Merseyside laparoscopic cholecystectomy course, Royal Liverpool Academy.

1. LAPAROSCOPIC CHOLECYSTECTOMY:
COMPLEX CASES AND CHALLENGES
Raimundas Lunevicius
Consultant Surgeon & Honorary Senior Lecturer
Emergency, Trauma, Biliary, Hernia Surgery
Aintree University Hospital NHS Foundation Trust, Liverpool, England
13th July 2018
1

2. CASE:
Consultant / Consultant’s secretary asks you to perform elective LC
What you should do?
Cases / challenges 2

3. The case: 64-year old lady, BMI 23
• Was asked, agreed
• Review: 3 admissions within 42 days
• CT-scan:
• ‘3 cm gall stone in gall bladder, containing a calcified core;
appearances in keeping with cholecystitis on a background of
gallbladder calculi.
• Density change in the liver is concerning for a development of a
liver abscess. There is no pericholecystic inflammatory change.
• I note that no abnormality was identified in the liver on the recent
ultrasound scan.’
• Elective LC in 4-6 weeks’ time
Cases / challenges / scenario 3

4. Cases / challenges / scenario 4

5. Laparoscopic surgery
Adhesions around GB: Adhesiolysis & Phlegmonic gallbladder
Tissues quite unusual: very soft, mildly phlegmonic
Conversion to open cholecystectomy
Difficult surgery
Early postoperative period: uneventful, discharge
HOWEVER, 10 days later
Cases / challenges 5

6. 10 days later
HISTOLOGIST REPORTED:
Adenocarcinoma of gallbladder
pT3 G3 (poorly differentiated) with perineural invasion
Re-assessment of all documents on SIGMA follows
And…
Cases / challenges 6

7. ULTRASOUND ABDOMEN (2 days before CT-scan):
There is at least one large gall stone seen within a very thick walled gall bladder. Whilst the
appearances could all be due to chronic cholecystitis, follow up is required to ensure there is
no underlying gall bladder neoplasm. Further evaluation by CT would be useful here.
Cases / challenges 7

8. 8

9. Example of gallbladder cancer
9

10. Cases / challenges
Post-operative period:
• Chemotherapy and RCT
• Death in 6 months due to cancer progression
10

11. Preoperative assessment: conclusions
Don’t say ‘Yes’ immediately
1. Please kindly ask to provide a hospital number
2. Carefully check all available information
3. Provide ‘Yes’ or ‘No’ answer in a day or two
Cases / challenges 11

12. Case: cardiac arrest
12

13. The complaint:
cardiac arrest, 61-year-old male
Dear Sir or Madam,
I am writing to you again about my gallbladder operation
performed by Mr Lunevicius on the xx/yy/abcd.
I have looked at the medical records that I received from XYZ,
but it is still unclear, why my operation went wrong causing me
to have a cardiac arrest and severe heart failure.
I would like a full and detailed report why I went into cardiac
arrest, one of my concerns the gas infected into my abdomen
causing the operation to be halted and cardiac arrest.
Yours sincerely,
13Cases / challenges / scenario

14. Events
• Elective
• Standard
• Pneumoperitoneum
• 5mm ports
• Anesthetist:
• Cardiac arrest
• Start CPR
• Ports out immediately
• CPR
• Effective
• Acute coronary unit
• Remains under the
care of cardiologist
Cases / challenges 14

15. Cardiac arrest (CA) / periarrest
• Between 2 and 40 per 100,000 laparoscopic cases
• The estimated chance of CA: 1:2,500 - 1:50,000
• 14 CAs during laparoscopic surg. in Australia & New
Zealand from 2002 to 2007
• 2 cases out of 14 (14%) regarded as anaesthetic-associated CA
due to drug allergies & considered coincidental to the laparoscopy
• 8 of the 14 patients (57%) were described as ‘fit and healthy’
• no medication history recorded for 3 patients
• ONLY the remaining 3 patients (21%) had hypertension, atrial
fibrillation and ischemic heart disease
BE VIGILANT: it can occur to every healthy and fit patient
My experience: 1: 2,000 (61-year-old; no history of heart disease)
Cases / challenges 15

16. Challenges: inspection of peritoneal cavity
• Assess the difficulty of cholecystectomy
Challenges: example 16

17. Know the Nassar’s Difficulty Grading Scale:
predict severity of pathology and difficulty of surgery
S. Zino, A. Mirza, M. K. Nassar, H. Qandeel, A. Nassar, A Difficulty Grading System For Laparoscopic Cholecystectomy.
ASGBI International Surgical Congress 2014, April 30 - May 2, Harrogate, United Kingdom. Accessed at
http://www.epostersonline.com/asgbi2014/?q=node/3031
Challenges 17

18. Nassar’s Difficulty Grade 5
1. Burnt out gallbaldder
2. Mirizzi type 2, etc.
3. Fistulae (yes/no), when
Solid chronic inflammatory mass blocking gallbladder
For general surgeon who is performing LC (dilemma):
• Do NOT do laparotomy as you may achieve nothing
• IF possible and safe: minimal fundotomy/fundectomy,
remove gallstones, and drain it
• Or stop: abandon laparoscopic procedure and refer a
patient to regional HB centre
Challenges 18

19. Achievement of sufficient
window of safety could be a challenge
• Pericholecystic adhesiolysis: diathermy or scissors (bowel nearby!)
• Intrahepatic or pseudointrahepatic gallbaldder: CHALLENGE !
• Achieve large window working laterally and medially
• See S4B
• See S5
• See Rouviere’s sulcus: open sulcus, closed sulcus, split, scar
• Work above Rouviere’s sulcus
• Work within subserosal layer and cystic plate
• Identify Cystic Pedicle and structures of Callot triangle
• There should be no additional structures; however:
• aberrant bile ducts (Lushka) is always a possibility
• 2 or more cystic arteries: in < 5% of cases
Challenges 19

20. Challenges: hepatobiliary triangle = cystohepatic=cholecystohepatic; CA – inside it20

21. Metallic clips vs Polymeric locking clips
Vicril / PDS Endoloops, Endo GIA
Hem-o-lok® Polymer Locking
Ligation System
The Hem-o-lok® System is available in
a range of clip sizes including
Medium
Medium-Large (green)
Large (purple)
Extra-Large
To change or modify your practice can be a challenge 21

22. Hem-o-lok® Polymer Locking Ligation
System
1. Bosses are designed to
retain clip in applier jaws.
2. Integrated teeth interface
with the vessel and are
designed to prevent slippage.
3. Bow-shape design allows
removal with appropriate
instruments.
4. Hinge allows flexibility in clip
placement prior to clip locking.
5. Locking mechanism
provides tactile feedback and
secure closure.
Challenge: to change or modify your practice 22

23. Challenge: modify practice: long metallic clips vs LARGE HEM-O-LOCKS23

24. Traction of Hartmann’s pouch: gentle, gentle, gentle
It is a commonest cause of PV injury and catastrophic bleeding
RHV
MHV LHV
CHA
LHA
PHA
CBD
IVC
PV
P6
P7
P5
P4
P3
P2
GB
Illustrated by Kenzo YASUI M.D.,Ph.D.
Challenge: control power of your left hand, HANDLE TISSUES GENTLY
Anatomy of the liver: Anterior-left lateral view
24

25. Specific population: know what is it
Very high BMI > 40
Pregnancy
Post-partum
Coagulation disorders
Liver cirrhosis
Laparoscopic subtotal cholecystectomy
ALTERNATIVE to open total cholecystectomy
Completion cholecystectomy
Challenges / know definitions of specific populations 25

26. Case
26

27. Example 1: Laparoscopic subtotal cholecystectomy
Inflammatory mass
Empyema / Aspiration:
α - haemolytic streptococcus
Fundus (domus) down
Transection:
at Hartmann’s pouch
85 gallstones removed
85% STC
Constituent type STC
Two vicril endoloops
Two drains
Uneventful post op period
Cases / challenges / scenario 27

28. Case
28

29. Example 2: Laparoscopic subtotal cholecystectomy
• Admission with acute calculus cholecystitis
• Co-morbid conditions:
• Thoracotomy / Metallic Aortic Valve, Warfarin (INR 3-4)
• Conservative management
• Tazocin / responded
• EUS as a outpatient
• Listed for elective LC
Cases / challenges / scenario 29

30. Example 2: Acute severe cholecystitis
US-scan, 13 Apr 2016 Tazocin
Cases / challenges / scenario 30

31. Example 2: EUS
EUS-HB, 1 Jun 2016
No choledocholithiasis, Cholecystolithiasis No choledocholithiasis
Cases / challenges / scenario
CBD
CBD
31

32. Example 2:
Laparoscopic subtotal cholecystectomy, 3 Oct 2016
• Elective surgery
• Intraoperative findings:
• Extensive adhesions / pericholecystytis
• great omentum, duodenum, adjacent liver, hepatoduodenal ligament
• Exclusively massive S4 (‘lobus quadratus’)
• Distended gallbladder / acute cholecystitis
• Full peri-cholecystic lysis of adhesions
• Lateral / medial GB’s serotomy:
• deep GB’s neck, inflamed tissues, large calculus impacted in GB’s
neck
• STOP
• as chance to obtain a critical window of safety is minimal
Cases / challenges / scenario 32

33. Example 2: laparoscopic subtotal cholecystectomy
• Large Estimer bag to the lateral supra-hepatic space
• ‘Anterior’ cholecystotomy at the level of Hartmann’s pouch
• 300 calculi extracted from GB: one by one + suction
• Transection of the GB at the same level (amputation)
• Resolving empyema
• Full removal of the distal GB’s portions (80%)
• Fenestrating type
• Two Robinson drains: supra & sub-hepatic
• Duration of surgery: 3 hours
Cases / challenges / scenario 33

34. Example 2: Postoperative specimen & gallstones
Cases / challenges / scenario 34

35. • D3 (morning): unwell, serohemorragic-bilious fluid +
bilious right lateral dressings + MET call due to >RR, >HR
• Re-laparoscopy (antibiotics IV)
• Inspection:
• no signs of bilious peritonitis / no peritonitis
• Intrammatory mass (fresh fibrinous adhesions) in peri-hepatic area
• 5 mm port through LUQ – omentum detached
• Drains – ok
• Surgicel & blood clots in subhepatic space: removed
• Peri-hepatic washout / warm saline solution / 3 L
• Another subhepatic drain
• Post op: uneventful, discharge
Cases / challenges / scenario 35

36. Example 2: take-home messages
• Laparoscopic 80% STC for AC in a high-risk patient:
• KNOW and EMPLOY ALL TECHNIQUES
• Medial and lateral GB mobilization (even partial) helps
• Try to achieve even minimal window of safety
• Amputate gallbladder (should feel well)
• GB’s fundus-down or body-up
Talk to anesthetist as they sometimes panic
Cases / challenges / scenario 36

37. Case: S-TC
• Quality is important
37

38. Laparoscopic subtotal cholecystectomy:
PRINCIPLES aim to achieve best quality of S-TC
To remove as much of gallbladder wall as you can
To remove all calculi from the remnant of gallbladder
To ablate mucosa of hepatic wall of the gallbladder
To close the stump of the gallbladder, when feasible
+
To wash tissues well
To drain
Fundectomy and removal of calculi:
exceptional operation
NOT ROUTINE S-TC
Challenges 38

39. Example: Symptomatic remnant cholecystolithiasis
An emergency laparoscopic converted to open sub-total cholecystectomy, 2013
July 2014 September 2014
Cases / challenges / scenario 39

40. 2015: THE 1st COMPLETION CHOLECYSTECTOMY
LAPAROTOMY: GB wall opened between two sutures, gallstone removed, remnant of
GB was partially excised, GB closed in two layers with 3-0 PDS sutures
Sep 2016: GB, CD, CBD And beautiful large calculus
Cases / challenges / scenario 40

41. 2016: THE 2ND COMPLETION CHOLECYSTECTOMY:
retrograde, small piece of GB’s neck remaining, argon applied on it, 3-0 PDS
Apr 2017: biliary colic
US: remnant?
May 2017:
MRI: high density signal: remnant?
The plan: THE 3RD COMPLETION CHOLECYSTECTOMY
Cases / challenges / scenario 41

42. Case: subvesical duct
42

43. Injury to bile duct
Classifications: many;
Strasberg A, B, C, D, E
is well recognised
Precise diagnosis
RHD → CBD
Management well known
Re Sectional bile duct injury:
if identified, clip it
as less harm
more benefits
Know second-order division bile duct
anatomy
Challenges: Injuries
Lunevicius R et all. Infundibular laparoscopic cholecystectomy method requires a quality renewal: 18 year 13 274 cholecystectomy
analysis with assessment of 45 iatrogenic bile duct injuries. Lith Surg 2015; 14: 14-30
43

44. Aberrant bile duct (Luschka) within cystic plate
• Recent case, March 8th 2018
• Identified at the level of Gb and Gf, 2-3 mm duct
dissected, hem-o-locked
• No any consequences
• If leaking Luschka duct would have been left – biloma or
bilious peritonitis / classified as Strasberg A bile duct
injury
Challenges 44

45. Case: residual cholecystolithiasis
45

46. Emergency admission, 38, female, BMI 40.2
Colicky pain, severe tenderness,
US: distended, one gallstone CT-scan: thin-walled gallbladder
Cases / challenges / scenario 46

47. Laparoscopic less-than-total cholecystectomy
Emergency surgery
• Laparoscopic
• Mass
• Necrotising gallbladder
• Aspiration & fundus down
• Gn and hepatoduodenal
ligament severely inflamed
• Difficulty grade 4: cystic pedicle
• STC: 80%
• Large calculus removed
• Constituent type: endoloops
• 2 drains
• No post op bile leak
Histology
• Gf and Gb: 6 × 5 × 3 cm
• Necrotising cholecystitis
47

48. Colicky type pain across the abdomen (it is not typical biliary colic), constipation,
un-explainable diarrhoea 3-4 times a week: two readmissions with pain
MRCP 7 months later:
Residual Gn + 14mm calculus within it
MRCP: Normal Main Bile duct
Opinions: Symptomatic remnant or IBS?
Elective laparoscopic completion cholecystectomy or observe
48

49. Case: Laparoscopic converted to open S-
TC: excision of peritoneal wall just
Is it a good choice? : laparoscopic converted to open S-TC
What you would expect to see on ERCP images?
Case / Challenges 49

50. Case 38. Postop-ERCP: Remnant of G after
open removal of peritoneal wall of G
Lap converted to open S-TC
The reason for conversion:
unsuccessful attempt to create a
window of safety (‘attempt to
dissect callot triangle –
obliterated – convert to open’)
Outcome of this conversion via
subcostal incision:
(1) STC leaving disintegrated
posterior wall in situ; anterior
wall’s transection line at the
level of Hartman pouch
(2) MSSA wound infection.
Q: was a conversion necessary?
Case / Challenges 50

51. Back to pre-op CT- scan: Fundus, corpus and neck before
surgery: disintegration of posterior wall, fluid, local hepatitis
When you can’t
perform laparoscopic
S-TC kindly ask help
Case / Challenges 51

52. Residual cholecystolithiasis and choledocholithiasis
following S-TC
• A big problem and challenge for surgeons
52

53. Examples
53

54. Case 34: Therapeutic ERCP:
multiple calculi 15 months after LSTC (choledocholithiasis) and
the remnant of Gn
54

55. Case 35:
Jaundice: therapeutic ERCP, no extraction of stones; pigtail stent.
Open STC performed (CBD not explored)
Postoperative symptoms: Large remnant of G and calculi
55

56. Case 35: stent before open STC
Q: Quality of open S-TC
56

57. Medical documentation: be precise
• 2011: total cholecystectomy for acute calculous
cholecystitis in the operation notes
57

58. Case 39. Acute calculous remnant cholecystitis:
L-STC in 2011 (described as total)
2013: severe pain / RUQ
CT-scan: ‘Multiple radiopaque gallstones are noted within a
thin-walled gallbladder. There is some high attenuation
within the gallbladder fossa adjacent to the liver which may
represent surgical clips. I note that the gallbladder was
completely seen on previous scan from 2011. Has the
patient had partial cholecystectomy?’
58

59. Free gallstone below the liver and
remnant of gallbladder with calculi in 2013
59

60. Hartmann’s pouch CD fusion with CHD
60

61. Arteries: Proper hepatic, posterior sectional
artery (S6-7) and anterior sectional artery (S5-8)
61

62. The 2nd readmission: US-scan: ‘Gall bladder appears
contracted containing multiple calculi’. MRCP & EUS: no
choledocholithiasis. Listed for open completion cholecystectomy
62

63. • Be accurate and precise describing any surgical
procedure
63

64. Case: Diagnosis?
64

65. Cholecysto-choledocholithiasis, jaundice:
Q: Management plan?
Case / Challenges 65

66. A: ERCP+ Stenting, open S-TC (90%), stent removal (image)
66

67. Q: Diagnosis and management plan?
67

68. A: Mirizzi, type 2: preop two stents
68

69. Open S-TC, choledochotomy, gallstones removed:
ERCP 8 weeks after: no residual stones, gallbladder's remnant
69

70. Case
70

71. Q: Diagnosis: cholecystolithiasis
71

72. Q: Diagnosis: cholecystolithiasis
72

73. Q: Pain in RUQ. Diagnosis?
Radiology report
73

74. Radiologist reported:
‘Patient informs of a full cholecystectomy, however there
appears to be a cystic structure in the GB fossa suggestive
of remnant GB
Appearances on postoperative CT from August 2016
would concur with partial cholecystectomy’
P.S. This patient underwent open subtotal cholecystectomy.
74

75. Q: Diagnosis?
Radiology report
75

76. Radiologist’s report:
• Complex appearances of the gallbladder fossa. Please
correlate with the surgical technique and clinical
presentation.
• Possibilities include a postoperative nature
(has any surgical material been placed in the gall bladder
fossa? has a remnant of gall bladder been left?), or
infection (but the patient does not report pain/pyrexia).
76