Atlas of General Surgical Techniques (Courtney M. Townsend Jr., B. Mark Evers)

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OPEN CHOLECYSTECTOMY

1.INCISION

The incision for open cholecystectomy is typically made 2 fingerbreadths below the right costal margin, although an upper midline incision can also be used (Figure 41-8, A).

Retractors are placed to retract the skin, as well as to retract the liver superiorly

(Figure 41-8, B).

A

Porta

hepatis

Gallbladder

Hepatic flexure of colon

B

FIGURE 41–8

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Clamps are placed proximally and distally on the cystic duct. The cystic duct is divided between the clamps (Figure 41-11, A), and the gallbladder is removed from the field.

The cystic duct stump is suture ligated using a 3-0 silk suture (Figures 41-11, B-D).

A B

C D

FIGURE 41–11

The cystic duct and cystic artery stumps are examined for any signs of bile leakage or bleeding (Figure 41-12). The abdomen is copiously irrigated with normal saline solution.

3.CLOSING

The placement of closed suction drains is not always required. They are placed only if bile leakage from the cystic duct stump is expected or observed. If bile leakage is observed, the surgeon must rule out common bile duct injury.

The fascia is closed in two layers using running or interrupted sutures.

The skin is then closed with absorbable subcuticular sutures or skin staples.

FIGURE 41–12

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STEP 4: POSTOPERATIVE CARE (LAPAROSCOPIC AND OPEN CHOLECYSTECTOMY)

Postoperative complications include hematoma, bleeding, or leakage from the cystic duct stump.

If a drain is placed operatively, the output should be monitored. If no bilious drainage is observed at 24 to 48 hours, the drain can be removed.

If bilious drainage is noted, this can initially be managed conservatively with continued observation. Liver function tests should be performed to evaluate for bile duct injury. If drainage persists, endoscopic retrograde cholangiopancreatography (ERCP) is indicated to definitively rule out injury. In addition, a common bile duct stent placed via ERCP will also treat persistent cystic duct leaks in the absence of common bile duct injury.

Clear liquids can be started immediately postoperatively for both laparoscopic and open cholecystectomy and generally advanced as tolerated. Patients undergoing open procedures may have a longer time to return to regular diet.

Patients are discharged home the same day after laparoscopic cholecystectomy and 2 to 3 days after open cholecystectomy.

Longer stay may be necessary in the setting of acute cholecystitis.

For uncomplicated gallstone disease, antibiotics are not continued postoperatively.

STEP 5: PEARLS AND PITFALLS

To avoid bile duct injury, it helps to retract the infundibulum of the gallbladder laterally to open up the triangle of Calot and form a 90-degree angle of the cystic duct with the common hepatic duct. Pulling the infundibulum superiorly orients the cystic duct similar to the common bile duct and can lead to injury.

After dividing the cystic duct and cystic artery, it is useful to begin the dissection of the gallbladder bluntly to make sure there are no ductal structures present.

A 5-mm port and a 5-mm clip applier can be used at the epigastrium. If this is done, a 5-mm camera will need to be present if a retrieval bag is going to be used to remove the gallbladder, because this comes in only the larger size.

Cholecystectomy can be performed from the top down in both the laparoscopic and the open settings, although it is more difficult in the laparoscopic setting.

The clips placed on the cystic duct and artery need to completely occlude the lumen. If this is not possible on the cystic duct, an Endoloop can be placed. In this setting, the anatomy should be reviewed to ensure that the cystic duct is ligated and the anatomy has not been incorrectly identified, because the clips are usually large enough to occlude the cystic duct.

Cholangiogram can be performed routinely or selectively, based on the preference of the operating surgeon.

If common bile duct stones are identified, a laparoscopic or open common bile duct exploration can be performed. Alternatively, ERCP can be performed to clear the duct postoperatively.

Multiple previous abdominal surgeries, severe cardiac disease, and severe acute cholecystitis are relative contraindications to laparoscopic cholecystectomy. When a patient has a history of multiple previous abdominal surgeries, an open technique should be used to place the initial umbilical port.

When performing laparoscopic procedures, it is best to convert to an open procedure if

(1)there is uncontrolled bleeding; (2) safe laparoscopic access to the abdominal cavity cannot be obtained; (3) the anatomy of the triangle of Calot cannot be clearly delineated; or

(4)injury to the common bile duct, small bowel, or any other structure is suspected. This should not be considered a failure.

SELECTED REFERENCES

1.Jones DB, Maithel SK, Schneider BE (eds): Atlas of Minimally Invasive Surgery. Woodbury, Conn, Ciné-Med, 2006, pp 12-39.

2. Cameron JL: Atlas of Surgery, vol 1. Philadelphia, BC Decker, 1990, pp 2-9.

3. Posther KE, Pappas TN: Acute cholecystitis. In Cameron JL (ed): Current Surgical Therapy, 8th ed. Philadelphia, Mosby, 2002, pp 385-391.

4. Hutter MM, Rattner DW: Open cholecystectomy: When is it indicated? In Cameron JL (ed): Current Surgical Therapy, 8th ed. Philadelphia, Mosby, 2002, pp 400-401.

The indications for hepaticojejunostomy include benign distal biliary stricture, recurrent cholangitis secondary to a stricture or stone disease, palliation of jaundice in patients with unresectable periampullary cancer, and bile duct injury (usually iatrogenic). With bile duct injuries, the duct is often normal caliber, making the operation more difficult.

The patient is placed supine on the operating room table, with both arms extended.

Subcutaneous heparin is given, and sequential compression devices are used to prevent venous thromboembolism.

A second-generation cephalosporin is used for antibiotic prophylaxis before skin incision and redosed for the first 24 hours.

A Foley catheter is placed to monitor urine output.

A nasogastric (NG) tube is placed to decompress the stomach. This is left in postoperatively.

Common hepatic duct

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STEP 3: OPERATIVE STEPS

CHOLEDOCHODUODENOSTOMY

1.INCISION

The operation is performed through a right subcostal incision (see Figure 42-1, A). It can also be done using an upper midline incision.

2.DISSECTION

Patients have often had previous cholecystectomy, and there may be adhesions between the liver and the portal structures. The adhesions are dissected sharply using electrocautery or scissors, or both.

The duodenum and extrahepatic biliary tree are exposed (see Figure 42-1, B).

The duodenum is kocherized out of the retroperitoneum (Figure 42-2). This may require mobilization of the hepatic flexure of the colon inferiorly. It is important to completely mobilize the duodenum to perform the choledochoduodenostomy without tension.

The duodenum is sharply dissected off the anterior surface of the distal common bile duct. The common bile duct should be clearly exposed in the anterior and lateral surfaces.

Using a no. 15 blade, an anterior choledochotomy is made in the common bile duct where it courses posterior to the duodenum. The choledochotomy is extended to a length of approximately 2 cm using Potts scissors (Figure 42-3). Stones are extracted if present.