Laparoscopic Cholecystectomy Technique
- Author: Danny A Sherwinter, MD; Chief Editor: Kurt E Roberts, MD more...
An important issue for surgeons performing a laparoscopic cholecystectomy is whether and when the procedure should be converted to an open cholecystectomy. In the following situations, a low threshold for conversion to an open procedure should be maintained :
Excessive bleeding is encountered
Patient anatomy is unclear
Multiple vessels are seen entering the “gallbladder,” or a very large cystic duct is seen (especially if it was normal on ultrasonography); these findings suggest that the surgeon may be in the wrong place
Conversion to an open procedure should not be considered a complication, and the possibility that it will prove necessary or advisable should be discussed with the patient preoperatively. In most series, conversion rates are higher with emergency operations. Reported rates range from 1.5% to 15%, with most studies reporting rates around 5% in elective cases.
A multivariate analysis identified male gender, elevated white blood cell count, low serum albumin, pericholecystic fluid noted on ultrasonography, diabetes mellitus, and elevated total bilirubin as independent predictors of conversion. Another multivariate analysis identified male sex, positive Murphy sign, gallbladder wall thickness exceeding 4 mm, and previous upper abdominal surgery as independent predictors of conversion to an open procedure.
The decision to convert to open cholecystectomy should be made when important anatomic structures cannot be clearly identified or when no progress is being made. As a general rule, if the junction of the gallbladder and the cystic duct has not been identified within 30 minutes of the start of the procedure, a laparoscopic cholecystectomy should be converted to an open cholecystectomy.
Conventional Laparoscopic Cholecystectomy
The skin is initially prepared with chlorhexidine from just below the nipple line to the inguinal ligaments and laterally to the anterior superior iliac spine. The operative field is then draped with sterile drapes.
Placement of ports and instruments
A 1.5-cm longitudinal incision is made at the inferior aspect of the umbilicus, then deepened through the subcutaneous fat to the anterior rectus sheath. A Kocher clamp is used to grasp the reflection of the linea alba onto the umbilicus and elevate it cephalad.
A 1.2-cm longitudinal incision is made in the linea alba with a No. 15 blade. Two U stitches, one on either side of the fascial incision, are placed with 0 polyglactin suture on a curved needle (see the video below).
The peritoneum is elevated between two straight clamps and incised so as to afford safe entry into the abdominal cavity. An 11-mm blunt Hasson trocar is placed into the abdominal cavity, and insufflation of carbon dioxide is initiated to a maximum pressure of 15 mm Hg.
The authors prefer a 30° laparoscope to a 0° laparoscope because they feel it gives better visualization of the cystic structures from multiple vantage points. A 30° scope requires a more skilled scope operator.
The laparoscope is white-balanced and advanced slowly into the abdominal cavity. A 1.2-cm incision is made three fingerbreadths below the xiphoid process and deepened into the subcutaneous fat. An 11-mm trocar is advanced into the abdominal cavity under direct vision (see the image below) in the direction of the gallbladder through the abdominal wall, with care taken to enter just to the right of the falciform ligament.
The table is then adjusted to place the patient in a reverse Trendelenburg position with the right side up to allow the small bowel and colon to fall away from the operative field (see the image below).
A 5-mm grasper is placed through the 11-mm subxiphoid port and applied to the fundus of the gallbladder. The gallbladder is then elevated cephalad over the dome of the liver to facilitate the surgeon’s choice of the optimal positions for the lateral 5-mm ports.
After appropriate port sites are chosen, the lateral skin incisions are made, and two 5-mm trocars are advanced into the peritoneal cavity under direct vision (see the first image below). A 5-mm grasper with locking mechanism is placed through each of these lateral ports (see the second image below).
Exposure and dissection
The lateral grasper is applied to the fundus and used to hold it cephalad over the dome of the liver (see the first image below); the medial grasper is used to retract the infundibulum caudolaterally (see the second and third images below). This maneuver straightens the cystic duct (ie, retracts it at 90° from the common bile duct [CBD]) and helps protect the CBD from inadvertent injury. In contrast, cephalad retraction of the infundibulum tends to bring the cystic duct in line with the CBD, making the CBD more prone to injury.
Occasionally, adhesions are encountered between the gallbladder and the omentum or duodenum. These may be carefully lysed with a hook cautery. The authors prefer to use an L-hook electrocautery, which allows a very clean and delicate dissection, but any electrosurgical device can be used for this purpose.
Once the area of the hilum of the gallbladder has been reached, the importance of exposure and delicate dissection cannot be overemphasized. The cystic duct and artery must be carefully dissected and identified in the triangle of Calot to obtain the critical view. This critical view is achieved when the surgeon can see only two structures (the cystic duct an artery) entering directly into the gallbladder (see the image below); it must be obtained before any structures are clipped or transected.
The key to obtaining the critical view is complete clearance of the areolar tissue in the subhepatic space. With the infundibulum held caudolaterally, the hook is used to score the anterior peritoneum overlying the infundibulum−cystic duct junction (see the image below).
Next, the peritoneum is incised along the medial aspect all the way to within 1 cm of the liver (see the image below), and the incision is continued cephalad toward the fundus of the gallbladder.
The gallbladder is then retracted caudomedially, and a similar dissection is carried out on the lateral surface. This technique is sometimes referred to as the flag technique.
An Endo Peanut or a Maryland dissector can be of great help in better defining these structures (see the images below). At this point, the surgeon should be able to identify the cystic duct and cystic artery entering directly into the gallbladder; this is the critical view.
Clipping and division of cystic structures
Once the critical view has been achieved and the cystic structures clearly identified, the structures can be clipped and divided (see the images below). An endoscopic clip applier is used to place clips on the artery and duct (two proximally and one distally), which are then divided with endoscopic shears (eg, Endo Shears; Covidien, Mansfield, MA).
When the cystic duct is large, there are several options that may be considered, including an endoscopic stapler, Endoloops, and the overlapping clip technique.[68, 69, 70] If an Endoloop is used, it should be placed through the subxiphoid port. The grasper from the infundibulum is used to gently hold the cystic stump through the loop; the loop is then pulled taut.
Mobilization and removal of gallbladder
Once the cystic structures have been clipped and divided, the infundibulum is retracted cephalad. A hook or spatula is used to develop a plane in the areolar tissue between gallbladder and liver with smooth sweeping movements from right to left and back again. As in any surgical procedure, the traction-countertraction rule is essential. As the dissection marches up the gallbladder bed, the assistant should reposition his or her graspers to ensure optimal tension on the areolar tissue between gallbladder and liver bed (see the images below).
It is important to be alert for any aberrant vessels and ducts that may arise from the liver bed and enter directly into the gallbladder. These should be clipped and not simply cauterized.
Before the last strands connecting the gallbladder to the liver are divided, a final inspection of the gallbladder fossa and the clipped cystic structures should be carried out. Any bleeding points in the gallbladder fossa should be controlled at this time, before the gallbladder is completely separated from the liver (see the image below). This is the surgeon’s last opportunity to visualize these areas well.
Both 5-mm graspers are applied to the gallbladder and used to hold it over the right upper quadrant. The laparoscope is transferred to the subxiphoid port, and an endoscopic retrieval pouch is inserted through the umbilical trocar. The gallbladder is placed in the bag, which is then cinched closed. (See the images below.) The authors prefer to leave the bag suspended from the umbilical trocar while they replace the camera through the same port and perform the final inspection and washout.
The table is returned to the neutral position. The gallbladder bed and the suprahepatic spaces are irrigated and suctioned to ensure adequate hemostasis and removal of any debris or bile that may have spilled (see the image below).
Port removal and closure
The subxiphoid port and the two 5-mm ports are removed under direct vision, followed by the Hasson trocar (see the image below).
Overall, the incidence of port-site hernias is very low. Tonouchi et al reported an incidence of 0.65-2.8%; their recommendation was to close all port sites larger than 10 mm. The authors, however, do not close the subxiphoid port. The fascia is closed at the umbilical port by using the two U stitches placed at the beginning of the procedure. All of the skin incisions are closed with 4-0 absorbable monofilament suture, followed by cyanoacrylate tissue adhesive. (See the image below.)
Finally, the patient is extubated, transferred to the postanesthesia care unit, and monitored for 4-6 hours. In cases of elective cholecystectomy, the patient can be discharged home with a combination oral pain medication containing acetaminophen and an opiate.
Alternative Minimally Invasive Approaches
Since the introduction and widespread adoption of laparoscopic cholecystectomy, investigators have attempted to make further improvements to the established technique, aiming to reduce the invasiveness of the procedure by decreasing the number and, more commonly, the size of the operating ports, as well as the size of the instruments.
Novitsky et al concluded that laparoscopic cholecystectomy can be safely performed with the use of 10-mm umbilical, 5-mm epigastric, 2-mm subcostal, and 2-mm lateral ports. They suggest that minilaparoscopy can be routinely offered to properly selected patients undergoing elective laparoscopic cholecystectomy.
Cholecystectomy can also be performed through single-port access (SPA) surgery, also known as single-incision laparoscopic surgery (SILS)—so-called single-port cholecystectomy.[73, 74] In these procedures, the surgeon operates almost exclusively through a single entry point, typically the patient’s umbilicus.
In a retrospective review that included 360 consecutive patients who underwent single-incision laparoscopic cholecystectomy (SILC), Sato et al concluded that SILC appeared to be relatively safe and to have an acceptable postoperative complication rate but noted that poor physical status and acute cholecystitis were significant risk factors for postoperative complications.
An approach in which three discrete ports are placed through three mini-incisions at a single site has also been described.
Robotic-assisted cholecystectomy is feasible and safe; however, its cost is high, and no clear benefit for patients has been established. At present, therefore, the use of this technology is not justified.[77, 78]
Hasson trocar/Veress needle injury
Intestinal injury may occur during establishment of abdominal access, adhesiolysis, or dissection of the gallbladder away from the duodenum or colon. An injury to the bowel should be repaired with careful one- or two-layer suture closure.
The rates of injury to viscera or vessels from a Hasson trocar or from a Veress needle are comparable (in the range of 0.2%).
When a large-vessel vascular injury occurs, it is usually at the time of initial abdominal access. Such injuries may be lethal complications. Development of a retroperitoneal hematoma or hypotension should be treated immediately by conversion to laparotomy.
Excessive bleeding in the region of the triangle of Calot should not be treated laparoscopically. In this situation, attempts at blind clipping or cauterization usually lead to worsening hemorrhage or hepatic artery injury. If, and only if, a bleeding site can be definitely identified and the locations of both the hepatic artery and the CBD are known, bleeding may be controlled with cauterization or clipping.
Bleeding in the gallbladder bed can usually be controlled by fulgurating the bleeding site. The authors prefer using a spatulated electrocautery wand for this purpose. If a larger intrahepatic sinus has been entered, hemostatic agents (eg, microfibrillar collagen) can be placed laparoscopically in the liver bed, and pressure can be maintained with a clamp. The argon plasma coagulator (APC) can be an excellent tool for severe gallbladder fossa oozing that is not responsive to simple electrocauterization.
The term postcholecystectomy syndrome refers to a set of abdominal symptoms that occur in as many as 40% of patients after cholecystectomy. Symptoms are often vague and include dyspepsia, flatulence, bloating, right upper quadrant pain, and epigastric pain. The most common causes of this syndrome are dietary indiscretion, retained CBD stones, inflammation of the cystic duct remnant, and sphincter of Oddi dysfunction.
Bile duct injury
The most dreaded complication of laparoscopic cholecystectomy is bile duct injury (injury to the CBD or the common hepatic duct). The estimated incidence of bile duct injury in cholecystectomies performed laparoscopically ranges from 0.3% to 2.7%. By way of comparison, biliary tract injuries are estimated to occur in 0.25-0.5% of open cholecystectomies.
A major risk factor for bile duct injury is relative inexperience on the part of the surgeon.[80, 81, 82] Other risk factors are the presence of aberrant biliary tree anatomy and the presence of local acute or chronic inflammation.
Bile duct injury may manifest as bile leak (which is due to partial or complete bile duct transection leading to bile leakage into the peritoneum) or as biliary obstruction (which may be either partial or complete and is secondary to acute ductal ligation or chronic stricture formation).
Bile duct injury may present at different points in the treatment of the patient, as follows:
Intraoperative presentation - Bile duct injury is identified during the index procedure
Delayed presentation - Patients may present 3-7 days after surgery with fever, abdominal pain, anorexia, ileus, ascites, nausea, or jaundice
Late-onset stricture - Patients may present months later with abdominal pain and jaundice
Management of bile duct injury depends on the degree of injury and the timing of identification. If the injury is identified intraoperatively, the injured duct should be repaired immediately. Depending on degree, most CBD injuries can be primarily repaired over a T-tube, though in some cases, repair may require transfer to a specialized center.
If the injury is identified postoperatively, computed tomography (CT) is indicated to look for collections or ductal dilatation (see the first image below). Biliary scintigraphy with99m Tc-IDA or hepatobiliary iminodiacetic acid (HIDA) can be used to diagnose and sometimes localize the source of bile leakage (see the second image below). Endoscopic retrograde cholangiopancreatography (ERCP) can be used both diagnostically and therapeutically (see the third and fourth images below).
Treatment of bile duct injury can be an involved subject but may be summarized as follows:
CT-guided drainage of biloma followed by ERCP with sphincterotomy and stent placement (see the image below) is the treatment of choice for less severe lesions, such as minor lacerations of the CBD, duct of Luschka leak, or displaced cystic duct clips
Lesions in the proximal biliary tree may be more amenable to percutaneous transhepatic approaches
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