Gallstone is one of the commonest disease procedures treated through the operating specialist. A method of laparoscopic cholecystectomy is referred to, that has already been used for seventeen many in some thousand situations, and which we feel offers stood the exam of your time. No claim is created this method is any better than any other method utilized by other surgeons, however no apology is offered to make this section tediously long. Laparoscopic Cholecystectomy is the flagship of laparoscopic surgery and the table mark for all laparoscopic surgery when it comes to efficacy, safety, patient acceptance as well as market penetration. It is the foundation laparoscopic surgery. Any laparoscopic procedure needs that the surgeon’s eye, hands, the camera, the operative field and also the monitor maintain one line.
Laparoscopic cholecystectomy includes 4 steps:
Step One: Creation of pneumoperitoneum as well as insertion of trocars.
Step Two: Separating of adhesions towards the gallbladder and the surrounding liver, having exposure of the peritoneal fold in which the cystic duct as well as artery are situated.
Step Three: Dissection as well as skeletonisation from the cystic duct as well as cystic artery as well as occlusion and also division of these structures.
Step Four: Dissection and extraction of the gallbladder and closure of incisions.
When the telescope is inserted a fast inspection is done of the peritoneal cavity to exclude obvious pathology and iatrogenic injury. The typical incisions for trocar insertion for laparoscopic cholecystectomy are:
- A 1 cm long infra-umbilical incision for that telescope trocar.
- A 5 mm incision within the right mid-axillary line about5 - 8 cm below the rib margin.
- A 5 mm incision in the right mid-clavicular line about 2 cm. below the costal margin.
- A 1 cm incision approximately in the junction of upper third minimizing 2/3rd of the line between your xiphisternum and umbilicus.
While fundamental essentials usual recommended websites for trocar entry, each situation merits placement of incision after visual examination according to the individual anatomy e.g. enlarged / shrunken liver. Adhesions while watching ascending colon may need the mid-axillary trocar to become placed more anteriorly or even more headwards. Adhesions may need totally unconventional placement of the trocar to circumvent these adhesions, but it is better than dissect / divide these types of adhesions before the trocar tend to be inserted at normal sites.
After the first entry of the infra-umbilical trocar, all subsequent trocar are inserted under vision to ensure during penetration no abdominal structure is injured. Each accessory trocar is pointed toward the gallbladder as it penetrates the abdominal wall. This can be a necessary step to minimize trauma towards the abdominal wall by avoiding angulating the trocar for the gallbladder if it's not directed primarily for the reason that direction and ensuring that all instruments with the trocar are angled within the correct direction.
The very first trocar is inserted within the right mid-axillary line. The primary function from the instrument inserted through this trocar would be to displace the fundus of the gallbladder headwards and this is best done from as lateral a situation as you possibly can. The caecum and also the ascending colon are identified to ensure that the website of penetration is well anterior to the peritoneal reflection from these structures. It has to be stressed again that the trocar is pointed toward the gallbladder as it penetrates the abdominal wall. This may seem obvious, however wants worrying as we have seen that the normal tendency while inserting a trocar with the abdominal wall under laparoscopic video image would be to allow it to be penetrate at right angles towards the abdominal wall through the least amount of route.
The next trocar to become inserted may be the one out of the best mid-clavicular line and also the distance below the costal margin is determined by how big the liver. Instruments manipulated by the surgeon’s left hand will pass through this trocar, whereas instruments in the right hand trocar will go through the epigastric port. Optimal coordination from the right and left hand require the ports be so placed that the instrument tips work in the abdomen at as wide an angle as possible. To make sure this, the sub-costal port should be placed as lateral as possible, without interfering with instruments with the mid axillary port. The epigastric trocar is inserted just to the best of the falciform ligament. If it's inserted too near to the umbilicus the telescope and also the operating instruments are almost parallel to one another with the result that the tip of the instrument, specially the tip from the scissors or even the clip applicator, can't be visualized clearly. We're feeling that if one has to err, it should be by placing the trocar nearer to the xiphisternum and further away from the umbilicus, so the operating end from the instrument is seen at right angles with regards to the telescope and the tip from the instrument could be clearly visualized. Value of this is best observed while ligating, clipping, or dividing the duct and the artery. The telescope and all sorts of the instruments passed through correctly positioned trocar sheaths will always be at angles to each other and never parallel to any one, ensuring optimal coordination. The sequence in which the trocar is inserted varies with different surgeons but the outcome ought to be the same. The individual has become placed in a 15o head high position and the table tilted with the right side up.
To achieve adequate exposure a fifth port may sometimes be expected. A swollen stomach and duodenum can greatly obscure the area - hence a nasogastric tube in most cases. While two 10 mm and two 5 mm trocar have been in standard use, one 10 mm trocar and several 5 mm as well as smaller size can be used.
All of adhesions which usually impair visualization and retraction of the gallbladder are divided by unipolar or bipolar diathermy. A grasping forceps inserted through the midaxillary trocar grasps the fundus of the gallbladder and firmly retracts it headwards, pointing towards the right shoulder, thereby functioning like a Deaver retractor, exposing the body from the gallbladder and also the adhesions round the gallbladder. The assistant/nurse holds the forceps maintaining the desired degree of traction on the fundus. If there is no assistant the handle of the forceps can be fixed to the drapes having a towel clip to maintain the required level of traction.
Adequate retraction of the gallbladder is a prerequisite of laparoscopic cholecystectomy. Many factors might make retraction difficult:
- A grossly distended gallbladder doesn't seem possible to grasp without risk of rupture and really should be aspirated under visual control with a needle inserted in the fundus. Bile leak in the puncture site can be prevented by grasping the fundus in the puncture site.
- A contracted fibrosed gallbladder does not enable the grasper on the fundus to push it upwards to retract the liver. This may require a 5th trocar in the left hypochondriac region for direct liver retraction.
- An very thick-walled gallbladder may need a toothed grasper for retraction.
- A stone impacted within the neck from the gallbladder with dense surrounding fibrosis and adhesions is, a major obstacle to retraction. The primary purpose of retraction is to retract the neck from the gallbladder laterally to put the cystic duct and artery about the stretch, and maintain the cystic duct at right angles towards the CBD Adhesions and fibrous thickening around the neck make this very difficult. Dissection should commence in the gallbladder neck and move medially mm by mm.
- Anterior and superior surface of the liver adherent to the anterior abdominal wall/diaphragm cause difficulty in retraction. These adhesions ought to be severed allowing free liver movement upwards. Many of these adhesions are avascular and can easily be divided by sharp dissection.
- A fibrotic cirrhotic liver adds greatly to the difficulties already present through the greatly increased vascularity of portal hypertension. The grasper on the fundus cannot push the rigid liver upwards. We invariably make use of a 5th port for retracting the liver having a suction tube which will help maintain a definite dissection field.
The technique all of us adopt to split up adhesions would be to grasp them as near towards the gallbladder wall as possible, or rather about the gallbladder wall, thereby shearing them from the gallbladder in an avascular plane [FIG. 6]. The movement of the forceps is always in the gallbladder towards those structures round the gallbladder to which it's adherent, i.e. the omentum, the colon, and also the duodenum. Starting in the area closest to the fundus, the adhesions are gradually separated towards the Hartman’s pouch. If adhesions do not strip easily, sharp diathermy dissection in the same plane can be used.
All adhesions to the liver adjacent to the gallbladder also have to become divided. Most of these require sharp dissection to avoid shearing from the liver capsule with problematic bleeding. Once this is done, the left hand forceps grasps the Hartman’s pouch and retracts it laterally. With traction on the fundus headwards, on Hartman’s pouch laterally, along with the duodenum displaced medially through the right hand forceps through the epigastric port, the peritoneal fold of the cystic duct and the cystic artery is placed on the stretch. The issue adhesions are when the gallbladder in the region of Hartman’s pouch and gallbladder neck is densely adherent towards the Common Bile Duct, Common Hepatic Duct, or duodenum. Dissection in such a situation must be completed in a clear field with optimal magnification, aided with a 30 degree telescope. At no stage should the integrity of either the Bile Duct or duodenum be compromised. It's possible to never repeat often enough, or stress strongly enough that endurance and precision would be the fundamentals of safe laparoscopic surgery.
At open up surgery, the operating specialist uses both hands, however the right hand is prevalent as it has free connection with and use of tissue. At laparoscopic surgery the best hand runs on the 36-39 cm long instrument through an entry port which acts as a fixed fulcrum significantly restricting freedom of movement. At laparoscopic surgery, the left hand is vitally important as by altering the degree and direction of traction it displays different areas for dissection. It literally feeds tissue right hand for dissection, coagulation, clipping, cutting and suturing. Appreciation from the need for the left hand and it is intelligent me is one of the most vital points in safe and smooth laparoscopic surgery, and must be ingrained from the beginning of one’s endeavour on this surgery, so that ultimately the laparoscopic surgeon is ambidextrous.
We have standardized a routine method of cystic duct dissection. With the left hand lifting Hartman’s pouch upwards and laterally, the posterior aspect of Hartman’s Pouch is displayed. Dissection commences in the safest area by division of the peritoneal fold between the Hartman’s Pouch and liver moving in that posterior plane medially towards the cystic duct. With the help of curved dissectors or a hook dissector, and pinpoint diathermy, the posterior junction from the gallbladder and cystic duct is clearly defined. By adhering to a plane flush using the gallbladder - cystic duct junction and dissecting deeper and medially a “posterior window” is done whereby the dissection is deepend behind the Hartman’s Pouch and commencement of the cystic duct till the liver is visible through this window. Gradual medial-ward dissection clears the cystic duct in this region. Once the window and clearance of the gallbladder cystic-duct junction and lateral aspect of the duct is completed posteriorly, anterior dissection is commenced. Traction on Hartman’s Pouch is now altered to drag it down and laterally exposing the anterior peritoneal fold of Calot’s triangle. Once again dissection begins by clearing the junction between Hartman’s Pouch anteriorly and it is reflection about the liver, gradually moving medially to and on the artery and also the duct. The cystic artery is identified at this time and dissected separate from the cystic duct. Once the lateral ends of the duct and artery are dissected, circumferential dissection proceeds medially till the entire circumference of both structures is dissected, skeletonised and carefully scrutinized. Dissection from the cystic duct is completed with firm lateral traction on Hartman’s pouch. This helps open the angle between the cystic duct and C.H.D. Dissection from the cystic duct stops short about 1 cm. from the CBD to avoid any chance of problems for the CBD.
The more the adhesions, or even the more uncertain the anatomy, the more the dissection should move further up the neck from the gallbladder so that the entire circumference of the gallbladder is dissected at the neck before dissecting the cystic duct medially for the CBD This stresses the most crucial safety theme in Laparoscopic cholecystectomy. At open surgery I had been taught, also taught, how the vital area of dissection may be the cystic duct and the CBD junction. It cannot be emphasized strongly enough that at laparoscopic cholecystectomy, the vital area of dissection is circumferential dissection from the gallbladder and cystic duct junction. This dissection is the essence of safe laparoscopic cholecystectomy. A structure not seen at open surgery but due to magnification often present at laparoscopic cholecystectomy is a branch from the cystic artery to the cystic duct which must be divided to ensure full skeletonization of the duct.
The greater part from the dissection is blunt dissection using the ‘Maryland” dissector, or the tip from the irrigationsuction cannula. It is stressed that dissection is definitely within the direction from the gallbladder for the CBD Sharp dissection by hook or scissor is safer than forced or rough traction-teasing. Once the cystic duct is fully dissected and skeletonised, trans-cystic duct laparoscopic cholangiography, if indicated, can be executed.
The artery is clip occluded after dissecting the artery to where it enters the gallbladder. Two medium size clips are applied on your body side of the artery and a third about the artery flush using the gallbladder. This ensures it's the cystic artery which is divided. An abnormally wide “cystic” artery should arouse suspicion of the “humped” right hepatic artery with a short cystic artery - hence the requirement to dissect the cystic artery flush with the gallbladder. Following the artery is separated, the medial and lateral peritoneal folds extending as much as the liver on each side from the neck are divided so that the gall bladder-duct junction is fully mobilized to give the “elephant head” appearance. This visually ensures there isn't any abnormal duct entering the cystic duct. We do not clip the duct till the “elephant head” is clearly demonstrated. This is the surest method of identifying any aberrant duct. Reusable clip applicators are utilized with the smaller medium size clip to occlude the artery since the small clip provides a firmer occlusion of this thin structure. We do not advocate use of the large clip in laparoscopic cholecystectomy - as it is unnecessary and very damaging.
Clip Size selection:
- Cystic duct upto 3 mm diameter: medium clip,
- Cystic duct Three to five mm diameter: medium-large clip,
- Cystic duct over 5 mm diameter: ligature.
How big various structures can be simply based on comparing with known size of tips of various instruments. The clip should be applied only after dissection from the entire circumference of the duct and artery. The direction of traction through the left hand on the Hartman’s Pouch at this time is important. Traction should be laterally so the Cystic Duct reaches right-angles towards the Common Hepatic Duct and Common Bile Duct junction. This helps to ensure that the clip is applied and then the Cystic Duct and doesn't have a bite of the Common Hepatic Duct. If at this time traction is within an upward-medial direction the Cystic Duct will be aligned parallel towards the Common Hepatic Duct and also the tip from the clip could take a bite from the Common Hepatic Duct. Whenever we reviewed the videos of patients referred to us for post laparoscopic cholecystectomy bile duct injuries we noticed that failure of lateral traction during cystic duct dissection or clipping was an important causes of common hepatic duct injury. What is loosely termed “CBD” injuries after laparoscopic cholecystectomy are almost always common hepatic duct injuries. The clip is driven home only when the distal limb of the clip can be seen behind the duct or artery to ensure no other structure is caught within the clip. This can be optimally seen when the telescope and also the clip applicator are at right angles to each other. The clip is applied at right angles to the structure to become occluded that is “fed” into the clip by left hand traction to ensure that the entire circumference from the duct/artery is within the clip. The position of the CBD is visualized before clip occlusion. If the clip isn't properly positioned or doesn't have a bite of the full diameter from the structure, it ought to be removed by grasping in the angle and tugging in the direction of the clip. The lateral traction of the left hand is reduced just before clip occlusion or ligature from the cystic duct to ensure that the CBD isn't tented to the clip or ligature. We ensure we leave a stump with a minimum of 0.5 cm from the cystic duct medial to the site of occlusion. Two clips on the body side and one in the neck of the gallbladder are applied and also the duct divided near to the clip on the specimen side.
Once both the cystic artery and also the cystic duct are divided the stumps of both these structures are carefully examined.
By modifying the direction of traction on the gallbladder the peritoneal folds are created taut first laterally after which medially and with sharp scissor or hook dissection with diathermy, the gallbladder is gradually dissected from the gallbladder fossa beginning with the neck and dealing towards the fundus. We feel it advantageous to proceed on this direction simply because, maximum tension can be maintained on the peritoneal folds and the liver is retracted upwards so the gallbladder fossa reaches all times displayed and any bleeding from this can be clearly visualized and coagulated carefully. With diathermy dissection, the stretched areolar tissue with occasional vessels or ductules is divided. The traction from the forceps on the fundus as also the direction and degree of traction of the left hand are constantly altered to keep the area under dissection on the stretch, permitting smooth dissection of the gallbladder. While dissecting the gallbladder, it is possible that certain may enter a deeper plane starting the liver tissue, or conversely, the gallbladder wall is nicked. If opened, the gallbladder wall round the rent ought to be held by a grasping forceps and a loop ligature or clip applied around the tear, sealing it. There is often an arterial bleeder in the fundus which needs specific coagulation. We keep your final fundus connection undivided and employ the gallbladder for traction to examine the liver bed for any bleeding that is coagulated. Sometimes hepatic venous ooze is difficult to prevent with diathermy. In these situations, the dissected gallbladder may be used as a tampon and compressed from the liver bed for a few minutes, stopping the bleeding.
Wherever there's gross fibrosis in the neck of the gallbladder and also the integrity from the CBD is compromised, we recommend the fundus first dissection, and clip or endo loop the cystic duct flush with the gallbladder. This is actually the safe method for a “partial cholecystectomy”. Occasionally, there isn't any plane of dissection between a small contracted gallbladder and also the liver bed. Rather than enter deep into the hepatic tissue it might be prudent to excise the gallbladder leaving a small sector of the wall stuck to the liver bed behind, sucking bile and very carefully collecting all spilled stones. The mucosa from the gallbladder wall adherent towards the liver is carefully diathermized. To minimize bleeding, this really is our standard method of gallbladder dissection in cirrhosis. Once hemostasis is secured, the abdomen is irrigated and sucked clean. The left tilt and head-high position of the patient is reversed. The abdomen is carefully reviewed and any fluid collection is aspirated, re-checking the pelvis and sub-diaphragmatic areas.
The gallbladder neck is drawn to the 11 mm trocar and it is gradually taken out from the abdominal cavity with the 11 mm. trocar. When the gallbladder is not distended and possesses small stones its extraction is not a problem. The gallbladder is not brought out with the trocar. The grasping forceps and also the entire trocar sheath are withdrawn from the abdominal cavity using the gallbladder to ensure that the edge of the sheath does not shear the gallbladder. The grasping forceps, the gallbladder and the sheath are removed as you unit. This gives the neck of te gallbladder in most cases to be brought out towards the abdominal surface. The gallbladder neck is then grasped with an artery forceps. With firm rotary movement it's withdrawn as the telescope/ camera keeps the intra-abdominal the main gallbladder constantly under vision to ensure that the intraabdominal part is not so distended that it could rupture. Once the gallbladder is grossly distended with bile, the bile is aspirated with the neck from the gallbladder with a fine tipped mastoid suction cannula.
A haemostat can be passed by the side from the gallbladder through the epigastric incision and it is jaws opened gently to stretch and dilate the peritoneum and fascia permitting easier extraction of the gallbladder without enlarging the incision. Very thick-walled, fibrotic non collapsible, gallbladders would be best removed with the umbilical port after extending the sheath incision. This is the favoured mode of extraction in very obese patients. A contaminated gall bladder is extracted in a plastic bag to avoid any contact with the abdominal wall incision.
A vexing problem in laparoscopic cholecystectomy is extraction from the gallbladder when it bears a heavy stone load. We make use of an ovum forceps as a stone extractor. The ovum forceps has large, scooped, spoon-shaped grasping ends, is strong enough to crush any gallstone, can go through single cm. incision in the neck from the exteriorized gallbladder and can evacuate a large stone load with each withdrawal.
The naso gastric tube is taken away on the O.T. table. All patients are saved in the recovery room for about one hour, with monitoring of pulse, B.P., ECG, oxygen saturation. All patients are administered I.M. analgesics the night after surgery. A well rested patient won't require any
Peristalsis usually returns 4 - 6 hours after surgery at which time oral fluids are started. All patients have I.V. Cephalosporin intra operative, the night time of surgery and if indicated the next morning. It's unusual in the Indian setting for patients to become discharged the same day - most patients go back home the next or on the 2nd post-operative day.
Virtually any deviation from the normal, smooth, pain-free recovery of a laparoscopic cholecystectomy should cause anxiety. Pain, fever, distension, ileus, jaundice, abdominal guarding or rebound when seen should ring alarm bells.
Variants in patient position, trocar insertion approach to occlusion or dissection are mere details and frills. The essence of all strategies is similar - clear dissection and display of relevant anatomy, creating the “elephant head”, secure occlusion from the duct and artery, dissection of the
gallbladder in the proper tissue plane, hemostasis, and clear visual field all the time.
SOME TAKE-AWAY SUGGESTIONS
- In most case, dissection commences in the neck from the gallbladder circumferentially and should progresses all around the cystic duct towards the CBD, and creating the “elephant head” the integrity from the biliary tract is ensured.
- Surgeon should assume every case has a short duct and/or other anatomical abnormalities. Anatomical abnormalities within the triangle of Calot are normal.
- A “short” cystic duct could be “lengthened” after dissecting and dividing the cystic artery flush with the gallbladder and teasing out fibrous bands which kink and shorten the duct.
- Laparoscopic cholangiography isn't any substitute for careful dissection. Its primary indication would be to exclude or confirm presence of CBD calculi.
- Bleeding. Panic a reaction to bleeding through panic clip application or even bulk diathermy results in disaster.
This is the basic principle of open up surgery - and applies much more stringently to laparoscopic surgery. The immediate response to brisk bleeding should be compression - most effectively by the gallbladder, followed by flushing and suction. If after several minutes of continuous, efficient compression through gallbladder or a gauze strip the bleeding site can't be obviously identified, precisely grasped and carefully clipped or coagulated it may, be a wise decision to think about conversion. Gentle pin-point coagulation or even the tiniest clip ought to be accustomed to arrest bleeding - never the additional large clip that could partially or absolutely occlude the adjacent hepatic duct / artery. It holds repeating that vital structures, ducts and vessels, are crammed in a very small region very close to the cystic duct as well as artery, prone to diathermy or clip injury.
- Bile within the peritoneal cavity is really a cause for concern. A common cause of bile leak is the place the grasping forceps employed for retracting the gall-bladder tears the gallbladder wall. The rent ought to be immediately grasped having a bigger bite of the wall and closed by having an endo-loop. Thin-walled, very distended gallbladders ought to be aspirated before being grasped. Similarly, bile can leak once the cystic duct is not fully clip occluded in the neck of the gallbladder and leaks bile included in the gallbladder after division from the duct while the gallbladder has been dissected from the gallbladder fossa. Biliary contamination of the peritoneal cavity is not to become taken lightly and when it will occur requires very thorough irrigation and suction. Following the gallbladder continues to be excised, the entire area is flushed and examined. If bile contamination is now seen, it could possess a sinister significance - this is often from the gallbladder fossa, a divided duct of Lushka, an inadequately occlded cystic duct, a divided accessory duct, or injury to the CBD.
- Spilled Stones or slipped clips in the peritoneal cavity can cause complications and should be retrieved.
- A quite narrow CBD can be mistaken as the continuation of the distally inserted cystic duct. Hence our insistence the sinologist always reports how big the CBD.
- The over-confident surgeon and also the “easy” case spell danger.
- A drain, when indicated, adds to safety.
- Malignancy is a complete contraindiacation to laparoscopic cholecystectomy.
- Diathermy complications are discussed somewhere else and therefore not stressed here, but the potential danger of diathermy should always remain in your mind. Diathermy injury is a very common cause of early and late complications in laparoscopic cholecystectomy
- Suture the sheath at both 10 mm ports. Omental prolapse, incisional or Richter hernia are not uncommon.
- Examine the specimen and check histopathology report in every case. This is mandatory since the patient leaves hospital before the histopathology report is received.
- Complications discovered at surgery have cheaper morbidity.