SURGICAL TECHNIQUES FOR CHOLECYSTECTOMY By Brig. Abrar Hussain Zaidi

Prologue Cholecystectomy is one the commonest general surgical procedures Gall stone disease, acalculus cholecystitis ,ca-gall bladder and hepatobiliary trauma –are the common indications for cholecystectomy. Different clinical situations demand different methods and techniques to perform the procedure. In any one situation one may need to change one surgical technique to another one if the difficulties arise. Availability of surgical expertise and armamentarium.

Surgical planning Terminology Elective cholecystectomy Emergency = Early = Delayed /interval = Prophylactic cholecystectomy Extended cholecystectomy Partial cholecystectomy

Clinical situations Asypmtomatic Biliary colics / dyspesia Acute Infection /complications-Acute cholecystitis-empyema- perforation Chronic cholecystitis,adhesions,fistulae, Assoiciated CBD calcli Malignancy

What we need to know General principles of operative procedures Common techniques Techniques in Difficult operations

General principles of operative procedures Basic principles are same for all techniques Care full selections of cases Complete evaluations and assessment Written consent Proper preparation Methodology Asepsis Exposure Inspection Care dissection at callot’s triangle Dealing with the cystic duct and artery Dissection of gallbladder bed Extraction Re-examination

Contemporary methods of Cholecystectomy Open Laparoscopic -conventional -SILS -Needle-scopic

OPEN CHOLECYSTECTOMY

Open Cholecystostomy Conventional open Oblique sub-costal incision Transverse incision Midline Rt. para-median Mini-lap open

Planning the incision

Planning the incision

Planning the incision

Planning the incision

Cutting through the abdominal wall layers Muscle cutting Muscle splitting Scissors Diathermy Protection of nerves vessels

Examination, planning, packing Visualize the primary area Release adhesions Examine the cavity/adjacent structures

Dissection in callot’s triangle Dissect out the Cystic artery and the duct Ligate and cut the artery and the duct Dissect out slowly Prevent damage to CBD

Exposing the Cystic Duct and Artery

Dissection at gall bladder bed Neck side first Fundus first method

Re-examination Remove old gauze packs New Dry White gauze pack------- wait Bile stainig - callot’s triangle - Liver bed Bleeding /Oozing -from liver bed -Callot’s triagle Instument and gauze count

Difficult gall bladder Wall thickness Anatomy not clear Thick adhesions Abdominal girth Other factors Concerns : Bleeding at porta Bile duct injuries Injury - duodenum,colon,stomach etc

Anterior partial Cholecystectomy Removal of fundus and part of anterior wall and the harman’s area Leaving the upper wall near porta-hepatis Method in difficult situations

Cholecystostomy Opening the gall bladder lume Removal of calculi Drainage of pus Insertion of drain inside and adjacent to gall bladder

Drains or no drains--?

Choledochotomy, operative cholangiogram

Do’s and Don'ts Plann well,cut well [to get well] Good Exposure Retraction Visualization of anatomy at callot’s Dissect lateral to medial Carefully use the instruments and diathermy Keep eye on assistants Packing and re-examination Drain if in dought

Do’s and Don'ts Never be in hurry - [don’t be a turtle either]. Never cut without proper visualization. Don’t apply forceps blindly –prefer packing. Never use diathermy close to the CBD. Don’t pull from medial to lateral.

Audit - the out come

Difficult situations Empyema Thick wall Extensive adhesions Cancer Fistulae Per-operative injuries CBD Hepatic artery/portal vein tributary Duodenal Gastric Colonic

Difficult situations Re-orientate yourself Never be in panic Pack relax and think Manage the difficulty at its merit

Difficult situations Options Difficult dissection Cholecystostomy Anterior partial Cholecystectomy Biopsy Drain Ask for help Treat the injuries as per T_Tube drain By pass

Laparoscopic Cholecystectomy

Innate Human Desire = To Be Minimally Harmed / Surgically The foundation of what is now referred to as minimally invasive surgery.

First solid state camera in 1982 1987 - Phillipe Mouret performed the first laparoscopic cholecystectomy. An ignition for the laparoscopic surgery.

Conceptual debates - ISSUES Post-operative pain Recovery / Hospital stay Visual field for surgeons Operation time Cost Cosmetic outcome Patient acceptance The complications

Advantages/ benefits Reduced operative trauma Reduced bleeding Reduced post operative pain and analgesic requirement Reduced operative trauma Reduced bleeding Faster recovery, discharge and return to work Reduced wound infection, seroma and haematoma Reduced chronic wound pain Less cardiorespiratory complications

Advantages/ benefits Less ileus from reduced handling Improved cosmesis Reduced contamination of theatre staff (Hepatitis and HIV) Interesting for surgeons Reduced outpatient/social costs

Advantages/ benefits Reduced risk of DVT/PE Reduced incisional hernia rate Fewer adhesions and less likely to develop obstruction Immunological benefits Better visualisation for the surgeon

Disadvantages/ Risks High risk of co-lateral injury eg Common bile duct in lap cholecystectomy Bowel/bladder/vascular injury in hernia surgery Verres needle injury Diathermy may lead to organ damage eg late cbd stricture Increased operating time

Disadvantages/ Risks Increased costs due to theatre time and equipment Tumour seeding Poor quality surgery eg cancer resection Loss of tactile sensation Long learning curve Loss of training opportunity eg appendicitis and inguinal hernia Some surgeons not able to develop skills

THE ART AND THE CRAFT

THE EQUIPMENT THE TECHNIQUE THE TRAINING

THE EQUIPMENT

The Equipment Laparoscope/video system Light source Insufflator Diathermy /coagulation:cutting system [+Harmonic ace] Suction irrigation system Specialized hand instruments

Trolley

The Equipment Laparoscope/video system There are two types: Telescopic rod lens system, that is connected to a video camera (single chip or three chip) or A digital laparoscope where the charge-coupled device[CCD] is placed at the end of the laparoscope, eliminateing the rod lens system.

Telescopic rod lens system There are three important structural differences in telescope available in the market. 6 to18 rod lens system telescopes 0 to 120 degree telescopes 1.5 mm to 15 mm of telescopes

Telescopic rod lens system

Three primary colours (Red,Blue, Green). Video camera Single chip VS three chip Three primary colours (Red,Blue, Green). In single chip camera all these 3 primary colours are sensed by single chip. In three chip camera there are 3 CCD- Chips for separate capture and processing of 3 primary colours—High resolution

Video camera

Monitor No different from the T.V. Basic principle of image reproduction is horizontal beam scanning on the face of the picture tube.

The existing television systems in use differ according to the country. The U.S.A uses the NTSC (National Television System Committee) system. In European countries the PAL (Phase Alternation by Line) system is in use. French system called SECAM (Sequential color and memory).

Light source A fiber optic cable system connected to a 'cold' light source (halogen or xenon), to illuminate the operative field,

Light source

Fiber optic cable

Insufflator The abdomen is insufflated with carbon dioxide gas [pneumoperitomeum] to create a working and viewing space. Elevates the abdominal wall above the internal organs like a dome. Gasless surgery –with mechanical wall elevators

Insufflator

Coagulation & cutting System Diathermy monopolar / bipolar Harmonic

Harmonic dissector

Harmonic dissector

Specialized hand instruments A-ACCESS INSTRUMENTS B-DISSECTING/OPERATING INSTRUMENTS C-RETRIEVAL INSTRUMENTS

Specialized hand instruments 5-10mm diameter instruments Trocars & Ports---access devices Graspers Scissors Dissectors Clip applier,Knotting devices,Staplers Cutting /coagulation – hooks,spatulas,balls,forceps Irrigation suction tubes Retrieval instruments

Disposable vs Reusable instruments Conventional vs. Needle scopic /miniaturized instruments—2mm size

Veress Needles

Trocars

Scissors

Dissectors

Graspers

Hook & spatula

Diathermy/harmonic dissector

Clip applicator

Staplers Knotting devices Suturing devices

Irrigation suction instruments

Irrigation suction instruments

Irrigation suction instruments

Retrieval instruments

Retrieval instruments

Retrieval instruments Extractor

The technique and the training

Learning the art parallels the steps followed in actual performance of a Laparoscopic procedure

The learning curve Step by step learning

SIMULATOR TRAINING-Endotrainers

SIMULATOR TRAINING-manikins

SILS

LAPAROSCOPIC CHOLECYSTECTOMY Indications patient selection Consent/special features Preparation Procedure Post-operative care Record and audit

Operation Room Set up

Approach

Positioning and setting the instruments Check the diathermy Focusing & White balancing of camera Pressures

Approach

Pneumoperitoneum

Insertion of access ports Camera Grasping and holding instruments Dissecting instruments Additional

Basic principles of surgical procedure are the same as for open surgery Only the technique differs

Inspection-diagnostic laparoscopy Primary area of concern Rest of the cavity Resectability Adhesions

Mobilizing the Gall bladder

Aspiration

Dissecting in Callot’s triangle Grasp the fundus of the gallbladder and elevate it over the anterior edge of the liver by progressive traction. The infundibulum, or Hartmann’s pouch, is pulled upward using a second grasper placed through the remaining accessory port. This exposes the cystic duct and artery as well as the common bile duct. Constant retraction and good exposure . The patient is then positioned in reverse Trendelenburg and tilted to his/her left.

Dissecting the Cystic Duct and Artery Fundus grasped with the lateral most grasper and pulled laterally, further exposing the cystic artery and cystic duct. Defined by the cystic artery above, the cystic duct below and the common bile duct medially. Dissecting instrument through the subxiphoid cannula Identifies the cystic duct by teasing away the peritoneal covering of the cystic duct-gallbladder junction. In acute cholecystitis, edematous layers of tissue will have to be stripped downward to expose the cystic duct. Dissection should continue in a lateral to medial direction, beginning at the infundibulum and continuing medially toward the entrance of the cystic duct into the gallbladder neck. Avoid damage to key structures such as CBD, right hepatic artery, and duodenum. Identify junction between the cystic duct and gallbladder neck the cystic duct is dissected circumferentially near the junction. In most cases, the cystic duct is anterior to the artery.

The cystic artery is then dissected circumferentially in a similar fashion. The artery is usually found just posterior to the cystic duct, toward the liver bed. The operator must be meticulous at this stage, as the right hepatic artery can be immediately adjacent to the cystic artery, and can be damaged with overzealous dissection. The cystic artery is then clipped twice proximally, once distally (toward the gallbladder) and divided with scissors. Again, the clip on the specimen side should be placed as close as possible to the gallbladder neck to allow for maximal clearance of the clips adjacent to the porta hepatis.  

Displaying the Cystic duct

Clipping the cystic duct

Cutting the cystic duct

Dealing with cystic artery

Summary of callot’s dissection

Dissecting out Gallbladder from liver bed

Dissecting out Gallbladder from liver bed

Preparing for Retrieval

Retrieval

Post-operative cholangiogram

Complition Re-inspection Irrigation suction Drain Deflation Check the ports Close the incisions Carefully collect the instruments/equipment

Post op follow up

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