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LosTERRYblesBooKTeaM

LosTERRYblesBooKTeaM

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LosTERRYblesBooKTeaM

LosTERRYblesBooKTeaM

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INDICATIONS
Cholecystectomy is indicated in symptomatic patients with proven disease of the gallbladder,
and the indications for laparoscopic cholecystectomy are essentially those for open
cholecystectomy. There are certain definitive contraindications, which at present include
peritonitis, small bowel obstruction, coagulopathy, and large diaphragmatic hernia. Relative
contraindications are becoming fewer as the surgical experience of the individual surgeon
increases. This list includes cirrhosis, previous intra-abdominal surgery with adhesions, and
acute gangrenous cholecystitis.
PREOPERATIVE PREPARATION
Following a history and physical examination, the diagnosis of biliary disease is documented
with ultrasound examination of the abdomen. The remainder of the gastrointestinal tract may
require additional studies. A chest x-ray and electrocardiogram are usually performed and
may indicate the need for further evaluation of the cardiopulmonary systems. Routine
laboratory blood tests are obtained and should include a liver function panel as well as
coagulation studies. The risks of laparoscopy, including trocar injuries to viscera or blood
vessels and the increased risk of bile duct injuries during laparoscopic cholecystectomy, are
discussed with the patient as well as the possibility of conversion to an open procedure. The
management of patients with gallstones and common duct stones remains to be defined. An
endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy are commonly
tried first. If the common duct is successfully cleared of stones, then a staged laparoscopic
cholecystectomy is performed. If the ERCP procedure is not successful, the patient should be
prepared for an open cholecystectomy with common duct exploration.
ANESTHESIA
General anesthesia with endotracheal intubation is recommended. Preoperative prophylactic
antibiotics for anticipated bile pathogens are administered such that adequate tissue levels
exist.
POSITION
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 (Figure 1).
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. In general, all members of the team are looking across the operating table at video
monitors and therefore the positions of the video monitors may require adjustment once all
members step to their final positions at operation. 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 intraabdominal pressure from the pneumoperitoneum impedes venous return and may raise the

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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.
OPERATIVE PREPARATION
The skin of the entire abdomen and lower anterior chest is prepared in the routine manner.
INCISION AND EXPOSURE
The abdomen is palpated to find the liver edge or unsuspected intraabdominal masses. The
patient is placed in a mild Trendelenburg position and an appropriate site for the creation of
the pneumoperitoneum is chosen. In the unoperated abdomen this is usually at the level of
the umbilicus (Figure 2); however, previous laparotomy incisions with presumed adhesions
may suggest a more lateral approach site which avoids the epigastric vessels (Figure 2 at X).
A 1-cm vertical or horizontal skin incision is made and the abdominal wall on either side of the
umbilicus is grasped by the surgeon and first assistant either by thumb and forefinger or by
towel clips so as to elevate the abdominal wall (Figure 3). 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 (Figure 4). An unobstructed free intraperitoneal
position for the Veress needle is verified by easy irrigation of clear saline in and out of the
peritoneal space (Figure 5) 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 (see Cholecystectomy, Hasson Open Technique, Laparoscopic) 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 (Figure 6). If a disposable trocar port is used, it is important to be certain that the safety
sheath is cocked. A characteristic popping sensation is felt as the trocar enters the peritoneal
space. The trocar is removed and the escape of free CO2 gas is verified.

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Although the Veress needle technique has a long history and is preferred by some, most
general surgeons use the Hasson technique, as shown in Cholecystectomy, Hasson Open
Technique, Laparoscopic.
The CO2 source is attached to this port and the videoscope with its sterile light source cord
inserted after white-balancing and focusing the system. Topical antifog solution is applied to
the optical end of the telescope, which may be either angled (30 degrees) or flat (zero
degrees) (Figure 7). A general examination of the intra-abdominal organs is performed taking
special note of any organ pathology or adhesions. The finding of any trocar-related injuries to
intra-abdominal viscera or blood vessels requires an immediate repair using advanced
laparoscopic techniques or more commonly open laparotomy.
Three additional trocar ports are placed, using direct visualization of their sites of intraabdominal penetration. The second 10-mm trocar port is placed in the epigastrium about 5
cm below the xiphoid, with its intra-abdominal entrance site being just to the right of the
falciform ligament (Figure 8). Two smaller 5-mm trocar ports for instruments are then placed:
one in the right upper quadrant near the midclavicular line several centimeters below the
costal margin and another quite laterally at almost the level of the umbilicus. These sites may
be varied according to the anatomy of the patient and the experience of the surgeon. The skin
of each selected site is infiltrated with a long-acting local anesthetic. This needle can then be
advanced into the peritoneal cavity under direct vision of the videoscope to verify proper
positioning for the planned port. The skin is opened with a scalpel, hemostasis is obtained,
and the subcutaneous fat is dilated with a small hemostat. The patient is placed in a mild (10
to 15 degrees) reversed Trendelenburg position, although some surgeons prefer to rotate the
patient slightly to the left (right side up) for better visualization of the gallbladder region.
The apex of the gallbladder fundus is grasped with a racheted forceps (A) through the lateral
port. The gallbladder and liver are then lifted superiorly (Figure 9) and the handle of the lateral
forceps (A) is secured to the drapes with a towel clip. This maneuver provides good exposure
of the undersurface of the liver and gallbladder. Omental or other loose adhesions to the
gallbladder are gently teased away by the surgeon (Figure 9).
The infundibulum of the gallbladder is grasped with forceps (B) through the middle port.
Lateral traction with the middle forceps exposes the region of the cystic duct and artery.
Dissecting forceps (C) are used by the surgeon through the epigastric port to open the
peritoneum over the presumed junction of the gallbladder and cystic duct (Figure 10). With
gentle teasing and spreading motions, the cystic duct and artery are exposed (Figure 11).
Each structure is exposed circumferentially.
The clear zone may be verified and elongated by sweeping back and forth (Figure 12). The
importance of the second assistant manning the videoscope now becomes apparent. He or
she must pull back and visualize the entrance of each new delicate instrument through the
ports and then follow the instrument down to the area of dissection, which is maintained in the
center of the field. Suitable magnification is controlled by the closeness of the videoscope to

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the dissection site. At this point, if the dissection is difficult because of inflammatory swelling
and scarring, the surgeon should consider conversion to an open procedure.
The cystic artery is cleared for a 1-cm zone and its path followed onto the surface of the
gallbladder. The clear zone is then doubly secured with metal clips both proximally and
distally (Figure 13). The cystic artery may be divided with endoscopic heavy scissors.
However, many prefer to wait until after the cystic duct cholangiogram as the intact cystic
artery may serve as a helpful tether should the cystic duct be transacted during its opening for
the cholangiogram catheter.
The cystic duct is also cleared for about 2 cm or so such that the surgeon can clearly identify
its continuity with the gallbladder and its junction with the common duct. A metal clip is
applied as high as possible on the cystic duct where it begins to dilate and form the
gallbladder. Using the endoscopic delicate scissors through the middle port (Figure 14), the
cystic duct is opened and bile is noted. If necessary, the opening may be dilated with the
scissor tips. The cholangiogram catheter of choice is passed through the middle port and the
duct cannulated (Figure 15). Some catheters are secured within a winged clamp whereas
others rely on an inflated intraluminal Fogarty-like balloon. A simple straight plastic catheter
may be secured with a gently applied metal clip over the lower cystic duct containing the
catheter. It should be snug enough to prevent leakage but loose enough to avoid crimping the
catheter and thus preventing dye injection.
In preparation for the cholangiogram the videoscope and metal instruments are removed. The
radiolucent ports are aligned in a vertical axis so as to minimize their appearance on the xray. The field is covered with a sterile towel and the x-ray equipment positioned. Simple dye
injections with individual films or a sustained injection under fluoroscopy are performed. The
principal ducts are visualized thus assuring anatomic integrity, the absence of ductal stones,
and flow into the duodenum. Upon completion of a satisfactory cholangiogram, the lower
cystic duct is doubly clipped and the cystic duct divided with endoscopic heavy scissors
(Figure 16). However, should an abnormal or confusing cholangiogram be obtained, then the
surgeon should convert to an open procedure with full anatomic verification.
The cystic duct junction with the gallbladder is grasped with forceps through the middle port
and the gallbladder is removed from its bed in a retrograde manner. Most surgeons score the
lateral peritoneum for a centimeter or so with electrocautery (Figure 17) and then elevate the
gallbladder from the liver bed. Appropriate traction, often to the sides, is required to provide
exposure of the zone of dissection with an electrocautery instrument between the gallbladder
and its bed (Figure 18). Vigorous traction with the forceps or dissection into the gallbladder
wall may produce an opening with spillage of bile and stones. Such openings should be
secured if possible using forceps, metal clips, or a suture loop, which is first placed over the
forceps and then closed like a lasso over the hole and the adjacent gallbladder wall that is
tented up by the forceps.
As the dissection proceeds well up the gallbladder bed, it may be necessary for the first
assistant to actively position and reposition the two forceps on the gallbladder so as to

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provide good exposure for the surgeon. When the dissection is almost complete and traction
on the gallbladder still allows superior displacement of the liver with a clear view of the
gallbladder bed and operative site, the surgeon should reinspect the clips on the cystic duct
and artery for their security and the liver bed for any bleeding sites. The region is irrigated
with saline (Figure 19) and the diluted bile and blood are aspirated from the lateral gutter just
over the edge of the liver. The final peritoneal attachments of the gallbladder are divided from
the liver and the gallbladder is positioned above the liver, which has now fallen back inferiorly
to its normal position.
The videoscope is removed from the umbilical port and inserted in the epigastric one. A
grasping forceps is passed through the umbilical port so as to pick up the specimen in the
region of the cystic duct (Figure 20). This exchange may be somewhat disorienting to the
surgeon and first assistant as left and right are now reversed in a mirror-image manner on the
monitor screens. If the gallbladder stones are small, one is usually able to withdraw the
gallbladder, forceps, and umbilical port back out to the level of the skin where the gallbladder
is grasped with a Kelly clamp (Figure 21). Bile and small stones may be easily aspirated
whereupon the gallbladder will exit easily through the umbilical site under direct vision of the
videoscope in the epigastric port. Extraction of large stones or many medium-sized stones
may require crushing prior to extraction (Figure 22) or require that the linea alba opening be
enlarged. After extraction, the umbilical site is temporarily occluded with the assistant's gloved
finger so as to maintain the pneumoperitoneum. The middle and lateral ports are removed as
the videoscope inspects for any bleeding at these sites. The videoscope is removed and the
pneumoperitoneum is evacuated so as to lessen postoperative discomfort.
CLOSURE
The operative sites are infiltrated with a long acting local anesthetic (bupivacaine) (Figure 23),
and the fascia at the 10-mm port sites is resutured with one or two absorbable sutures (Figure
24). The skin is approximated with absorbable subcutaneous sutures. Adhesive skin strips
and a dry sterile dressing are applied.
POSTOPERATIVE CARE
The orogastric tube is removed in the operating room prior to emergence from general
anesthesia. Pain at the operative site is usually well controlled with oral medications.
Although patients have some transient nausea, most are able to take oral liquids within 6 to 8
hours and may be discharged home within one day. Follow-up by the surgeon is important, as
biliary injuries are often occult and delayed in presentation. Prolonged or new, unexpected
pain should be evaluated with physical examination, laboratory tests, and a HIDA
radionuclide scan.

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