Prof. Dr. R. K. Mishra INTRODUCTION Laparoscopic surgery has undergone rapid development in recent years. Laparoscopic cholecystectomy was first performed in 1985. Since the introduction of laparoscopic cholecystectomy into general practice in 1990, it has rapidly become the dominant procedure for gallbladder surgery. By the end of the decade, laparoscopic cholecystectomy had spread throughout the world. The importance of laparoscopic cholecystectomy was the cultural change it engendered rather than the operation it replaced. In terms of technique, laparoscopic cholecystectomy is now the gold standard for the treatment of symptomatic gallstone disease. It is most commonly performed minimal access surgery by general surgeons’ worldwide. In Europe and America, 98% of all the cholecystectomy is performed by laparoscopy. The credit of popularizing minimal access surgery goes to laparoscopic cholecystectomy. This is most popular and most accepted minimal access surgical procedure worldwide. Laparoscopic surgery has expanded from gallbladder surgery to virtually every operation in the abdominal cavity. INDICATIONS (FIG. 1) ■ Cholelithiasis ■ Mucocele gallbladder ■ Empyema gallbladder ■ Cholesterolosis ■ Typhoid carrier ■ Porcelain gallbladder ■ Acute cholecystitis (calculous and acalculous) ■ Adenomatous gallbladder polyps ■ As part of other procedures, viz., Whipple’s procedure. CONTRAINDICATIONS ■ Hemodynamic instability ■ Uncorrected coagulopathy ■ Generalized peritonitis ■ Severe cardiopulmonary disease ■ Abdominal wall infection ■ Multiple previous upper abdominal procedures ■ Late pregnancy The general anesthesia and the pneumoperitoneum required as part of the laparoscopic procedure do increase the risk in certain groups of patients. Contraindications to laparoscopic cholecystectomy are primarily related to anesthetic concerns and include diffuse peritonitis with hemodynamic compromise and uncontrolled bleeding disorders. Most surgeons would not recommend laparoscopy in those with pre-existing disease conditions. Patients with severe cardiac diseases and chronic obstructive pulmonary disease (COPD) should not be considered a good candidate for laparoscopy. The laparoscopic cholecystectomy may also be more difficult in patients who have had previous upper abdominal surgery. The elderly may also be at increased risk for complications with general anesthesia combined with pneumoperitoneum. Relative contraindications are dependent on the surgeon’s judgment and experience but include patients with previous extensive abdominal surgery, cirrhosis with portal hypertension, severe cardiopulmonary disease, active cholangitis, and morbid obesity. ADVANTAGES OF LAPAROSCOPIC APPROACH ■ Cosmetically better outcome ■ Less tissue dissection and disruption of tissue planes ■ Less pain postoperatively ■ Low intraoperative and postoperative complications in experienced hand Fig. 1: Appearance of fundus of gallbladder in first look. ■ Early return to work.
SECTION 2: Laparoscopic General Surgical Procedures TIMING OF SURGERY The optimal timing of surgery will depend upon the patient’s overall medical condition and underlying diagnosis. ■ Acute cholecystitis: Patients with acute cholecystitis, who are surgical candidates, should undergo cholecystectomy as soon as they are fully resuscitated, and the most qualified surgeon is available. Early cholecystectomy has been associated with improved patient outcomes compared with interval cholecystectomy. ■ Gallstone pancreatitis: Patients with gallstone pancreatitis have a high risk of recurrence within 30 days of their attack and therefore should undergo cholecystectomy during their index hospitalization after their symptoms resolve. ■ Obstructive jaundice: A history of pancreatitis or jaundice raises the likelihood of common bile duct (CBD) stones. Patients with isolated obstructive jaundice with or without cholangitis should either have their CBD cleared with urgent endoscopic retrograde cholangiopancreatography (ERCP) preoperatively or with cholangiography and laparoscopic common duct exploration at the time of surgery. If ERCP is successful, the patient should electively be scheduled for cholecystectomy. ■ Medical comorbidities: Identification of bleeding diatheses and poor cardiopulmonary reserve will help to identify patients who may not tolerate pneumoperitoneum or will have higher likelihood for conversion to open operation. In patients with multiple comorbidities or acute medical problem, a trial of antibiotics with consideration for a percutaneous cholecystostomy tube with delayed laparoscopic cholecystectomy in 6–8 weeks may be preferable. PREOPERATIVE INVESTIGATIONS Apart from routine preoperative investigations, in fit patients, the only investigations needed are ultrasound examination. Although practiced in some centers, intravenous cholangiography may not be confirmative and is attended with the risk of anaphylactic reactions. Laboratory Testing Laboratory testing in patients being evaluated for acute cholecystitis typically includes a complete blood count, liver enzymes, amylase, and lipase. Elevations in the serum total bilirubin and alkaline phosphatase concentrations are not common in uncomplicated cholecystitis, since biliary obstruction is limited to the gallbladder; if present, they should raise concerns about complicating conditions such as cholangitis, choledocholithiasis, or Mirizzi’s syndrome. However, mild elevations have been reported even in the absence of these complications and may be due to the passage of small stones, sludge, or pus. For young, otherwise healthy patients with gallstones but no evidence of pericholecystic inflammation or bile duct dilation, additional preoperative laboratory testing is not routinely necessary, unless a new clinical event has occurred, such as significant pain, fever, or jaundice, or the physical examination suggests that an abnormality is present. An electrocardiogram or chest radiograph is obtained as appropriate. For patients with complicated biliary tract disease, abnormal tests (e.g., liver function tests, amylase, and lipase) should be repeated to serve as a baseline for postoperative comparison. Coagulation tests are not routinely needed but may be obtained, if there is a reason to believe an abnormality may be present. Imaging Ultrasonography (US) of the right upper quadrant establishes the diagnosis of gallstones or abnormalities of the gallbladder wall. The US may also demonstrate CBD dilatation, stones, or evidence of acute inflammation of the gallbladder. Nuclear cholescintigraphy may be useful in cases in which the diagnosis remains uncertain after US. Magnetic resonance cholangiopancreatography (MRCP) may be useful to evaluate the common duct in patients with mild elevations of their transaminases or mild CBD dilatation on US. Endoscopic Retrograde Cholangiopancreatography If a patient has a dilated CBD, CBD stones, or jaundice, consideration should be given to a preoperative ERCP with clearing of the stones followed by laparoscopic cholecystectomy. In the absence of frank jaundice or cholangitis, mild abnormalities of liver enzymes and/ or bile duct dilation may also be managed effectively with intraoperative evaluation of the CBD, rather than preoperative ERCP. Patient Position Patient is operated in the supine position with a steep head-up and left tilt. This typical positioning of laparoscopic cholecystectomy should be achieved once the pneumoperitoneum has been established. The patient is then placed in reverse Trendelenburg’s position and rotated to the left to give maximal exposure to the right upper quadrant. Position of Surgical Team (Fig. 2) The surgeon stands on the left side of the patient with the scrub nurse-camera holder-assistant. One assistant stands right to the patient and should hold the fundus-grasping forceps.
Tasks Analysis ■ Preparation of the patient ■ Creation of pneumoperitoneum ■ Insertion of ports ■ Diagnostic laparoscopy ■ Dissection of visceral peritoneum ■ Dissection of Calot’s triangle ■ Clipping and division of cystic duct and artery ■ Dissection of gallbladder from liver bed ■ Extraction of gallbladder and any spilled stone ■ Irrigation and suction of operating field ■ Final diagnostic laparoscopy ■ Removal of the instrument with complete exit of CO2 ■ Closure of wound. Port Location (Figs. 3A to C) Fig. 2: Position of surgical team. Four ports are used—optical (10 mm), one 5 mm, one 10 mm operating, and one 5.0 mm assisting port. The optical port is at or near the umbilicus and routinely a 30° laparoscope is used. Some surgeons who have started laparoscopy earlier are more comfortable with 0° telescope. The laparoscope is inserted through a 10-mm umbilical port and the abdominal cavity is explored for any obvious abnormalities. The secondary ports are then placed under direct visualization with the laparoscope. The surgeon places a 10-mm trocar in the midline and left to the falciform ligament at the epigastrium. Two 5-mm ports, one subcostal trocar in the right upper quadrant and another 5 mm trocar, lower, near the right anterior axillary line, are placed. B A C Figs. 3A to C: (A) Ideal port position for laparoscopic cholecystectomy; (B and C) Port position of cholecystectomy. 179
SECTION 2: Laparoscopic General Surgical Procedures LAPAROSCOPIC ANATOMY (FIG. 4) Laparoscopic view of the right upper quadrant on first look will demonstrate primarily the subphrenic spaces, abdominal surface of diaphragm, and diaphragmatic surface of the liver. The fundus of the gallbladder can be seen popping from the inferior surface of liver. The falciform ligament is seen as a prominent dividing point between left subphrenic space and the right subphrenic space. As the gallbladder is elevated and Fig. 4: Topographic anatomy of gallbladder: (1) Gallbladder; (2) Cystic artery; (3) Mscagni lymph node; (4) Proper hepatic artery; (5) Abdominal aorta; (6) Portal vein; (7) Gastroduodenal artery. retracted toward the diaphragm, adhesion to the omentum or duodenum and transverse colon is seen. Exposure of Gallbladder and Cystic Pedicle (Figs. 5A to D) A grasper is used through the right lower 5-mm trocar to grasp the gallbladder fundus and retract it up over the liver edge to expose the entire length of the gallbladder. If there are adhesions to the gallbladder, they will need to be taken down using blunt and sharp dissection. With the entire gallbladder visualized, a second grasper is inserted through the other right upper quadrant trocar to grasp the gallbladder infundibulum and retract it up and to the right to expose the triangle of Calot. Careful evaluation of the anatomy reveals whether it is partially intrahepatic, on a mesentery, or possesses a Phrygian cap or any other odd shape. Hartmann’s pouch should be identified and seen to be funnel down to continue as tubular structure, the cystic duct. It is important to identify Hartmann’s pouch clearly, because most of the laparoscopic surgeons clip and divide the cystic duct, high on its termination at Hartmann’s pouch, rather than attempting to trace the cystic duct’s junction with the CBD. Dissection of the junction of cystic duct with the CBD increases the chance of traction injury and bleeding from small vessels and lymphatic. A B C D Figs. 5A to D: Proper traction for exposure of cystic pedicle.
A B C D Figs. 6A to D: Clearing adhesions by hook. Cystic artery can be seen, if attention is given, as it runs along the surface of gallbladder. A lymph node may be seen anterior to the cystic artery. The cystic artery gives off a small artery that supplies the cystic duct. This tiny twig often avulsed and bleeds at the time of creating window between artery and duct. This bleeding stops when the cystic duct is clipped. Adhesiolysis (Figs. 6A to D) Any adhesion should be cleared from the gallbladder. The surgeon uses a dissector through the epigastric trocar to tear the peritoneal attachments from the infundibulum. The attachments are taken down from high on the gallbladder, beginning laterally in order to help avoid injury to the CBD. Sharp dissection may be carried out with the help of scissors attached with monopolar current. At the time of separating adhesion, surgeon should try to be as near as possible toward gallbladder. The cystic pedicle is a triangular fold of peritoneum containing the cystic duct and artery, the cystic node, and a variable amount of fat. It has a superior and an inferior leaf, which are continuous over the anterior edge formed by the cystic duct (Fig. 7). An important consideration is the frequent anomalies of the structures contained between the two leaves (15–20%). The normal configuration is for an anterior cystic duct with the cystic artery situated posterosuperiorly and arising from the right hepatic artery usually behind the CBD. Fig. 7: Pledget can be used for adhesiolysis. Dissection of Cystic Pedicle (Figs. 8A to D) The dissection of the cystic pedicle can be carried out with two-handed technique. The dissection should be started with anteromedial traction by left hand grasper placed on the anterior edge of Hartmann’s pouch. The anteromedial traction by left hand will expose the posterior peritoneum. The peritoneum of the posterior leaf of the cystic pedicle is divided superficially as far back as the liver. Posterior leaf is better to dissect before anterior leaf because it is relatively less vascular and the bleeding, if any, will not soil the anterior peritoneum; whereas if anterior peritoneum is tackled first, it may make the dissection area of posterior peritoneum filled 181
SECTION 2: Laparoscopic General Surgical Procedures A B C D Figs. 8A to D: Dissection of cystic pedicle. with blood making dissection of this area difficult. Once the visceral peritoneum is dissected, a pledget mounted securely in a pledget holder is used for blunt dissection. Critical View of Safety Anterior and posterior dissection continues with alternating inferolateral and superomedial retraction of the neck until the gallbladder is dissected away from the liver, creating a “window” crossed by two structures—the cystic duct and artery. This is the “critical view of safety (CVS)” that should be achieved prior to clipping or dividing any tubular structures. There is no need to dissect down to the cystic duct–CBD junction unless the cystic duct is very short. The cystic artery should be dissected in a similar fashion. Calot’s node, or the cystic duct lymph node, is usually encountered adjacent and anterior to the artery and can be a useful landmark. The surgeon should be aware of certain anatomic variations in order to avoid misidentification of structures. A common anomaly is the right hepatic artery looping onto the infundibulum and being mistaken for the cystic artery. A short cystic duct is also seen quite frequently and could drain into the right hepatic duct, the common duct, or a low-lying aberrant right sectoral duct. In the presence of severe, acute, or chronic inflammation, or with a large stone in the neck of the gallbladder, the infundibulum may be “tethered” to the hepatic duct, which may lead the surgeon to misidentify the CBD for the cystic duct. Separation of Cystic Duct from Artery (Figs. 9A to D) Once the cystic duct is visualized, the dissector can be used to create a window in the triangle of Calot between the cystic duct and cystic artery. This window should be created high near the gallbladder-cystic duct junction to avoid injury to the common duct. The separation of the cystic duct anteriorly from the cystic artery behind can be performed by a Maryland’s grasper by gently opening the jaw of Maryland between the duct and artery. The opening of the jaw of Maryland dissector should be in the line of duct never at right angle to avoid injury of artery behind. Sufficient length of the cystic duct and artery on the gallbladder side should be mobilized so that three clips can be applied. The electrosurgical hook may be inserted into the window and hooked around the cystic duct. With an up and down movement, the hook is used to clear as much tissue as possible from the duct nearer to the cystic duct–gallbladder junction. Tissue that is not dissected free from the duct is retracted by the hook away from all structures and is divided using active cutting current. Depending on the length of the duct, it is usually not necessary to dissect it all the way down to its junction with the CBD. In a similar fashion, the hook can be used to isolate the cystic artery for a length that is adequate enough to clip it.
A B C D Figs. 9A to D: Cystic duct is separated from artery by creating a window. Clipping and Division of Cystic Artery (Figs. 10A to D) The cystic artery is clipped and then divided by harmonic scalpel (Figs. 10I and J). Two clips are placed proximally on the cystic artery and one clip is applied distally. The artery is then grasped with a duckbill grasper on the gallbladder wall and then divided between second and third clip. Clipping and Division of Cystic Duct (Figs. 10E to L) After isolating the cystic duct and artery, the clipper is introduced through the epigastric port and at least two clips are placed on the proximal side of the cystic duct. Care is taken not to place the clips too low because retraction can tent up the CBD or cause it to be obstructed. Another clip is placed on the gallbladder side of the cystic duct, leaving enough distance between the clips to divide it. In a similar fashion, clips are placed on the cystic artery, two proximally and one on the gallbladder side of the artery. The harmonic scalpel are then used through the epigastric port to divide the cystic duct and artery between the clips. Both the jaw of scissors should be under vision. Intraoperative Cholangiogram (Figs. 11A and B) In many institutions, routine intraoperative cholangiogram (IOC) is performed. Routine cholangiogram decreases the risk of CBD injury in case of difficult anatomy. If a cholangiogram is to be performed, the cystic duct is isolated and occluded with a clip, which is placed high on the duct at its junction with the gallbladder. This will avoid leakage of contents from the gallbladder when the duct is opened. The scissors are used to incise the duct. The opening in the cystic duct is made on the anterosuperior aspect. Correct alignment of the cystic duct and infusion of saline facilitates insertion of ureteric catheter to perform cholangiography. Insertion is difficult, if the opening in the cystic duct is made too close to the gallbladder. The dissector is used to spread the incision to adequately dilate it for introduction of the cholangiogram catheter. The catheter is introduced through one of the 5-mm port. It is secured by either inflating a balloon or placing a clip to hold it in place. The catheter is then flushed with saline to ensure appropriate placement. All instruments are removed and a dynamic cholangiogram with real-time fluoroscopy is performed. The contrast medium should be injected slowly during screening and the patient should be in a slight Trendelenburg’s position with the table rotated slightly to the right. It is essential that the entire biliary tract be outlined. When the cholangiogram is completed, the catheter is removed, and two clips are placed proximally on the duct. The duct is then divided. Surgeon should ligate or clip cystic duct when he is sure up to the point of absolute certainness. 183
SECTION 2: Laparoscopic General Surgical Procedures The main advantages of intraoperative cholangiography during cholecystectomy are: ■ Detection of CBD stone ■ Reduction of the incidence of residual CBD stone ■ Delineation of the biliary anatomical variations at risk for bile duct injury Intraoperative cholangiogram is a highly sensitive tool for detecting choledocholithiasis, with an overall accuracy of A B C D E F G H Figs. 10A to H
I J K L Figs. 10I to L Figs. 10A to L: Cystic duct and artery are clipped and divided. A B Figs. 11A and B: Intraoperative cholangiogram. (CBD: common bile duct; CHD: common hepatic duct) 95%. Routine intraoperative cholangiography can diagnose unsuspected CBD stone in 1–14% (average 5%) of patients without indications for ductal exploration. The failure of laparoscopic IOC is due to: ■ The narrowness of the cystic duct ■ Cystic duct rupture ■ Obstructive cystic valves ■ Impacted cystic stones ■ Dye extravasation from cystic duct perforation With increased experience, successful laparoscopic IOC can be achieved in 90–99% of cases, a rate similar to that of IOC during open cholecystectomy. Intraoperative Ultrasonography If there is any concern for choledocholithiasis (elevated bilirubin and dilated duct) or uncertain anatomy, the CBD should be imaged intraoperatively. This should occur after the first clip is placed on the cystic duct. IOC 185
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