This document discusses laparoscopic cholecystectomy (LC), including: - The history and development of LC since its invention in 1985. - The standard four-port technique for LC and strategies to minimize bile duct injuries like adopting the Critical View of Safety method. - Potential complications of LC like hemorrhage, bile leak, and bile duct injury which can occur if the hepatocystic triangle anatomy is not correctly identified. - Techniques to help identify anatomy like intraoperative cholangiography and using landmarks like Rouviere's sulcus and the epicholedochal plexus.

1. LAPAROSCOPIC
CHOLECYSTECTOMY
DR. SHOUPTIK BASU
1ST YEAR POST GRADUATE TRAINEE
DEPARTMENT OF GENERAL SURGERY
BANKURA SAMMILANI MEDICAL COLLEGE AND HOSPITAL

2. Objectives
• Development and Dissemination of Lap Chole.
• Basic Instruments
• Standard Laparoscopic Cholecystectomy
• Avoiding Bile Duct Injuries
• Exit Strategies for a Difficult gall bladder
• Variations in Standard Laparoscopic
Cholecystectomy
• The Future : Recent Advances

3. Prof. (Dr.) Med Erich
Mühe – [1985]
A Surgeon ahead of his time
ReynoldsW.The First Laparoscopic
Cholecystectomy. JSLS : Journal of theSociety of
Laparoendoscopic Surgeons. 2001;5(1):89-94.
Galloscope

4. SAGES AND EAES recognize his work in 1999
1999 Annual Karl Storz Lecture in NewTechnology, which was given Friday, March
26, 1999, in San Antonio,Texas. Dr Mühe's lecture was titled “The First Laparoscopic
Cholecystectomy: Overcoming the Roadblocks on the Road to the Future.”
Rejection in the GSS, 1986
Mühe received the GSS Anniversary Award for his pioneering work in
endoscopic surgery. In receiving this award, his laparoscopic
cholecystectomy was described by Franz Gall, president of the GSS, as one
of the greatest original achievements of German medicine in recent history.

5. DEVELOPMENT OF Laparoscopic Cholecystectomy
THE FRENCH REVOLUTION
Moret, Gynecologist
First Lap
Cholecystectomy 1987
Dubois and Perrisat ,
Surgeon performed LC
and Cholecystostomy and
removal of stones , 1988
THE US REVOLUTION
“The French Technique”
Bill Saye (Gyne) and
Barry Mc Kernan (Surg)
1st Lap Chole in US ,
1988
Eddy Joe Reddick
Douglas Olsen

6. The first Indian Lap Chole ?
“I soon realised the value of diagnostic laparoscopy in a surgical unit in a
developing country and tried to pass on my enthusiasm to all my
colleagues. Surgeons in large cities viewed my passion with indifference if
not scorn. To my gratification surgeons in small towns, in the course of
innumerable workshops, were very receptive, specially so since they lacked
other diagnostic facilities and very many of them had laparoscopy
equipment as part of the family planning programme. From these
somewhat primitive beginnings, laparoscopy and its logical sequel
laparoscopic surgery has grown in the country in a phenomenal way. The
first laparoscopic cholecystectomy in India was performed in 1990 at the JJ
Hospital, Mumbai, followed a few months later in Pune by Dr. Jyotsna
Kulkarni. ”
Dr.Tehemton Erach Udwadia
Honoured with Padma
Bhushan

7. INDICATIONS FOR Lap Chole
• Asymptomatic Cholelithiasis
No indication except
Immunosuppression
Porcelain Gall Bladder with
Gallstones-Risk of CA
• Symptomatic Cholelithiasis
Biliary colic and Cholecystitis
(Acute/Chronic)
• Complicated Cholelithasis
Gall Stone pancreatitis close to
discharge
Choledocolithiasis with Cholangitis
after the Cholangitis is resolved (pre-
Op ERCP is a prerequisite)
Cholelithiasis
Conditions unrelated to Gall
bladder Disease
• Acute Acalculous cholecystitis
• Biliary Diskinesia
(dec EF on HIDA scan)
• Polyps, Cholesterosis and
Adenomyomatosis
(Size > 1cm)

8. Contra-INDICATIONS FOR
Lap Chole
Absolute Relative
• Major upper abdominal surgery,
• History of ascites,
• Coagulopathy.
• Extremely limited

9. Status of Lap Chole Today…
 More than 50 techniques have been described in Literature
 These are modifications by Surgeons to improve Post
operative outcomes or cosmesis
 Mainly Reduction in port size/number.

10. Armamentarium
INSUFFULATOR
CAMERAAND
RECORDING UNIT
LIGHT SOURCE & CABLE
MONITOR TROCARS
DISPOSABLE
TROCARS
TELESCOPE
REDUCER
VERESS NEEDLE

11. Commonly used Hand Instruments
PALMER GRIP
LIGA CLIP APPLICATOR
ASPIRATION NEEDLE
MARYLAND
TRAUMATIC GRASPER
ATRAUMATIC GRASPER
FINE SCISSORS
(METZENBAUM)
MONOPOLAR L - HOOK
STONE EXTRACTOR
ALLIGATOR / GB EXTRACTOR
SUCTION-IRRIGATION
CANNULA

12. TECHNIQUES
STANDARD LC MODIFIED LC
REDUCED
PORT SIZE
REDUCED
PORT NUMBER
SSLC/TUSS HYBRID NOTES

13. STANDARD Lap Cholecystectomy
• Most Commonly done
• Four Ports (10-10-5-5)
• Operating Table must allow
Fluoroscopy (Optional)
• American (Surgeon on the Left) /
French position (Surgeon in-
between patient’s legs)
• Under General Anaesthesia, patient
supine arms abducted 90 deg.
(Some use arms tucked in)
• Ryles tube decompression may be
required
EpigastricTrocar through
the Falciform Lig
MidAxillary trocar inserted
towards theGB
3 working ports
Triangulating onto the
GB

14. Hepatocystic triangle dissection
• Patient is placed in Reverse Trendelenburg position
• Dissect the omental adhesions to the Gall bladder
• A locking grasper holds the fundus and retracts it superiorly and towards the
right shoulder
• Another grasper holds the infundibulum and retracts it laterally, to the right.
This separates the cystic duct from the Common Bile Duct.
• Dissect the Hepato-cystic triangle with short bursts of Electro cautery or
blunt graspers.
• Identify the node of Calot in this location and gently separate it from the
gallbladder. [Don’t go below it…]
adhesiolysis Post. dissection Ant. dissection

15. • After the anterior and posterior dissection are complete and a
window is created, and the cystic duct and artery are
skeletonized. It is advisable to dissect the superior peritoneal
fold to reveal the cystic plate. Hence the Critical view of safety
is attained.

16. • Apply clips to the cystic duct and artery and divide them.
• Intra operative Cholangiogram can be done any time prior to
dividing the duct for aberrant anatomy and CBD stones

17. • Gall bladder is removed from the liver bed by using L-hook
electrocautery
• Before specimen extraction.
• Check the liver bed, and Cystic structures for haemostasis.
• Drain is optional (HRPOM)

18. • A severely contaminated specimen or CA GB specimen is best
extracted in an Endobag (or - Gloves as endobag)
• Umbilical or Epigastric post may be used for extraction.
• Ports are closed with Port Vicryl

19. • Haemorrhage
• Bile Leak
• Bile Duct Injury
• Failure to recognize Aberrant Anatomy
Complications of Laparoscopic
Cholecystectomy

20. The SAGES Safe Cholecystectomy Program
Strategies for Minimizing Bile Duct Injuries:
Adopting a Universal
Culture of Safety in Cholecystectomy (COSIC)
Why ?
• Bile duct injury rates have increased (3 per 1,000 procedures)
• Life altering complications leading to significant morbidity and cost.
• Because bile duct injuries are relatively infrequent, definitive studies
comparing methods to minimize these complications will likely
never be performed.
AIM:
Secure Identification of Structures

21. Why do Bile Duct Injuries Occur…?
• Incorrect interpretation of
anatomy
Incorrect Traction
Blind Haemostasis
• Accidental
Mechanical – Scissors
Energy Driven

23. 6 strategies
1. Use the Critical View of Safety Method (CVS)
2. Intra-op time out before cutting/clipping
3. Understand potential aberrant anatomy
4. Liberal use of Cholangiogram
5. Recognize a risky dissection- HALT !!! – Finish safely
6. Get help from an experienced Surgeon
• The hepatocystic triangle is cleared of fat
and fibrous tissue.
• The lower one third of the gallbladder is
separated from the liver to expose the cystic
plate.
• Two and only two structures should be seen
entering the gallbladder.

24. RATIONALE….Secure
Identification
Open Cholecystectomy Lap. Cholecystectomy

25. What’s wrong with the Infundibular
Technique…?

26. Aberrant Ducts ? May God Help you !!!
• After dividing the artery and
peritoneal attachments.
• GB- Duct junction is mobilized to
give an Elephant head appearance.
• Visually ensures no aberrant duct is
entering the Cystic duct.
• Don’t Clip the duct until this is
achieved.
• Surest way to identify aberrant
ducts.
ComprehensiveTextbook of Laparoscopic Surgery , by IAGES 2 Ed

27. Orientation:
Hepato-cystic Triangle
• Area between cystic duct and Gall
Bladder & the Liver and the Hepatic
Duct.
• Most Bile Duct andVascular Injuries
occur HERE !!!
Variation duringTraction &
Dissection

28. Calot’s triangle Hepato-cystic
triangle
Based on the location of the CysticArtery
CysticArtery is neither consistently
present or Anatomically Precise…
Preffered NOMENCLATURE
V/S
PLEASE
FORGET MY
TRIANGLE
I KNOWYOU
CAN’T !!!

29. Orienting various Anatomic
Landmarks
I. FALCIFORM LIGAMENT
• Lies between Segments 3 and 4
• The CHD is between the mid-plane of
the liver between Segments 4 and 5

30. Rouviere’s sulcus usually “points” to the neck of
the gallbladder (the narrow part that then tapers
into the cystic duct) and can then be used as a
reference point to facilitate identification and
dissection in Calot’s triangle. The Right Portal
pedicle enters the liver here.
Identifiable in most healthy livers (Absent 20%).
Hugh et al reported that fewer common bile duct
injuries occur during laparoscopic
cholecystectomy if dissection begins ventral /
anterior to Rouviere’s sulcus.
Scar
Open
Closed
II. The importance of the
Rouviere’s sulcus …
[Stay anterior to it]

31. III. EPICHOLEDOCHAL PLEXUS
Produces a pattern of vessels on the outside of the common
duct.Thus differentiates this from the cystic duct by its
external appearance.

32. IV. DUODENUM
Relationship of the duct to the Duodenum…
Any duct that goes directly behind the Duodenum is
the Common Bile duct.

33. Intraoperative
Cholangiogram (IOC)
• Delineate the biliary anatomy
and to evaluate the common
bile duct for filling defects,
obstruction (pathologic or
iatrogenic), or contrast
extravasation indicative of
injury.
• Routine IOC vs Selective IOC
debatable.
SAGES says it diminishes Bile
Duct Injury.

34. Indocyanine Green
(Fluorescence Cholangiography)
• Sends fluorescent
signal detected by an
advanced Laparoscope
• Excreted through Bile
as it concentrates there
• Better visualization of
Ductal Anatomy
• Near Infra-red light is
used

35. • fundus was punctured
• 50 % methylene blue diluted by saline solution was injected into the gall bladder
for coloration of biliary tree.
“Conclusion:
We believe that the incidence of bile duct injury related to anatomic
misidentification can be decreased or even totally suppressed by intraoperative
injection of methylene blue into the gall bladder fundus and visualisation of the
gall bladder, cystic duct and ductus choledochus.”
Other Dyes : Methylene Blue

36. Light Cholangiography (LCP)…
Cold Light source through the Duodenum may help
“In group I cold light was used to illuminate the common bile duct by
leading an optical fiber into the common duct with a duodenoscope at the
time of LC.The light coming from the fiber in the CBD could clearly
illuminate the location of CBD and hepatic duct establishing its location
relative to the cystic duct.This method was compared with the dye
injection technique using methelenum coeruleum.”
CONCLUSION: LCP is the only technique that can clearly and directly show the
location of the extrahepatic biliary system and may be useful in selecting cases of
uncertain anatomy in the prevention of bile duct injury.

37. Trouble shooting (Intra Operative)
• Spilled stones
• Slipped Clips
• Heavy Stone load

38. Exit Strategies for a Difficult
Gallbladder
I. Difficult Fundus Retraction
– Aspiration of bile from the gallbladder, with a long laparoscopic needle
– large stone or contracted gallbladder, the lateral-most trocar can be upsized
to a 10 mm dilating trocar, and a large claw forceps can be used to hold the
gallbladder
II. Inflamed and Indurated Calot’s Triangle / Acute Cholecystitis
– gentle dissection by an experienced surgeon
– Increase the number of ports (4 to 5) if required.
– suction irrigator can be used bluntly to delineate the structures.
– Use electrocautery judiciously (prevents injury)
– intraoperative cholangiogram
– If the gallbladder is severely contracted and adherent to the liver bed, it
would be wise to leave the posterior wall of the GB in place.

39. III . Fundus First Approach
– indicated when the triangle of Calot cannot be easily
visualized (dense inflammation)
– port placement is similar
– assistant’s job is to grab the gallbladder just as it meets the
uppermost portion of the liver bed
– the surgeon grabs next to the assistant’s placement on the
gallbladder side and uses Electro-cautery to dissect the
peritoneum around the Gall Bladder
– Cautery is then used to carefully separate the gallbladder
away from the liver bed
– The gallbladder is circumferentially dissected, with the
surgeon
– Blunt dissection, as well as using a suction irrigation, may be
necessary
– As the gallbladder is approached inferiorly, the first structure
that should be identified is the cystic artery -> It should be
clipped
– The dissection then continues along the infundibulum of the
gallbladder until no structure, other than the cystic duct,
remains.
– Once the cystic duct is completely skeletonized and the
cystic artery taken, the cystic duct can be traversed with clips
– Gall bladder removed in a standard fashion

40. Reduced Port Size LC
• Epigastric port can be changed to 5mm -> Specimen Retrieved through
Umbilicus but a Camera change to 5mm-> 5mm Clip applicator is used and
Endoloop ligation of the Cystic Duct.-> Bipolar to cut the Cystic Artery
• Epigastric Port Remains as 10mm and Umbilicus is 5mm -> Specimen
extracted via Epigastrium and normal Clip applicators are used.
• Two ports may be converted to 3mm then the configuration becomes 10-5-3-3.
Here 3mm instruments are used
• Minilaparoscopic Cholecystectomy
one 10 mm port and rest all 5 mm
one 5 mm and other <5 mm ports
one 10 mm port, one 5 mm and rest 2 to 3 mm ports
• Micro-Laparoscopic Cholecystectomy
10 mm and rest all 2-3 mm ports have been used

41. Reduced Number LC
• Initial attempts were made by surgeons to reduce the port numbers from 4 to 3 for
performing standard LC. (10-10-5 3 port Modified LC)
– It’s Fallacy:
vision achieved is quite different
no major difference
Some Surgeon’s claim there is less pain, faster recovery and less scars
however this view is based on personal experiences of surgeons.
Best for – Short Gall bladder and a Floppy Liver
• 3 ports with Sutured FundalTraction (5-10-5 SF Modified LC)
– 18 G needle to take a figure of 8 bite on
the fundus for traction.
Standard Clip applicator can be applied
– Demerits:
Minor bile leak from the fundal bite
Epigastric 10mm port causes more pain comparatively
No cosmetic advantage if a 10 mm umbilical port is truncated to 5mm

42. • One can also use micro laparoscopic instruments, i.e. 3 mm or 2 mm
instruments for performing reduced port LC -> here intracorporeal ligation of
cystic duct is advisable because of the paucity of good 3mm clip applicators.
• 2 port LC with 2 SutureTractions (10-10-SF-SH) or (5-10-SF-SH)
– Two traction sutures are on the Fundus (SF) and on the Hartmann’s pouch (SH)
– So how does this work ?
For anterior as well as posterior dissection of the Calot’s triangle, a doublesuture
swinging traction of the Hartmann’s can be employed with one suture extracted
from the epigastric port and one from the right lumbar port.Thus with traction on
the right lumbar suture, anterior dissection of Calot’s triangle is possible, while with
an epigastric suture traction posterior dissection is possible.
– Fallacy-
Quality ofTraction is not like instrument traction
Can be combined with Micro-Laparoscopy but one port must be 10mm for GB
extraction

43. Single Site Laparoscopic Cholecystectomy
(SSLC) / Trans-umbilical Single Site Surgery
(TUSS)
• SSLC means when all ports are placed at single
site; here it is practically in or around umbilicus.
• First Reported by Piskun
• Single skin and sheath incision or single skin and
separate sheath incisions or separate skin and
sheath incisions but at the same site.
• Port devices such as SILS port (Covidien),Tri port
or Quad port (Olympus) or X cone(Storz) through
the single incision.
• larger skin incision (at least 20 mm) then that
needs in standard LC. (size should increase if it’s a
thick Gallbladder with multiple stones)
• Risk of Incisional Hernias

44. Bhandarkar, D., Mittal, G., Shah, R., Katara, A., & Udwadia, T. E. (2011). Single-incision laparoscopic cholecystectomy: How I do it? Journal of
Minimal Access Surgery, 7(1), 17–23.
• Standard instruments / Multiple curved
instruments are used
• No more than 3 instruments around the
umbilicus as its difficult to handle them
• Additional 3mm / 5mm trocars can be
used in case of difficulty
• Sutures may be used for traction
• Hybrid procedures combine the
principles of SILS and Multiport
methods

45. Another French Revolution
Langenbuch:1867 Moret :1987
B. Dallemange, J
Marescaux,S. Perretta-2007
Trans-Gastric
Cholecystectomy

46. NOTES
No Laparoscope…
A flexible endoscope
Hybrid: uses a 5mm port
through the umbilicus
and the endoscope
through the vagina
Trans-gastric and trans
colonic approaches
First Reported by:
R.Zorron and B. Dellmange and S. Perratta
Techniques are in infancy
One Reported case of
Rectal Injury during th
vaginal puncture

47. The Future…Hybrid • Combination of a flexible
transumbilical double-channel
endoscope and a 3-mm rigid
transcutaneous trocar placed in
the left hypochondrium for liver
retraction
• Instruments used through the
two working channels of the
endoscope were either a grasping
forceps or snare for grasping and
pulling and a hot-biopsy forceps
for cold and hot preparation and
dissection. Endoclips were used
for cystic duct and artery closure.
• So far, our endoscope-based
transumbilical cholecystectomy
technique has not yielded
satisfactory results in humans.

48. Will Robots take
over…
• The future direction lies in the
development of robotic surgery.
• Transcontinental robot-assisted
remote surgery (telesurgery) has
been reported.
• No clinical trials available for verifying
the advantages of robotic over
conventional surgery
• Offers the advantage of surgeon
comfort, elimination of surgeon
tremor and improved imaging and
increased degrees of freedom of the
operative instruments
• More time consuming.

49. • One of the major drawbacks of
laparoscopic surgery has been due to
the carbon dioxide
pneumoperitoneum.
• Carbon dioxide pneumoperitoneum
can have severe physiological
disturbances.
• It is especially useful when operating
on critical patients with a
cardiorespiratory problem, who
would benefit most from laparoscopic
surgery due to the reduced trauma
and advantages for recovery.
• Mechanical lifting of the abdomen is
based on the traction and subsequent
elevation of the abdominal wall.
• Trocars may not be required.
Laparolift System.
Gasless Laparoscopic
Cholecystectomy
Mühe's Modifications: Gasless Technique,
LC through Trocar Sleeve, and “Open
Laparoscope”

50. • Absorbable clips have been used, but
have not been found to be
advantageous
• Pre-tied loop or an Endo-GIA stapler
can be used for a dilated cystic duct
• Harmonic scalpel has been used as the
sole instrument for dividing the cystic
duct and artery (‘clipless laparoscopic
cholecystectomy’)
• A combined method of endoscopic
sphincterotomy with common bile duct
stone extraction and laparoscopic
cholecystectomy under general
anesthesia, for a single-session
treatment of patients with gallstones
with simultaneous CBD stones is
described, - the so called “rendez-vous”
technique.
Miscellaneous

51. Controversies of Lap Chole :
Should I practice Open Chole in 2018 … ?
Which is better – open or laparoscopic cholecystectomy?
There can be no doubt that with laparoscopic cholecystectomy, the pain felt by the
patient is less, overall morbidity is less, recovery is faster, hospital stay is reduced,
cosmesis is better and return to work is earlier.
As more and more experience is gained, the contraindications to the procedure have
shrunk, so that the only absolute contraindications to laparoscopic cholecystectomy
are the same as those for open cholecystectomy.
There was an initial increased incidence of iatrogenic complications, especially bile
duct injury, but even this is gradually coming down.

52. To conclude
• Laparoscopic Cholecystectomy is the Gold standard
Surgery for the Gall bladder.
• Considering the many techniques , a surgeon makes the
decision to choose the technique based on his
competency.
• It’s important to Recognize complications early.
• Always consult a Senior Hepato-biliary surgeon when in
doubt or when in trouble.
• Recent Advancements in guidelines, instruments and
techniques make surgery easier and decrease the
complications.

53. PRIMUM NON
NOCERE
THANK YOU…..