Teaching laparoscopic cholecystectomy

Authors

Abstract

Cholecystectomy is the most common laparoscopic procedure performed worldwide. This authoritative and instructive video shows a laparoscopic cholecystectomy with intraoperative cholangiogram.

Catégorie

live recorded

Mots-clés

Laparoscopic cholecystectomy, cholelithiasis

Type de vidéo

Durée

24'00''

Publication

2011-12

Popularité

Favoris

Audio

Sous-titres

E-publication

WeBSurg.com, Dec 2011;11(12).
URL: http://www.websurg.com/doi-vd01en3510.htm

Teaching laparoscopic cholecystectomy

1. Introduction 00'19''

We’re doing a laparoscopic cholecystectomy on a 55-year-old female patient, with a history of pancreatitis associated with migration of gallstones. She had two previous attacks of pancreatitis. We saw this woman a first time after the first attack of pancreatitis and we decided to do a cholecystectomy but during this time, she developed a second attack, so we had to wait 8 days for this grade B Balthazar Score pancreatitis. We are planning to do a cholecystectomy plus, of course, an intraoperative cholangiogram.

2. Patient position 01'13''

The position of the patient is supine on the table with the leg sprayed. The surgeon is working between the legs of the patient and if you have a view of the abdomen, we have here the umbilicus and we know that the gallbladder is here, so the idea is to get the view of course, and to have some sort of triangulation of the instruments to work on this area. Ideally, we should put one trocar here for retraction or holding of the gallbladder with the left hand of the surgeon, we will put another port there approximately to get this triangle, so exposure of the gallbladder will be done in this fashion and personally I will use another port very close to the gallbladder that will help me dissect the triangle of Calot. The most common position is right hypochondrium, then in the middle of the left hypochondrium, and some people use a grasper just next to the xiphoid process, and this grasper will be used to hold the gallbladder. These are the alternatives. These two trocars are usually the ones that I use. Alternatively, either a little bit on the right or left side of the patient, depending on the surgeon’s preference. We have created the pneumoperitoneum with an insufflation in the left hypochondrium, and now we will go with the optical trocar. This patient has no previous surgery, so no risk for adhesions. And so we will do a direct approach with the trocar. Of course again, depending on the experience of the surgeon and the rules in the institution – people consider that this approach is a bit more dangerous than an open approach, and again this is very depending on the experience of the surgeon. First trocar in the umbilicus and then we will go inside the peritoneal cavity with a 0-degree laparoscope, and we can immediately see that we will have a good distention of the stomach, so we will ask the anesthesiologist to deflate the stomach with a gastric tube. So I’m just checking the peritoneal cavity, that’s a basic rule for laparoscopy.

3. Exploration of abdominal cavity 04'07''

We have a vision so we need to explore macroscopically, to rule out any additional problems, and then we will move towards the liver and the gallbladder. In this area, there is no indirect signs of the pancreatitis, of course we can’t access the pancreas. My first port will be in the right hypochondrium, I’m using a 5mm instrument. My second port will be the one in the left hypochondrium, always control the introduction of the trocar with a scope. The majority of surgeons will be working with these two ports, right hand, left hand, and some retraction coming from the upper part of the abdomen. Personally, I use another technique, which allows me to be very close to the gallbladder, and in fact, I’m inserting a port in the right hypochondrium, and you see in this manner we have a triangulation of the instruments towards the gallbladder and of course we can change the use of the different instruments. So, right hypochondrium is introduced, left hypochondrium is introduced, and I will check first the gallbladder, which is totally normal, and so you see the 3 instruments – it’s a very classic technique. The first is to use this grasper to grab the gallbladder, this is the upper trocar, and to dissect with these two instruments. But you see that sometimes if you use it really on the right side of the patient, you can’t retract the left liver lobe that comes in the front, so you will retract with your grasper. Personally, I use another way – the assistant that is on the left side of the patient is using the grasper coming from the left, and it’s very helpful in exposure of the triangle of Calot.

4. Exposure of triangle of Calot 07'01''

You see now, my hook is coming from the upper trocar, and you see with that, I have no problems with the left liver lobe, and I have perfect traction and counter-traction on the triangle of Calot, the area is exposed perfectly well. Another advantage is that my right hand, dissecting hand, is very close to the field, so I don’t have to cross the abdomen to reach the triangle of Calot. It is a very comfortable position, this patient has a history of pancreatitis, so the rule is to perform an intraoperative cholangiogram.

5. Dissection of triangle of Calot 07'45''

We dissect with a hook, which is probably the best instrument for cholecystectomy and we are opening the anterior peritoneum. My gauze is there, always have a look on the duodenum, and now we are just changing the position of the grasper a little bit, to expose the posterior layer. The idea of this first incision is to increase the distance between the gallbladder and the common bile duct. A bit of blunt to increase the space, changing the position of the grasper a bit, and we go back to. And you see the look on the back is always very important to assess properly the anatomy. So, again we will dissect carefully the different elements with always a look at the back. By changing a little bit the position of the two graspers, we see that we can improve easily the view on the triangle of Calot. Hold the monopolar on the area – you have to be very careful and step by step we’ll try. You see we have some.

6. Dissection of cystic elements 10'28''

So dissection is performed very close to the gallbladder because we know that we can have different structures like ducts through the posterior sector of the liver, we can have artery, the right hepatic artery crossing in this area, so that’s why we have to be very careful and we can see progressively the crossing of the artery here. And the cystic duct, but before cutting or keeping anything, we want to clear the triangle because we know that things can happen there, so we have to be sure that nothing is left in this area. You see the alternance of anterior and posterior dissection, it’s important to be sure of the anatomy. So now we have a good view. So I’ll continue to open the triangle again just to be sure that nothing is in the triangle so now we’re ready to clip the different structures that I have mentioned.

7. Intraoperative cholangiogram 12'57''

We have to do an intraoperative cholangiogram. So I’ll put a clip on the proximal cystic duct and artery. This woman has micro-lithiasis so this is probably why she has this migration. Artery, and now I’ll divide the cystic duct. And I’m always massaging the cystic duct before inserting the catheter because you don’t know if there are some stones. You can see some little things coming. So that’s probably again a direct demonstration that there were things passing down the cystic duct. So now the catheter is inside. So now we’ll do the cholangiogram. The cholangiogram is very important. You have different options, either we’re doing a preop image like MRCP or of course this patient had a previous CT-scan because of the series of pancreatitis but the rule for me is to – even if we have a preop imaging in this circumstance, we have to do an intraoperative cholangiogram because the risk of residual stones is very important. So gentle injection. The passage in the duodenum is very easy and I’m just trying to inject, clamping a little bit the main biliary tract, just to have the vision of all the biliary tree, and then I have to count the different structures just to be sure mostly that the lateral sector is still in place, which is the most risky here. That’s a very important one to look for. 5-8, it’s easy but 6-7 are here, and that’s the other one, which are the most at risk during cholecystectomy and just a last look at the lower part to see that as we’ve seen on the first image, that there were no stone inside the common bile duct so we can clip the cystic duct.

8. Cholecystectomy 18'44''

Here we are. And again with the help of the 2 graspers, with a system of traction, counter-traction, we’ll dissect the gallbladder from the fossa. See that this grasper is quite interesting to allow for traction from the surgeon to help identify the cleavage plane. And that’s it. I’ll just suck a bit of bile from the cholangiogram, just a little bit above the liver, then we’re going back. We always check the triangle of Calot. Just a little touch of coagulation there. Of course, no drainage. The gallbladder will be placed in a bag. No drainage and extraction through the umbilical port. To do that, this is the port coming from the left hypochondrium and the grasper from this port that will drive the bag towards the umbilical trocar. So one last check is performed before leaving: everything looks fine. So we’re getting out. First we remove the trocars under vision. And now we’ll pass this grasper inside the umbilical port and get the bag at the level of the umbilicus.

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