Acs0521 Cholecystectomy And Common Bile Duct Exploration 2009

© 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

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(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

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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.

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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.

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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

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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

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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.

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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.

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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.

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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.

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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

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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


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.

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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


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


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.

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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

Acs0521 Cholecystectomy And Common Bile Duct Exploration 2009

Acs0521 Cholecystectomy And Common Bile Duct Exploration 2009

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