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Acs0521 Cholecystectomy And Common Bile Duct Exploration 2009


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  • 1. © 2009 BC Decker Inc ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 21 CHOLECYSTECTOMY AND COMMON BILE DUCT EXPLORATION — 1 21 CHOLECYSTECTOMY AND COMMON BILE DUCT EXPLORATION Gerald M. Fried, MD, FRCS(C), FACS, Liane S. Feldman, MD, FRCS(C), FACS, and Dennis R. Klassen, MD, FRCS(C), FACS Cholecystectomy is the treatment of choice for symptomatic obtain certain data preoperatively. Useful information can be gallstones because it removes the organ that contributes to obtained from the patient’s history, imaging studies, and both the formation of gallstones and the complications ensuing laboratory tests. from them.1 The morbidity associated with cholecystectomy is attributable to injury to the abdominal wall in the process Preoperative Data of gaining access to the gallbladder (i.e., the incision in the History and physical examination A good medical abdominal wall and its closure) or to inadvertent injury to history provides information about associated medical surrounding structures during dissection of the gallbladder. problems that may affect the patient’s tolerance of pneumo- Efforts to diminish the morbidity of open cholecystectomy peritoneum. Patients with cardiorespiratory disease may have have led to the development of laparoscopic cholecystectomy, difficulty with the effects of CO2 pneumoperitoneum on made possible by modern optics and video technology. cardiac output, lung inflation pressure, acid-base balance, Carl Langenbuch performed the first cholecystectomy in and the ability of the lungs to eliminate CO2. Most bleeding Berlin, Germany, in 1882. Erich Mühe performed the first disorders can also be identified through the history. A disease- laparoscopic cholecystectomy in Germany in 1985,2 and by specific history is important in identifying patients in whom 1992, 90% of cholecystectomies in the United States were previous episodes of acute cholecystitis may make laparo- being performed laparoscopically. Compared with open scopic cholecystectomy more difficult, as well as those at cholecystectomy, the laparoscopic approach has dramatically increased risk for choledocholithiasis (e.g., those who have reduced hospital stay, postoperative pain, and convalescent had jaundice, pancreatitis, or cholangitis).4–9 time. However, rapid adoption of laparoscopic cholecystec- Physical examination identifies patients whose body habi- tomy as the so-called gold standard for treatment of symp- tus is likely to make laparoscopic cholecystectomy difficult tomatic gallstone disease was associated with complications, and is helpful for determining optimal trocar placement. including an increased incidence of major bile duct injuries. Abdominal examination also reveals any scars, stomas, or Since the early 1990s, considerable advances have been hernias that are likely to necessitate the use of special tech- made in instrumentation and equipment, and a great deal of niques for trocar insertion. experience with laparoscopic cholecystectomy has been Imaging studies Ultrasonography is highly operator amassed worldwide. Of particular significance is the minia- dependent, but in capable hands, it can provide very useful turization of and improvement in optics and instruments, information. It is the best test for diagnosing cholelithiasis, and which have reduced the morbidity of the procedure by making it can usually determine the size and number of stones.4 Large possible ever-smaller incisions. With proper patient selection stones indicate that a larger incision in the skin and the fascia and preparation, laparoscopic cholecystectomy is being safely will be necessary to retrieve the gallbladder. Multiple small performed on an outpatient basis in many centers.3 stones suggest that the patient is more likely to require opera- The primary goal of cholecystectomy is removal of the tive cholangiography (if a policy of selective cholangiography gallbladder with minimal risk of injury to the bile ducts and is practiced) [see Operative Technique, Step 5, below]. A surrounding structures. Our approach is designed to maxi- shrunken gallbladder, a thickened gallbladder wall, and peri- mize the safety of both routine and complicated cholecystec- cholecystic fluid on ultrasonographic examination are significant tomies. In what follows, we describe our approach and discuss predictors of conversion to open cholecystectomy. The pres- current indications and techniques for imaging and exploring ence of a dilated CBD or CBD stones preoperatively is predi- the common bile duct (CBD). ctive of choledocholithiasis. Other intra-abdominal pathologic conditions, either related to or separate from the hepatic- Laparoscopic Cholecystectomy biliary-pancreatic system, may influence operative planning. Preoperative imaging studies of the CBD may allow pre ope ra t i v e e v a l ua t i o n the surgeon to identify patients with CBD stones before To plan the surgical procedure, assess the likelihood of surgery. Such imaging may involve endoscopic retrograde conversion to open cholecystectomy, and determine which cholangiopancreatography (ERCP) [see 5:18 Gastrointestinal patients are at high risk for CBD stones, the surgeon must Endoscopy],10 magnetic resonance cholangiopancreatography DOI 10.2310/7800.S05C21 04/09
  • 2. © 2009 BC Decker Inc ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 21 CHOLECYSTECTOMY AND COMMON BILE DUCT EXPLORATION — 2 (MRCP) [see Figure 1],11,12 or endoscopic ultrasonography Selection of Patients (EUS). These imaging modalities also provide an anatomic Patients eligible for outpatient cholecystectomy map of the extrahepatic biliary tree, identifying unusual anat- Patients in good general health who have a reasonable amount omy preoperatively and helping the surgeon plan a safe oper- of support from family or friends and who do not live too far ation. Endoscopic sphincterotomy (ES) is performed during away from adequate medical facilities are eligible for outpa- ERCP if stones are identified in the CBD. MRCP has an tient cholecystectomy, especially if they are at low risk for advantage over ERCP and EUS in that it is noninvasive and conversion to laparotomy [see Special Considerations, does not make use of injected iodinated contrast solutions.11 Conversion to Laparotomy, below].3 These patients can gen- Most surgeons would probably recommend that preoperative erally be discharged home from the recovery room 6 to 12 cholangiography be performed selectively in patients with hours after surgery provided that the operation went smoothly, clinical or biochemical features associated with a high risk of their vital signs are stable, they are able to void, they can choledocholithiasis. The specific modality used in such a case manage at least a liquid diet without vomiting, and their pain varies with the technology and expertise available locally. can be controlled with oral analgesics. Laboratory tests Preoperative blood tests should include Technically challenging patients Before performing liver function, renal function, electrolyte, and coagulation laparoscopic cholecystectomy, the surgeon can often predict studies. Abnormal liver function test results may reflect cho- which patients are likely to be technically challenging. These ledocholithiasis or primary hepatic dysfunction. include patients who have a particularly unsuitable body habitus, those who are highly likely to have multiple and a dense peritoneal adhesions, and those who are likely to have distorted anatomy in the region of the gallbladder. Morbidly obese patients present specific difficulties [see Operative Technique, Step 1, Special Considerations in LHD Obese Patients, below].13 Small, muscular patients have a RHD CHD noncompliant abdominal wall, resulting in a small working space in the abdomen and necessitating high inflation pres- CBD sures to obtain reasonable exposure. Patients with a history of multiple abdominal operations, especially in the upper abdomen, and those who have a his- PD tory of peritonitis are likely to pose difficulties because of GB Stones peritoneal adhesions.14 These adhesions make access to the Duo abdomen more risky and exposure of the gallbladder more difficult. Patients who have undergone gastroduodenal sur- gery, those who have any history of acute cholecystitis, those who have a long history of recurrent gallbladder attacks, and those who have recently had severe pancreatitis are particu- larly difficult candidates for laparoscopic cholecystectomy. These patients may have dense adhesions in the region of the b gallbladder, the anatomy may be distorted, the cystic duct may be foreshortened, and the CBD may be very closely and densely adherent to the gallbladder. Such patients are a chal- RHD LHD lenge to the most experienced laparoscopic surgeon. When such problems are encountered, conversion to open cholecys- tectomy should be considered early in the operation.14,15 Acc CBD Predictors of choledocholithiasis CBD stones may be discovered preoperatively, intraoperatively, or postoperatively. PD The surgeon’s goal is to clear the ducts but to use the smallest CBD number of procedures with the lowest risk of morbidity. Thus, Stones before elective laparoscopic cholecystectomy, it is desirable to classify patients into one of three groups: high risk (those who have clinical jaundice or cholangitis, visible choledocholithiasis, GB or a dilated CBD on ultrasonography), moderate risk (those who have hyperbilirubinemia, elevated alkaline phosphatase levels, pancreatitis, or multiple small gallstones), and low risk. In our institution, where MRCP and EUS are available and Figure 1 Laparoscopic cholecystectomy. (a) and (b) reliable and where ERCP achieves stone clearance rates Preoperative magnetic resonance cholangiopancreatography higher than 90%, we recommend the following approach: alerts the surgeon to abnormal anatomy and the presence of stones in the distal common bile duct (CBD). Acc = accessory (1) preoperative ERCP and sphincterotomy (if required) for duct entering the common hepatic duct near the neck of the high-risk patients and (2) MRCP, EUS, or intraoperative gallbladder; CHD = common hepatic duct; Duo = duodenum; fluoroscopic cholangiography for moderate-risk patients. GB = gallbladder, containing stones; LHD = left hepatic duct; Patients at low risk for CBD stones do not routinely undergo PD = pancreatic duct; RHD = right hepatic duct. cholangiography [see Figure 2]. Laparoscopic CBD exploration 04/09
  • 3. © 2009 BC Decker Inc ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 21 CHOLECYSTECTOMY AND COMMON BILE DUCT EXPLORATION — 3 and postoperative ERCP appear to be equally effective in tially fills the hernia. Patients with large inguinal hernias clearing stones from the CBD. may require an external support to minimize this problem Ultimately, surgeons and institutions must establish a rea- and the discomfort related to pneumoscrotum. Patients sonable approach to choledocholithiasis that takes into with umbilical hernias can have their hernias repaired while account the expertise and equipment locally available. they are undergoing laparoscopic cholecystectomy. For Contraindications There are few absolute contraindica- such patients, the initial trocar should be placed by open tions to laparoscopic cholecystectomy. Certainly, no patient insertion according to the Hasson technique [see Operative who poses an unacceptable risk for open cholecystectomy Technique, Step 1, below], with care taken to avoid injury should be considered for laparoscopic cholecystectomy, to the contents of the hernia. The sutures required to close because it is always possible that conversion will become nec- the hernia defect can be placed before insertion of the ini- essary. Of the relative contraindications, surgical inexperience tial trocar. For patients with small incisional hernias, lap- is the most important. aroscopic cholecystectomy can proceed as usual. The hernia Neither ascites nor hernia is a contraindication to laparo- may be repaired at the same operation if the cholecystec- scopic cholecystectomy. Ascites can be drained and the tomy goes smoothly and there is no peritoneal contamina- gallbladder visualized. Large hernias may present a prob- tion. For large incisional hernias, we would proceed with lem, however, because with insufflation, the gas preferen- laparoscopic cholecystectomy, limiting adhesiolysis to that Patient is identified preoperatively as being at moderate or high risk for CBD stones Perform preoperative cholangiography Stones are detected No stones are detected Intraoperative CBD exploration (open or laparoscopic) is planned Intraoperative CBD exploration Exploration is successful Exploration is unsuccessful (open or laparoscopic) is not planned Continue with laparoscopic Perform postoperative Perform ERCP with ES cholecystectomy ERCP with ES ERCP with ES is ERCP with ES is unsuccessful successful Perform cholecystectomy and intraoperative CBD exploration (open or Proceed to laparoscopic laparoscopic) cholecystectomy Figure 2 Laparoscopic cholecystectomy. Shown is an algorithm outlining the use of preoperative cholangiography in patients at moderate or high risk for common bile duct (CBD) stones. ERCP = endoscopic retrograde cholangiopancreatography; ES = endoscopic sphincterotomy. 04/09
  • 4. © 2009 BC Decker Inc ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 21 CHOLECYSTECTOMY AND COMMON BILE DUCT EXPLORATION — 4 required to safely perform the procedure. Patients with for patients at increased risk for DVT [see 6:6 Venous Throm- stomas may also undergo laparoscopic cholecystectomy boembolism]. As yet, however, there is no convincing evidence provided that the appropriate steps are taken to prevent that the incidence of DVT is higher with laparoscopy than injury to the bowel during placement of trocars and divi- with open surgery. sion of adhesions. Patients with cirrhosis or portal hypertension are at high Patient Positioning risk for morbidity and mortality with open cholecystec- Typically, the patient is positioned supine and the surgeon tomy.16,17 If absolutely necessary, laparoscopic cholecystec- stands to the patient’s left side [see Figure 3]. tomy may be attempted by an experienced surgeon. The risk The camera operator usually stands on the patient’s left of bleeding can be minimized by rigorous preoperative prep- and to the left of the surgeon, while the assistant stands on aration, meticulous dissection with the help of magnification the patient’s right. The video monitor is positioned on the available through the laparoscope, and use of electrocautery patient’s right above the level of the costal margin. If a second and enabling hemostatic devices. monitor is available, it should be positioned on the patient’s Patients with bleeding diatheses, such as hemophilia, von left to the right of the surgeon, where the assistant can have Willebrand disease, and thrombocytopenia, may undergo an unobstructed and comfortable view. Exposure can be laparoscopic cholecystectomy. They require appropriate pre- improved by tilting the patient in the reverse Trendelenburg operative and postoperative care and monitoring, and a position and rotating the table with the patient’s right side up. hematologist should be consulted. Gravity pulls the duodenum, colon, and omentum away from Questions have been raised about whether laparoscopic the gallbladder, thereby increasing the working space avail- cholecystectomy should be performed in pregnant patients; it able in the upper abdomen. has been argued that the increased intra-abdominal pressure The operating room (OR) table should allow easy access may pose a risk to the fetus. Because of the enlarged uterus, for a fluoroscopic C arm to facilitate intraoperative cholang- open insertion of the initial trocar is mandatory, and the posi- iography. The table cover should be radiolucent. tioning of other trocars may have to be modified according Equipment to the position of the uterus. Inflation pressures should be kept as low as possible, and prophylaxis of deep vein thrombosis The equipment required for laparoscopic cholecystectomy (DVT) is recommended. Despite these potential problems, includes an optical system, an electronic insufflator, safe performance of laparoscopic cholecystectomy and other trocars (cannulas), surgical instruments, and hemostatic laparoscopic procedures in pregnant patients is increasingly devices [see Table 1]. being described in the literature. If cholecystectomy is necessary Optical system The laparoscope can provide either a before delivery, the second trimester is the best time for it.18–21 straight, end-on (0°) view or an angled (30° or 45°) view. Patients in whom preoperative imaging gives rise to a strong Scopes that provide an end-on view are easier to learn to use, suspicion of gallbladder cancer should probably undergo open surgical management. Anesthesia o p e ra t i v e pl a n n i n g Antibiotic Prophylaxis 2nd Video Monitor Some surgeons recommend routine preoperative adminis- (Optional) tration of antibiotics to all patients undergoing cholecystec- tomy, on the grounds that inadvertent entry into the gallbladder is not uncommon and can lead to spillage of bile or stones Video Monitor into the peritoneal cavity. Other surgeons do not recommend routine prophylaxis. Resolution of this controversy awaits appropriate prospective trials. We recommend selective use of Surgeon antibiotic prophylaxis for patients at highest risk for bacteria in the bile (including those with acute cholecystitis or CBD stones, those who have previously undergone instrumentation of the biliary tree, and those older than 70 years) and for Assistant patients with prosthetic heart valves and joint prostheses. Prophylaxis of DVT The reverse Trendelenburg position used during laparo- Camera Operator scopic cholecystectomy, coupled with the positive intra-abdominal pressure generated by CO2 pneumoperito- neum and the vasodilatation induced by general anesthesia, Figure 3 Laparoscopic cholecystectomy. A patient undergo- leads to venous pooling in the lower extremities. This conse- ing laparoscopic cholecystectomy should be positioned so as quence may be minimized by using antiembolic stockings or to allow easy access to the gallbladder and a clear view of the by wrapping the legs with elastic bandages. Subcutaneous monitors. Shown are the positions of the surgeon, the camera heparin and pneumatic compression devices may be employed operator, and the assistant in the operating room. 04/09
  • 5. © 2009 BC Decker Inc ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 21 CHOLECYSTECTOMY AND COMMON BILE DUCT EXPLORATION — 5 but angled scopes are more versatile. Scopes with a 30° angle space, are less subject to signal interference, and require less cause less disorientation than those with a 45° angle and are power. The introduction of high-definition optics has further ideal for laparoscopic cholecystectomy. Excellent 30° scopes improved the quality of the image. The associated 16:9 dis- are currently available in diameters of 10, 5, and 3.5 mm. play increases the width of the field of view. Fully digital flat-panel displays are now available that yield The resolution and quality of the final image depend on (1) better resolution than analog video monitors, take up less the brightness of the light source; (2) the integrity of the Table 1 Equipment for Laparoscopic Cholecystectomy Instrument/Device Number Size Comments Laparoscopic cart High-intensity halogen light source (150–300 watts) High-flow electronic insufflator (minimum flow rate of 106 L/min) Laparoscopic camera box Videocassette digital video and still image recorder (optional) Digital still image capture system (optional) Laparoscope 1 3.5–10 mm Available in 0° and angled views; we prefer to use a 30° 5 mm diameter laparoscope Atraumatic grasping forceps 2–4 2–10 mm Selection of graspers should allow surgeon choice appropriate to thickness and consistency of gallbladder wall; insulation is unnecessary Large-tooth grasping forceps 1 10 mm Used to extract gallbladder at end of procedure Curved dissector 1 2–5 mm Should have a rotatable shaft; insulation is required Scissors 2–3 2–5 mm One curved and one straight scissors with rotating shaft and insulation; additional microscissors may be helpful for incising cystic duct Clip appliers 1–2 5–10 mm Either disposable multiple clip applier or 2 manually loaded reusable single clip appliers for small and medium-to-large clips; 5 and 10 mm diameter Dissecting electrocautery hook or spatula 1 5 mm Available in various shapes according to surgeon’s preference; instrument should have channel for suction and irrigation controlled by trumpet valve(s); insulation required High-frequency electrical cord 1 Cord should be designed with appropriate connectors for electrosurgical unit and instruments being used Suction-irrigation probe 1 5–10 mm Probe should have trumpet valve controls for suction and irrigation; may be used with pump for hydrodissection 10-to-5 mm reducers 2 Allow use of 5 mm instruments in 10 mm trocar without loss of pneumoperitoneum; these are often unncessary with newer disposable trocars and may be built into some reusable trocars 5-to-3 mm reducer 1 Allows use of 2–3 mm instruments and ligating loops in 5 mm trocars Ligating loops Endoscopic needle holders 1–2 5 mm Cholangiogram clamp with catheter 1 5 mm Allow passage of catheter and clamping of catheter in cystic duct Veress needle 1 Used if initial trocar is inserted by percutaneous technique Allis or Babcock forceps 1–2 5 mm Allow atraumatic grasping of bowel or gallbladder Long spinal needle 1 14 gauge Useful for aspirating gallbladder percutaneously in cases of acute cholecystitis or hydrops Retrieval bag 1 Useful for preventing spillage of bile or stones in removal of inflamed or friable gallbladder; facilitates retrieval of spilled stones 04/09
  • 6. © 2009 BC Decker Inc ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 21 CHOLECYSTECTOMY AND COMMON BILE DUCT EXPLORATION — 6 fiberoptic cord used to convey the light; (3) clean and secure op erative techniqu e connections between the light source and the scope; (4) the quality of the laparoscope, the camera, and the monitor; and Step 1: Placement of Trocars and Accessory Ports (5) correct wiring of the components. The distal end of the Placement of initial trocar The first step in laparo- scope must be kept clean and free of condensation: bile, scopic cholecystectomy is the creation of pneumoperitoneum blood, or fat will reduce brightness and distort the image. and the insertion of an initial trocar through which the Lens fogging can be prevented by immersion in heated water laparoscope can be passed. This step is critical because com- or by antifogging solutions. plications resulting from improper placement may cause Insufflator CO2 is the preferred insufflating gas for lap- serious morbidity and death. The surgeon may use either a aroscopic procedures because it is highly soluble in water and percutaneous technique or an open technique. We prefer the does not support combustion when electrocautery is used. open technique, which eliminates the risks inherent in the The CO2 should be insufflated with an electronic pump capa- blind puncture [see Figure 4].22,23 ble of a flow rate of at least 10 L /min; most current systems Scars Patients who have previously undergone abdominal have a maximum flow rate of 20 L /min or higher. The insuf- surgery may have adhesions, both to the undersurface of the flator is connected to one of the trocars by means of a flexible abdominal wall and intra-abdominally. Adhesions to the under- tube and a stopcock. surface of the abdominal wall make access to the abdominal Trocars For cholecystectomy, at least one trocar site cavity potentially hazardous, particularly when the percutane- must be large enough to allow passage of the gallbladder and ous method is used for placement of the initial trocar. Scars any stones removed. Most surgeons prefer to use a 10/12 mm from previous operations may affect insertion of the initial trocar at the umbilicus for this purpose. The other trocars can trocar, depending on its orientation and location. If a patient range from 2 to 12 mm, depending on the size of the instru- has a scar in the lower abdomen (e.g., from a Pfannenstiel inci- ments to be placed through them. The conventional approach sion or an incision in the right lower quadrant for an appendec- is to use a 10/12 mm trocar at the operating port site and tomy), the position of the initial trocar need not be changed. If 5 mm trocars for the other instruments; however, if a 5 mm the scar is in the upper abdomen, the initial trocar may be laparoscope and a 5 mm clip applier are used, the operating inserted below the umbilicus in the midline. If there is a long port size can be reduced to 5 mm. Although 2 mm instrumen- midline scar that is impossible to avoid, careful dissection of the tation is also available, it must be remembered that, as a rule, peritoneum through a vertical incision that is somewhat longer the smaller the working port, the less versatile the instruments. than usual affords safe access to the peritoneum in most cases. In our experience, the combination of a 10 mm umbilical An alternative is to insert the initial trocar high in the trocar, a 5 mm operating port, and 2 mm ports for grasping epigastrium or in the right anterior axillary line, where bowel forceps is a good one: optical quality is maintained, little flex- adhesions are less common. The laparoscope is inserted ibility is lost with respect to selecting operating instruments, through this trocar and used to examine the undersurface of trocar size is minimized, and the cosmetic result is excellent. the old scar for a clear site near the umbilicus, where a 10 mm Hemostatic devices Hemostasis can be achieved with trocar can be placed. Previous laparoscopy, which rarely monopolar or bipolar electrocauterization. A monopolar elec- creates significant intra-abdominal adhesions, rarely necessi- trocautery can be connected to most available instruments; tates modification of trocar insertion. however, bipolar electrocauterization may eventually prove The surgeon should also consider the reason for the previous safer. With a monopolar electrocautery, depth of burn is less surgery. For example, a patient who underwent an appendec- predictable, current can be conducted through noninsulated tomy for perforated appendicitis may have had diffuse peritoni- instruments and trocars, and any area of the instrument that is tis and may have adhesions well away from the old scar. stripped of insulation may conduct current and result in a burn. Placement of accessory ports In most cases, four ports Caution is essential when the electrocautery is used near metal- are necessary. The first port is for the laparoscope; the remain- lic hemostatic clips because delayed sloughing may occur. ing ports are for grasping forceps, dissectors, and clip appli- Electrocauterization should be avoided near the CBD because ers. The precise position of the accessory ports depends on delayed bile duct injuries and leaks may occur as a result of the surgeon’s preference, the patient’s body habitus, and the sloughing from a burned area and devascularization of the duct. presence or absence of previous scars or intra-abdominal Care must be exercised when cautery is employed near the adhesions [see Figure 5]. A rigid approach to port placement bowel and when intra-abdominal adhesions are being taken is inappropriate: trocar placement determines operative down. The electrocautery can be used with a forceps, scissors, exposure, and improper placement will haunt the surgeon hooks (L or J shaped), a spatula, and other instruments. Some throughout the procedure. In some cases, a fifth trocar is cautery probes incorporate nonstick surfaces to prevent buildup required to elevate a floppy liver or to depress or retract the of eschar. The use of hand-activated cautery probes and the omentum or a bulky hepatic flexure of the colon [see Figure 5]. presence of a channel that allows suction and irrigation through Most surgeons elect to place one of the grasping forceps on the cautery probes are especially convenient. the fundus of the gallbladder through an accessory port placed More advanced energy sources and instruments are also approximately in the anterior axillary line below the level of available. Bipolar devices designed to weld tissues have proved the gallbladder. Because the level of the gallbladder varies capable of achieving superb hemostasis. Ultrasonic dissecting from patient to patient, the placement of this accessory port shears can also be used to dissect and coagulate tissues effec- should not be decided on until the gallbladder is visualized. If tively and precisely. For laparoscopic cholecystectomy, how- the gallbladder is low lying and the trocar is placed too high, ever, such advanced—and costly—devices are rarely needed. the surgeon will have difficulty achieving the appropriate angle 04/09
  • 7. © 2009 BC Decker Inc ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 21 CHOLECYSTECTOMY AND COMMON BILE DUCT EXPLORATION — 7 a b c Figure 4 Laparoscopic cholecystectomy. With the open insertion technique, the initial trocar is placed under direct vision. (a) The umbilical skin is elevated with a sharp towel clip. A curvilinear incision is made in the inferior umbilical fold. The skin flap is elevated, and the raphe leading from the dermis to the fascia is thereby exposed. (b) The fascia is grasped in the midline between forceps and elevated. The fascia and the underlying peritoneum are incised under direct vision. (c) A blunt instrument is placed into the peritoneum to ensure that the undersurface of the peritoneum is free of adhesions. The opening can be enlarged sufficiently to allow placement of a blunt 10/11 mm trocar. of retraction. As a general rule, positioning the trocar in the because its only likely function is to allow retraction of the anterior axillary line approximately halfway between the costal gallbladder. In some cases of acute cholecystitis, however, a margin and the anterosuperior iliac spine provides the appro- larger port may be preferable so that a larger grasper can be priate exposure. A 2 to 5 mm port usually suffices at this site inserted and used to hold the gallbladder without tearing it. 04/09
  • 8. © 2009 BC Decker Inc ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 21 CHOLECYSTECTOMY AND COMMON BILE DUCT EXPLORATION — 8 a 5–12 mm b Dissecting Forceps 2–5 mm and Clip Appliers Grasping Forceps 2–5 mm 5–12 mm Grasping 10–12 mm Dissecting Forceps Laparoscope 2–5 mm Forceps and Clip Grasping Appliers Forceps 10–12 mm Laparoscope Figure 5 Laparoscopic cholecystectomy. (a) and (b) are two popular options for trocar positioning and instrument placement. A second accessory port (also 2 to 5 mm) allows the sur- is within the abdominal wall than if the trocar had been geon to grasp the gallbladder in the area of the Hartmann placed perpendicularly; accordingly, the trocar is less mobile. pouch for retraction. This port is usually positioned just If the trocars are not easily rotated, the instruments placed beneath the right costal margin. Some surgeons prefer it to be through them will be difficult to manipulate smoothly. Thus, approximately at the midclavicular line; others prefer it to be in the patient with a very thick pannus, a standard-length higher and more medial, just to the right of the falciform trocar may be too short. Displacement of trocars can lead to ligament. insufflation into the abdominal wall and consequently to sub- The main operating port should be 5 or 10 mm in diam- cutaneous emphysema, which further thickens the abdominal eter so that clip appliers can be readily placed through it and wall and hinders exposure. the laparoscope can be moved to this port at the end of the To prevent such problems, special extra-length trocars procedure. The positioning of this port is determined by the designed for morbidly obese patients have been developed. It surgeon’s preference and, in particular, by the patient’s body may also be necessary to place the trocars closer to the area habitus. The optimum placement is at about the same hori- of the gallbladder to ensure that the operating instruments zontal level as the gallbladder or slightly higher so that during can reach the gallbladder. For example, the initial port may the operation, the laparoscope and the operating instrument have to be placed above the umbilicus. form an angle of about 90°. Some surgeons prefer to place In obese patients, the bulky falciform ligament and the the operative port in the midline, to the right of the falciform large omentum may adversely affect exposure. A 30° laparo- ligament; others prefer to place it to the left of the falciform scope may help the surgeon see over the omentum and the ligament, passing the trocar underneath the ligament and high-lying hepatic flexure of the colon. In some cases, it is elevating it with the trocar. useful to place a fifth port so that the surgeon can retract the Surgeons should be encouraged to use both hands when hepatic flexure downward. Fat may envelop the cystic duct performing laparoscopic cholecystectomy. One hand should and artery and the portal structures, obscuring normal ana- control the grasping forceps holding the Hartmann pouch so tomic landmarks. When the electrocautery is used, the heat that the gallbladder can be moved to provide the best possible melts the fat and causes it to sizzle and spray onto the lens exposure. The other hand should control the dissecting of the laparoscope, resulting in a blurry image. To prevent instruments placed through the operating port. this, the camera operator should pull the scope slightly away Special considerations in obese patients Port place- from the operative field during electrocauterization and then ment in obese patients may be complicated by the thick advance the scope during dissection. This should also be abdominal wall, the large amount of intra-abdominal fat, or done when an ultrasonic dissector is being used. both. A thick abdominal wall makes it more difficult to rotate Given that obese patients are more difficult candidates for the trocar around the normal fulcrum point in the abdominal open cholecystectomy and have a higher complication rate wall. Consequently, the trocar must be placed at the angle with laparotomy, the advantages of laparoscopic cholecystec- most likely to be used during the procedure. When a trocar tomy in these individuals justify the effort needed to over- is tunneled through the abdominal wall, more of the cannula come the technical problems. 04/09
  • 9. © 2009 BC Decker Inc ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 21 CHOLECYSTECTOMY AND COMMON BILE DUCT EXPLORATION — 9 Step 2: Exposure of the Gallbladder and Calot Triangle Dissection of adhesions Adhesions must be dissected to provide an unimpeded view of the gallbladder through the laparoscope. Not all intra-abdominal adhesions must be taken down, just enough to allow entry of accessory trocars under direct vision and thus permit access to the gallbladder. This process is facilitated by pneumoperitoneum, which provides traction on adhesions to the abdominal wall, and by the mag- nification provided by the optical system, which allows iden- tification of the avascular plane of attachment. Duodenum The most difficult problem is positioning the dissecting instruments so that they can reach the undersurface of the anterior abdominal wall. A rigid trocar inserted through the anterior abdominal wall cannot be rotated enough to allow scissors passed through this port to cut adhesions to the ante- rior abdominal wall. In such cases, one or two trocars should be placed laterally, near the anterior axillary or midaxillary line. Instruments passed through these ports can easily be Figure 6 Laparoscopic cholecystectomy. Adhesions of the angled parallel to the anterior abdominal wall, and the adhe- duodenum and omentum to the gallbladder wall obscure the sions can then be dissected without difficulty. view of structures of the Calot triangle. Bowel adhesions should be taken down with endoscopic scissors at their insertion to the abdominal wall, where they are least vascular. Electrocauterization, which is generally unnecessary, should be avoided because of the risk of thermal injury to the bowel. Interloop adhesions, which rarely inter- fere with exposure of the gallbladder, need not be dissected. CBD Frequently, adhesions to the gallbladder occur as a reaction CD to inflammatory attacks [see Figure 6]. They are usually rela- tively avascular. Dissection of these adhesions should begin at the fundus of the gallbladder and should then proceed down toward the neck of the gallbladder. The best way to take them down is to grasp the gallbladder with one grasping HP forceps at the site where the adhesions attach and gradually place traction on the adhesions with the other hand. Usually, the adhesions peel down in an avascular plane. Dissection should continue until all adhesions to the inferolateral aspect of the gallbladder have been taken down. It is not necessary to divide adhesions between the superior surface of the liver and the undersurface of the diaphragm unless they impede superior retraction of the liver. Figure 7 Laparoscopic cholecystectomy. Initial view of the Exposing the Calot triangle Obtaining adequate expo- gallbladder and related structures is facilitated by appropriate tilting of the operating table. The Hartmann pouch (HP), sure of the Calot triangle is a key step. First, the patient is cystic duct (CD), and common bile duct (CBD) can be readily placed in a reverse Trendelenburg position, with the table identified before any dissection. rotated toward the left side. Next, the fundus of the gallblad- der and the right lobe of the liver are elevated toward the patient’s right shoulder. One grasping forceps, inserted patients, retraction of the fundus is difficult, and exposure of through the most lateral right-side port and held by an assis- the Calot triangle is unsatisfactory. This problem is best tant, is placed on the fundus of the gallbladder [see Figure 7], managed by aspirating the contents of the gallbladder either and the gallbladder is retracted superiorly and laterally above percutaneously with a 14- or 16-gauge needle inserted into the right hepatic lobe. This maneuver straightens out folds in the fundus of the gallbladder under laparoscopic vision or by the body of the gallbladder and permits initial visualization of using the 5 mm trocar in the right upper abdomen to punc- the area of the Calot triangle. If the Calot triangle is still ture the fundus and then aspirate with the suction irrigator. obscured, the patient can be placed in a steeper reverse Tren- After the needle is withdrawn, a large atraumatic grasping delenburg position, and the stomach can be emptied of air via forceps can be used to hold the gallbladder and occlude the an orogastric tube inserted by the anesthetist, or, if necessary, hole; a 10 mm forceps may be preferred if the wall is mark- a fifth trocar can be inserted on the patient’s right side to edly thickened. An alternative is to place a stitch or a ligating push down the duodenum. loop around the fundus of the collapsed gallbladder; the tail In some patients, such as those with acute cholecystitis and of the suture can then be grasped with a forceps to achieve a hydrops of the gallbladder, the gallbladder is tense and dis- secure grip and prevent further leakage of gallbladder contents tended, making it difficult to grasp and easy to tear. In these from the needle hole. 04/09
  • 10. © 2009 BC Decker Inc ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 21 CHOLECYSTECTOMY AND COMMON BILE DUCT EXPLORATION — 10 Once the fundus of the gallbladder is retracted superiorly forceps, or a curved dissector, is used to dislodge the stone and by the assistant, the surgeon places a grasping forceps in the milk it up toward the fundus; with the same forceps or another area of the Hartmann pouch. Using both hands, the surgeon large grasper, the stone is held up and away from the neck of controls the grasper on the Hartmann pouch and the operat- the gallbladder, and appropriate retraction is provided. ing instrument. The surgeon maneuvers the Hartmann pouch If the stone cannot be disimpacted, an instrument can be to provide various angles for safe dissection of the Calot tri- used to elevate the infundibulum of the gallbladder superi- angle. Initially, lateral and inferior traction are placed on the orly, allowing exposure of the Calot triangle. Alternatively, Hartmann pouch, opening up the angle between the cystic one can attempt to crush the stone, but small pieces of the duct and the common ducts [see Figure 8], avoiding their stone may fall into the cystic duct. A third option is to place alignment [see Figure 9]. a stitch in the Hartmann pouch and grasp the end of the A large stone impacted in the gallbladder neck may impede stitch to provide exposure. the surgeon’s ability to place the forceps on the Hartmann pouch. This problem can usually be managed by dislodging the Step 3: Stripping of the Peritoneum stone early in the operation, as follows: the gallbladder is grasped The key to avoiding injury to the major ducts during as low as possible with one grasping forceps; a widely opening laparoscopic cholecystectomy is accurate identification of dissecting instrument, such as a right-angle dissector, a Babcock the junction between the gallbladder and the cystic duct [see Figure 10]. Unless the gallbladder–cystic duct junction is immediately obvious on examination of the Calot triangle anteriorly, our approach is to begin dissection of the Calot triangle posteriorly [see Figure 11]. From this approach, the CHD insertion of the gallbladder neck into the cystic duct is usually more clearly identified, especially with the aid of a 30° laparoscope. Exposure is obtained by retracting the Hart- mann pouch superomedially and is facilitated by looking from below with a 30° scope. Dissection should always start high on the gallbladder and hug the gallbladder closely until the anatomy is identified CD clearly. Using a curved dissector, the surgeon gently teases away peritoneum attaching the neck of the gallbladder to the CBD liver posterolaterally to visualize the funneling of the neck of the gallbladder into the cystic duct [see Figure 12]. Only the posterior layer of peritoneum is dissected; care must be taken not to dissect deeply in this area because of the risk of injury to the cystic artery [see Figure 13]. Figure 8 Laparoscopic cholecystectomy. The area of the In some problem cases, edema, fibrosis, and adhesions Hartmann pouch is retracted laterally. The cystic duct (CD) make identification of the gallbladder–cystic duct junction is seen at an angle to the common hepatic duct (CHD) and very difficult. An anatomic landmark on the liver known the common bile duct (CBD). as the Rouvier sulcus may be helpful in such circumstances [see Figure 11]. This sulcus, or the remnant of it, is present in CD CBD GB-CD Junction Figure 9 Laparoscopic cholecystectomy. In this case, the gallbladder is retracted cephalad. The cystic duct (CD) can be seen running in the same direction as the common bile duct Figure 10 Laparoscopic cholecystectomy. The gallbladder– (CBD). The CBD may be misinterpreted as being the cystic cystic duct (GB-CD) junction is clearly seen. This should be duct and consequently is at risk for injury. dissected circumferentially, allowing a 360° view. 04/09
  • 11. © 2009 BC Decker Inc ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 21 CHOLECYSTECTOMY AND COMMON BILE DUCT EXPLORATION — 11 Figure 13 Laparoscopic cholecystectomy. Arterial bleeding can be seen (arrow) from a branch of the cystic artery injured during dissection from the posterior approach. Figure 11 Laparoscopic cholecystectomy. A view from below with a 30° laparoscope demonstrates the point for beginning dissection (arrow), where the gallbladder funnels down to its junction with the cystic duct. Just below this point can be seen a cleft in the liver known as the Rouvier sulcus. This cleft, present in 70 to 80% of livers, reliably indicates the plane of the common bile duct. Figure 14 Laparoscopic cholecystectomy. The superior border of the cystic duct has been dissected. Funneling of the gallbladder into the cystic duct is clearly seen (arrow). Figure 12 Laparoscopic cholecystectomy. The peritoneum is the surgeon’s movement between the posterior and anterior dissected from the gallbladder–cystic duct junction (arrow), as seen from below through a 30° angled laparoscope. aspects of the Calot triangle, providing complete visualiza- tion. Dissection should always take place at the gallbladder– cystic duct junction, staying close to the gallbladder to avoid 70 to 80% of livers and usually contains the right portal triad inadvertent injury to the CBD. A curved dissecting forceps is or its branches. Its location is consistently to the right of the used to strip the fibroareolar tissue just superior to the cystic hepatic hilum and anterior to the caudate process (Couinaud duct. The superior border of the cystic duct can then be iden- segment 1). This landmark reliably indicates the plane of the tified and the cystic duct gently and gradually dissected CBD. Therefore, dissection dorsal to it should be done with [see Figure 14]. The cystic duct lymph node is a useful land- caution. Once the funneling of the gallbladder into the cystic mark at this location and may facilitate identification of the duct has been identified, the area of the Hartmann pouch gallbladder–cystic duct junction. should be again pulled laterally and inferiorly so that the When traction is placed as described, the cystic artery tends anterior peritoneum can be dissected while the 30° scope is to run parallel and somewhat cephalad to the cystic duct. angled to view the area. The two-handed technique facilitates This artery can often be identified by noting its close relation 04/09
  • 12. © 2009 BC Decker Inc ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 21 CHOLECYSTECTOMY AND COMMON BILE DUCT EXPLORATION — 12 to the cystic duct lymph node. Complete dissection of the completely to ensure that the clips are secure and that there area between the cystic duct and the artery develops a window is no pulsatile bleeding. Once the artery is completely divided, through which the liver should be visible. The cystic duct is the proximal end will retract medially, making it more diffi- then encircled with a curved dissecting instrument or an cult to expose and control the artery safely if bleeding occurs. L-shaped hook. Downward traction should be applied to the Electrocauterization should be avoided near the cystic duct cystic duct to open this window and ensure that there is no and all metallic clips. Electric current will be conducted ductal structure running through this space in the Calot through metallic clips and may result in delayed sloughing of triangle to join the cystic duct (i.e., the right hepatic duct). the duct or a clip. Delayed injuries to the CBD may be caused Dissection of the Calot triangle should be completed before by a direct burn to the duct or by sparking from noninsulated the cystic duct is clipped or divided. This is best accom- instruments or clips during dissection. An alternative is to use plished by dissecting the neck of the gallbladder from the liver locking polymer clips that fit through 5 mm ports, clip across bed. Unequivocal identification of the gallbladder–cystic duct a greater width of tissue, and do not conduct electricity. junction is imperative.24,25 The cystic duct should be dissected Control of the short or wide cystic duct Edema and for a length sufficient to permit secure placement of two clips; acute inflammation may lead to thickening and foreshortening it is not necessary, and indeed may be hazardous, to attempt of the cystic duct, with subsequent difficulties in dissection and to dissect the cystic duct–CBD junction. ligation. If the duct is edematous, clips may cut through it; if The cystic artery is exposed next [see Figure 15]. A small the duct is too wide, the clip may not occlude it completely. A vein can usually be identified in the space between the cystic modified clipping technique can be employed, with placement duct and the cystic artery; it can usually be pulled up anteri- of an initial clip to occlude as much of the duct as possible. The orly and cauterized. Because dissection is done near the gall- occluded portion of the duct is then incised, and a second clip bladder, it is not unusual to encounter more than one branch is placed flush with the first so as to occlude the rest of the of the cystic artery. Each of these branches should be dis- duct. Alternatively, wider polymer clips may be used. sected free of the fibroareolar tissue. Care should also be taken Because this technique is not always possible, the surgeon to ensure that the right hepatic artery is not inadvertently should be familiar with techniques for ligating the duct with injured as a result of being mistaken for the cystic artery. either intracorporeal or extracorporeal ties. It is extremely helpful to know how to tie extracorporeal ties so that the Step 4: Control and Division of the Cystic Duct and cystic duct can be ligated in continuity before it is divided. In Cystic Artery some cases, the duct can be divided, held with a forceps, and At this point, the cystic duct is clipped on the gallbladder controlled with a ligating loop. If there is concern about side, and a cholangiogram is obtained if desired [see Step 5, secure closure of the cystic duct, a closed suction drain may below]. If a cholangiogram is not desired, three or four clips be placed. If inflammation, as in cholecystitis, has caused the should be placed on the cystic duct and the cystic duct duct to be shorter than usual, dissection must be kept close divided between them. Two or three hemostatic clips are to the gallbladder to avoid inadvertent injury to the CBD. placed on the cystic artery, and the vessel is divided. It is A short cystic duct is often associated with acute cholecystitis. prudent to incise the artery partially before transecting it Patient blunt dissection with the suction-irrigation device may be the safest technique. Cystic duct stones Stones in the cystic duct may be visu- alized or felt during laparoscopic cholecystectomy. Every effort should be made to milk them into the gallbladder before apply- ing clips. Placing a clip across a stone may push a fragment of the stone into the CBD and will increase the risk that the clip will become displaced, leading to a bile leak. If the stone cannot be milked into the gallbladder, a small incision can be made in the cystic duct (as is done for cholangiography), and the stone can often be expressed and retrieved. Given that cystic duct stones are predictive of CBD stones, cholangiogra- CA phy or intraoperative ultrasonography is indicated.26 Step 5: Intraoperative Cholangiography Whether intraoperative cholangiography should be per- formed routinely is still controversial. Advocates believe that GB CD this technique enhances understanding of the biliary anat- omy, thus reducing the risk of bile duct injury27,28; at present, however, there are no objective data to confirm this impres- sion. Cholangiography is not a substitute for meticulous dis- section, and injuries to the CBD can occur before cystic duct dissection reaches the point at which cholangiography can be Figure 15 Laparoscopic cholecystectomy. Dissection of the performed. Catheter-induced injuries and perforations of the Calot triangle further exposes the cystic duct (CD) and the biliary tree have been reported, and cholangiograms have cystic artery (CA) near their entry into the gallbladder (GB) been misinterpreted. On the other hand, one of the main in preparation for clipping and division. advantages of cholangiography is that injuries can be 04/09
  • 13. © 2009 BC Decker Inc ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 21 CHOLECYSTECTOMY AND COMMON BILE DUCT EXPLORATION — 13 recognized during the operation and promptly repaired. The cannulas and operating instruments should be posi- Another advantage of routine cholangiography is that it helps tioned so as not to obstruct the view of the biliary tree. If the develop the skills required for more complex biliary tract pro- cannulas cannot be positioned outside the x-ray window, cedures, such as transcystic CBD exploration. radiolucent cannulas should be used, or the cannulas should The two methods of laparoscopic cholangiography differ be removed and replaced after the cholangiogram. A cholan- in their technique for introducing the cholangiogram catheter giogram that does not visualize the biliary tree from the liver into the cystic duct. In both approaches, a clip is placed at to the duodenum is inadequate. the gallbladder–cystic duct junction and a small incision is Fluoroscopic cholangiography [see Figure 17 ] may be per- made in the anterior wall of the cystic duct. In the first tech- formed either with hard-copy film or with digital imaging and nique, a specially designed 5 mm cholangiogram clamp (the storage. After the C arm is positioned, with the operating staff Olsen clamp) with a 5 French catheter is inserted via a sub- protected behind a lead screen, full-strength contrast is slowly costal trocar. For easy guidance of the catheter into the inci- injected under fluoroscopic control. The goal is to visualize sion in the cystic duct, the catheter should be parallel, rather the biliary tree in its entirety, including the right and left than perpendicular, to the cystic duct. This angle is facili- hepatic ductal systems as well as the distal duct. Once the tated by placing the subcostal port directly below the costal cholangiogram is obtained, the catheter is removed, and the margin, near the anterior axillary line. A fifth trocar may cystic duct is double-clipped and transected. occasionally be needed if exposure is lost when one of the Laparoscopic ultrasonography Evaluation of the biliary grasping forceps is removed to allow passage of the cholang- tree with intraoperative laparoscopic ultrasonography appears iogram clamp. The clamp and the catheter are then brought to be as accurate as intraoperative fluorocholangiography to the cystic duct under direct vision, and the catheter is in identifying biliary stones.28,29 This modality has several steered into the duct [see Figure 16]. The clamp is then advantages over conventional cholangiography: it does not closed, holding the catheter in position and sealing the duct expose patients and staff to radiation; contrast agents are to avoid extravasation of dye. unnecessary; there is no need to cannulate the cystic duct; In the second method, the cholangiogram catheter is intro- significantly less time is required; the capital cost of most duced percutaneously through a 12- to 14-gauge catheter, ultrasound units is less than that of fluoroscopic equipment; inserted subcostally as described (see above). The surgeon then and disposable cholangiogram catheters are not needed. grasps the cholangiogram catheter and directs it into the cystic Most of the laparoscopic ultrasound devices in use at pres- duct. A hemostatic clip is applied to secure the catheter in ent are 7.5 MHz linear-array rigid probes 10 mm in diameter. place. If passage of the catheter into the cystic duct is prevented Flexible probes capable of multiple frequencies are also avail- by the Heister valve, a guide wire can be passed initially. able, and it is likely that future probes will be increasingly If the cystic duct is tiny and cannulation is expected to be versatile. The probe is inserted through a 10/12 mm port difficult or impossible, the gallbladder can be punctured, bile (usually a periumbilical or epigastric port) and placed directly aspirated, and contrast material injected through the gallblad- on the porta hepatis, perpendicular to the structures of the der until the biliary tree is filled. hepatoduodenal ligament. The probe is then moved to the cystic duct–CBD junction. The transverse image obtained Catheter Cystic Duct Figure 16 Laparoscopic cholecystectomy. The cystic duct has been clipped, a small incision has been made for placement of the cholangiogram catheter, and the catheter has been advanced through the specialized cholangiogram Figure 17 Laparoscopic cholecystectomy. Shown is a normal clamp into the cystic duct. intraoperative cholangiogram. 04/09
  • 14. © 2009 BC Decker Inc ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 21 CHOLECYSTECTOMY AND COMMON BILE DUCT EXPLORATION — 14 should show the three tubular structures of the hepatoduode- facilitates this dissection. It is sometimes helpful to apply nal ligament in the so-called “Mickey Mouse head” configu- downward and lateral traction on the forceps grasping the ration: the CBD, the portal vein, and the hepatic artery fundus. Bleeding during this stage generally indicates that the [see Figure 18]. As the probe is moved distally, it is rotated surgeon has entered the wrong plane and dissection has clockwise to allow identification of the distal CBD and the entered the liver. Bleeding can usually be readily controlled pancreatic duct where they unite at the papilla. Instillation of with the electrocautery. In some difficult cases (e.g., an saline into the right upper quadrant can enhance acoustic intrahepatic gallbladder), it may be prudent to leave some of coupling and improve visualization. the posterior wall of the gallbladder in situ and cauterize it Because of its many advantages, intraoperative laparoscopic rather than persist with an excessively bloody dissection.16 ultrasonography may eventually replace fluorocholangiogra- Dissection continues until the gallbladder is attached only phy in this setting, particularly for surgeons who practice rou- by a small piece of peritoneum at the fundus. Before the last tine intraoperative evaluation of the CBD.30 Although the attachment to the gallbladder is completely divided, the vital learning curve for effective performance of laparoscopic ultra- clips are reinspected to ensure that they have not slipped off, sound examination is not long, surgeons should receive expert and the operative field is checked for hemostasis and the pres- mentoring and formal instruction in ultrasonography before ence of any bile leakage. The final attachment to the gallblad- attempting it. During the first few attempts, it may be instruc- der is then divided. The gallbladder is placed over the right tive to perform intraoperative laparoscopic ultrasonography lobe of the liver and laterally so that it can be found again to in conjunction with fluorocholangiography. It should be be retrieved. The grasping forceps on the gallbladder should emphasized that intraoperative laparoscopic ultrasonography not be removed. is not a replacement for intraoperative cholangiography if the Perforation of the gallbladder The gallbladder may be purpose of the examination is to define an anomalous anat- accidentally breached at some point in the operation, with the omy or to evaluate a suspected injury or leak. result that bile and stones spill into the peritoneal cavity.31,32 Efforts should be made to suction the spilled bile, which Step 6: Dissection of the Gallbladder from the Liver Bed accumulates in the suprahepatic space, the right subhepatic The gallbladder is grasped near the cystic duct insertion space, and the lower abdomen because of the patient’s posi- and pulled down toward the right anterosuperior iliac spine, tion. Each of these areas should be irrigated and the effluent placing the areolar tissue between the gallbladder and liver aspirated until it is clear. Stones should be located and anteriorly under tension. The areolar tissue is cauterized with removed whenever possible. An effective way of removing an L-shaped hook dissector or spatula, and dissection is car- small stones is to irrigate the subhepatic space copiously. ried upward as far as possible for as long as there is sufficient Cholesterol stones usually float on the irrigation fluid and can exposure. When exposure begins to diminish, the cystic duct then be suctioned through a 10 mm suction probe or through end of the gallbladder should be pulled up toward or over the a 32 French chest tube passed through the 10 mm operating left lobe of the liver to expose the posteroinferior attachments port. Unfortunately, small stones may be lost in the omentum of the gallbladder. A two-handed approach by the surgeon or between bowel loops. In such cases, it is probably appro- priate to leave the stones within the peritoneum rather than perform a laparotomy to attempt to retrieve them. However, there have been reports of serious morbidity, including intra-abdominal abscess, fistula, empyema, and bowel obstruction, resulting from lost stones. If the gallbladder is perforated and it seems likely that Common CBD Hepatic multiple stones will be spilled, the surgeon should introduce Artery a sterile bag into the peritoneal cavity, placing it close to the perforation. Spilled stones can then be transferred immediately into the bag. After the gallbladder is removed from the liver Portal Vein bed, it, too, is placed in the bag, affording some protection to the wound when it is removed from the abdominal cavity. Step 7: Extraction of the Gallbladder The laparoscope is moved to the epigastric port, and a large-tooth grasping forceps is inserted through the umbilical port to grasp the gallbladder at the area of the cystic duct. Under direct vision, the gallbladder is then retrieved and pulled out as far as possible through the umbilical port. If the gallbladder is small enough, it can be drawn right into the trocar sleeve, and it and the trocar can then be removed together. It is sometimes necessary to stretch the fascial Figure 18 Laparoscopic cholecystectomy. A transverse opening with a Kelly clamp or to aspirate bile from the gall- intraoperative ultrasound scan of the hepatoduodenal bladder. It is far preferable to enlarge the incision than to ligament reveals a typical “Mickey Mouse head” appearance. have stones or bile spill into the abdominal cavity from a Visible are the common bile duct (CBD), the common hepatic ripped gallbladder. Enlargement of this incision is easier if artery, and the portal vein. initial access was obtained via the Hasson technique. All of 04/09
  • 15. © 2009 BC Decker Inc ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 21 CHOLECYSTECTOMY AND COMMON BILE DUCT EXPLORATION — 15 the other ports are then removed from the abdominal wall Trocar injury Trocar injury to blood vessels or bowel is under direct vision to ensure that there is no bleeding. All much more dangerous than Veress needle injury to the same residual CO2 should be removed to prevent postoperative structures. Major vascular injuries virtually never occur when shoulder pain. The fascial opening at the umbilicus should be trocars are placed under direct vision; however, they remain sutured closed to prevent subsequent herniation, and all skin a potentially lethal—although rare—complication of percuta- incisions should be closed. neous trocar insertion. If active bleeding follows removal Need for drainage The decision to place a drain after of the trocar from the cannula, prompt laparotomy is laparoscopic cholecystectomy should be governed by the mandatory; if bleeding passes unnoticed and insufflation same principles applied to patients undergoing open chole- begins, massive air embolism will result. At the time of lapa- cystectomy. There are two main indications for drainage: (1) rotomy, both the anterior and the posterior wall of the vessel the cystic duct was not closed securely, and (2) the CBD was must be examined after proximal and distal control of the explored by either a direct or a transcystic approach. vessel have been obtained. Drain placement is easily accomplished. A closed suction Bowel injuries can result from either percutaneous or open drain is inserted intra-abdominally through the 10 mm insertion of the initial trocar. With open insertion, the bowel operative port. A grasping forceps placed through the right injury should be immediately obvious and can be repaired lateral port is used to pull one end of the drain out through after the injured bowel is pulled through an enlarged umbili- the abdominal wall. The other end is then positioned cal incision; laparoscopic cholecystectomy can then proceed. according to the surgeon’s preference, usually in the subhe- Bowel injuries caused by percutaneous insertion may occur patic space. even in the absence of abdominal wall adhesions and can be managed in the same way as those caused by open insertion. compl ica t i o n s The one caveat is that it is possible to spear the bowel in a through-and-through fashion so that when the laparoscope is Intraoperative Complications inserted through the trocar, the view is normal and the injury Veress needle injury A syringe must always be attached is not recognized. This type of injury can be diagnosed only to the Veress needle, and fluid must be aspirated before insuf- if the laparoscope is repositioned to the operating port at flation is initiated: failure to do so may lead to insufflation some time during the procedure and the undersurface of the into a vessel and consequently to massive gas embolism. umbilical site is carefully examined. This step is mandatory If the aspirate from the syringe attached to the Veress needle during the course of the operation, preferably early. contains copious amounts of blood, a major vascular injury Bleeding Abdominal wall Bleeding from the abdominal may have occurred, and immediate laparotomy is indicated. wall can usually be prevented by careful trocar placement. Because the problem at this point is a needle injury, it can The abdominal wall should be transilluminated before percu- usually be repaired easily and without serious sequelae. taneous trocar insertion and the larger vessels avoided. If a Puncture of the bowel by a Veress needle is usually signaled vessel is speared, the cannula usually tamponades the bleed- by aspiration of bowel contents through the needle. If this ing reasonably effectively during the procedure. occurs, the needle should be withdrawn and the approximate Once the procedure is completed, each trocar is removed course and direction of the puncture remembered. The initial under direct vision. If bleeding follows the removal of a trocar should then be inserted by means of the open tech- trocar, the puncture hole can be occluded with digital pressure nique, under direct vision, to ensure that the undersurface of to maintain pneumoperitoneum and the bleeding controlled the abdominal wall is free of adherent bowel. Once pneumo- by cauterization or suture repair. Alternatively, the surgeon peritoneum is created, careful examination of the abdomen may place a Foley catheter through the trocar site with a through the laparoscope is undertaken. In most cases, either stylet, inflate the balloon, and place traction on the catheter further leakage of bowel contents, staining of the serosal sur- for 4 to 6 hours; however, tissue ischemia can make this tech- face with bowel contents, or an ecchymosis on the serosal nique quite painful. surface of the bowel helps the surgeon locate the site of the Omental or mesenteric adhesions Generally, omental adhe- bowel injury. If ecchymosis is present without spillage of sions can be bluntly teased from their attachments to the gall- bowel contents, the bowel loop should be marked with a bladder, with the plane of dissection kept close to the suture and reinspected at the end of the procedure. If ongo- gallbladder, where the adhesions are less vascular. Adhesions ing leakage of bowel contents is noted, the injured loop of to the liver should be taken down with the electrocautery to bowel can be either repaired by means of laparoscopic sutur- prevent capsular tears. Persistent bleeding from omental ing or grasped with an atraumatic forceps and gently with- adhesions is unusual but can be managed by means of elec- drawn through an enlarged umbilical incision for suture trocauterization (with care taken to avoid damage to the duo- repair. The bowel is returned to the peritoneal cavity, and the denum or colon) or the application of hemostatic clips or a laparoscopic cholecystectomy is completed. pretied ligating loop. Improper placement of the Veress needle into the omen- Cystic artery branch Arterial bleeding encountered during tum, the retroperitoneum, or the preperitoneal space may be dissection in the Calot triangle is usually from loss of control signaled by high inflation pressures, uneven distribution of of the cystic artery or one of its branches. Biliary surgeons the gas on percussion, or marked subcutaneous emphysema. must be aware of the many anatomic variations in the vascu- If such misplacement goes unrecognized, creation of a safe lature of the gallbladder and the liver. Because the main cystic intraperitoneal space is impossible, and subsequent blind artery frequently branches, it is common to find more than insertion of the trocar may result in injury to an intraperito- one artery if dissection is maintained close to the gallbladder. neal structure. If what seems to be the main cystic artery is small, a posterior 04/09
  • 16. © 2009 BC Decker Inc ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 21 CHOLECYSTECTOMY AND COMMON BILE DUCT EXPLORATION — 16 Patient has severe abdominal pain, has high or prolonged fever, experiences ileus, or becomes jaundiced Perform abdominal ultrasonography No fluid collection is seen Perform 99mTc-HIDA scan Scan is normal Scan Is abnormal Observe patient Perform cholangigraphy Figure 19 Laparoscopic cholecystectomy. Shown is an algorithm outlining a screening approach that is often useful when the patient shows signs (e.g., pain, fever, or ileus) that are suggestive of a postoperative intra-abdominal complication, such as fluid collection or bile leakage. ERCP = endoscopic retrograde cholangiopancreatography; MRCP = magnetic resonance cholangiopancreatography. cystic artery may be present and may have to be clipped to apply pressure to the bleeding vessel. Conversion to open during the dissection. cholecystectomy is indicated whenever bleeding cannot be Prevention of arterial bleeding begins by dissecting the promptly controlled laparoscopically. artery carefully and completely before clipping and by inspect- Liver bed Bleeding from the liver bed may be encountered ing the clips to ensure that they are placed completely across when the wrong plane is developed during dissection of the the artery without incorporating additional tissue (e.g., a pos- gallbladder. Patients who have portal hypertension, cirrhosis, terior cystic artery or right hepatic artery). When arterial or coagulation disorders are at particularly high risk. Control bleeding is encountered, it is essential to maintain adequate of bleeding requires good exposure, accomplished via lateral exposure and to avoid blind application of hemostatic clips or and superior retraction of the gallbladder; hence, bleeding is cauterization. The laparoscope should be withdrawn slightly most easily controlled before the gallbladder is detached from so that the lens is not spattered with blood. The surgeon the liver bed. Most liver bed bleeding can be controlled with should then pass an atraumatic grasping forceps through a the electrocautery, and it should be controlled as it is encoun- port other than the operating port and attempt to grasp the tered to allow exposure of the specific bleeding site. Either a bleeding vessel. An additional trocar may have to be inserted hook-shaped or a spatula-shaped coagulation electrode is for simultaneous suction-irrigation. Once proximal control is effective. If oozing continues, oxidized cellulose can be placed obtained, the operative field should be suctioned and irri- as a pack through the operative port and pressure applied on gated to improve exposure. Hemostatic clips are then applied the raw surface of the liver. If needed, fibrin glue can be under direct vision; in addition, a sponge may be introduced applied to the bleeding raw surface. 04/09
  • 17. © 2009 BC Decker Inc ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 21 CHOLECYSTECTOMY AND COMMON BILE DUCT EXPLORATION — 17 Fluid collection is seen Aspirate fluid Fluid is enteric contents Fluid is bile Fluid is blood Perform immediate Perform percutaneous Observe patient laparotomy drainage Patient is ill Patient is stable Perform immediate Perform MRCP or ERCP laparotomy to delineate biliary anatomy Postoperative Complications be performed to identify the site of bile leakage, determine If a patient (1) complains of a great deal of abdominal pain whether obstruction is also present, and assess the integrity of necessitating systemic narcotics, (2) has a high or prolonged the extrahepatic biliary tree. If the bile ducts are in continuity fever, (3) experiences ileus, or (4) becomes jaundiced, an intra- and the bile is coming from the cystic duct stump or a small abdominal complication may have occurred. Blood should be lateral tear in the bile duct, ES, with or without stenting, drawn for assessment of the white blood cell count, hemoglo- usually controls the leak. Percutaneous placement of a drain bin concentration, liver function, and serum amylase level. under ultrasonographic guidance allows control of the bile Abdominal ultrasonography may help diagnose dilated intra- leakage and measurement of the quantity of fluid present. hepatic ducts and subhepatic fluid collections [see Figure 19]. Fever Postoperative fever is a common complication of Fluid collection or bile leakage When a significant fluid laparoscopic cholecystectomy. As noted, it may be indicative collection is seen, it should be aspirated percutaneously under of a complication such as bile collection or bile leakage. Other ultrasonographic guidance. If the fluid is blood and the patient common reasons for postoperative fever (e.g., atelectasis) is hemodynamically stable and requires no transfusion, obser- should also be considered. vation of the patient and culture of the fluid are usually suffi- Abnormal liver function When postoperative blood cient. If the fluid is enteric contents, immediate laparotomy is tests indicate significantly abnormal liver function, possible indicated. If the fluid is bile and the patient is ill, immediate causes include injury to the biliary tree and retained CBD laparotomy should be considered; if the patient is stable and stones [see Figure 20].33 Cholangiography is required, even if the appropriate facilities are available, MRCP or ERCP may it was performed intraoperatively. If MRCP or ERCP yields 04/09
  • 18. © 2009 BC Decker Inc ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 21 CHOLECYSTECTOMY AND COMMON BILE DUCT EXPLORATION — 18 Postoperative liver function tests yield abnormal results Perform ERCP to detect biliary tree injury or retained CBD stones ERCP yields ERCP reveals ERCP reveals normal results presence of CBD leakage of bile stones Observe patient Determine whether Perform ES CBD is in continuity Duct is completely ERCP yields interrupted or lacks normal results continuity Perform percutaneous drainage Reoperate at an early in conjunction with ES or stage endoscopic stenting. Remove any retained stones Figure 20 Laparoscopic cholecystectomy. Shown is an algorithm outlining an approach to abnormal liver function test results after laparoscopic cholecystectomy. CBD = common bile duct; ERCP = endoscopic retrograde cholangiopancreatography; ES = endoscopic sphincterotomy. normal results, observation is sufficient; the abnormalities s p ecial cons iderations may be attributable to a passed stone or drug-related cholesta- Conversion to Laparotomy sis. If stones are present, ES can usually solve the problem. If ERCP demonstrates extravasation of bile, it is important to Conversion from laparoscopy to laparotomy may be required establish whether the CBD is in continuity. If the duct is in any laparoscopic cholecystectomy, in accordance with the interrupted, early reoperation, ideally at a specialized center, judgment of the surgeon. The most common reason for such is the best option. If the duct is in continuity, endoscopic and conversion is the inability to identify important anatomic radiologic techniques may successfully resolve the problem structures in the region of the gallbladder. Distorted anatomy without substantial morbidity.34,35 Percutaneous drainage is may be the result of previous operations, inflammation, or instituted to control the fistula, and sphincterotomy or stent- anatomic variations. Conversion may also be required because ing is useful to overcome any resistance at the sphincter of of an intraoperative complication [see Postoperative Compli- Oddi. Any retained stones causing distal obstruction should cations, above]. Ideally, the surgeon would wish to convert also be removed. Major ductal injuries usually call for opera- before any complication occurs. It must be emphasized that tive repair. When such an injury is identified at operation, the conversion to open surgery should not be considered a failure surgeon must decide whether to attempt repair immediately; or a complication. Rather, it should be considered a prudent this decision should be based on the surgeon’s experience maneuver for achieving the desired objective—namely, safe with reconstructive biliary surgery and on the local expertise removal of the gallbladder. Accordingly, every patient consent available. At a minimum, adequate drainage must be estab- obtained for a laparoscopic cholecystectomy must explicitly lished. Most major ductal injuries are not, in fact, identified allow for the possibility of conversion to an open procedure. intraoperatively. When such an injury is identified postopera- Attempts have been made to predict the probability of conver- tively, adequate drainage must be established and the anat- sion on the basis of preoperative information.36,37 It is clearly omy of the injury clarified as well as possible before repair. useful to stratify patients according to the likelihood of con- MRCP or transhepatic cholangiography may be required to version. This information is helpful in selecting patients for delineate the anatomy of the proximal biliary tree when ERCP laparoscopic cholecystectomy in an outpatient versus hospital does not opacify the biliary tract above the injury. If surgical setting, in determining the resources required in the OR, and repair is indicated, it should be performed by a surgeon expe- in assisting patients in planning their work and family needs rienced in complex biliary tract procedures. Often referral to around the time of surgery. a specialized center is the most appropriate decision, espe- Factors found to be predictive of an increased probability cially in the case of more proximal biliary injuries. of conversion include acute cholecystitis, either at the time of 04/09
  • 19. © 2009 BC Decker Inc ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 21 CHOLECYSTECTOMY AND COMMON BILE DUCT EXPLORATION — 19 surgery or at any point in the past; age greater than 65 years; from the gallbladder toward the Calot triangle. Dissection of male sex; and thickening of the gallbladder wall to more than the lower part of the gallbladder from the liver bed early in 3 mm as measured by ultrasonography. Other factors more the operation may aid in identification of the gallbladder variably associated with an increased likelihood of conversion neck–cystic duct junction (analogous to an open, retrograde are obesity, previous upper abdominal operations (especially dissection). The surgeon should be aware that edema and gastroduodenal), multiple gallbladder attacks over a long acute inflammation may cause foreshortening of the cystic period, and severe pancreatitis. Factors not associated with duct. If the anatomy cannot be identified, preliminary an increased likelihood of conversion are jaundice, previous cholangiography through the emptied gallbladder may indi- ES, previous lower abdominal procedures, stomas, mild cate the position of the cystic duct and the CBD. pancreatitis, and diabetes. Often the obstructing stone responsible for the acute attack On the basis of our data, a 45-year-old woman with no is in the neck of the gallbladder; thus, the cystic duct will be history of acute cholecystitis and no gallbladder wall thicken- normal and easily secured with clips. If the stone is in the ing has a probability of conversion lower than 1%; such a cystic duct, it must be removed before the duct is clipped or patient is a good candidate for laparoscopic cholecystectomy ligated. A thickened, edematous cystic duct is better con- in an outpatient setting. Conversely, a 70-year-old man with trolled by ligation with an extracorporeal tie or a ligating loop acute cholecystitis and ultrasonographic evidence of gallblad- than by clipping. If closure of the cystic duct is tenuous, closed der wall thickening has a probability of conversion of about suction drainage is advisable. Obviously, conversion to open 30%; such a patient would be better managed in a traditional cholecystectomy is indicated if the anatomy remains obscure. hospital environment. Conversion should also be considered if no progress is made after a predesignated period (e.g., 15 minutes) because at this Acute Cholecystitis point, the surgeon is unlikely to make any headway. Laparoscopic cholecystectomy has been shown to be safe and effective for treating acute cholecystitis.38,39 There are, CBD Stones however, several technical problems in this setting that must Identification of patients at risk About 10% of all be addressed if the procedure is to be performed with mini- patients undergoing cholecystectomy for symptomatic gall- mal risk. It should also be recognized that the probability of stones will also have choledocholithiasis. To select from the conversion to laparotomy is greatly increased in these circum- various diagnostic and therapeutic options for managing cho- stances. There appears to be no advantage to delaying surgery ledocholithiasis, it is helpful to know preoperatively whether in patients with acute cholecystitis, even if rapid improvement the patient is at high, moderate, or low risk for stones. Patients is noted with nonoperative management.40,41 Many patients with obvious clinical jaundice or cholangitis, a dilated CBD, return within a short time with recurrent attacks, and delay- or stones visualized in the CBD on preoperative ultrasonog- ing surgery does not reduce the probability of conversion. raphy are likely to have choledocholithiasis (risk > 50%). Technical difficulties associated with cholecystectomy for Patients who have a history of jaundice or pancreatitis, mod- acute cholecystitis include dense adhesions, the increased erately elevated preoperative levels of alkaline phosphatase or vascularity of tissues, difficulty in grasping the gallbladder, an bilirubin, or ultrasonographic evidence of multiple small gall- impacted stone in the gallbladder neck or the cystic duct, stones are somewhat less likely to have choledocholithiasis shortening and thickening of the cystic duct, and close (risk 10 to 50%). Patients with large gallstones, no history of approximation of the CBD to the gallbladder wall. jaundice or pancreatitis, and normal liver function are unlikely The surgeon should not hesitate to insert additional ports to have choledocholithiasis (risk < 5%). (e.g., for a suction-irrigation apparatus) if necessary. Because Diagnostic and therapeutic options One argument for the tense, distended gallbladder is difficult to grasp reliably, it routine intraoperative cholangiography is that it is a good way should be aspirated through the fundus early in the procedure, of identifying unsuspected CBD stones. However, more as previously described. If the graspers fail to grasp the wall or selective approaches to diagnosing choledocholithiasis make cause it to tear, exposure of the Calot triangle can be achieved use of preoperative cholangiography via MRCP, EUS, or, by propping up or levering the neck of the gallbladder and the more invasively, ERCP [see 5:18 Gastrointestinal Endoscopy]. right liver with a blunt instrument. A sponge can be used for Preoperative identification of choledocholithiasis allows the this purpose, thereby reducing the potential trauma of the surgeon to attempt preoperative clearance of the CBD by retraction. This maneuver is also useful when an impacted means of ES or intraoperative clearance during laparoscopy, stone in the neck of the gallbladder prevents the surgeon from depending on his or her expertise. Preoperative cholangiogra- grasping the gallbladder in the area of the Hartmann pouch. phy is suggested when the patient’s history and the results of Dense adhesions that may be present between the gallbladder laboratory and diagnostic tests suggest that there is a moder- and the omentum, duodenum, or colon should be dissected ate or high risk of CBD stones. It is our practice to have bluntly (e.g., with a suction tip). Because the tissues are friable patients at high risk for CBD stones undergo ERCP and ES and vascular, oozing may be encountered. Electrocauterization if warranted. For patients at moderate risk, MRCP or EUS should be only sparingly employed until the vital structures in is done first, followed by therapeutic ERCP if CBD stones the Calot triangle are identified. Instead, the surgeon should are identified. Intraoperative cholangiography can also be move to another area of dissection, allowing most of the oozing used to identify choledocholithiasis. ERCP with ES may to coagulate on its own. Liberal use of suction and irrigation result in pancreatitis, perforation, or bleeding and carries a will keep the operative field free of blood. mortality of approximately 0.2%. In the identification of anatomic structures, it is important When stones are detected during the operation, the to keep dissection close to the gallbladder wall, working down options include laparoscopic transcystic duct exploration, 04/09
  • 20. © 2009 BC Decker Inc ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 21 CHOLECYSTECTOMY AND COMMON BILE DUCT EXPLORATION — 20 laparoscopic choledochotomy and CBD exploration, open Endoscopic transcystic CBD exploration When stones are 4 to CBD exploration, and postoperative ERCP with ES.10,42 If a 8 mm in diameter, the helical stone basket wires are generally single small ( 2 mm) stone is visualized, it can probably be too close together to permit retrieval. Hence, choledocho- flushed into the duodenum by irrigating the CBD via the scopic basketing is used. A videocholedochoscope with a cholangiogram catheter and administering glucagon, 1 to 2 working channel is either passed over the guide wire or mg intravenously, to relax the sphincter of Oddi. Even if a inserted directly into the cystic duct. Because the usual lap- stone of this size does not pass intraoperatively, it will usually aroscopic grasping forceps may damage the choledochoscope, pass on its own postoperatively. forceps with rubber-covered jaws should be used. The image Laparoscopic transcystic CBD exploration Access to from the choledochoscope can be displayed on the monitor the biliary tree The cholangiogram is reviewed; the size of the by means of an audiovisual mixer (i.e., a picture within a cystic duct, the site where the cystic duct inserts into the CBD, picture) or displayed on a separate monitor. and the size and location of the CBD stones all contribute to Once the choledochoscope enters the cystic duct, warm the success or failure of transcystic CBD exploration.43–45 For saline irrigation is begun under low pressure to distend the example, transcystic exploration is extremely challenging in a CBD and provide a working space. The choledochoscope patient who has a long, spiraling cystic duct with a medial inser- usually enters the CBD rather than the common hepatic tion. The size of the stones to be removed dictates the approach duct. When a stone is seen, a 2.4 French straight four-wire to the CBD: stones smaller than 4 mm can usually be retrieved basket is inserted through the operating port. The stones in fluoroscopically directed baskets and generally do not neces- closest to the cystic duct are removed first by advancing the sitate cystic duct dilatation; larger stones (4 to 8 mm) are closed basket beyond each stone, opening the basket, and retrieved under direct vision with the choledochoscope. pulling the basket back, thereby trapping the stone. The A hydrophilic guide wire is inserted through the cholangio- basket is then closed and pulled up against the choledocho- gram catheter into the CBD under fluoroscopic guidance. scope so that they can be withdrawn as a unit. Multiple passes The cholangiogram catheter is then removed. If the largest may be required until the duct is clear. A completion cholan- stone is larger than the cystic duct, dilatation of the duct is giogram is done to ensure that the duct is clear and to rule necessary, not only for passage of the stone but also to allow out proximal stones. The dilated, traumatized cystic duct is passage of the choledochoscope, which may be 3 to 5 mm in ligated with a ligating loop rather than a hemostatic clip. If diameter. drainage is required, a red rubber catheter can be inserted Dilatation is accomplished with either a balloon dilator or into the CBD via the cystic duct. sequential plastic dilators. Because plastic dilators may cause Because of the angle created by the cephalad and superior the cystic duct to split, balloon dilatation is recommended. A retraction of the gallbladder, it may be difficult to pass the balloon 3 to 5 cm in length is passed over the guide wire and choledochoscope into the proximal ducts. If a common positioned with its distal end just inside the CBD and its hepatic duct stone is seen on the cholangiogram, the patient proximal end just outside the incision in the cystic duct. The is placed in a steep reverse Trendelenburg position. In this balloon is then inflated to the pressure recommended by the position, any nonimpacted stones may fall into the distal duct manufacturer and observed closely for evidence of shearing of for retrieval. It may be possible to pass the choledochoscope the cystic duct. The cystic duct should not be dilated to a into the proximal ducts by applying caudal traction to the diameter greater than 8 mm. Larger stones in the CBD may cystic duct so as to align it with the common hepatic duct. be either fragmented with electrohydraulic or mechanical An additional access port in the right upper quadrant may be lithotripsy, if available, or removed via choledochotomy. needed. If the cystic duct is long or spiraling or inserts medi- Once dilatation is complete, the guide wire may be removed ally, this measure may not be feasible, in which case, access or left in place to guide passage of a choledochoscope or baskets. must be obtained by means of choledochotomy. When the choledochoscope is used, a second incision in the Laparoscopic CBD exploration Large stones (> 1 cm), cystic duct, close to the CBD, avoids the Heister valves and as well as most stones in the common hepatic ducts, are not allows removal of the guide wire. If baskets are used, a 6 French retrievable with the techniques described above. Ductal clear- plastic introducer sheath may be inserted through the trocar ance can be achieved via choledochotomy if the duct is dilated used for cholangiography into the cystic duct. This sheath is and the surgeon is sufficiently experienced.46,47 The anterior especially useful if multiple stones must be removed. wall of the CBD is bluntly dissected for a distance of 1 to Fluoroscopic wire basket transcystic CBD exploration Stones 2 cm. When small vessels are encountered, it is preferable to smaller than 2 to 4 mm that do not pass with irrigation apply pressure and wait for hemostasis rather than use the through the cholangiocatheter after injection of glucagon can electrocautery in this area. Adrenaline-soaked gauzes placed usually be retrieved by using a 4 French or 5 French helical through the 12 mm umbilical port are very effective for this stone basket passed into the CBD over a guide wire under purpose. Two stay sutures are placed in the CBD. An addi- fluoroscopic guidance. The baskets can be passed alongside tional 5 mm trocar is placed in the right lower quadrant for the cholangiocatheter or inserted via a plastic sheath replac- insertion of an additional needle driver. A small longitudinal ing the cholangiocatheter. The basket is opened in the ampulla choledochotomy (a few millimeters longer than the circum- of Vater, pulled back into the CBD, and rotated clockwise ference of the largest stone) is made with curved microscis- until the stone is entrapped. The stone and basket are then sors on the anterior aspect of the duct while the stay sutures removed together. A Fogarty catheter should not be used, are elevated. A choledochoscope is then inserted, and warm because the stones are likely to be pulled up into the hepatic saline irrigation is initiated. In most cases, baskets should ducts, where they are much more difficult to remove. suffice for stone retrieval; however, lithotriptor probes and 04/09
  • 21. © 2009 BC Decker Inc ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 21 CHOLECYSTECTOMY AND COMMON BILE DUCT EXPLORATION — 21 lasers are available for use through the working channel of the The abdomen is opened and then explored; the abdominal choledochoscope. The choice of approach depends on avail- viscera are inspected and palpated, and a retraction system is ability and individual surgical experience. put in place. Long curved or angled clamps, such as Kelly or Subsequently, a 12 or 14 French latex T tube is fashioned Mixter, are placed on the gallbladder fundus and infundibu- with short limbs, placed entirely intraperitoneally to prevent lum for the application of gentle traction. The fundus is CO2 from escaping, and positioned in the CBD. The elevated and the infundibulum is pulled laterally and away choledochotomy is then closed with fine interrupted absorb- from the liver [see Figure 21]. If the gallbladder is not too able sutures. The first suture is placed right next to the T inflamed and edematous, the procedure may be performed tube, securing it distally, and the second is placed at the most similarly to the typical laparoscopic approach: the surgeon proximal end of the choledochotomy; lifting these two sutures identifies and ligates the cystic duct and artery and then facilitates placement of additional sutures. Intracorporeal removes the gallbladder from the liver bed. knots are preferred to avoid sawing of the delicate tissues. With more difficult open cases, the above technique may The end of the T tube is then pulled out through a trocar, not be possible. In such cases, a retrograde or so-called fundus and cholangiography is performed after completion of the down approach is usually employed. Staying as close to the procedure. gallbladder wall as is possible, the surgeon uses electrocautery or sharp and digital blunt dissection to remove the gallbladder from the liver bed, continuing downward to the cystic duct Open Cholecystectomy and artery [see Figure 22]. Anatomic variations of the duct and Open cholecystectomy is usually reserved for patients in artery must always be anticipated. These structures can be whom the laparoscopic approach is not feasible or is contrain- very difficult to identify and safely dissect in cases of severe dicated. As such, it is typically performed only in the most inflammation and markedly edematous tissues. In such cases, difficult situations or when additional maneuvers such as palpation and gentle digital blunt dissection of the duct and CBD exploration are anticipated. Conversion from the lap- artery between the thumb and index finger is useful aroscopic to the open approach is not considered a complica- [see Figure 23]. Opening the gallbladder to remove stones or tion and does not represent failure. Rather, conversion to this aspirate bile or pus may be necessary when it is tense and time-honored and effective procedure represents the prudent distended or necrotic and gangrenous. As with laparoscopic judgment of a safe surgeon. cholecystectomy, it is critical to identify the cystic duct and artery and their anatomic relations to the gallbladder and CBD ope r a t iv e te c h n i q ue before division and to avoid injury to the CBD or common The choice of incision depends on the surgeon’s experience hepatic duct. The cystic duct and artery may be suture ligated and preference, along with patient factors such as previous or divided between clips. Stones found in the cystic duct surgical procedures and body habitus. Typically, open chole- should be gently milked back into the gallbladder. cystectomy is performed through a right subcostal (Kocher) incision, but it can also be approached through an upper mid- s p ecial cons iderations line incision or, less commonly, through a right paramedian or transverse incision. A mechanical retraction system should Cholangiography be used, if available, so that the hands of the participating The indications for cholangiography are the same as for surgeons are free; there is no good rationale for struggling to laparoscopic cholecystectomy. Several techniques for the per- perform difficult biliary surgery with handheld retractors. formance of cholangiography can be used. Usually, the same a b c Figure 21 Open cholecystectomy. (a) Shown are the resting positions of the cystic duct and the common bile duct (CBD) (with the Calot triangle closed). (b) Improper upward retraction of the Hartmann pouch lines up the CBD and the cystic duct so that one can easily encircle the CBD or clamp the cystic duct and the CBD. (c) Correct downward and rightward retraction opens the Calot triangle; dissection proceeds lateral to the CBD. 04/09
  • 22. © 2009 BC Decker Inc ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 21 CHOLECYSTECTOMY AND COMMON BILE DUCT EXPLORATION — 22 Figure 22 Open cholecystectomy. In so-called fundus down dissection, the fundus and infundibulum are retracted up and away from the liver while dissection is performed with electrocautery. Sharp dissection with scissors or scalpel and blunt digital dissection all may be used, at the surgeon’s discretion. technique as for laparoscopic cholecystectomy is employed; the cystic duct is ligated or clipped high near the infundibulum and incised just below this point for insertion of a cholangiog- Figure 23 Open cholecystectomy. In patients with severe raphy catheter, which is secured against leakage by another inflammation and edema, the surgeon must be cautious clip or ligature. Alternatively, the cystic duct can be divided when approaching the Calot triangle during fundus down near the infundibulum and the gallbladder removed; then the dissection. In such circumstances, digital palpation can be cystic duct is cannulated. Needle puncture cholangiography very helpful in safely identifying the cystic duct and artery. can also be performed via the cystic duct or the common duct. Once cholangiography is complete, the gallbladder is removed supply of the duct, which courses laterally on either side of the and sent for pathologic examination. The operative field is duct in the 3 o’clock and 9 o’clock positions [see Figure 24]. In inspected for hemostasis and irrigated. Any bile leak is identi- some cases, stones are immediately visible and can simply be fied. Drains are not routinely placed but can be used at the plucked from the duct once it is opened. Flushing the duct surgeon’s discretion. If drains are used, a closed suction with saline, proximally and then distally, through a 12 or 14 Jackson-Pratt or similar drain is recommended; the drain French Foley or red rubber catheter may also clear the duct of should be brought out through a separate stab incision. stones. The intravenous administration of 1 to 2 mg of gluca- gon will relax the sphincter of Oddi, which may help in the Open CBD Exploration flushing of stones from the duct. In some cases, stones will be Open CBD exploration has become a rare procedure, but impacted within the duct and will require additional maneu- it remains a skill that surgeons require. If ERCP has failed or vers. The Kocher maneuver (liberally mobilizing the lateral is not possible, if the surgeon does not have the experience duodenum and head of the pancreas) will allow the surgeon to and necessary tools to perform laparoscopic duct exploration, hold and palpate the duodenum, the head of the pancreas, and or if laparoscopic efforts have failed, then open exploration stones within the duct, facilitating instrumentation. Stone becomes necessary. Ductal stones are identified either preop- retrieval forceps, biliary Fogarty catheters, and wire baskets eratively or intraoperatively by ultrasonography, cholangiog- can all be employed to retrieve stones. A choledochoscope can raphy, or palpation. also be used, either at the outset of exploration or for stone Appropriate retraction and exposure are crucial. The ante- retrieval, if simpler maneuvers are not successful. rior aspect of the duct is exposed over a distance of 1 to 2 cm, Either T tube cholangiography or choledochoscopy may be avoiding electrocautery during dissection. Two stay sutures of employed to confirm clearance of ductal stones. If no stones a 3-0 monofilament are placed lateral to the midline of the are present, primary closure of the choledochotomy has been duct. The common hepatic duct is sharply opened with a successfully employed, although most surgeons will leave in No. 11 or No. 15 scalpel and longitudinally incised further place a 12 or 14 French T tube, which is brought out through with a Potts arteriotomy or similar scissors. When performing a separate stab incision in the right lateral abdominal wall [see these maneuvers, the surgeon must respect the arterial blood Figure 25]. If stone clearance is not achieved, a T tube is 04/09
  • 23. © 2009 BC Decker Inc ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 21 CHOLECYSTECTOMY AND COMMON BILE DUCT EXPLORATION — 23 a b Figure 24 Open common bile duct exploration. (a) The common bile duct is opened vertically between laterally positioned stay sutures. (b) A catheter is then used to irrigate and flush stones from the duct. If stones are impacted within the duct, they can be retrieved with Fogarty catheters, wire stone retrieval baskets, or stone retrieval forceps. The choledochoscope can be used if any of these methods fail or as the initial method of exploration. a b Figure 25 Open common bile duct exploration. (a) After common bile duct exploration, a T tube is fashioned and is placed into the duct. (b) Interrupted 4-0 absorbable sutures are used to close the choledochotomy snug around the tube. Completion cholangiography may then be performed. The tube is brought out through the right abdominal wall, through a separate stab incision, and secured to the skin. 04/09
  • 24. © 2009 BC Decker Inc ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 21 CHOLECYSTECTOMY AND COMMON BILE DUCT EXPLORATION — 24 mandatory for decompression of the biliary tract and to pro- stones may require ERCP, percutaneous transhepatic instru- vide a route for future duct instrumentation. The T tube is mentation, T tube tract instrumentation, or combinations of connected to a bag for free drainage. Several days later, cho- these for removal. langiography is repeated. If it shows good flow into the duo- denum without obstruction, the tube may be clamped and removed at the 2-week mark. If there are retained stones, a more mature tract must be allowed to develop over 4 to 6 weeks for future instrumentation and stone retrieval. Retained Financial Disclosures: None Reported. References 1. McSherry CK. Cholecystectomy: the gold 19. Curet MJ, Allen D, Josloff RK, et al. 36. Fried GM, Barkun JS, Sigman HH, standard. Am J Surg 1989;158:174. 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World J Surg 1995;197:109. erative ultrasonography versus cholangiogra- 1999;23:343. 13. Johnson AB, Fink AS. Alternative methods phy during laparoscopic cholecystectomy: a for management of the complicated gallblad- prospective comparative study. J Am Coll der. Semin Laparosc Surg 1998;5:115. Surg 1997;185:274. 14. Angrisani L, Lorenzo M, De Palma G, et al. 31. Sarli L, Pietra N, Costi R, et al. Gall-bladder Laparoscopic cholecystectomy in obese perforation during laparoscopic cholecystec- patients compared with nonobese patients. tomy. World J Surg 1999;23:1186. Surg Laparosc Endosc 1995;5:197. 32. Schafer M, Suter L, Klaiber C, et al. Spilled Recommended Reading 15. Curet MJ. Special problems in laparoscopic gallstones after laparoscopic cholecystectomy. Asbun HJ, Rossi RL. Techniques of laparoscopic surgery: previous abdominal surgery, obesity, Surg Endosc 1998;12:305. cholecystectomy: the difficult operation. Surg Clin and pregnancy. Surg Clin North Am 2000; 33. 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Lillemoe KD, Martin SA, Cameron JL, et al. retained common bile duct stones. Ann Surg Endosc 1995;9:407. Major bile duct injuries during laparoscopic 1993;218:371. 18. Amos JD, Schorr SJ, Norman PF, et al. Lap- cholecystectomy: follow-up after combined Bass EB, Pitt HA, Lillemoe KD. Cost-effectiveness aroscopic surgery during pregnancy. Am J surgical and radiologic management. Ann of laparoscopic cholecystectomy versus open Surg 1996;171:435. Surg 1997;225:459. cholecystectomy. Am J Surg 1993;165:466. 04/09
  • 25. © 2009 BC Decker Inc ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 21 CHOLECYSTECTOMY AND COMMON BILE DUCT EXPLORATION — 25 Bernard HR, Hartman TW. Complications after phy and cholangiography in the laparoscopic era. conversions in 1300 patients and analysis of risk laparoscopic cholecystectomy. Am J Surg Ann Surg 1996;223:212. factors. Surg Endosc 1995;9:25. 1993;165:533. Liberman MA, Phillips EH, Carroll BJ, et al. Cost- Society of American Gastrointestinal Endoscopic Branum G, Schmitt C, Baillie J, et al. Manage- effective management of complicated choledo- Surgeons. Guidelines for the clinical application of ment of major biliary complications after laparo- cholithiasis: laparoscopic transcystic duct explora- laparoscopic biliary tract surgery. Surg Endosc scopic cholecystectomy. Ann Surg 1993;217:532. tion or endoscopic sphincterotomy. J Am Coll 1994;8:1457. Clair DG, Brooks DC. Laparoscopic cholangiog- Surg 1996;182:488. Soper NJ, Flye MW, Brunt LM, et al. Diagnosis raphy: the case for a selective approach. Surg Clin MacFadyen BV, Vecchio R, Ricardo AE, et al. and management of biliary complications of lap- North Am 1994;74:961. Bile duct injury after laparoscopic cholecystecto- aroscopic cholecystectomy. Am J Surg Cotton PB. Endoscopic retrograde cholangiopan- my: the United States experience. Surg Endosc 1993;165:663. creatography and laparoscopic cholecystectomy. 1998;12:315. Strasberg SM, Hertl M, Soper NJ. An analysis of Am J Surg 1993;165:474. McGahan JP, Stein M. Complications of the problem of biliary injury during laparoscopic Crist DW, Gadacz TR. Laparoscopic anatomy of laparoscopic cholecystectomy: imaging and cholecystectomy. J Am Coll Surg 1995;180:101. the biliary tree. Surg Clin North Am intervention. AJR Am J Roentgenol Traverso LW, Hargrave K. A prospective cost 1993;73:785. 1995;165:1089. analysis of laparoscopic cholecystectomy. Am J Cuschieri A, Lezoche E, Morino M, et al. E.A.E.S. Menack MJ, Arregui ME. Laparoscopic sonogra- Surg 1995;169:503. multicenter prospective randomised trial compar- phy of the biliary tree and pancreas. Surg Clin Wherry DC, Rob CG, Marohn MR, et al. An ex- ing two-stage vs single-stage management of pa- North Am 2000;80:1151. ternal audit of laparoscopic cholecystectomy per- tients with gallstone disease and ductal calculi. formed in medical treatment facilities of the De- Millitz K, Moote DJ, Sparrow RK, et al. Pneumo- Surg Endosc 1999;13:952. partment of Defense. Ann Surg 1994;220:626. peritoneum after laparoscopic cholecystectomy: Deziel DJ. Complications of cholecystectomy: Woods MS, Traverso LW, Kozarek RA, et al. frequency and duration as seen on upright chest incidence, clinical manifestations, and diagnosis. Characteristics of biliary tract complications dur- radiographs. AJR Am J Roentgenol Surg Clin North Am 1994;74:809. ing laparoscopic cholecystectomy: a multi-institu- 1994;163:837. Deziel DJ, Millikan KW, Economou SG, et al. tional study. Am J Surg 1994;167:27. Complications of laparoscopic cholecystectomy: a National Institutes of Health Consensus Develop- Zucker KA, Josloff RK. Transcystic common bile national survey of 4,292 hospitals and an analysis ment Conference Statement on Gallstones and duct exploration. In: MacFadyen BV, Ponsky JL, of 77,604 cases. Am J Surg 1993;165:9. Laparoscopic Cholecystectomy. Am J Surg editors. Operative laparoscopy and thoracoscopy. Freeman ML, Nelson DB, Sherman S, et al. 1993;165:390. Philadelphia: Lippincott-Raven Publishers; 1996. Complications of endoscopic biliary sphinctero- Olsen D. Bile duct injuries during laparoscopic tomy. N Engl J Med 1996;335:909. cholecystectomy. Surg Endosc 1997;11:133. Halpin VJ, Dunnegan D, Soper NJ. Laparoscopic Phillips EH, Carroll BJ, Pearlstein AR, et al. Lap- intracorporeal ultrasound vs fluoroscopic intraop- aroscopic choledochoscopy and extraction of erative cholangiography. Surg Endosc common bile duct stones. World J Surg 2002;16:336. 1993;17:22. Hunter JG, Trus T. Laparoscopic cholecystecto- Ress AM, Sarr MG, Nagorney DM, et al. Spec- my, intraoperative cholangiography, and common trum and management of major complications of bile duct exploration. In: Nyhus LM, Baker RJ, laparoscopic cholecystectomy. Am J Surg Fischer JE, editors. Mastery of surgery. 3rd ed. 1993;165:655. Acknowledgments New York: Little, Brown & Co; 1997. Ros A, Gustafsson L, Krook H, et al. Laparoscop- Kane RL, Lurie N, Borbas C, et al. The outcomes ic cholecystectomy versus mini-laparotomy chole- Figures 2, 5 Tom Moore. of elective laparoscopic and open cholecystecto- cystectomy: a prospective, randomized, single- Figure 18 Courtesy of Nathaniel J. Soper, MD, mies. J Am Coll Surg 1995;180:136. blind study. Ann Surg 2001;234:741. Northwestern University Feinberg School of Korman J, Cosgrove J, Furman M, et al. The role Schrenk P, Woisetschlager R, Wayand WU. Medicine, Chicago. of endoscopic retrograde cholangiopancreatogra- Laparoscopic cholecystectomy: cause of Figures 21 through 25 Alice Y. Chen. 04/09