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20.1 Acute Cholecystitis 197
Positioning of patient: make sure you are in the right position—between
the legs in the lithotomy (the “French”) position or on the left side of the patient
in the supine position (the “American” position). A reverse Trendelenburg position and a slight rotation of the table to the left side would be helpful. I personally
like the French position as it offers a more ergonomic way of working in any
operation in the upper abdomen.
Positioning of trocars: the first should be at the umbilicus (upper or lower
aspect, depending on the distance between the umbilicus and the costal margin).
The two working trocars are located at the epigastrium and the RUQ. The trocar
for retraction of the gallbladder should be located at the anterior axillary line
away from the gallbladder. Try to triangulate your trocar positions and keep a
distance of 8–10 cm between different trocars. Position of the trocars may vary
according to the habitus of the patient.
In obese patients and often in difficult cases, you may need to insert an additional (fifth) trocar at the LUQ (left upper quadrant; some prefer to insert it at the
right midabdomen) to help retract the colon, with the attached omentum, downward or even the duodenum. Do not hesitate to insert additional 5-mm trocars to
improve your exposure. They do not need closure and are not painful afterward.
Do not limit yourself to a certain number of trocars because it is “the common
practice.” Instead, use as many trocars as you need to optimize the procedure.
For the cholecystectomy:
1. As a beginner, use a high-quality 0°, 10-mm scope. This is the best scope
that provides you with the optimal vision and is easy to drive by the inex-
perienced assistant. After you gain experience you may find that the 30°
scope is more versatile in obtaining a complete view.
2. As in open surgery, work with both hands. This will improve your perfor-
mance and dexterity.
3. Deal with the adhesions first (if they are present) to gain an initial anatomi-
cal orientation.
4. In cases of acute inflammation with marked distension of the gallbladder, it
may be difficult to grasp and manipulate it. The edematous tense and friable
wall may even render it a risky task because of the possibility of tearing off the
wall and causing an unnecessary spillage of potentially infected bile, stones, or
even pus. Therefore, as a rule always first decompress the distended gallblad-
der by aspirating its liquid contents. Do it under vision with a long, large-bore
needle inserted through the anterior abdominal wall (a Veress needle could be
ideal) or by using a designated endoscopic needle connected to a suction tube
or large syringe through one of the trocars in the right abdomen.
5. By grasping the fundus, retract the gallbladder toward the right shoulder and the
infundibulum laterally so that Calot’s triangle opens up. Do not apply excessive
198 Moshe Schein · Ahmad Assalia
traction because of the risk of “tenting” of the CBD, which may result in injury;
excessive traction may also tear the gallbladder—it does not look nice…
6. What to do with the “impossible-to-grasp” infundibulum? This is usually
due to a large stone impacted in the distal portion of the gallbladder or
extreme thickness of its wall due to severe inflammation. If Hartmann’s
pouch is packed with stones or with one big stone, try to move—“milk”—
the stone upward; if this fails, just retract the infundibulum upward with
an open blunt grasper or the jaws of the endoclinch grasper, without even
trying to grasp the wall (retract it en bloc). This will do the job of opening
up Calot’s triangle. Normally, one of these two tricks works very well. I
personally have never had to open the gallbladder (unless it happened
“spontaneously” during dissection) to remove impacted stones, but it may
be a logical option if the above maneuvers fail; then, you have to try to
minimize the risks of contamination and “lost stones.”
7. Start dissecting the triangle as close as possible to the gallbladder. Stay on
the gallbladder wall. You have nothing to look for far away from the gall-
bladder. If you stick to it, the chances for biliary injury are minimized.
8. Minimize the use of cautery in this area. Usually, a simple hook cautery will
suffice. Set it up to the minimal required coagulation degree (around 30) .
Elegant blunt or sharp dissection or even gentle use of the suction device
will help identify the important structures.
9. Always open the anterior and the posterior peritoneal layer at Calot’s triangle and extend it to both sides of the gallbladder. By doing this, you will
be able to improve the retraction and take the gallbladder away from the
porta hepatis. Clear up Calot’s triangle and create a space there where you
can see just the cystic duct and artery entering the gallbladder and the
liver clearly visible behind—the “critical view.”
10. Do not cut what you think are the cystic duct and the cystic artery before
making sure that these are the only structures entering the gallbladder. The
gallbladder should be seen to funnel down and terminate in the cystic duct.
Do not hesitate to continue the dissection to be sure. It is better to spend
another 5–10 min with your patient than 5-10 years with your lawyer! Take
all the time that you need. It is better to “lose” an extra moment than to lose
the patient in a moment.
11. Try to define the cystic duct but do not overskeletonize it. This may cause
an injury. While disconnecting the cystic duct and artery, go close to the
gallbladder and as high as possible. Leave room for mistakes. Never place
clips on a nonidentified structure.
12. In cases of thickened or widened cystic duct, make sure your clips securely
close the whole width of the cystic duct without cutting it. This may occur
with friable ducts in cases of acute severe inflammation. When in doubt,
use an endoloop or even a stapler (white vascular load). But, before using a
stapler, try to be sure again that you will staple off the cystic duct. In this
case, you will have to replace the epigastric trocar with a 12-mm one.
20.1 Acute Cholecystitis 199
13. For dissection of the gallbladder from the liver, simple traction, countertraction, and diathermy will do the job.
14. In cases of bleeding, do not blindly apply any clips or cautery. This is dangerous. Do not panic; first apply direct pressure with a blunt instrument or
gauze, reorganize your setup, and then control the bleeding source under
direct vision. Take a suction device in one hand and fine forceps in the
other and precisely find and control the bleeding even if this necessitates
the introduction of another trocar.
15. If you are unable to control the bleeding safely, then convert. Blind attempts to
control bleeding in the porta hepatis may culminate in more bleeding, ligation
of the right hepatic artery, or biliary injury. In contrast, bleeding from the liver
(gallbladder bed) is almost always controllable with pressure, patience, and
the use of electrocoagulation. It is helpful to increase the coagulation intensity
for this purpose together with switching to the “spray” mode.
16. In cases of bleeding from the porta hepatis or the gallbladder bed, and if the
bleeding is not profuse or originating from a “pumper,” you may apply a piece
of Surgicel, followed by local pressure and patience. Usually, this will prevent
unnecessary application of clips with its potential risk. You may leave the
Surgicel there as it is absorbable and even has some antibacterial potential.
17. What do you do if you face difficulty in identifying the anatomy in Calot’s
triangle? The options are as follows: try the (a) fundus first (“fundus down”)
approach; (b) subtotal cholecystectomy performed with the fundus down
approach; or (3) convert. When choosing the first two options the most lateral
trocar will serve to retract the liver, while the mid-upper right trocar provides
countertraction on the gallbladder. If you have decided on partial cholecystectomy, then you can do it as described for the open procedure. Proceed downward to Hartman’s pouch and stop there. Make sure there are no stones left in
the pouch. Then, either oversew the infundibulum or use the endostapler.
18. In cases of unclear anatomy, be liberal in performing intraoperative cholangiography (IOC) before committing yourself. This is done easily using different
available kits. You should also perform this in cases of suspected CBD stones.
19. If according to preoperative imaging there is a suspicion of gallbladder
malignancy or if you suspect it intraoperatively, it might be wise to start
with an open procedure or to convert because of the possibility of disseminating malignant cells. This is the only proven malignancy for which laparoscopy may be detrimental.
20. Irrigate and suction out any blood or spilled bile and stones. Make every
effort to clean up any spilled stones. They may cause late abscesses; the large
ones have been implicated in a long list of bizarre complications. You should
irrigate the operative field, the subhepatis space, and the subphrenic space.
Aspirate gently in the porta hepatis area so that the clips previously applied
on the duct and artery will not be dislodged. Take a final look at the operative field and gallbladder fossa before leaving the abdomen. Take out the
trocars under direct vision to identify and control any trocar site bleeding.
200 Moshe Schein · Ahmad Assalia
21. Use a retrieval bag if the gallbladder is inflamed, enlarged, or damaged
during resection. You may retrieve it through the umbilical or the epigastric trocar openings, enlarging them slightly as necessary. You may aspirate any bile and crush the gallbladder stones before attempting to remove
the GB from the abdomen.
22. Usually, there is no need to place a drain. If you decide for some reason
(difficult case or difficult cystic stump, “wet” operative field, suspected
accessory ducts that were identified or not), you may take it out through
one of the lateral 5-mm trocars in the right abdomen (see >Chap. 42).
When should you convert?
1. Vascular or bowel injury
2. Difficult or unclear anatomy
3. Uncontrollable bleeding
4. Suspected gallbladder malignancy
5. Identified biliary injury (see also the next section)
In general, be liberal with conversion. This reflects mature judgment. Safety
of the patient is your goal and not your ego (we hope). In the difficult cholecystectomy, a trial of up to 1 hr or so is reasonable. Failure to progress is an indication
for conversion.
Intra-operative cholangiogram is a religion—not science. (Nathaniel J. Soper)
Complications of Laparoscopic Cholecystectomy
Ahmad Assalia and Moshe Schein
Although relatively rare—but more common than after open cholecystec-
tomy—complications of LC can cause severe morbidity and be life threatening.
They are also a major source of litigation. Only surgeons who do not operate do
not “produce” complications. But, we surgeons tend to minimize the importance
of adverse events after operations that we have performed and are reluctant to
consider them; this is our human nature and the fault of the overdeveloped “surgical ego.” But, in all of the post-LC disasters that we have personally produced (fortunately few) or post-LC legal cases we have reviewed (not so rare), we have been
able, looking through the retrospectoscope, variously to identify operative technical errors, serious faults in postoperative judgment, or negligent procrastination
(the “surgical ostrich syndrome”; >Chap. 45).
We have already discussed how to avoid complications during LC by proper
technique and optimal judgment. Next, we dwell on the management of postoperative complications.
20.1 Acute Cholecystitis 201
The key is to be suspicious: the normal course following LC is characterized
by minimal pain, mainly at trocar sites, and some nausea and even vomiting,
which should resolve in the first 24 hrs. Anything beyond that s hou ld ra ise t he su s-
picion that something wrong is happening. Hemodynamic instability, continuing
pain or nausea/vomiting, abdominal distension, fever, and jaundice are all signs
of untoward complications. The abdominal pain could be localized (excluding
trocar sites) or diffuse. If you have left a drain behind, any significant blood or
anything bilious or resembling succus entericus might suggest disaster.
These are the common scenarios that you may encounter following LC:
Biliary leakage
Biliary leakage could originate from the cystic duct, “accessory” ducts (of
Lushka), or the major bile ducts. Leakage from the cystic duct is usually secondary to dislodgement of clips, inadvertent injury during dissection, or inadequate
closure of a large, friable, and edematous duct. In general, leakage from the cys-
tic or accessory ducts does not require operative intervention unless the leak is
uncontrollable and causes sepsis or diffuse peritonitis (if a drain has been left in
situ during the operation, and is adequately controlling the leak, you can sit and
relax as most such leaks will close sponataneouly within a week or so).
The patient with a bile leak may present with abdominal pain, malaise,
fever, jaundice, and abdominal distension. The jaundice is the result of bile
absorption from the peritoneal surface or due to an associated injury to the bile
duct. These signs following LC warrant urgent intervention. We repeat: as a rule,
if the patient is not septic and there is no generalized peritonitis, there is no need
for immediate surgical intervention. Put your patient on NPO, intravenous flu-
ids, and antibiotics and obtain a full lab workup. Abdominal US is the next step.
If this is not diagnostic (i.e., no dilated bile ducts, no significant sub- or perihepatic fluid collection), then CT may be more helpful. Remember that immediately after LC there is almost always a small local fluid collection; this is normal.
Only if this is larger than expected, associated with diffuse intra-abdominal
fluid or dilatation of the bile ducts (intrahepatic), should it raise the suspicion
that there is a bile leak and possible CBD injury.
Early imaging might be falsely negative. Biliary scintigraphy for the diagnosis of bile leak is probably useless. If there is a significant fluid collection without bile duct dilatation, you should perform percutaneous drainage guided by
either US or CT scan to rule out or confirm bile leakage. After you have drained
the biloma, the next step is endoscopic retrograde cholangiography (ERC) to
identify any associated bile duct injury and, if necessary, to control leakages from
cystic or accessory ducts by sphincterotomy and placement of a biliary stent.
202 Moshe Schein · Ahmad Assalia
Common bile duct injury
Injury to the CBD is the most serious complication of LC. Its incidence may
be as high as 0.5%. Even experienced surgeons may encounter such a complication and not just the “freshmen.” If the ERC reveals such an injury, then transfer
your patient to a tertiary care facility to the care of a solid hepatobiliary surgeon.
The best results for bile duct reconstructions are obtained in the right hands.
Remember, the patient has a “one-shot chance” with this kind of surgery.
Preferably, this shot should be done by an experienced hepatobiliary surgeon to
ensure optimal outcome. Obviously, you, or your seniors, may know how to hook
up the cut end of the CBD to a loop of jejunum, but here small details make a big
difference. Sometimes, the injury is complicated and has an associated vascular
injury. No urgency exists for immediate reconstruction once the patient is not
septic and has been adequately drained.
When to re-operate.
This is necessary only if the patient is grossly septic or has generalized
peritonitis. In all other cases of “pure” bile leakage, percutaneous drainage and
ERC would suffice.
How to re-explore?
Whether you wish to attempt your re-exploration laparoscopically (see
>
Chap. 52.3) or by open surgery is up to you.
When to pursue biliary reconstruction?
The following variables might help you to determine the appropriate timing
for definitive reconstruction (in most cases with Roux-en-Y hepaticojejunostomy):
Pattern of injury
Timing of diagnosis
Degree of inflammation and peritonitis
Condition of local tissues
Size of bile ducts
The general status of the patient
Surgeon’s preference and experience
In general, all you want to do if forced to re-operate is to drain the bile collections, divert the bile leak by intubating the proximal bile duct or point of leakage. Your primary goal in the acute phase is to control SIRS or sepsis and not
biliary reconstruction.
Early reconstruction could be accomplished if ideal conditions are present:
patient is stable and not septic, no significant biloma or peritonitis, within the first
48 hrs from surgery, and preferably, a sharp and not diathermy mechanism of injury.
In all other cases, allow for the patient to recuperate adequately, the sepsis or inflammation to resolve, and perhaps the bile ducts to dilate to some degree to, it is hoped,
make the late definitive reconstruction easier—by an expert in this field.
20.1 Acute Cholecystitis 203
Regarding what to do if duct injury is diagnosed during the cholecystec-
tomy, see Chap 20.3.
Bleeding (see also > Chap. 58):
Bleeding during or following LC can range from nonsignificant to life
threatening. Potential sources are:
Mesentery or major blood vessels during initial access. (One has to be truly
negligent to produce such complications.) An immediate conversion and control
of the bleeding is mandatory.
Trocar sites. Normally, this is identified and dealt with intraoperatively
but occasionally is missed. Usually, it does not require operative re-intervention, but it could be troublesome, causing blood loss and abdominal wall hematomas. This is especially true in patients with portal hypertension and
patients on antiplatelet aggregation agents (aspirin/Plavix). In cases of intraoperative bleeding from the trocar site, you may angulate the trocar to the
direction that applies pressure to the bleeding point. If bleeding continues, insert a Foley catheter through your trocar, inflate the balloon inside the abdomen ( under vision), and pull out the trocar and the catheter so that it acts as a
balloon tamponade for at least 5–6 min. If this does not work well, then you can
pass a transfacial suture with a straight needle or a suture passer. Routinely visualize your trocar sites from inside the abdomen after you pull out the trocars
so that you can identify bleeding before exiting the abdomen.
Cystic artery or right hepatic artery. This was previously described (in tech-
nical aspects of LC).
Liver bed. Also as above.
If bleeding occurs postoperatively, the patient may present with tachycardia,
hypotension, and pallor. Blood count confirms the clinical suspicion. A drain in
place may indicate bleeding but do not count on this; they usually become clotted
and obstructed. As a rule, any bleeding causing hemodynamic instability warrants immediate surgical reintervention. We may be biased, but we personally
prefer an open re-intervention rather than a laparoscopic one. The reasons are:
Laparoscopy requires some extra time that patients may not have.
Laparoscopy is not appropriate in the setting of hemodynamic instability.
With laparoscopy, identifying the bleeding source could be difficult as the
bloody field absorbs light and affects adequate visualization. In addition,
evacuation of large clots could be a difficult task in laparoscopy.
Anything that affects visualization may cause CBD injury or additional
vascular injury from misguided clips or diathermy.
In all other cases of postoperative bleeding, selected patients might be
managed by nonoperative means: optimizing the coagulation profile, blood
204 Moshe Schein · Ahmad Assalia
transfusion, and again patience. In cases of continued bleeding and if the patient
is warm, is nonacidotic, and has normalized coagulation status, re-operation is
indicated. In this situation laparoscopy may be appropriate. For more about
postoperative bleeding, see > Chaps. 56 and 57.
Visceral injury (see also > Chap. 58):
Visceral injuries, if not recognized immediately, are commonly lethal. They
have to be prevented, and if inflicted, they must be diagnosed immediately and
corrected promptly.
Most commonly, such injuries occur not only during initial peritoneal access
from Veress needle or trocar insertion (yes, they can occur also during open peritoneal access under vision) but also during subsequent port placement, adhesiolysis, or dissection of the duodenum or colon adherent to the gallbladder.
When you recognize visceral injuries during the operation, they can be
safely repaired laparoscopically in experienced hands. If you do not have that
experience, consider mini-incision or even a formal laparotomy for proper visualization and repair. With bowel injury caused by Veress needle or trocar, always
look for a second enterotomy on the contralateral bowel wall.
Unrecognized bowel injury will present itself postoperatively. More on this
is found in > Chap. 57. But, we wish to repeat and emphasize again, and again, that
most patients with such injuries die because of the surgeon’s blasé attitude. Patients
with a hole in their duodenum after LC do not present with classical peritonitis,
and most will die before the leaking duodenal contents reach the trocar site or
drains. Thus, if you ignore the soft, warning signs of excessive pain and need for
analgesia, tachycardia, and oliguria, you will not be able to save the patient for
most w ill die wit hin 24 hrs. And t he pla int iff ’s ex per t witnes s, read ing through the
dead patient’s chart, will find the typical scenario: the nurse reports to the surgeon
that “the patient is not doing too well”; the surgeon prescribes more morphine
over the phone and goes back to sleep. So does the patient—permanently.
Timely recognition of complications and re-intervention, if necessary, will
save lives and prevent significant long-term disabilities.
Reference
Way LW, Stewart L, Gantert W, et al. (2003) Causes and prevention of laparoscopic bile duct
injuries: analysis of 252 cases from a human factors and cognitive psychology perspective. Ann Surg 237:460–469.
Acute Cholangitis
Gary Gecelter
Thus with stone obstruction of the duct … dilation of the gallbladder is rarely
observed; the organ has already undergone contraction; with obstruction from
other causes, dilation is to be expected; atrophy exists only in 1/12 cases.
(Ludwig Courvoisier, 1843–1918)
What Is the Mechanism?
Acute ascending cholangitis is an infectious inflammatory consequence of
biliary obstruction. Increased intrabiliary pressure above 30 cmH2O (normal
10–15) is associated with complete bile stasis and induces cholangiovenous reflux. This results in translocation of organisms and an inflammatory response
that can result in death if not properly treated.
Cholangitis may “ascend” from an obstruction arising in the extrahepatic
biliary tree, the two common causes being common bile duct (CBD) stones and
pancreatic (or periampullary) carcinoma. Choledocholithiasis is more common
as a primary cause of cholangitis, whereas the endoscopic treatment of periampullary carcinomas is the most common cause of iatrogenic cholangitis. Also,
patients who have undergone a previous hepaticojejunostomy or endoscopic retrograde cholangiopancreatography (ERCP) stenting for iatrogenic biliary injury
or stricture often present with recurrent attacks of cholangitis. Typical of cholangitis arising from choledocholithiasis is the prior history of “fluctuant” jaundice—an awareness of having been jaundiced at various times in the past. This
is in contrast to patients who present with progressive (or crescendo) jaundice
typical of periampullary tumors. The patient may also admit to having had gallstones diagnosed in the past or may have had a prior cholecystectomy. However,
this classic presentation is by no means a rule, so do not presume a diagnosis
when the patient presents for the first time with obstructive jaundice.
20.2
What Are the Risks?
As with any acute illness, age and comorbidity are major determinants of the
risk of dying from acute cholangitis. It is useful to run an APACHE II (Acute
Physiological and Chronic Health Evaluation II) baseline in the emergency room
Gary Gecelter
St. Francis Hospital, 100 Port Washington Boulevard, Roslyn, NY 11576, USA
M. Schein et al. (eds.), Schein’s Common Sense Emergency Abdominal Surger y,
DOI: 10.1007/978-3-540-74821-2_20.2, © Springer-Verlag Berlin Heidelberg 2010
205
206 Gary Gecelter
(ER) and to keep a mental note of the changes as you monitor your patient to ensure that your interventions, or lack thereof, are not causing a rise in your patient’s
score (> Chap. 6). If an elderly patient with high levels of serum bilirubin has leu-
kocytosis (or worse, leukopenia), decreased urine output, a bad chest, and is
drowsy, you should immediately consider him or her as a high-risk case. Renal failure, liver abscesses, and malignancies are associated with higher mortality. As a
rule in this condition, the direct bilirubin decreases as the treatment takes effect.
How to Make the Diagnosis (
Charcot’s triad (Jean Martin Charcot of Paris, 1825–1893) characterizes acute
ascending cholangitis:
Right upper quadrant (RUQ) pain
Fever
Jaundice
The fever and jaundice are easy to determine. Disproportionate pain may
be due to coexisting acute cholecystitis. RUQ tenderness may be due to either
cholecystitis (Murphy’s sign) or tenderness in the liver itself. The distinction is
probably unimportant as the treatment is the same. The feel of the liver, however,
may lend itself to a bedside provisional diagnosis: a hard nodular liver is likely
to be due to metastasis from a gallbladder cancer (especially in countries like
Chile, India, and other endemic zones for gallbladder cancer) or a pancreatic or
other gastrointestinal (GI) malignancy.
>
Fig. 20.2.1)
Fig. 20.2.1. “Oh, the urine is dark … what do you call that, triad? Charcoal triad?”
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