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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_788_Библиотеки_им_академика_М_И_Перельмана.pdf
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4.1 Retrograde Cholecystectomy
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Fig. 4.1.4 Cholecystectomy. Varia-
tions in biliary anatomy.
The cystic duct and common hepatic
duct have a long parallel run before
they join to form a relatively short
common bile duct.
1 Cystic duct
2 Common hepatic duct
3 Common bile duct
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Fig. 4.1.5 Cholecystectomy. Variations in biliary anatomy.
“High” confluence of the cystic duct
and the left and right hepatic ducts
at almost the same level.
1 Cystic duct
2 Common hepatic duct
3 Common bile duct
Fig. 4.1.6 Cholecystectomy. Variations in biliary anatomy.
The cystic duct coming from the right
joins the common hepatic duct to
form the common bile duct (most
common anatomic pattern).
1 Gallbladder
2 Cystic duct
3 Common hepatic duct
4 Common bile duct
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Fig. 4.1.7 Cholecystectomy. Variations
in biliary anatomy.
An accessory hepatic duct drains into
the cystic duct.
1 Cystic duct
2 Common hepatic duct
3 Common bile duct
4 Gallbladder
5 Accessory hepatic duct
Fig. 4.1.8 Cholecystectomy. Variations
in biliary anatomy.
The cystic duct forms an anterior spiral
to drain into the common hepatic duct
from the left.
1 Cystic duct
2 Common hepatic duct
3 Common bile duct
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Fig. 4.1.9 Cholecystectomy. Variations
in biliary anatomy.
The cystic duct forms a posterior spiral
to drain into the common hepatic duct
from the left.
1 Cystic duct
2 Common hepatic duct
3 Common bile duct
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Variations in Vascular Anatomy
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Fig. 4.1.10 a−c Cholecystectomy. Variations in biliary anatomy.
Variations in the confluence of the hepatic ducts into the common hepatic duct.
1 Common bile duct
2 Cystic duct
3 Common hepatic duct
4 Left hepatic duct
5 Right hepatic duct
6 Anterior branch, right
7 Posterior branch, right
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Fig. 4.1.11 Cholecystectomy. Variations in
vascular anatomy.
Left branch of the hepatic artery proper
runs anterior to the common hepatic duct.
The medial branch of the hepatic artery
originates from the left hepatic branch. The
cystic artery takes its origin from the right
branch.
1 Common hepatic artery
2 Gastroduodenal artery
3 Right gastric artery
4 Hepatic artery proper
5 Right branch
6 Cystic artery
7 Left branch
8 Common hepatic duct
9 Common bile duct
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Fig. 4.1.12 Cholecystectomy. Variations in
vascular anatomy.
The right branch of the hepatic artery proper
runs posterior to the common hepatic duct.
The cystic artery originates from the right
branch.
1 Common hepatic artery
2 Gastroduodenal artery
3 Right gastric artery
4 Hepatic artery proper
5 Right branch
6 Cystic artery
7 Left branch
8 Common hepatic duct
9 Common bile duct
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1
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Fig. 4.1.13 Cholecystectomy. Variations in
vascular anatomy.
The right branch of the hepatic artery proper
runs posterior to the common hepatic duct.
The hepatic artery proper trifurcates into right,
median, and left branches. The cystic artery
originates from the right branch.
1 Common hepatic artery
2 Gastroduodenal artery
3 Right gastric artery
4 Hepatic artery proper
5 Right branch
6 Cystic artery
7 Left branch
8 Common hepatic duct
9 Common bile duct
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Fig. 4.1.14 Cholecystectomy. Variations in
vascular anatomy.
The hepatic artery divides early into the right
branch, left branch, and gastroduodenal artery;
there is no hepatic artery proper as such. The
median branch of the hepatic artery originates
from the left branch. The right branch lies
anterior to the common hepatic and cystic
ducts.
1 Common hepatic artery
2 Gasstroduodenal artery
3 Right gastric artery
4 Cystic duct
5 Right branch
6 Cystic artery
7 Left branch
8 Common hepatic duct
9 Common bile duct
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4.1 Retrograde Cholecystectomy
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Fig. 4.1.15 Cholecystectomy. Variations in
vascular anatomy.
The cystic artery originates from the left
branch of the hepatic artery. The right
branch runs posterior to the hepatic duct.
1 Common hepatic artery
2 Gastroduodenal artery
3 Right gastric artery
4 Hepatic artery proper
5 Right branch
6 Cystic artery
7 Left branch
8 Common hepatic duct
9 Common bile duct
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Fig. 4.1.16 Cholecystectomy. Variations in
vascular anatomy.
The cystic artery originates from the right
branch after the right branch has crossed
anteriorly over the common hepatic duct.
1 Common hepatic artery
2 Gastroduodenal artery
3 Right gastric artery
4 Hepatic artery proper
5 Right branch
6 Cystic artery
7 Left branch
8 Common hepatic duct
9 Common bile duct
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Fig. 4.1.17 Cholecystectomy. Variations in
vascular anatomy.
The cystic artery originates from the hepatic artery proper. The right branch of the
hepatic artery runs posterior to the common hepatic duct.
1 Common hepatic artery
2 Gastroduodenal artery
3 Right gastric artery
4 Hepatic artery proper
5 Right branch
6 Cystic artery
7 Left branch
8 Common hepatic duct
9 Common bile duct
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Fig. 4.1.18 Cholecystectomy. Variations in
vascular anatomy.
The cystic artery originates from the bifur-
cation of the hepatic artery proper. The
right branch of the hepatic artery runs
posterior to the common hepatic duct.
1 Common hepatic artery
2 Gastroduodenal artery
3 Right gastric artery
4 Hepatic artery proper
5 Right branch
6 Cystic artery
7 Left branch
8 Common hepatic duct
9 Common bile duct
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Fig. 4.1.19 Cholecystectomy. Variations
in vascular anatomy.
The anterior branch of the cystic artery
originates from the gastroduodenal artery
and runs along the surface of the cystic
duct. The right branch of the hepatic
artery runs posterior to the common he-
patic duct.
1 Common hepatic artery
2 Gastroduodenal artery
3 Right gastric artery
4 Hepatic artery proper
5 Right branch
6 Cystic artery
7 Left branch
8 Common hepatic duct
9 Common bile duct
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Fig. 4.1.20 Cholecystectomy. Variations
in vascular anatomy.
The cystic artery originates from an accessory of the right hepatic branch
(generally from the superior mesenteric
artery).
1 Common hepatic artery
2 Gastroduodenal artery
3 Right gastric artery
4 Hepatic artery proper
5 Accessory of the right branch of
the hepatic artery
6 Cystic artery
7 Left branch
8 Common hepatic duct
9 Common bile duct
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Position of Operating Team
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Fig. 4.1.21 Cholecystectomy. Variations in vascular anatomy.
Arteries supplying the common bile duct. The illustration shows the network of the circumferential arterial arcades (marginal arteries) originating
from the anterior and posterior superior pancreaticoduodenal arteries.
The cutaway view of the terminal common bile duct shows dense anastomoses of tiny arteries in the mucosa and submucosa which are supplied
by the circumferential adventitial arterial network.
1 Gastroduodenal artery
2 Anterior superior pancreaticoduodenal artery
3 Posterior superior pancreaticoduodenal artery
4 Marginal arteris and circumferential arcades
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Dense arterial networks extending inferiorly from the posterior superior
pancreaticoduodenal artery and superiorly from the inferior pancreaticoduodenal artery supply the terminal common bile duct and the
duodenal papilla (according to Spengler and Böhmig, and Dziwisch and
Lierse).
1 Common bile duct
2 Major duodenal papilla (of Vater)
3 Posterior superior pancreaticoduodenal artery
30–35°
10–20°
Fig. 4.1.23 Cholecystectomy. Positioning
Position the patient on a radiolucent table in a reverse Trendelenburg
position with the table inclined to the left to facilitate dissection in Calot’s
triangle. A thorax stop placed between the eighth and tenth left ribs
makes intraoperative repositioning safe.
Because of the position of the operating team (Fig. 4.1.27), we recommend placing the patient with the left arm extended to permit venous
access. A C-arm fluoroscopic image intensifier should be available for in-
traoperative fluoroscopy.
2nd assistant
Surgeon
st
assistant
1
Fig. 4.1.24 Cholecystectomy.
Position of the operating team and instruments according to Götz and
Pier. See Fig. 4.1.27 for placement of instrument table.
92
4.1 Retrograde Cholecystectomy
Surgeon
Assistant
Fig. 4.1.25 Cholecystectomy.
Positioning and approach in the United States. See Fig. 4.1.27 for placement of instrument table.
st
1
assistant
Surgeon
2nd assistant
Fig. 4.1.26 Cholecystectomy.
Positioning and approach in France. See Fig. 4.1.27 for placement of instrument table.
Surgeon’s
monitor
nd
2
assistant
st
1
assistant
Instrument table
Assistants’ monitor
Electrocautery
unit
Insufflator
Surgeon
Aspirator/
irrigator set
OR nurse
Fig. 4.1.27 Cholecystectomy. Position of the operating team in relation
to the equipment.
Always place the monitor in the surgeon’s field of vision. We recommend
a second monitor opposite the two assistants. The light sources, one for
the monitors and the video recorder each (if one is being used), are placed
together on the patient’s right.
The bipolar electrocautery unit, aspirator/irrigator set, and insufflator are
behind the surgeon. A second monitor may also be positioned here for
the assistants. For safety reasons, do not place the aspirator/irrigator set
next to electrical equipment. If a tube comes loose and fluid is spilled into
the air, it could cause a short circuit in the electrical equipment.
The operating room nurse stands behind the instrument table at the
patient’s feet. This position provides the best view of the operating site
and is well suited for passing instruments.
The thorax stop on the left side of the operating table is another
important detail. It permits positioning the patient with the
table steeply inclined to the left.
Trocar Placement (Fig. 4.1.28)
The layered, somewhat circuitous abdominal wall trocar punc-
ture reduces the risk of hernia or prolapse of omentum as the
camera trocar is withdrawn, since the fascia and muscle planes
cover each other in an individual, staggered, overriding fashion
(Semm’s Z-technique).
Select the incision site for working trocars by depressing the
abdominal wall while inspecting the abdomen laparoscopically
from within. Transillumination is useful in locating an avascular
area. The instrument trocar at port T2 will later be used to ad-
vance dissection swabs, scissors, the bipolar electrocautery, the
aspirator/irrigator, etc. The surgeon holds these various instruments with the right hand.
Instruments are rarely exchanged through the other trocars. The
second assistant holds the working trocar with his or her left
hand and maintains the working sleeve in position with the ex-
tended left index finger (see Fig. 4.1.83). This reduces the risk of
losing pneumoperitoneum pressure should the trocar valve jam
as the surgeon extracts an instrument. Changing instruments
without loss of pressure is possible only after the surgeon has
retracted the instrument into the converter sleeve.
To prevent a postoperative flank hematoma, one has to obtain
immediate hemostasis if subcutaneous bleeding occurs as the
lateral working trocars are placed (T3, T4). The assistant ad-
vances a 5-mm grasper through the T3 trocar, grasps the fun-
dus, and pushes the gallbladder superiorly toward the diaphragm (see Fig. 4.2.31). This maneuver opens Calot’s triangle
and broadly exposes the vascular and biliary structures to be
dissected and/or protected. The first assistant operates the laparoscope and camera inserted through the T1 trocar and the T5
trocar for gallbladder removal.
A second CO
insufflation hose (bypass) can be connected to the
2
T4 trocar. If two gas hoses are used, at T4 and T1, the units can
work at maximum insufflation and in the event of even signifi-
cant CO
losses, intraabdominal pressure can be maintaine d at
2
optimal levels. Our experience has shown that most procedures
can be completed without delay despite a constant loss of pressure through worn valve gaskets by using this CO
bypass ar-
2
rangement.
Complications
Intraoperative Complications
Injury to the Common Bile Duct
Injuries to the common bile duct and the common hepatic duct
may occur. Variations in anatomy increase the risk of injury.
Corrective action: Experienced laparoscopic surgeons can man-
age injuries that do not compromise the integrity of the duct by
placing a fine atraumatic suture and a T-drain to decompress
the bile duct. Where this is not possible, conversion to laparotomy is indicated, especially if the injury involves part or all
of the common duct circumference.
Trocar Placement and Complications
T2
T3
T4
T1
Fig. 4.1.28 Cholecystectomy. Trocar placement.
The illustration shows the standardized ports for laparoscopic cholecystectomy (Götz). Different trocar placement is used only if specifically indicated such as in the presence of suspected adhesions in the upper abdomen. Insert the laparoscope/camera trocar T1 (10.5-mm trocar with
trumpet valve and tapered stylet) in the inferior umbilical fossa using
Semm’s Z technique (see chapter 2.2).
Insert the first instrument trocar T2 (sharp pyramidal-tipped 10.5-mm
trocar with flap valve and instrument sleeve) into the abdomen under laparoscopic visualization through a right paramedian incision about two
finger breadths inferior to the right costal arch. Insert the trocar as shown
in chapter 2.2 with your finger extended along the body of the trocar
while gently pushing with a twisting motion of the wrist. Insert the second
instrument trocar T3 (sharp pyramidal-tipped 5.5-mm trocar with flap
valve and instrument tube) through a port site in the midclavicular line
about two finger breadths inferior to the right costal arch. Do this under
laparoscopic visualization while observing the same safety precautions as
above. The surgeon then inserts a 5-mm grasper through this trocar to
grasp the infundibulum.
Now make a 13 or 18-mm incision (depending on whether you are using a
15 or 20-mm gallbladder extraction sleeve) in the anterior axillary line to
accommodate the third instrument trocar T4 (sharp pyramidal-tipped 15
or 20-mm trocar with flap valve).
Alternative: open trocar placement.
93
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4.1 Retrograde Cholecystectomy
Constriction of the Cystic-Common Duct Confluence
An improperly placed clip can constrict this confluence or the
lumen of the common bile duct itself. This can occur if the anatomical pattern is not clear or if excessive tension has been applied to the cystic duct.
Corrective action: Remove the improperly placed clip(s) under
laparoscopic vision and place clip(s) at the appropriate locations. Laparotomy and an end-to-end anastomosis are indicated
to repair a severed common hepatic or common bile duct. If
more than 2 cm of the duct are compromised, primary suture
of the severed ends is generally no longer possible. These defects are repaired with a Roux-en-Y jejunal loop.
Vascular Injuries
The reported incidence of injuries to vascular structures (such
as the cystic artery, right hepatic artery, or common hepatic
artery) varies from 0.25% to 0.30%. However, improper trocar
placement can puncture the abdominal aorta or the common iliac
artery or the inferior vena cava or right common iliac vein re-
spectively.
The most frequent cause of sudden intraoperative bleeding is
avulsion of the cystic artery (as can occur when applying ten-
sion to the gallbladder while transecting the cystic duct), slip-
page of a ligature or clip, or puncture of a vascular structure
with an instrument in the liver hilus.
Corrective action: Expose the surgical site and identify the
source of bleeding. Judicious use of suction to clear the field is
always necessary. Grasp the stump of the vessel with an atraumatic clamp and ligate it with a clip or internal ligature.
Note: If bleeding cannot be controlled or the anatomy is in
doubt, immediate conversion to laparotomy is indicated. This
also applies to injuries of the hepatic artery proper and the right
branch of this artery.
Injuries to the Gastrointestinal Tract
Injury to the gastrointestinal tract is relatively rare and accounts
for only 0.14−0.2% of all complications. Generally these include
minor injuries to the duodenal serosa in the presence of an adherent gallbladder. Perforations of the stomach and duodenum
resulting from improper trocar handling have been reported.
Corrective action: Close seromuscular tears with interrupted sutures. Serosal defects may by sealed with fibrin glue. Place a
drain in the area of the lesion (see also Fig. 4.1.50 and
Fig. 4.1.74).
Corrective action: If a leakage from the bile duct is detected by
intraluminal endoscopy, place a transpapillary drain via endoscopy for at least three weeks, longer if necessary. If ERC demonstrates the absence of any obstruction or lesion in the biliary
system, diagnostic laparoscopy is indicated. If the situation cannot be diagnosed or managed laparoscopically, conversion to laparotomy is advisable.
Peritonitis
Corrective action: In the presence of localized peritonitis and
normal intestinal peristalsis, exploratory laparoscopy may be
indicated if the operating team has the necessary experience. Irrigate and clean the surgical site, and repair any leak in bile duct
or intestine; most frequently a duodenal injury will be detected.
Place a drain. In the presence of generalized peritonitis, immediate open intervention is mandatory with inspection of the
surgical site and exploration of the entire abdominal cavity. It is
essential to Gram stain and culture the exudate.
Subhepatic Subphrenic Abscess
Corrective action: Repeat laparoscopy and laparoscopic management, or laparotomy. Irrigate the site; locate and treat the
source of infection (undetected intestinal injury, lost gallstone,
etc.). Place a drain. It is essential to Gram stain and culture the
pus.
Bleeding
Bleeding may occur from the stump of the cystic artery (clip
slippage), the liver bed, or, less frequently, from other vessels.
Corrective action: Repeat laparoscopy to expose the source of
bleeding and achieve hemostasis. This procedure requires an
operating team experienced in laparoscopic surgery.
In the surgical site is not clearly seen, i. e., if the source of bleeding cannot be identified or hemostasis cannot be achieved via
laparoscopy, convert to laparotomy to control the bleeding.
Conversion is always an option and is indicated if any doubt exists.
Jaundice
Perform appropriate laboratory tests and endoscopy (ERC) to
determine the cause.
Corrective action: In the presence of stenosis or obstruction secondary to biliary stone disease, intraluminal endoscopic management is the preferred treatment. If this is unsuccessful, conventional intervention is indicated.
Immediate Postoperative Complications
Bile Drainage
Bile loss through the subhepatic drain (routinely placed by us)
generally stops after three days if the bile flows freely through
the sphincter of Oddi. If subhepatic bile loss continues or even
increases, immediate endoscopic retrograde cholangiography
(ERC) is indicated. The surgeon should then determine the
method of management after identifying the source of the leakage.
Possible sources of bile loss include:
쐌 Aberrant bile ducts in the liver bed.
쐌 A severed accessory bile duct.
쐌 Slippage of a cystic duct ligature or clip.
쐌 An undetected bile duct injury.
Late Complications
Possible causes include a partially retained gallbladder, lost infected gallstones, recurrent gallstones in the common bile duct,
bile duct strictures, and stenosis of the papillary sphincter.
Postoperative complaints following cholecystectomy require
extensive diagnostic studies involving the entire upper abdomen. The so-called “post-cholecystectomy syndrome,” if one
can be identified, accounts for about 2−5% of the causes. Endoluminal endoscopy is the procedure of choice in arriving at a
differential diagnosis.
Complications
95
Step-by-Step Procedure
1. Set up C-arm for intraoperative fluoroscopy.
2. Adjust the electrocautery unit to a medium setting.
3. Connect the aspirator/irrigator set.
4. Start the recording unit.
II Establishing the Pneumoperitoneum
1. Select pressure level according to patient’s size, age, and
weight (6−8 mm Hg for children; 10−14 mm Hg for adults).
2. Connect all equipment required for operation.
3. Make a periumbilical skin incision (approx. 1 cm).
4. Insert the Veress needle.
5. Perform safety tests: rotation, injection, aspiration, suction,
and manometer tests (see chapter 2.2).
6. Perform insufflation procedure according to chapter 2.2. Caution: insufflate infants at 1 l/min maximum.
Laparoscopy
1. Insert the laparoscope/camera trocar using Semm’s Z-tech-
nique (chapter 2.2).
2. Explore the peritoneal cavity (see chapter 3.2).
3. Insert the instrument trocars under laparoscopic visualization
(see chapter 2.2).
4. Establish final diagnosis and indication.
5. Apply tension to the hepatoduodenal ligament by grasping
the fundus and infundibulum.
6. Incise the visceral peritoneal covering.
7. Bluntly dissect the cystic duct and cystic artery with grasper
and dissector.
8. Expose the confluence of the cystic to common bile duct, and
the outline of the common hepatic duct.
9. Locate and dissect around the cystic duct and cystic artery.
10. Ligate the cystic duct, placing a double ligature or clips on the
common duct side and a single clip on the gallbladder side.
11. Transect the cystic duct between the ligatures or clips.
12. If possible, expose the right hepatic artery at the origin of the
cystic artery from the right hepatic artery.
13. Dissect out the cystic artery.
14. Ligate the cystic artery, placing a double ligature or clips
toward its origin and a single clip toward the gallbladder.
15. Transect the cystic artery between the ligatures or clips.
16. Dissect the gallbladder from the liver bed. Remain subserosal
in the dissection, using both blunt dissection with a swab and
sharp dissection after coagulating with electrocautery.
17. Aspirate the gallbladder if indicated.
18. Remove the transected gallbladder through a 15- or 20-mm
gallbladder extraction sleeve.
19. In the presence of large concretions or a grossly distended
gallbladder, remove the gallbladder in a sterile bag directly
through the abdominal wall, at the site of the largest trocar
port.
20. Irrigate the operative site.
21. Inspect the wound area to verify hemostasis. Control minor
bleeding with bipolar electrocautery. Verify proper positioning and integrity of the ligatures or clips
22. Place a no. 16 Robinson drain in Winslow’s foramen via the
right lateral gallbladder extraction sleeve (optional for many
surgeons).
23. Remove the instrument trocars under laparoscopic control.
Note: Residual bleeding from the trocar incisions may occur and
may need adequate attention.
24. Close right lateral fascial incision (15 or 20-mm trocar).
25. Close skin incision.
Operative Techniques
Fig. 4.1.29 Cholecystectomy. Aspirating the gallbladder in the presence
of a hydrops.
In the presence of hydrops and thickening of the wall of the gallbladder,
we recommend beginning laparoscopic cholecystectomy with aspiration
of the gallbladder. Aspirate at the fundus. You can later close the opening
with a grasper inserted through port T4. Lift the gallbladder anteriorly
with a probe inserted through the 20-mm gallbladder extractor at
port T4, while holding the fundus of the gallbladder with atraumatic
graspers inserted through the 10.5-mm instrument trocar at port T2.
Aspirate with a 15-cm long tip through port T3.
T2
T3
T4
96
4.1 Retrograde Cholecystectomy
T4
Fig. 4.1.30 Cholecystectomy. Closing the aspiration opening after suc-
tion.
After aspirating the gallbladder, close the opening with a grasper inserted
through the 20-mm trocar at port T4. Now retract the gallbladder anteriorly and superiorly toward the diaphragm. You can also close the opening
with a clip or Roeder knot.
T4
T3
Fig. 4.1.31 Cholecystectomy. Lysis of gallbladder adhesions.
Often there will be adhesions between the gallbladder and the greater
omentum, the duodenum, the right colon flexure, or the transverse
colon. Generally these adhesions can be separated by blunt dissection
with a grasper or dissector. If this is unsuccessful, coagulate the adhesion
with bipolar electrocauterty and transect it close to the gallbladder with
the dissection scissors (see Fig. 4.1.28 for key to instrument numbers).
T2
T3
T4
Fig. 4.1.32 Cholecystectomy. Holding the gallbladder.
If exploration of the peritoneal cavity has not revealed any further pathologic changes, one may begin the cholecystectomy proper. Grip the gallbladder near the fundus with a 5.5-mm grasper introduced through the
15 or 20-mm trocar located at T4 and move it upwards toward the diaphragm. Insert a second 5.5-mm grasper through the 5.5-mm instrument
trocar located at the medioclavicular port (T3). Grasp the infundibulum of
the gallbladder and move it laterally to expose the structures within
Calot’s triangle.
T4
T2
T3
Fig. 4.1.33 Cholecystectomy. Incision of the peritoneal covering of
Calot’s triangle.
As you reach Calot’s triangle, turn the camera horizontally for better
orientation. Place the patient in a reverse Trendelenburg position and turn
the operating table to the left (see Fig. 4.1.23).
Now dissect the peritoneal covering with the scissors. Dissection is easier
if one applies tension to the hepatoduodenal ligament by pulling the infundibulum inferiorly and to the right with the grasper inserted through
port T3 (see Fig. 4.1.28 for key to instrument numbers).
Complications
97
T2
(T4)
T3
Fig. 4.1.34 Cholecystectomy. Technique of dissecting Calot’s triangle.
Blunt dissection is indicated in Calot’s triangle. Do not use monopolar
electrocautery. After dissecting the peritoneal covering as shown in
Fig. 4.1.33, bluntly dissect the tissue off the vascular structures with a
swab dissector (2). Dissect medially away from the gallbladder toward the
common bile duct (1). This is the best way to reduce the risk of vascular
injury (see Fig. 4.1.28 for key instrument numbers).
Dissection is improved by applying tension to the infundibulum with a
grasper. Do not pull too hard, as this could elongate the cystic duct and
the confluence with the common bile duct so that the clip or ligature is
placed onto the common bile duct.
T2
T2
T3
Fig. 4.1.35 Cholecystectomy. Blunt dissection of the cystic duct with a
grasper.
Expose the full length of the cystic duct. Identify the union with the infundibulum, the confluence with the common bile duct, and the hepatic
duct, keeping in mind the possible variations in the anatomy of the cystic
duct (see Figs. 4.1.4 to 4.1.10 ).
Use only scissors, swab dissector, and grasper to dissect Calot’s triangle.
Always dissect away from the gallbladder toward the common bile duct
(see Fig. 4.1.34). Otherwise, vascular injury may result as shown in
Fig. 4.1.70. Use of monopolar electrocautery is contraindicated in this
area, because of the risk of electric current leakage.
Dissect the tissue by opening the jaws of the grasper inserted through the
10.5-mm instrument trocar (right paramedian port T2). Completely expose both the cystic duct and the cystic artery to ensure proper seating of
the clips or internal ligature. Open a window in Calot’s triangle by gently
opening the jaws of the grasper parallel to the vessel.
Note: We ligate the cystic duct and cystic artery in the manner dictated by
the specific anatomy of the operative site.
T5
Fig. 4.1.36 Cholecystectomy. Blunt dissection of Calot’s triangle.
To reduce the risk of vascular injury, always dissect medially toward the
hepatoduodenal ligament (see Fig. 4.1.34).
Fine tissue strands can be pushed out of the way with a swab dissector.
This method has proven to be especially effective at the confluence with
the common bile duct (see Fig. 4.1.37; see Fig. 4.1.28 for key to instrument numbers).