74 o Surgicot

Procedures tncluding Minimol Access procedures

Abdominol Extrointestinol Surgery

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SpeciolNotes
Correct positioning of the patient is imperative to assure accurate visualization ofthe biliary tract. Test drains for patency. Drains are anchored with a skin stitch. Instruments coming into contact with bile are isolated in a basin. Syringes fiIled with saline or radiopaque dye must be labeled to avoid confusion and ensure succeisful x-ray
exposures.

A "scout" film is taken before surgery begins. Observe x-ray precautions, see p. 21,. Protective goggles may be worn for choledochoscopy.
TAPAROSCOPIC CHOTECYSTECTOMY

Definition
Endoscopic excision of the gallbladder. Discussion

duced through this port, seizing the fundus ofthe gallbladder and distracting it until the hilum can be seen. Local dissection offat or adhesions may be necessary to achieve visualization of the gallbladder prior to this maneuver. To maintain traction on the gallbladder, the handle of the grasper can be fastened to the drape. A fourth trocar may be inserted 2 to 3 cm below the right costal margin just medial to the $haft of the grasper (holding the gallbladder). By appropriate dissection the hilum ofthe gallbladder is visualized including the cystic duct and the cystic artery. The cystic artery is divided between clips. A clip is placed on the junction of the cystic duct and gallbladder. A cholangiogram may then be performed. Cholangiogram. The cystic duct is incised as close to the gallbladder as possible. A cholangiogram catheter is inserted (with or without prior placement of

The laparoscopic approach may prove difficult or impossible ifthe patient is obese or ifthere are excessive adhesions (related to a previous surgery, recurrent attacks of cholecystitis, and so on), ductal or vascular anomalies exist, unexpected pathology is encountered, acute inflammation distorts normal tissue planes, or there is excessive bleedirig or surgical injury. In any of those instances the procedure must be promptly converted to open laparotomy. Procedure
Pneumoperitoneum is achieved. Usually a 10 to 11 mm trocar is inserted infraumbilically through which a laparoscope with camera is introduced. The laparoscope may be removed and reinserted via a subsequently placed port. The abdomen is explored. A subzyphoid trocar is inserted. The patient's right side is rotated anteriorly 15 to 20". A third trocar is placed in the right anterior axillary li.ne halfway between the iliac crest and the twelfth rib. A locking grasping forceps is intro-

cholangiogram clamp. Saline rnay be injected into the catheter to checkfor leaks. Radiopaque dye (diluted to half strength) is injected after the patient is repositioned as necessary. Standard x-ray films are obtained. (Alternative techniques may be employed.) Choledochoscopy. The cystic duct is pneumatically dilated through which the common bile duct is cannulated with a choledochoscope or a ureteroscope. A separate camera-monitor system may be utilized. A guide wire is passed via the cystic duct, and the choledochoscope is advanced over the wire. An endoscopic stone basket may be used to retrieve calculi. If the stone is too large to be removed, lithotripsy of the stone may be employed using a mechanical, electrical, or laser energy source (crushing forceps, electrohydraulic lithotuipter, or pulse-dye laser). Limitation of choledochoseopy exists due to the size of the instruments cuffently in use. Postoperatively, extraction of remnants of calculi may be facilitated by endoscopic retrograde cholangiopancreaticography (ERCP) including duodenal pap-

a guide wire) and clipped or held in place with

illary sphincterotomy. Some surgeons may perform

duct choledochotomy. As indicated, the procedure may

require conversion to open laparotomy to correct the

oommon duct pathology. The cystic duct is then ligated