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78
Ultrasound unit
3.7 Staging of Neoplastic Disease with Ultrasound
Monitor
Fig. 3.7.2 Staging of neoplastic disease
with ultrasound. If the operating team
and equipment are positioned as in the
chapter “Diagnostic Laparoscopy,” the ultrasound unit is placed on the patient’s
left in the surgeon’s field of view. Alternatively, the examiner may stand between
the patient’s legs with the ultrasound
unit to his or her left. In both cases, use
of an electronic split-screen imaging feature permits simultaneous visualization of
the position of the probe and the ultrasound image on one monitor. This greatly
facilitates precise anatomic and topographic identification of ultrasound findings. An experienced OR nurse operates
the ultrasound unit, or the surgeon may
operate it by remote control.
Assistant
Surgeon
Instruments
Equipment
Avoiding Problems
Laparoscopic ultrasound requires both thorough familiarity
with the ultrasound anatomy of the entire abdomen and exten-
sive experience with conventional intraoperative ultrasound to
ensure correct interpretation of laparoscopic ultrasound findings and phenomena.
Optimal ultrasound results require appropriate adaptations
(and, if necessary, intraoperative changes) in patient positioning, trocar positions, and transducer placement according to the
equipment used and the specific conditions encountered. This
applies particularly to ultrasound lymph-node staging. Obtaining the acquired acoustic contact may require intraabdominal
and/or intraluminal application of fluid.
The ultrasound examination should be comprehensive, i. e., it
should include a complete assessment of all organs and areas of
interest. This can only be achieved if the physician adheres to a
OR Nurse
standardized examination procedure and uses flexible ultrasound probes.
Intraluminal gas in the gastrointestinal tract will significantly
compromise the examination. For this reason, endoscopic examinations immediately prior to surgery should be avoided, or
they should be performed following the ultrasound examination. Ultrasound should also be performed prior to taking biopsies to avoid artifacts. Assessing hollow viscera and differentiating lymph nodes from sections of vascular structures may present problems. The use of color Doppler ultrasound can help
avoid misinterpretation.
In all phases of the examination involving direct tissue contact,
it is important to proceed by applying sufficient pressure to
achieve acoustic coupling of the transducer and the tissue to be
examined while avoiding compression of luminal or cystic
structures.
Complications
79
a b
Fig. 3.7.3a, b Staging of neoplastic disease with ultrasound. Trocar
placement. A trocar placed below the umbilicus is suitable for ultrasound
examination of the right hepatic lobe, distal gastric region, head of the
pancreas, and periaortic region (a). The left hepatic lobe, proximal gastric
Fig. 3.7.4a Staging of neoplastic disease with ultrasound. Examination
of the liver. Ultrasound examination of the liver is an integral part of tumor
staging, regardless of the site of the primary tumor. Using an ultrasound
frequency of 5 MHz will provide sufficient penetration at the necessary
resolution.
A standardized examination procedure is essential to ensure comprehensive exploration of all segments of the liver. Beginning with the right he-
patic lobe, the transducer is placed on the diaphragmatic surface as far
superiorly and close to the diaphragm as possible. Using continuous sideto-side sweeps from medial to lateral and back, the surgeon scans the entire width of the right hepatic lobe in one imaging plane. The flexible tip of
the transducer permits uninterrupted contact between the tip and the
convex surface of the liver. Gradually moving the probe one transducer
width at a time (about 3 cm) adds layers to the scanned image until the
inferior margin of the liver is reached.
region, parts of the antrum, body and tail of the pancreas, and the left
upper abdomen can usually be better visualized through a trocar placed in
a left lateral position (b).
Fig. 3.7.4b−c 컄
80
3.7 Staging of Neoplastic Disease with Ultrasound
b
c
Fig. 3.7.4b, c Staging of neoplastic disease with ultrasound. Examina-
tion of the liver. The presence of hepatomegaly or the use of higherfrequency ultrasound arrays that do not completely penetrate the liver
(f > 7 MHz), requires additional examination of the right hepatic lobe
from the visceral surface in a caudocranial direction (b). After reintroduc-
ing the probe through the left lateral trocar, the surgeon scans the left hepatic lobe continuously using the technique described for the right liver
lobe. Due to its minimal thickness, this part of the organ can almost al-
ways be completely scanned in one view (c). The vascular anatomy of the
liver according to Couinaud is the key for the topographic and anatomic
localization of focal lesions. Besides the assessment of the liver itself, the
left hepatic lobe serves as an acoustic window for assessing the superior
periaortic region when localizing enlarged lymph nodes and for assessing
parts of the pancreas and stomach.
3.7.5
3.7.6
Figs. 3.7.5 and 3.7.6 Staging of neoplastic disease with ultrasound. Examination of the pancreas. In the presence of malignant processes of the
pancreas and distal common bile duct, the transducer is introduced
through a trocar placed below the umbilicus, and the head of the gland including the uncinate process of the pancreas is visualized at a frequency
of 7.5 MHz. The surgeon also locates local lymph nodes from this transducer position. Use of color Doppler will permit demarcation of vascular
structures appearing in cross section. If a tumor is present in the head of
the pancreas, the common bile duct and pancreatic duct can be distinguished from vascular structures included in the tumor by using color
Doppler ultrasound.
The body and tail section of the pancreas can be visualized in a transgastric view (Fig. 3.7.5). The stomach must be compressed or filled with 400
to 500 ml of fluid. A better method, albeit more complicated, is to open
the lesser sac and position the transducer on the anterior surface of the
pancreas (Fig. 3.7.6). This eliminates artifacts due to the acoustic window
and permits reliable exploration of all segments of the organ, assuring optimal quality of the findings.
3.8 Comments on Laparoscopic Ultrasonography for Staging
Fig. 3.7.7 Fig. 3.7.8
81
Figs. 3.7.7 and 3.7.8 Staging of neoplastic disease with ultrasound. Ex-
amination of the stomach. After the stomach has been filled with fluid it
can be visualized by high-frequency ultrasound (7−10 MHz) through a trocar placed below the umbilicus or in the left lateral abdomen. The typical
five-layer anatomy of the gastric wall familiar from intraluminal ultrasound permits the examiner to draw conclusions about the depth of
penetration of malignant gastric processes and about the penetration of
neighboring organs. A proven method is to image the posterior gastric
wall from an anterior view (Fig. 3.7.7) and image the anterior gastric wall
from the posterior view (after opening the lesser sac; Fig. 3.7.8). This elim-
inates the problem of having to image layers in the near field. Transgastric
imaging may also be used to localize enlarged lymph nodes in the gastric
drainage region.
3.8 Comments on Laparoscopic Ultrasonography for Staging
G. V an Stiegmann
Ultrasonography done at open operation has a proven track record. Using widely available and relatively simple technology,
the surgeon can detect and sample unsuspected liver tumors or
metastatic deposits, guide hepatic resection or ablative treatment such as cryotherapy, evaluate the curability of cancer of
the pancreas, detect unseen (and non palpable) neuroendocrine
tumors in and about the pancreas, and better stage some hematological malginancies. Intuitively, laparoscopic ultrasono-
graphy seems useful; however, introduction of this new imaging option raises several questions: Can laparoscopic ultrasono-
graphy be done with the accuracy and precision of ultrasono-
graphy done at open operation? What is the marginal gain pro-
vided by performing laparoscopic ultrasonography as compared
with staging laparoscopy alone? Is laparoscopic ultrasound im-
aging, without biopsy confirmation, accurate enough to define
incurability? Should the laparoscopic staging operation be done
under the same anesthetic as the definitive operation or as a
separate procedure?
Staging by laparoscopy alone, in patients with hepatobiliary and
pancreatic cancer, is beneficial. The goal of laparoscopic staging
is to prevent futile laparatomy in patients with incurable dis-
ease. The addition of laparoscopic ultrasonography appears to
extend the accuracy of laparoscopic staging from 15 to 20% in
these malignancies. Laparoscopic ultrasonography is probably
not as accurate as ultrasonography done at laparatomy,
however, since the two techniques are very different. At lapara-
tomy, organs such as the liver are routinely mobilized from their
peritoneal attachments for optimal inspection, palpation, and
ultrasound evaluation. Similar mobilization can be done laparoscopically but few surgeons can justify the time and effort
these maneuvers require. The laparoscopic surgeon is also restricted because of the absence of three-dimensional perspective and loss of the sense of touch; both of which subtly enhance
the yield of ultrasonography at open operation. Ultrasound
technology may help compensate for these senses that have
been lost to laparoscopy, but cannot completely replace them.
Most surgeons are appropriately unwilling to declare a tumor
incurable on the basis of an equivocal ultrasound image. In the
absence of palpation and optimal visualization, histological
confirmation of tumor dissemination outside the area of the
proposed resection is required to conclude incurability in most
cases. Improvement in ultrasound-directed tissue sampling
may be the most important determinant of long-term success
for laparoscopic ultrasound technology. Directed biopsy is more
difficult using laparoscopic ultrasound control than with ultrasound guidance at open operation. The presence of the abdominal wall and a pneumoperitoneum between the biopsy needle
and the target creates a difficult to overcome fulcrum effect and
often places the intended specimen out of reach of the standard
length biopsy needle. Laparoscopic ultrasound-guided tissue
sampling taxes the skill of the most experienced operator.
Newer probes, which allow passage of a core or aspirating
needle via a needle guide aligned parallel with the beam of the
ultrasound waves, should obviate this frustration. These dedicated biopsy devices may diminish concerns about equivalency
between the open and laparoscopic ultrasound methods since
histological confirmation is the endpoint.
Should the laparoscopic staging operation be done synchronously with laparotomy for definitive treatment, or as a
separate procedure? From the patients’ perspective, economic
82
3.9 Visual Exploration of the Pelvic Organs in Women
and practical disadvantages associated with a second voyage to
the operating room and a second anesthetic weigh in favor of a
synchronous approach. From the surgeons’ perspective, a con-
verse efficiency issue arises when a large block of operating
time is reserved, only to discover incurable disease within the
first few minutes of the staging procedure. A separate staging
procedure is desirable in many cases because of the need to obtain more reliable “permanent section” histological analysis as
opposed to “frozen section” diagnosis. The synchronous approach is best used at centers with high levels of competence in
complex hepatobiliary and pancreatic surgery.
Wider experience with laparoscopic ultrasonography is needed
to firmly def ine its role in staging malignancy and to answer
some of the questions posed above. The accuracy of the laparoscopic method needs to be compared with the accuracy of endoluminal sonography, particularly for staging tumors of the
pancreas. Dedicated laparoscopic ultrasonographic biopsy
probes must be developed and refined to facilitate optimal
tissue acquisition. One conclusion is inescapable: ultrasonography is necessary to optimize the accuracy of laparoscopic diagnosis and staging.
3.9 Visual Exploration of the Pelvic Organs in Women
W. Jonat
Goals and Methods
Laparoscopic exploration of the lower abdomen includes examination and description of the female reproductive organs. The
examination includes the uterus, the fallopian tubes, the ovaries, and the peritoneal lining of the pelvis. Normal and pathological findings are recorded.
If the examination reveals unexpected pathological changes
that appear to warrant a gynecological intervention, a gynecologist should be part of the decision making or the patient
should be referred to an appropriate facility unless the presen-
tation, clinical findings, or available facilities and circumstances
do not permit this.
Note: If one encounters an unexpected emergency, the surgeon
should restrict himself or herself to performing the surgical
measures required by the situation.
Normal Gynecologic Anatomy
ostium is surrounded by ten to fifteen fimbriae. One of these
fimbriae, the ovarian fimbria, is attached to the ovary.
The fallopian tube lies on the accessible superior margin of
the broad ligament between the round ligament of the
uterus (anterior) and the ovarian ligament (posterior). It is
connected to the broad ligament via the mesosalpinx.
In adult women, the ovaries generally lie on each side in the
ovarian fossa, a recess located at the bifurcation of the common iliac artery. This recess is bounded posteriorly by the
ureter. Each ovary is connected to the uterus by the ovarian
ligament and the suspensory ligament of the ovary, and connected to the mesosalpinx and broad ligament via the mesovarium. The uterine face of the ovary lies medial and anterior, whereas the tubal aspect lies posterior, in contact with
the infundibulum of the fallopian tube. The shape, size, and
surface of the ovaries depend on the patient’s age and the
functional state of the ovary within the menstrual cycle or
during pregnancy. Depending on hormonal stimulation,
several follicle cysts measuring as large as 2−3 cm may be
detected.
The laparoscopically visible portion of the female reproductive
system includes the following organs:
쐌 Uterus, consisting of the body, fundus, and part of the cervix.
The body is covered superiorly, posteriorly, and anteriorly by
serosa. The broad ligament of the uterus extends from the
lateral margins of the uterus on either side as a peritoneal
fold. The round ligament extends anteriorly from the body of
the uterus where it is joined by the fallopian tubes to the
deep inguinal ring. The sacrouterine ligaments are the laparoscopically visible part of the structure that sagittally and
transversely suspend the uterine cervix.
쐌 The adnexae: fallopian tubes and ovaries.
The tubes connect the uterine cavity with the peritoneal cavity. Each tube is divided into four segments, of which three
are visible laparoscopically:
The isthmus is directed transversely and posteriorly toward
the fimbriated end; it measures approximately one-third of
the length of the tube.
The ampulla of the fallopian tube.
The infundibulum of the tube with the abdominal ostium,
which opens as a funnel into the abdominal cavity. This
Figure 3.9.1 shows the normal gynecologic anatomy on the left,
which the surgeon observes during laparoscopy. On the right
side is shown a hydro- or pyosalpinx.
Specific Pathological Changes
Several gynecological syndromes remain asymptomatic at least
for a time and may be initially observed laparoscopically only.
These include uterine myomata, endometriosis, tubal occlusion,
and benign or malignant ovarian tumors.
Uterine Myomata (Fig. 3.9.2)
Myomata are benign neoplasms of the myometrium. They vary
greatly depending on the original site and its direction of
growth. These include:
쐌 Subserous myomata: Readily discernible nodes projecting
into the abdominal cavity.
쐌 Intramural myomata: Myomata in the uterine wall visible as
knotty growths.
쐌 Intraligamentary myomata: Nodes between the plates of the
broad ligament infiltrating the loose pelvis connective tissue.
쐌 Submucosal myomata: Nodes growing inward toward the
uterine cavity. These are not detectable laparoscopically.
Endometriosis (Fig. 3.9.3)
Endometriosis is the occurrence of endometrial tissue outside
the uterine cavity. Laparoscopic examination may reveal en-
dometriosis in the rectouterine pouch, in the peritoneum
around the bladder, the ovaries, or the fallopian tubes.
Endometriosis in the peritoneal lining of the abdomen and pel-
vis appears as small nodes the size of a pin head ranging in color
from dark red to black. They often cause adhesions between the
uterus and rectum or uterus and bladder.
These tissue changes are often very painful. Describe their num-
ber and location.
Infertility Due to Fallopian Tube Stricture
or Stenosis
After an acute process such as pelvic inflammatory disease or
appendicitis, inspection of the pelvis will often reveal numerous
adhesions of and to the tubes which may be the cause of the infertility. Even in the absence of adhesions, laparoscopy may de-
tect a stricture of the tubular ampulla with a fused fimbriated
tunnel.
(Fig. 3.9.4)
Specific Pathological Changes
Fig. 3.9.1 Visual exploration of the pelvic organs in women. Normal
gynecologic anatomy on the left side, hydrosalpinx on the right.
83
Ovarian Tumors (Fig. 3.9.5)
Because of their position in the abdominal cavity, even large
ovarian tumors may exhibit few symptoms. For this reason,
ovarian tumors are generally only detected in their advanced
stages. The surgeon should take advantage of the opportunity
for early detection afforded by minimally invasive procedures.
Detection of an ovarian tumor is tantamount to cancer unless
proven otherwise. The laparoscopic image provides no indica-
tion as to the histology of the ovarian neoplasm.
Consequently, every ovarian tumor is regarded as malignant
and is either confirmed or questioned by histological examina-
tion.
Note: In addition to the many possible benign or malignant,
solid or cystic tumors, enlargement of the ovaries can also occur
because of retained physiologic follicle cysts or fluid accumula-
tion without cell proliferation.
Inflammatory adnexal processes may also simulate ovarian
tumors (Fig. 3.9.1).
Thus, it is extremely important to describe the size and surface
texture of the ovaries during laparoscopic procedures.
Summary
Description of the gynecological anatomy is one of the objec-
tives of a laparoscopic procedure in women.
Laparoscopic findings provide the gynecologist with valuable
information about the reproductive organs and help in the
timely detection of asymptomatic disorders.
Fig. 3.9.2 Visual exploration of the pelvic organs in women. Uterine myomata.
Fig. 3.9.3 Visual exploration of the pelvic organs in women. Endometriosis.
84
ab c
Fig. 3.9.4 Visual exploration of the pelvic organs in women. (a) Hematosalpinx or hydrosalpinx. (b) Clipping. (c) Ligation of the proximal tube.
3.9 Visual Exploration of the Pelvic Organs in Women
Bibliography
Fig. 3.9.5 Visual exploration of the pelvic organs in women. Ovarian
tumor.
Burghardt E. Staging. General Principes. In Burghardt E. Surgical Gynecologic
Oncology, p. 457). Stuttgart: Thieme; 1993.
Geisthövel F. Endometriose. In Bettendorf G. Reproduktionsmedizin, S. 362.
Stuttgart: Fischer; 1989.
Glatthaar E. Endometriose als Krankheitsbild. In Käser O, Friedberg V, Ober
G., Thomsen K, Zander J. Gynäkologie und Geburtshilfe, Bd. III, Spezielle
Gynäkologie. Stuttgart: Thieme; 1972.
Gomel V. Classification of operations for tubal and peritoneal factors causing
infertility. Clin. Obstet. Gynec. 1980; 23:1259.
Malinak LR. Infertility and endometriosis: operative technique, clinical stag-
ing and prognosis. Clin. Obstet. Gynec. 1980; 23:925.
Monaghan JM. Epithelial ovarian cancer. Laparoscopy. In Burghardt E. Surgi-
cal Gynecologic Oncology, p. 448. Stuttgart, Thieme; 1993.
4. Laparoscopic Cholecystectomy
4.1 Retrograde Cholecystectomy
F. Götz, A. Pier
85
Goals and Methods
The primary indication for removal of the gallbladder is symp-
tomatic cholelithiasis. The gallbladder is removed because it
provides the matrix for gallstone formation. Bile duct stones are
rare; generally they are concretions that have been overlooked.
Since about 15% of patients with cholecystolithiasis also have
stones in the bile ducts, exploration of the bile ducts is indicated
in these patients. History, symptoms, and clinical findings aid in
arriving at a diagnosis. Ultrasound is the diagnostic method of
choice.
Renewed attempts to manage gallstones via cholecystotomy
without cholecystectomy have been abandoned. With the earlier attempts there was a high mortality associated with suture
failures; more recently this mortality has been lower, but the in-
cidence of recurrent gallstones has been high. It is not yet clear
whether laparoscopic cholecystotomy decreases or eliminates
gallstone formation. We and other groups have successfully
performed gas-free laparoscopic cholecystectomy using me-
chanical methods with an intraperitoneal arm to lift the abdominal wall. This procedure appears to be feasible in principle, but
further studies will be required to determine its usefulness.
Tumors of the biliary tree are managed through a conventional
laparotomy.
Cholelithiasis and Choledocholithiasis
The procedure of choice involves two interventions:
1. Transpapillary removal of the stones via endoluminal endoscopy preferably without papillotomy. This procedure can be
done independently prior to cholecystectomy or at the time
of cholecystectomy as a laparoscopically-guided endoluminal procedure, after confirmation of the CD stones by laparoscopic cholangiography.
2. Cholecystectomy.
If bile duct stones are unexpectedly detected during a cholecystectomy, they can be removed by endoluminal endoscopy in a
second procedure or at the original cholecystectomy if the necessary expertise is readily available.
Dilating the papilla instead of incising it helps reduce the risk of
bleeding, perforation, and exacerbation of a possible existing
insufficiency of the papillary sphincter.
If the stone(s) cannot be cleared by endoluminal endoscopy, laparoscopic exploration of the common duct (necessary expertise available) or conversion to open operation is indicated.
Contraindications
General Contraindications
Indications
Indications for Laparoscopic Cholecystectomy
쐌 Symptomatic cholelithiasis.
쐌 Acute cholecystitis.
쐌 Cholecystogram showing non-function (gallstone occluding
the cystic duct).
쐌 Chronic cholecystitis (with or without concretions).
Limited Indications
쐌 Acute cholecystitis where the wall of the gallbladder is less
than 7 mm thick.
쐌 Hydrops of the gallbladder.
쐌 Empyema of the gallbladder.
쐌 Pathological condition following other than a biliary tract
operation (e. g., acalculous cholecystitis).
Note: When in doubt or if intraoperative difficulties are encountered, immediate conversion to laparotomy is indicated.
Limiting factors include patients unable to tolerate extensive
surgical procedures due to poor general health. If this is the
case, less experienced laparoscopic surgeons should opt for
laparotomy.
Anesthetic risk factors such as cardiopulmonary disorders (see
chapter 2.5) and coagulation disorders that do not respond to
treatment.
Special Contraindications
쐌 Gallbladder or bile duct tumors.
쐌 Portal hypertension.
쐌 Acute pancreatitis. (This has become a relative contraindica-
tion if the pancreatitis is due to an impacted common duct
stone that can be removed by retrograde, endoluminal endoscopic maneuvers).
쐌 Biliary fistula.
쐌 Mirizzi’s syndrome.
쐌 Pregnancy in the final trimester.
Surgical Risks and Patient Information
The most frequent complication is bile duct injury. Published
studies cite an incidence of 0.3−0.8%. The rate of conversion to
open procedures ranges from 1.2% to 7%. When in doubt about
variations in anatomy or serious challenges in techniques, immediate conversion is indicated. The decision to convert to an
open procedure does not represent a complication or a defeat.
Various study groups have reported mortality in cholecystectomy ranging from 0.04% to 0.08%.
86
4.1 Retrograde Cholecystectomy
If the proper diagnosis has been made and the operating team
has the required level of skill, laparoscopic cholecystectomy is
indicated as the standard procedure. Complications requiring
conversion to an open operation must be satisfactorily remedied during that same operation.
As a conventional cholcystectomy, the surgical risks increase
with the patient’s age. Secondary, corrective operations and
perforation of the gallbladder also increase the risks involved.
The incidence of postoperative bleeding and intraoperative intestinal injury that escapes detection is less than 1%.
The incidence of postoperative complications following laparo-
scopic cholecystectomy is about 1.8%. Secondary, corrective
operations are required in about 0.8−1.2% of patients. The primary indication for remedial operations is bile duct injury.
Special Preparations
쐌 Ultrasound examination to confirm cholelithiasis.
쐌 Intravenous cholangiography (to supplement ultrasound
scan where indicated).
쐌 Endoluminal gastroduodenoscopy to exclude pathological
changes in the stomach and duodenum where this is not
feasible, MDP is indicated.
쐌 Endoscopic retrograde cholangiopancreatography (ERCP) if
ultrasound and cholangiography findings are inconclusive
and the patient has a history of cholestasis.
쐌 CT scan if a tumor is suspected.
쐌 In elective laparoscopic surgery, a swab impregnated with
disinfectant is inserted into the previously cleaned umbilical
fossa 24 hours preoperatively or the patient can be shown
how to clean his or her navel repeatedly with soap and water.
쐌 Nasogastric tub e, indwelling urinary catheter prior to opera-
tion.
Anatomy (Figs. 4.1.1 to 4. 1.22)
Anesthesia
General anesthesia.
Patient Positioning (Fig.4.2.23)
Position of Operating Team (Figs.4.2.24 to
4.1.27)
Figures 4.1.24 to 4.1.26 show three different arrangements for
positioning the operating team. The number of persons in the
operating team and their positions depend on the number and
location of incisions to be made. Variety within German, American, and French operating room styles has found a peaceful expression in how people, objects, and actions are coordinated
into a smooth surgical ballet in these three countries.
Our technique eliminates the use of monopolar electrocautery
for dissection. The surgeon always stands opposite the organ to
be removed or explored and manipulates the dissection instrument. The first assistent guides the laparoscope (trocar 1). This
person should be experienced in laparoscopic surgical techniques. The first assistant also manipulates the grasper (trocar 4) with which the fundus of the gallbladder is pushed superiorly toward the diaphragm. The second assistant holds trocars 2 and 3 to prevent them from inadvertently being pulled
out when the surgeon changes instruments.
The second assistant also maintains the proper angle between
the instruments and the surgical site. This enables the surgeon
to reach the surgical site rapidly without having to follow the
instruments with laparoscope and camera and visualization on
the monitor screen each time an instrument is exchanged.
12
3194 26 5
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15
14
21
18.18
13
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16
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12
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Fig. 4.1.1 Cholecystectomy. Surgical anatomy.
Topography of the upper abdominal organs.
Exposure of the neurovascular structures in
the porta hepatis and the lesser curvature
6
of the stomach.
1 Right hepatic lobe
7
2 Round ligament of the liver
3 Left hepatic lobe
4 Hepatic branch of the anterior vagus nerve
5 Gastric cardia
6 Fundus of the stomach
7 Left gastric artery and vein
8 Body of the stomach
9 Body of the pancreas
20
10 Right gastric artery and vein
11 Gastroduodenal artery
12 Hepatic lymph nodes
17
13 Common bile duct, hepatic artery proper
9
14 Gallbladder
15 Cystic artery and vein
16 Inferior vena cava
17 Celiac plexus
18 Cystic duct, cystic lymph node
19 Caudate hepatic lobe
20 Celiac lymph nodes
25
21 Common hepatic duct, portal vein
22 Hepatic plexus
23 Common hepatic artery
24 Foramen lymph node
25 Gastric lymph nodes
26 Anterior vagal trunk
Surgical Anatomy
87
1
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1
2
3
4
5a
10
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6
1
7
Fig. 4.1.2 Cholecystectomy. Surgical anatomy.
Vascular structures of the hepatoduodenal ligament. Exposure of the lym-
phatic drainage of the liver, gallbladder, and bile ducts.
1 Liver
2 Portal vein
3 Hepatic artery proper
4 Common hepatic duct
5 Common bile duct
a Supraduodenal part
b Retroduodenal part
c Intra- or retropancreatic part
d Intramural or intraduodenal part
6 Hepatic lymph nodes
7 Cystic lymph node
8 Foramen lymph node
9 Pancreaticoduodenal lymph nodes
10 Celiac lymph node
8
9
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5b
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5c
5d
a
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b
1
2
3
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c
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Fig. 4.1.3 Cholecystectomy. Surgical anatomy.
Variations in the location of the gallbladder.
a Shallow liver bed. Approximately three-quarters of the gallbladder are
covered by visceral peritoneum.
b Deep liver bed. Only one-third of the gallbladder is covered by visceral
peritoneum.
c Gallbladder hangs on a mesenteric attachment. The gallbladder is al-
most entirely covered by visceral peritoneum.
1 Liver
2 Gallbladder
3 Visceral peritoneum
4 Mesenteric attachment of gallbladder
1
4
2
.
3
Fig. 4.1.3d Cholecystectomy.
Multimedia representation of the
anatomy of the right upper abdomen
(K.−H. Höhne, R. Mass, and J. Nuthmann. Voxelman Atlas).