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Laparoscopic cholecystectomy

Do not be embarrassed by your mistakes. Nothing can teach us better than our understanding of them. This is one of the best ways of self-education.    Thomas Carlyle

The procedure should be performed on a table allowing operative cholangiography.

There is no routine need for a nasogastric tube or Foley catheter.

Typically there is no requirement for invasive anesthetic monitoring.


  As laparoscopic cholecystectomy makes extensive use of supporting equipment, it is important to position this equipment such that it is easily visualized by all members of the surgical team. Figures show three different arrangements for positioning the operating team. The number of persons in the operationg team and their positions depend on the number and locating of incisions to be made.
   
 

 

Our technique eliminates the use of curved laparoscopic grasper in the left hand of the surgeon.

The surgeon stand always the opposite the organ to be removed or explored and manipulates the dissection instrument.

The assistant manipulates the laparoscope and grasper and should be experienced in laparoscopic technique.
   

 

Estabilishing  the Pneumoperitoneum by making a periumbilical skin incision and inserting the Veress needle.

Important information

Pneumoperitoneum


 The surgeon must have a clear line of sight to both the video monitor and the high flow CO2 insufflator such that he or she can monitor both the intra-abdominal pressure and gas flow rates.
 

The patient is placed supine with the arms either secured at the sides or out at right angles so as to allow the maximum access to monitoring devices by the anesthesiologist at the head of the table. An orogastric tube is passed after the patient is asleep. Foley catheter placement is optional. As increased intra-abdominal pressure from the pneumoperitoneum impedes venous return and may raise the risk of deep venous thrombosis, both legs are either wrapped or placed in elastic stockings over which sequential pneumatic compression stockings may be placed.

The electrocautery grounding pad is placed near the hip avoiding any region where internal metal orthopedic parts or electronic devices may have been implanted. The position of the patient on the table relative to placement of the x-ray cassette for a cholangiogram or the C arm for fluoroscopy is rechecked. The legs, arms, and upper chest are covered with blankets to minimize heat loss.

Veress needle insertion

A Veress needle is held like a pencil by the surgeon who inserts it through the linea alba and peritoneum where a characteristic popping sensation is felt. An unobstructed free intraperitoneal position for the Veress needle is verified by easy irrigation of clear saline in and out of the peritoneal space and by the hanging drop method where the saline in the translucent hub of the Veress needle is drawn into the peritoneal space when the abdominal wall is lifted.

If one does not obtain a free flow or an unobstructed saline irrigation, then the Veress needle may be removed and reinserted. In general it is safer to convert the umbilical site into the Hasson open approach if any difficulty is experienced with the placement, irrigation, or insufflation of the Veress needle. The appropriate tubing and cables for the CO2 insufflation, the fiberoptic light source, and the laparoscopic videoscope with its sterile sheath are positioned as are the lines for the cautery or laser, suction, and saline irrigation.
 

  The pneumoperitoneum begins with a low flow of about 1 or 2 L/min with a low-pressure limit of approximately 5 to 7 cmH2O. Once 1 to 2 L of CO2 are in, the abdomen should be hyperresonant to percussion. The flow rate may be increased; however, the pressure should be limited to 15 cmH2O.

Three to four liters of CO2 are required to fully inflate the abdomen and the Veress needle is removed. After grasping either side of the umbilicus, a 10-mm trocar port is inserted with a twisting motion, aiming towards the pelvis.


Inserting the laparoscope trocar


Select the incision site for working trocars by depressing the abdominal wall while inspecting the abdomen laparoscopically from within. Translumination is useful in locating an avaskular area. The instrument trocar will later be used to advance dissection swabs, scissors, the bipolor electrocautery, the aspirator/irrigator, etc. The surgeon holds these various instruments with the right hand.

The surgeon advances a 5-mm curved grasper (ergonomically projected by prof. Buess in Tuebingen Group), graspes the Hartmann pouch, and pushes from the infundibulum, which helps to open Calot’s triangle and broadly exposes the vascular and biliary structures to be dissected and/or protected.

The assistant operates with the camera-laparoscope inserted from the paraumbilical trocar, and grasper trocar, grasps and pushes the fundus of gallbladder superiorly toward the diaphragm.
 

 


Applying the tension to the hepatoduodenal ligament by grasping the fundus and infundibulum.

Incising the visceral peritoneal covering

Exposure of the confluence of the cystic to common bile duct, and the outline of the common bile duct.

Dissection around the cystic duct and cystic artery.

Cholangiography


Lateral retraction of Hartmann’s pouch is maintained by a grasper, this time coming from the subxiphoid port. The cystic duct is incised through the right. The cystic valve can occasionally make this difficult. A No.4 ureteric catheter with an end hole is inserted through the Olsen-Reddick cholangiogram clamp into the cystic duct and the clamp closed around the duct. Operative cholangiography is then performed with aid of C-arm fluoroscopy. Cholangiography confirms the biliary anatomy and reveals the common duct stones, allowing laparoscopic duct exploration.

Removal of gallbladder.
 

Once cholangiography is completed, the ureteric catheter is removed and the cystic duct is clamped.
 

 
 

 

Clipping the cystic duct, placing double clips on the common bile duct side and single clip on the gallbladder side.

Transsection of the cystic duct between theclips.

Dissection out of  the cystic artery (the exposure of right hepatic artery at the origin of the cystic artery from the right hepatic artery is preferable)

Anatomical Variations

    The major anatomical variations are involved with the common bile duct and the right hepatic artery. A very small common bile duct can be mistaken for the cystic duct and completely excised.

Even more worrisome is the variant of a low junction of the left and right hepatic ducts or a low junction of the right anterior and right posterior hepatic ducts.

In these situations the cystic duct can enter the right hepatic duct or the right posterior hepatic duct.
 

The right or right posterior ducts can therefore be mistaken for the cystic duct and divided. More rarely, but even more difficult, particularly in the setting of acute cholecystitis, is when there is no cystic duct and Hartmann’s pouch opens directly underneath the right hepatic duct or the common duct.

Transecting of the clipped cystic artery
 

 

Dissection of the gallbladder from the liver bed. Remain the subserosal in the dissection, using both blint and and sharp dissections.

Removing of  the gallbladder through a subxiphoid or periumbilical trocar aperture (in the site of the largest trocar port).

Irrigate the operative site.

Inspecting of  the wound area to verify hemostasis, control the minor bleeding with bipolar electrocautery. Verify proper positioning and integrity of the clips
 

 

 

 
Placing a drain in Winslow’s foramen via the right lateral gallbladder extraction sleeve (optional for many surgeons, first of all for bleeding cotrol)

Removing of  the instruments under laparoscopic control

The operative sites are the fascia at the 10-mm port sites is resutured with one or two absorbable sutures.

The skin is approximated with absorbable subcutaneous sutures. The dry sterile dressing are applied.