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203
PLATE
93
SUTURE OF PORT SITE e cystic artery is cleared for a -cm
zone and its path followed onto the surface of the gallbladder. e clear
zone is then doubly secured with metal clips both proximally and distally
(figure 13). e cystic artery may be divided with endoscopic heavy scissors. However, many prefer to wait until a er the cystic duct cholangiogram,
as the intact cystic artery may serve as a helpful tether should the cystic
duct be transacted during its opening for the cholangiogram catheter.
e cystic duct is also cleared for about cm or so such that the surgeon
can clearly identify its continuity with the gallbladder and its junction with
the common duct. A metal clip is applied as high as possible on the cystic
duct where it begins to dilate and form the gallbladder. If a cholangiogram
is not to be performed, then two clips are placed on the proximal cystic
duct and the duct is divided. If a cholangiogram is to be performed, the
surgeon should be certain that all the equipment is available. is includes
a catheter of choice, two syringes (one for saline and one for contrast),
a stopcock for the syringes, and extension tubing. All of the air must be
emptied from the tubing prior to performing the cholangiogram. In preparation for insertion of the cholangiocath, using the endoscopic scissors
through the middle port (figure 14), the cystic duct is opened and bile
is noted. If necessary, the opening may be dilated with the scissor tips.
e cholangiogram catheter of choice is passed through the middle port
and the duct cannulated (figure 15). Some catheters are secured within
a winged clamp, whereas others rely on an in ated intraluminal Fogartylike balloon. A simple straight plastic catheter may be secured with a gently applied metal clip over the lower cystic duct containing the catheter.
It should be snug enough to prevent leakage but loose enough to avoid
crimping the catheter and thus preventing dye injection. Alternatively, a
-guage angiocath is inserted into the abdominal wall between the mid-
C, L
clavicular trocar and that in the anterior axillary line. A French ureteral
catheter or other similar catheter may be inserted into the abdominal cavity through this angiocath and then guided into the cystic duct and held
in place with a clip.
In preparation for the cholangiogram, the videoscope and metal instruments are removed. e radiolucent ports are aligned in a vertical axis so as
to minimize their appearance on the x-ray. e eld is covered with a sterile
towel and the x-ray equipment positioned. Simple dye injections with individual lms or a sustained injection under uoroscopy are performed. e
principal ducts are visualized thus ensuring anatomic integrity, the absence
of ductal stones, and ow into the duodenum. Upon completion of a satisfactory cholangiogram, the lower cystic duct is doubly clipped and the
cystic duct divided with endoscopic scissors (figure 16). However, should
an abnormal or confusing cholangiogram be obtained, the surgeon should
convert to an open procedure with full anatomic veri cation.
e cystic duct junction with the gallbladder is grasped with forceps
through the middle port and the gallbladder is removed from its bed beginning inferiorly and carrying the dissection up the gallbladder fossa. Most
surgeons score the lateral peritoneum for a centimeter or so with electrocautery (figure 17) and then elevate the gallbladder from the liver bed.
Appropriate traction, o en to the sides, is required to provide exposure of
the zone of dissection with an electrocautery instrument between the gallbladder and its bed (figure 18). Vigorous traction with the forceps or dissection into the gallbladder wall may produce an opening with spillage of
bile and stones. Such openings should be secured if possible using forceps,
metal clips, or a suture loop, which is rst placed over the forceps and then
closed like a lasso over the hole and the adjacent gallbladder wall that is
tented up by the forceps.
CONTINUES
204
205
PLATE
94
SUTURE OF PORT SITE As the dissection proceeds well up
the gallbladder bed, it may be necessary for the rst assistant to actively
position and reposition the two forceps on the gallbladder so as to provide
good exposure for the surgeon. When the dissection is almost complete
and traction on the gallbladder still allows superior displacement of the
liver with a clear view of the gallbladder bed and operative site, the surgeon
should reinspect the clips on the cystic duct and artery for their security
and the liver bed for any bleeding sites. e region is irrigated with saline
(figure 19) and the diluted bile and blood are aspirated from the lateral
gutter just over the edge of the liver. e nal peritoneal attachments of the
gallbladder are divided from the liver and the gallbladder is positioned above
the liver, which has now fallen back inferiorly to its normal position.
e videoscope is removed from the umbilical port and inserted in the
epigastric one. If a -mm port was used at the xiphoid site in order to reduce
the incidence of incisional hernia, then a -mm laparoscope is substituted
for the -mm scope. Consideration should be given to contain the gallbladder in a laparoscopic retrieval bag prior to removal, especially if the
gallbladder is abnormal and there is a concern for malignancy, it is infected,
or it has been opened.
A grasping forceps is passed through the umbilical port so as to pick up
the end of the specimen in the region of the cystic duct or the specimen
retrieval bag (figure 20). is exchange may be somewhat disorienting
to the surgeon and rst assistant as le and right are now reversed in a
mirror-image manner on the monitor screens. If the gallbladder stones are
small, one is usually able to withdraw the gall-bladder, forceps, and umbili-
C, L
cal port back out to the level of the skin where the gallbladder is grasped
with a Kelly clamp (figure 21). Bile and small stones may be easily aspirated whereupon the gallbladder will exit easily through the umbilical site
under direct vision of the videoscope in the epigastric port.
Extraction of large stones or many medium-sized stones may require
crushing prior to extraction (figure 22) or require that the linea alba opening be enlarged. A er extraction, the umbilical site is temporarily occluded
with the assistant’s gloved nger so as to maintain the pneumoperitoneum.
e middle and lateral ports are removed as the videoscope inspects for any
bleeding at these sites. e videoscope is removed and the pneumoperitoneum is evacuated so as to lessen postoperative discomfort.
CLOSURE e operative sites are in ltrated with a long-acting local anes-
thetic (bupivacaine) (figure 23), and the fascia at the -mm port sites
is resutured with one or two absorbable sutures (figure 24). e skin is
approximated with absorbable subcutaneous sutures. Adhesive skin strips
and a dry sterile dressing are applied.
POSTOPERATIVE CARE e orogastric tube is removed in the operating
room prior to emergence from general anesthesia. Pain at the operative site
is usually well controlled with oral medications. Although patients have
some transient nausea, most are able to take oral liquids within to hours
and may be discharged home within one day. Follow-up by the surgeon
is important, as biliary injuries are o en occult and delayed in presentation. Prolonged or new, unexpected pain should be evaluated with physical
examination, laboratory tests, and a HIDA radionuclide scan. ■
206
207
PLATE
95
INDICATIONS Cholecystectomy is indicated in patients with proven dis-
ease of the gallbladder that produces symptoms. e incidental nding of
gallstones by x-ray or a history of vague indigestion is insu cient evidence
for operation in itself, especially in the elderly, and does not justify the risk
involved. On the other hand, it is doubtful whether gallstones can ever be
considered harmless, because, if the patient lives long enough, complications are likely to develop. Today, most patients have laparoscopic removal
of their gallbladder. e procedure described here is called “open” and is
most commonly performed at a conversion to open when the initial laparoscopic approach encounters complex technical events (swollen, gangrenous gallbladder, confusing anatomy, or abnormal cholangiograms, etc.)
or major complications (ductal, blood vessel, or bowel injury) that are best
treated with open exposure. Although open cholecystectomy is no longer
the primary operation of choice, its mastery is essential in combination
with the laparoscopic approach.
PREOPERATIVE PREPARATION A low-fat diet is advised. e patient
should be free from respiratory infection. A roentgenogram of the chest
is taken. Very obese patients should reduce their weight substantially by
dieting, unless they are having recurrent attacks of colic. e entire gastrointestinal tract should be surveyed for additional disorders, i.e., hiatal
hernia, ulcer of the stomach or duodenum, and carcinoma or diverticulitis
of the colon.
ANESTHESIA General anesthesia with endotracheal intubation is recom-
mended. Deep anesthesia is avoided by the use of a suitable muscle relaxant. Spinal, either single-injection or continuous technique, may be used in
preference to general anesthesia. In those patients su ering from extensive
liver damage, barbiturates as well as other anesthetic agents suspected of
hepatotoxicity should be avoided. In elderly or debilitated patients, local
in ltration anesthesia is satisfactory, although some type of analgesia is
usually necessary as a supplement at certain stages of the procedure.
POSITION e proper position of the patient on the operating table is
essential to secure su cient exposure (figure 1). Arrangements should
be made for an operative cholangiogram. An x-ray cassette or uoroscopic
C-arm needs su cient space to be centered under the patient to ensure
coverage of the liver, duodenum, and head of the pancreas. e exposure
can be enhanced by tilting the table until the body as a whole is in a semierect position. e weight of the liver then tends to lower the gallbladder
below the costal margin. Retraction is also aided in this position, because
the intestines have a tendency to fall away from the site of operation.
OPERATIVE PREPARATION e skin is prepared in the routine manner.
INCISION AND EXPOSURE Two incisions are commonly used: the verti-
cal high midline and the oblique subcostal (figure 2). A midline incision
is used if other pathology, such as hiatus hernia or duodenal ulcer, requires
surgical consideration. ose favoring the subcostal incision believe the
exposure is good, early postoperative wound discomfort minimal, and the
C, R M
incidence of late postoperative hernias much lower than that following the
vertical incisions. A er the incision is made, the details of the procedure are
identical, irrespective of the type of incision employed.
DETAILS OF PROCEDURE A er the peritoneal cavity has been opened,
the gloved hand, moistened with warm saline solution, is used to explore the
abdominal cavity, unless there is an acute suppurative infection involving
the gallbladder. e stomach and particularly the duodenum are inspected
and palpated, and there is a general abdominal exploration that includes
careful evaluation of the size of the esophageal hiatus. e surgeon next
passes the right hand up over the dome of the liver, allowing air between the
diaphragm and liver to aid in displacing the liver downward (figure 3).
When assistance is limited, an external ring self-retaining retractor
with adjustable retracting blades (such as a Bookwalter type) may be used
advantageously, or an ordinary retractor of the Halsted type may be used on
the right side to retract the costal margin. A half-length clamp is applied
to the falciform ligament and another to the fundus of the gallbladder
( figure 4). Most surgeons prefer to divide the falciform ligament between
half-length clamps, and both ends should be ligated; otherwise, active arterial bleeding will result. Downward traction is maintained by the clamps
on the fundus of the gallbladder and on the round ligament. is traction
is exaggerated with each inspiration as the liver is projected downward
(figure 4). A er the liver has been pulled downward as far as easy traction
allows, the half-length clamps are pulled toward the costal margin to present
the undersurfaces of the liver and gallbladder (figure 5). An assistant then
holds these clamps while the surgeon prepares to wall o the eld. If the gallbladder is acutely in amed and distended, it is desirable to aspirate some of
the contents through a trocar before the half-length clamp is applied to the
fundus; otherwise, small stones may be forced into the cystic and common
ducts. Adhesions between the undersurface of the gallbladder and adjacent structures are frequently found, drawing the duodenum or transverse
colon up into the region of the ampulla. Adequate exposure is maintained
by the assistant, who exerts downward traction with a warm, moist sponge.
e adhesions are divided with curved scissors until an avascular cleavage
plane can be developed adjacent to the wall of the gallbladder (figure 6).
A er the initial incision is made, it is usually possible to brush these adhesions away with gauze sponges held in thumb forceps (figure 7). Once the
gallbladder is freed of its adhesions, it can be li ed upward to a ord better
exposure. In order that the adjacent structures may be packed away with
moist gauze pads, the surgeon inserts the le hand into the wound, palm
down, to direct the gauze pads downward. e pads are introduced with
long, smooth forceps. e stomach and transverse colon are packed away,
and a nal gauze pack is inserted into the region of the foramen of Winslow
(figure 8). e gauze pads are held in position either by a large S retractor
along the lower end of the eld or by the le hand of the rst assistant, who,
with ngers slightly exed and spread apart, maintains moderate downward
and slightly outward pressure, better de ning the region of the gastrohepatic
ligament.
CONTINUES
208
Foam
Pneumatic
sequential
compression
stockings
Electrocautery
ground pad
Table reversed open
area for X-ray
Gallbladder
Rectus muscle
Incisions
Diaphragm
Inferior
margin
of liver
Costal margin
Liver
Round ligament
Fundus of
gallbladder
Transverse colon
Stomach
Gallbladder
Duodenum
Hepatoduodenal
ligament
Foramen of
Winslow
“S” retractor
Table
control
1
2
3
4
5
6
7
8
209
PLATE
96
DETAILS OF PROCEDURE A er the eld has been adequately
walled o , the surgeon introduces the le index nger into the foramen of
Winslow and, with nger and thumb, thoroughly palpates the region for
evidence of calculi in the common duct as well as for thickening of the head
of the pancreas. A half-length clamp, with the concavity turned upward, is
used to grasp the undersurface of the gallbladder to attain traction toward
the operator (figure 9). e early application of clamps in the region of
the ampulla of the gallbladder is one of the frequent causes of accidental
injury to the common duct. is is especially true when the gallbladder is
acutely distended, because the ampulla of the gallbladder may run parallel
to the common duct for a considerable distance. If the clamp is applied
blindly where the neck of the gallbladder passes into the cystic duct, part or
all of the common duct may be accidentally included in it (figure 10). For
this reason it is always advisable to apply the half-length clamp well up on
the undersurface of the gallbladder before any attempt is made to visualize
the region of the ampulla of the gallbladder. e enucleation of the gallbladder is started by dividing the peritoneum on the inferior aspect of the
gallbladder and extending it downward to the region of the ampulla. e
peritoneum usually is divided with an electrocautery or long Metzenbaum
dissecting scissors. e incision is carefully extended downward along with
hepatoduodenal ligament (Figures 11 and 12). By means of blunt gauze
dissection the region of the ampulla is freed down to the region of the cystic duct (figure 13). A er the ampulla of the gallbladder has been clearly
de ned, the clamp on the undersurface of the gallbladder is reapplied lower
to the region of the ampulla.
With traction maintained on the ampulla, the cystic duct is de ned by
means of blunt dissection (figure 13). A long right-angle clamp is then
passed behind the cystic duct. e jaws of the clamp are separated cautiously as counter-pressure is placed on the upper side of the lower end of
the gallbladder by the surgeon’s index nger. Slowly and with great care, the
cystic duct is isolated from the common duct (figure 14). e cystic artery
C, R M
is likewise isolated with a long right-angle clamp. If the upward traction on
the gallbladder is marked, and the common duct is quite exible, it is not
uncommon to have it angulate sharply upward, giving the appearance of a
prolonged cystic duct. Under such circumstances, injury to the common
duct or its division may result when the right-angle clamp is applied to the
supposed cystic duct (figure 15 and insert). Such a disaster may occur
when the exposure appears too easy in a thin patient because of the extreme
mobilization of the common duct.
A er the cystic duct has been isolated, it is thoroughly palpated to ascertain that no calculi have been forced into it or the common duct by the
application of clamps and that none will be overlooked in the stump of the
cystic duct. e size of the cystic duct is carefully noted before the rightangle crushing clamp is applied. If the cystic duct is dilated and if it seems
from palpation that the gallbladder contains calculi so small that they could
pass through it easily, it is advisable to perform a choledochostomy. Regardless, an operative cholangiogram is performed routinely through the cystic
duct a er it has been divided (Plate , figure 24). Because it is more di cult to divide the cystic duct between two closely applied right-angle clamps,
a curved half-length clamp is placed adjacent to the initial right-angle clamp.
e curvature of the half-length clamp makes it ideally suited for directing
the scissors downward during the division of the cystic duct (figure 16).
Whenever possible, unless occluded by severe in ammation, the cystic duct
and cystic artery are isolated separately to permit individual ligation. Under
no circumstances is a right-angle clamp applied to the supposed region of
the cystic duct in the hope that both the cystic artery and cystic duct can be
included in one mass ligature. It is surprising how much additional cystic
duct can o en be developed by maintaining traction on the duct as blunt
gauze dissection is carried out. A er the cholangiogram, the cystic duct is
ligated with a trans xing suture (figure 17) or ligature, being sure not to
encroach on the common duct. In general, the free length beyond the tie
should approximate the diameter of the duct or vessel.
CONTINUES
210
211
PLATE
97
DETAILS OF PROCEDURE If the cystic artery was not
divided before the cystic duct, it is now carefully isolated by a right-angle
clamp similar to those used in isolating the cystic duct (figure 18). e
cystic artery should be isolated as far away from the region of the hepatic
duct as possible. A clamp is never applied blindly to this region, lest the
hepatic artery lie in an anomalous location and be clamped and divided,
resulting in a fatality (figure 19). Anomalies of the blood supply in this
region are so common that this possibility must be considered in every
case. e cystic artery is divided between clamps similar to those utilized
in the division of the cystic duct (figure 20). e cystic artery should be
tied as soon as it has been divided to avoid possible di culties while the
gallbladder is being removed (figure 21). If desired, the ligation of the
cystic duct can be delayed until a er the cystic artery has been ligated.
Some prefer to ligate the cystic artery routinely and leave the cystic duct
intact until the gallbladder is completely freed from the liver bed. is
approach minimizes possible injury to the ductal system as complete
exposure is obtained before the cystic duct is divided. If the clamp or tie on
the cystic artery slips o , resulting in vigorous bleeding, the hepatic artery
may be compressed in the gastrohepatic ligament (Pringle maneuver) by
the thumb and index nger of the le hand, temporarily controlling the
bleeding (figure 22). e eld can be dried with suction by the assistant,
and, as the surgeon releases compression of the hepatic artery, a hemostat
may be applied safely and exactly to the bleeding point. e stumps of the
cystic artery and cystic duct each are inspected thoroughly and, before the
operation proceeds, the common duct is again visualized to make certain
that it is not angulated or otherwise disturbed. Blind clamping in a bloody
eld is all too frequently responsible for injury to the ducts, producing
the complication of stricture. Classic anatomic relationships in this area
should never be taken for granted, since normal variations are more common in this critical zone than anywhere else in the body.
A er the cystic duct and artery have been tied, removal of the gallbladder is begun. e incision, initially made on the inferior surface of the gallbladder about cm from the liver edge, is extended upward around the
fundus (figure 23). An edematous cleavage plane can be developed easily
by injecting a few milliliters of saline between the serosa and the seromuscular layer, utilizing this cleavage plane for dissection. It is important that
the serosa be divided with a scalpel or scissors along both the lateral and
medial margins of the gallbladder so that the gallbladder is not torn from
the liver bed by traction. If this occurs, raw liver surface results, and it may
be impossible to peritonealize the liver bed. With the le hand, the surgeon
holds the clamps that have been applied to the gallbladder and, by careful
scissors dissection, divides the loose areolar tissue between the gallbladder
and the liver. is allows the gallbladder to be dissected from its bed without dividing any sizable vessels. e nal peritoneal attachment between
gallbladder and liver is severed.
C, R M
When facilities permit, an operative cholangiogram (figure 24) should
be made routinely to ensure complete clearance of the ductal system. A
syringe of saline as well as diluted contrast media should be connected by a
two-way adapter in a closed system to avoid the introduction of air into the
ducts. e cholangiogram catheter is lled with saline and it is introduced
a short distance into the cystic duct. e tube is secured in the cystic duct
by one tied suture utilizing a surgeon’s knot. All gauze packs, clamps, and
retractors are removed as the table is returned to a level position by the anesthesiologist. Five milliliters of contrast media, to concentration, are
injected and the x-ray immediately taken. Limited amounts of a dilute solution prevent the obliteration of any small calculi within the ducts. A second
injection of to mL is made to outline the ductal system completely and
ensure patency of the ampula of Vater. e tube should be displaced laterally
and the duodenum gently pushed to the right to ensure a clear roentgenogram without interference from the skeletal system or the tube lled with
contrast media. Two roentgenograms are taken to provide a comparison in
case doubtful shadows are noted, and another complete series of cholangiograms may be obtained if interpretation of the rst two lms is di cult.
Alternatively, a uoroscopic examination with continuous dye injection and
periodic lms may be performed. If no further studies are warranted, the
tube is removed and the cystic duct ligated near the common duct. If the
cystic duct cannot be used for the cholangiogram, a ne gauge needle, such
as a butter y, can be inserted into the common duct (figure 25). e metal
needle may be bent anteriorly as shown in the lateral view inset to facilitate its placement. Two or three dye injections are made and the needle is
removed. e puncture site in the common duct is oversewn with a
absorbable suture and some surgeons place a closed suction Silastic suction
drain (Jackson-Pratt) in Morrison’s pouch.
e portal vessel area and the gallbladder bed are inspected for hemostasis and the omentum is tacked against the gallbladder bed. Culture of the
gallbladder bile is performed routinely.
CLOSURE e routine closure is performed. Most surgeons do not use a
drain when the eld is dry and there is no evidence of leakage from accessory ducts.
POSTOPERATIVE CARE e orogastric tube is removed in the operating
room by the anesthesiologist, while a nasogastric tube may be bene cial for
a day or two if signi cant infection, ileus, or debility is present. Perioperative antibiotics are administered unless signi cant infection, gangrenous
gallbladder, or cholangitis require several days of coverage for resolution of
sepsis. Coughing and ambulation are encouraged immediately. Oral intake
of uids is begun within a day, whereupon intravenous hydration and electrolyte replacement are discontinued. e diet is advanced to solid food
as tolerated; however, foods that historically trigger the biliary attacks are
resumed gradually. ■
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