct and the cystic artery, which in this case is no more than a branch of the hepatic artery. A small arteriole, which previously was the artery of the cystic duct is situated just underneath. It will be coagulated. The cystic artery will be clipped remaining in contact to the hepatic artery. The artery of the cystic duct will also be clipped. However, it could have also been coagulated. Contrarily to multiple-trocar surgery with gallbladder’s bed retraction, it is quite difficult to have a perfect view of this region. Therefore, a clip is always placed in contact to the hepatic artery. In this case, several clips are necessary and their quantity shows how difficult it is to place them. The cystic branches can then be divided. This will allow to free the cystic duct, which will be dissected and skeletonized, then clipped and divided. A good exposure of the gallbladder’s bed is of high importance here, as vascular or biliary duct anomalies probably constitute the most important danger for the dissection of the Calot’s triangle. This explains the need for skeletonization of these structures before division. Should you have the slightest doubt, do not hesitate to use X-rays to find out whether it is the cystic duct or a branch of the bile ducts. This is essential to avoid any potential complications involving vascular or bile ducts.

8. Cystic duct and artery division 05'46''

Once the cystic duct and the arterial branches are divided, traction on the gallbladder is exerted to free the gallbladder’s bed by means of the hook. This single incision technique, which allows to introduce three trocars and double-curved instruments through an umbilical incision, has one major advantage: it allows to have a perfect visualization of the operative field and to work in absolutely safe conditions. Smoke is evacuated by means of an aspiration connected to the hollow, double-curved instruments. An ultimate control is performed. Some small branches present a slight bleeding, so they will be coagulated in an elective fashion using a bipolar forceps, if need be.

9. Specimen extraction 07'06''

A plastic bag is then introduced in the abdominal cavity through a 12mm trocar. The gallbladder will be placed in the bag. The whole system, including the trocars, will be removed through the umbilical incision.