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Standard laparoscopic cholecystectomy

This video demonstrates the steps in performing a standard cholecystectomy in an uninflamed gallbladder using the ''French technique'' with surgeon standing between the patient's legs. The surgeon demonstrates safe dissection of the Calot's triangle to identify the cystic duct and artery as well as a small posterior branch. The patient also had an accessory bile duct, which was identified during the removal of gallbladder from the liver bed and controlled.

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STANDARD LAPAROSCOPIC CHOLECYSTECTOMY

Autores

D Mutter, J Marescaux

Resumo

This video demonstrates the steps in performing a standard cholecystectomy in an uninflamed gallbladder using the "French technique" with surgeon standing between the patient's legs. The surgeon demonstrates safe dissection of the Calot's triangle to identify the cystic duct and artery as well as a small posterior branch. The patient also had an accessory bile duct, which was identified during the removal of gallbladder from the liver bed and controlled.

Classificação

basic techniques

Palavras-chave

laparoscopy,cholecystectomy,Calot's triangle,cystic artery,cystic duct,common bile duct,accessory biliary duct

Tipo de mídia

Vídeo cirúrgico

Duração

18'51''

Data da publicação

2004-12

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Áudio

Legendas

E-publicação

WeBSurg.com, Dec 2004;4(12).
URL: http://www.websurg.com/doi-vd01en1608e.htm

STANDARD LAPAROSCOPIC CHOLECYSTECTOMY

1. Patient and trocar placement 00'21''

The surgeon stands between the patient’s legs and the 2 assistants on either side. The patient is placed in a reverse Trendelenburg position. Abdominal insufflation is performed. The abdomen is controlled for adhesions or any abnormalities. Here we have the control of the previous hernia repair. The scar is just visible on the opposite side. The other ports are placed under direct control. One port is placed at epigastric level. Another is placed laterally to the first one. Lightening of the parietal wall is performed in order to avoid any injury to the epigastric vessel and all ports are placed under direct control. The 5mm port is not placed too laterally in order to avoid positioning problems. Direct control of port insertion is done and the 3 ports are placed under direct control. The 2nd port is placed close to the midline. The 3rd and last port is an epigastric port.

2. Exposure 01'51''

A first grasper is placed in the epigastric port. This will allow removal of the omentum, grasping of the gallbladder, and exposure of the operative field. The position of the patient is slightly modified with a reverse Trendelenburg position. This allows for downward retraction of the omentum. Here the gallbladder neck is well exposed. By pulling on the Hartmann’s pouch, we can see that we have a good exposure of the hepatic pedicle. By removing the fat, we can identify very clearly the position of the common bile duct. Now the dissection may start.

3. Dissection of Calot's triangle 02'46''

The intervention starts with grasping of the Hartmann’s pouch. We always use very low voltage (26 Watts). Our strategy is to open the anterior part of the peritoneum, then the posterior part in order to lengthen the cystic pedicle and then to dissect the cystic duct and the cystic artery separately. By grasping the tissue and performing progressive cautery, we try to avoid any bleeding in the operative field in order to have a very good view of the operative field during the whole procedure. We have performed the anterior opening of the peritoneum. Here you can see that we have progressively identified the cystic pedicle. We will then open the posterior part of the peritoneum. We have a hook that is used in monopolar cautery at a very low voltage in order to avoid diffusion of electrical currents to the common bile duct and furthermore we have a hook that is posteriorly completely protected in order to avoid any electrical injury. So here we lengthen the hepatic pedicle. Here we can identify the cystic duct. Nevertheless we don’t perform intraoperative cholangiography in a routine way and for this reason we aim to dissect Calot’s triangle completely before cutting any anatomical duct. The cystic duct and cystic artery have to be identified very precisely in order to avoid any bile duct injury. Here we slightly modify the position of the grasping of the Hartmann’s pouch, and as you see, millimetre by millimetre, we identify the small adhesions. Calot’s triangle is progressively freed. Here we identify precisely the junction of the cystic duct to the Hartmann’s pouch. This dissection allows a very safe identification of all the anatomical landmarks. Nevertheless on the posterior aspect, we might have injury of some small vessels of the pedicle. Here in the fat the dissection is continued. The dissection aims to free the cystic duct completely in order to ensure a safe application of the clips. In the same way, we want to clearly identify the artery in order to avoid any injury. Here you can see that we have completely freed the cystic duct from its adhesions. After a safe identification of the cystic duct, we are going to identify the cystic artery. If we have a dissection problem, it can be easier in some cases to control and cut the cystic duct in order to dissect the vessels in a second intent to identify the artery. Here you can see small vessels at the posterior aspect of the pedicle. This dissection might be slightly hemorrhagic before a perfect control of the vascular elements is achieved. Here you can see very clearly that there are 2 branches on the vessels: a posterior artery going on the anterior surface and an artery going on the posterior surface of the gallbladder. Gentle freeing f the gallbladder allows a better identification of anatomical elements. We control permanently anteriorly and posteriorly the elements in order to obtain a perfect freeing of Calot’s triangle. We continue the freeing of the gallbladder. There is absolutely no urgent moment to cut the duct. Freeing of these elements is completed. The posterior pulling of Calot’s triangle has a major danger to push on the hepatic artery and to be at the origin of hepatic artery injury. Here we can identify posteriorly the small accessory vessel, the vascular branch here, the main cystic artery in order to have a safe control of both elements. We will now control the cystic duct. No accessory cystic duct can be found here.

4. Clipping and division of cystic duct and artery 09'17''

Safe dissection of the cystic duct can be performed without intraoperative cholangiography. The clips are applied safely on the dissected elements with 2 clips one on the remnant part, and one clip is placed on the side of the gallbladder. Two clips must go over the duct and control it completely. One clip is placed at the neck of the gallbladder. Control of the cystic duct is cut twice in order to confirm that it is the cystic duct which will allow us to complete the dissection of the cystic artery with the main branch and a little accessory branch which will be also controlled by a clip application. A clip is applied on the cystic artery and on the little accessory branch in order to have complete and safe vascular control. Positioning of the clips is done very safely and bleeding must be avoided at the end of the dissection. It looks like a little accessory vein. Here again the section of the elements is done twice to control that it is clearly a vessel and the artery and then to control the elements.

5. Gallbladder bed dissection 11'17''

The whole of Calot’s triangle has been identified. Now cholecystectomy can be performed first by cutting the peritoneal adhesions. The small vascular branches are cut very close to the gallbladder in order to avoid intraoperative bleeding. The gallbladder bed is examined closely to identify an accessory Luschka’s duct, if present (which is a direct biliary duct going to the gallbladder and coming out of the liver). Monopolar cautery is frequently at the origin of some smoke. So when smoke is present, I use to have little gas leak which then allows the smoke to go out of the abdominal cavity, hence increasing the quality of the abdominal view. Careful hemostasis is performed. Injury of the gallbladder must be avoided in order to avoid having free bile in the abdominal cavity, in order to avoid potential postoperative infection, and postoperative pain that may be due to the presence of bile in the abdomen. Here we can see at the end of the dissection another superficial vein which will be carefully controlled. Here is the arteriovenous pedicle which may be accompanied by a small accessory biliary duct and for this reason we control this little hepatic pedicle using again clip application. The whole dissection is performed almost without modification of the position of the grasper. Change in instrument position is the most time-demanding part of the operation. Tension must be always placed on the tissue as the low voltage cautery allows very well dissection of these elements. Here you can see that at the end of the dissection we change the position of the grasper to go on the opposite side of the gallbladder. The assistant keeps the grasper close to the liver presenting the peritoneum and the dissection is uneventful.

6. Extraction 15'25''

We then place a bag in the abdomen. The gallbladder is always removed after introduction in a bag. The bag is placed into the abdomen and the gallbladder is placed into the bag to avoid any contamination of the port site by a potential pathology or bile leakage if there is a rupture of the gallbladder during its extraction. The bag is then extracted through the umbilical port. It is pushed through the port. The port is retracted. The bag is exposed using a grasper. The gallbladder is then extracted into the bag. A suction drain is used in order to empty the bile. The gallbladder is opened. Suction of the bile is performed. Stones will be extracted one after the other. Usually emptying of the gallbladder allows extraction of the stones without contamination of the parietal wall. A 10mm port is placed again in the abdominal cavity. The abdomen is reinsufflated again after gallbladder extraction. The gallbladder bed is controlled for any bleeding or bile leak. Positioning of clips is also controlled. Then ports are removed under direct visual control. We remove the ports and if there is no bleeding in the port sites, they are completely removed. We have the entry site of the right port here with insufflation. After removal of the 5mm port, the patient is exsufflated under direct control. Fascial closure is performed on the umbilical incision and the skin is re-approximated.