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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_788_Библиотеки_им_академика_М_И_Перельмана.pdf
98
T3
4.1 Retrograde Cholecystectomy
T2
Fig. 4.1.37 Cholecystectomy. Ligation of the cystic duct with surgical
clips.
After locating and completely exposing the cystic duct, ligate it. Place two
clips centrally; a single clip is sufficient for the peripheral ligature.
Note: The proximal clips should be placed at least 10 mm from the visible
confluence to avoid partial occlusion of the common bile duct (see
Fig. 4.1.66; see Fig. 4.1.28 for key to instrument numbers).
Elevate the cystic duct stump to verify that the clips are properly seated.
T2
T3
Fig. 4.1.38 Cholecystectomy. Surgical clips.
Alternative: laparoscopic application of absorbable clips.
컅 Fig. 4.1.39 Cholecystectomy. Transection of the cystic artery.
After the cystic duct has been transected, the cystic artery is liberated. To
positively identify the cystic artery, expose its origin from the right hepatic artery. Anatomic variations of cystic artery are common (see
Figs. 4.1.4 to 4.1.20).
Apply two clips to the central end of the cystic artery and one clip to the
peripheral end and transect the vessel with scissors inserted through the
10.5-mm instrument trocar at port T2. Leave a generous stump beyond
the second clip.
Note: Often after transecting the cystic artery, one will find an additional
posterior arterial branch that supplies the posterior aspect of the gallbladder (posterior branch of the cystic artery). For this reason, continue careful blunt dissection down to the liver parenchyma after transecting the
obvious anterior cystic artery (see Fig. 4.1.42).
T3
T2
Complications
99
Fig. 4.1.40 Cholecystectomy. Alternative technique for ligating the cys-
tic duct and cystic artery.
Instead of the clip technique previously described, one can use an internal
ligature with an extracorporeal knot to ligate the cystic duct and cystic
artery. This safe and inexpensive ligature technique is indicated particularly when the bile duct system is extensively dilated as is often observed
in the presence of acute cholecystitis.
Use an internal ligature with a minimum length of 90 cm. Introduce the
ligature into the abdominal cavity with a grasper inserted through the tro-
car at port T2. Hold the end of the suture (which extends 2 cm past the
grasper) at a right angle to the shaft of the trocar and pass it around the
tissue structure to be ligated. Then grasp it again and pull it back through
the same sleeve (port T2). Angling the suture makes it easier to retrieve
with the grasper after you have passed it around the structure and released it. Now secure the ligature with an extracorporeal Roeder knot (see
chapter 2.3).
Fig. 4.1.42 Cholecystectomy. Subserosal dissection of the gallbladder. 컄
Begin dissection of the gallbladder with a swab dissector close to the liver
at the infundibulum. The cystic duct and cystic artery have been clipped
or ligated and transected. Dissect off the remaining connective tissue
with a swab dissector, coagulating and transecting it if necessary (see
Fig. 4.1.28 for key to instrument numbers).
Fig. 4.1.41 Cholecystectomy. Subserosal dissection of the gallbladder.
Pulling the gallbladder neck to the right while holding the fundus upwards
broadly exposes Calot’s triangle and makes it easier to dissect the vascular
structures. If positive identification of the structures in the hepatoduodenal ligament is not possible, dissect the posterior aspect of
Calot’s triangle as well by waving the gallbladder neck like a flag. To minimize the risk of vascular injury, dissect medially with a swab dissector.
Where positive identification of the anatomic structures is still not
possible, intraoperative cholangiography or endoscopic retrograde
cholangiography (ERC) is indicated. If this is not feasible, convert to an
open procedure (see Fig. 4.1.28 for key to instrument numbers).
T3
T2
100
T3
T4
4.1 Retrograde Cholecystectomy
T2
T3
a b
Fig. 4.1.43a, b Cholecystectomy. Bluntly dissecting the gallbladder off
the liver bed.
Overview (a). Moving the camera anteriorly makes dissection easier.
T3
T2
Alternatively use a swab dissector and scissors to dissect the gallbladder
off the liver bed. Coagulate blood vessels with bipolar electrocautery (b;
see Fig. 4.1.28 for key to instrument numbers).
a b
Fig. 4.1.44a, b Cholecystectomy. Coagulating minor blood vessels with
bipolar electrocautery.
Coagulate visible blood vessels with bipolar electrocautery (port T2)
before transecting them (a). For fine vascular structures, we recommend
grasping the structure and rotating the electrocautery 90° to ensure that
both jaws are in contact with the tissue (b).
T1
T4
3 mm
Complications
101
Fig. 4.1.45 Cholecystectomy. Removing the transected gallbladder
through a gallbladder extractor sleeve under laparoscopic control.
Generally a 15- or 20-mm gallbladder extractor (port T4) can be used for
safe, contamination-free removal of the gallbladder under laparoscopic
visualization.
When removing the gallbladder, make sure to pull it completely into the
gallbladder extractor sleeve. This prevents tissue from jamming in the flap
valve of the instrument trocar when the extractor is withdrawn from the
abdomen.
We recommend pulling the gallbladder into the extractor with the stump
of the cystic duct uppermost. This reduces the risk of bile spillage through
the stump when the gallbladder is compressed as it is drawn into the extractor.
Fig. 4.1.47 Cholecystectomy. Aspirating the gallbladder before ex- 컄
tracting it.
After dissecting the gallbladder from the liver bed, extract it using a 15- or
20-mm gallbladder extractor sleeve (port T4).
In the presence of hydrops, aspirate the gallbladder. Once aspirated, the
gallbladder can usually be removed through a gallbladder extractor sleeve
without any problem.
Retract the emptied gallbladder completely into the gallbladder extractor
sleeve to prevent it from jamming in the flap valve.
If the gallbladder contains concretions larger than 20 mm diameter, you
will not be able to retract it completely into the extractor. In such cases, it
is best to use a sterile specimen bag to reduce the risk of contaminating
the abdominal wall (see Fig. 4.1.28 for key to instrument numbers).
Fig. 4.1.46 Cholecystectomy. Extracting the gallbladder with the aid of a
gallbladder extractor sleeve.
The excised gallbladder can be extracted through a 15- or 20-mm gallbladder extractor sleeve without contaminating the abdominal wall.
When you pull the gallbladder into the gallbladder extractor sleeve, make
sure that the extractor projects about 3 mm beyond the end of the instrument trocar. Only remove the gallbladder from the abdomen after you
have completely retracted it into the extractor. This prevents the gallbladder from jamming in the flap valve.
T3
T2
T4
102
4.1 Retrograde Cholecystectomy
T3
T2
T4
Fig. 4.1.48 Cholecystectomy. Alternative: extracting the gallbladder in a
sterile specimen or retrieval bag.
A grossly distended gallbladder can be safely removed in a sterile plastic
bag. Tie a knot in the end of the bag to strengthen it. Aspirate the gallbladder before placing it in the bag (see Fig. 4.1.28 for key to instrument
numbers).
T3
T4
Fig. 4.1.49 Cholecystectomy. Alternative: extracting the gallbladder in a
sterile specimen or retrieval bag.
Spread the abdominal incision with retractors. Extract the bag containing
the gallbladder with a clamp on one end of the bag. If necessary, one can
insert a finger into the incision to push from within.
Fig. 4.1.50 Cholecystectomy. Placing a drainage catheter into the operative site (optional).
Expose the liver bed with a grasper inserted through the 5.5-mm instrument trocar at port T3 to inspect the operative site and verify hemostasis.
Irrigate and apply suction to remove residual blood and clots. Control
minor bleeding with bipolar electrocautery (see Fig. 4.1.28 for key to instrument numbers).
T2
Complete the procedure by placing a no. 16 Robinson drain in Winslow’s
foramen through the 15- or 20-mm instrument trocar. This can be used to
evacuate residual CO
bile detected in the drainage fluid provided us with an early sign of bile
leakage.
Checking the clips on the cystic artery and cystic duct stump is a final step
in the operation.
in addition to irrigation fluid. In five of our patients,
2
T3
T4
T2
T4
Complications
103
T2
Fig. 4.1.51 Cholecystectomy. Procedure in the presence of dense inflammatory adhesions to other organs.
Laparoscopic cholecystectomy in patients who have dense adhesions
from a previous operation requires the highest degree of laparoscopic
surgical skill and experience.
Grasp the fundus of the gallbladder with an instrument inserted through
port T4. Separate the adhesions using a combination of blunt and sharp
dissection following coagulation (see Fig. 4.1.28) for key to instrument
numbers).
Note: Thermal injury can result when lysing adhesions close to the intestines. Proceed carefully, paying attention to the position of the
duodenum.
T4
Fig. 4.1.52 Cholecystectomy. Procedure in the presence of repeated
gallbladder inflammation and thickened scarred wall.
Chronic inflammation can cause the gallbladder to become so thick and
scarred that dissecting it from the liver bed becomes difficult or even impossible. In such a situation aspirate the gallbladder and empty it
completely, ligate the cystic duct and cystic artery as described, and resect the parts of the gallbladder that project beyond the liver bed (dotted
line). Then ablate the mucosa with electrocautery (Thorek, 1934). Place a
drain, and administer intravenous antibiotics (see Fig. 4.1.28 for key to in-
strument numbers).
T2
T2
T3
Fig. 4.1.53 Cholecystectomy. Procedure in the presence of inflammatory gallbladder adhesions to the liver capsule.
Inflammatory pericholecystic adhesions are often found in the presence
of chronic inflammation. Generally one can separate these adhesions with
retrograde blunt and sharp dissection with swab dissector and scissors
while coagulating vascularized structures. Aspiration is recommended in
the presence of a grossly distended gallbladder or thickening of the wall of
the gallbladder. This makes it easier to manipulate and dissect the gall-
bladder. Successful subserosal blunt dissection of the infundibulum off
the liver bed greatly facilitates further dissection (see Fig. 4.1.28 for key to
instrument numbers).
Fig. 4.1.54 Cholecystectomy. Alternate dissection technique using
hooked bipolar elctrocautery.
Electrocautery should not be used when dissecting structures in Calot’s
triangle due to the risk of thermal injury from current leakage. Once the
anatomy has been exposed by blunt dissection and clearly identified, you
may use bipolar electrocautery (hooked electrode inserted through
port T2) to transect the cystic duct and cystic artery. Monopolar electrocautery is contraindicated due to the risk of injuring adjacent structures
(see Fig. 4.1.28 for key to instrument numbers).
104
Fig. 4.1.55 Cholecystectomy. Using monopolar or bipolar electrocautery
to dissect the gallbladder off the liver bed.
As an alternative to combined blunt and sharp dissection, one may use
monopolar electrocautery (hooked electrode inserted through port T2)
to dissect the gallbladder off the liver bed. The illustration shows dissec-
tion using hooked-electrode bipolar electrocautery. This method allows
one to first coagulate the tissue and then advance the cutting wire into
the coagulation zone to transect the tissue without changing instruments.
Bipolar electrocautery has these advantages over monopolar electro-
cautery:
쐌 The electric current only flows between the jaws.
쐌 Risk of current leakage is minimal.
쐌 High-temperature zone is limited.
See Fig. 4.1.28 for key to instrument numbers.
4.1 Retrograde Cholecystectomy
T2
Zone 1 Zone 2 Zone 3 Zone 4
Fig. 4.1.56 Cholecystectomy. Complications with monopolar electrocautery.
Causes of thermal injury include using monopolar electrocautery units
with defective insulation. The type and extent of the injury depend on the
location of the defects.
Zone 1: Insulation defects often occur at the tip of the instrument. The
frequent insertion of the instrument through the trocar valve subjects the
tip to high mechanical stresses.
Zone 2: Insulation defects on the shaft of the instrument can produce injury when it comes into contact with an organ. Such injuries are usually
difficult to manage if the injured area is beyond the surgeon’s field of vision.
Zone 3: When metal trocars are used, electric current can leak by contact
of the electrode with the trocar into the abdominal wall or other organs in
contact with the trocar.
Zone 4: Insulation defects on the grip are generally due to design flaws.
When the surgeon receives an electric shock, the uncontrolled instrument
movement may injure the patient as well.
T2
T2
T1
Fig. 4.1.57 Cholecystectomy. Complication: intestinal injury due to an
insulation defect in the monopolar electrocautery unit.
Shaft insulation defects can cause a charge to accumulate in the metal
trocar. Using a plastic sleeve to make the electrocautery easier to manipulate can act like a capacitor and produce high charge condensation. It is
impossible to tell the location of the discharge and the degree of damage
(see Fig. 4.1.28 for key to instrument numbers).
T1
Fig. 4.1.58 Cholecystectomy. Complication: intestinal injury due to inadvertent contact with an instrument trocar.
When the electrode accidentally comes into contact with an instrument
trocar, the resulting current discharge can damage abdominal organs.
Note: The surgeon may fail to notice this injury if it occurs outside his field
of vision (see Fig. 4.1.28 for key to instrument numbers).
T3
T3/4
Complications
105
Fig. 4.1.59 Cholecystectomy. Complication: tear in the capsule of the
liver due to adhesions.
In the presence of active right upper abdominal peritonitis, the liver will
often be adherent to the lateral abdominal wall. Retracting the gallbladder superiorly can produce shear forces along the adhesions between the
lateral abdominal wall and the gallbladder that are strong enough to tear
the capsule of the liver.
Prevention:
쐌 In the presence of adhesions between the right hepatic lobe (espe-
cially segments VI and VII) and the abdominal wall, lysis and coagulation of the adhesions is indicated.
Corrective action:
쐌 Suture the liver.
쐌 Repair defect with fibrin glue.
쐌 If necessary, convert to laparotomy.
See Fig. 4.1.28 for key to instrument numbers.
Fig. 4.1.61 Cholecystectomy. Complication: accidental perforation of
the gallbladder.
Intraoperative perforation of the gallbladder in the absence of infection is
not a complication. Gallstones that escape into the peritoneum must be
retrieved. Remove smaller concretions with suction. Use a sterile bag to
remove larger stones (Fig. 4.1.63).
The risk of perforation increases in the presence of acute cholecystitis, hy-
drops, or phlegmonous or gangrenous tissue changes in the gallbladder
wall. Perforations most often occur in the fundus as the surgeon dissects
the gallbladder off the liver bed.
Prevention:
Hold the grasper to place tension on tissues as close to the area of dissec-
tion as possible. Using blunt dissection is helpful.
Corrective action:
쐌 Irrigate and debride the operative site.
쐌 Administer antibiotics.
쐌 Close the perforation with a ligature, clip, or grasper (see Fig.
4.1.62a−c)
See Fig. 4.1.28 for key to instrument numbers.
Fig. 4.1.60 Cholecystectomy. Complication: tear in the capsule of the
liver at the round ligament.
If the gallbladder is medially displaced or the round ligament is wide and
fatty, retracting the gallbladder superiorly can tear the liver capsule immediately adjacent to the round ligament.
Prevention:
쐌 Retract the gallbladder toward the diaphragm under laparoscopic con-
trol, applying only gentle pressure.
쐌 If necessary, incise the insertion of the round ligament after coagulat-
ing with bipolar electrocautery.
Corrective action:
쐌 Suture the capsule.
쐌 Repair defect with fibrin glue.
쐌 If necessary, convert to laparotomy.
See Fig. 4.1.28 for key to instrument numbers.
T2
106
4.1 Retrograde Cholecystectomy
a Roeder knot. b Clip.
c Closing the perforation with a grasper.
Fig. 4.1.62 Cholecystectomy. Closing a perforated gallbladder.
T2
T4
Fig. 4.1.63 Cholecystectomy. Retrieving gallstones with a strerile bag.
Lost clips or gallstones must be removed from the abdominal cavity.
Remove a single concretion directly through the 15- or 20-mm gallbladder extractor sleeve (port T4). If multiple concretions are to be removed,
using a sterile plastic bag saves time. Special bags are available for this
purpose (see Fig. 4.1.28 for key to instrument numbers).
T3
Fig. 4.1.64a, b Cholecystectomy.
Potential complication: anatomic
variant of the cystic duct.
Clear identification of the individual structures of the extrahepatic biliary system is particularly
difficult in the presence of a short
cystic duct. See Figs. 4.1.4 to
4.1.10 for further anatomic variations.
a
b
Prevention of injuries:
쐌 Dissect the peritoneal covering to a safe point to the left of the com-
mon hepatic duct and common bile duct.
쐌 Avoid hasty identification of a structure.
쐌 Expose the cystic duct and cystic artery before applying clips or liga-
tures.
쐌 Look for pulsation when identifying arteries.
쐌 Before ligating the cystic duct, relieve the tension applied with the
grasper inserted through port T3 (see Fig. 4.1.33).
Note: Tension on the infundibulum causes the confluence to rise like a
tent.
쐌 When in doubt, use intraoperative cholangiography for positive identi-
fication.
쐌 Where positive identification of the anatomic structures is still not
possible, intraoperative ERC or conversion to an open procedure is in-
dicated.
쐌 Dissect the common bile duct to a point far to the left of and superior
to the structure to ensure positive identification of the extrahepatic
biliary system.
쐌 Use a Roeder knot if the cystic duct is extremely short or grossly di-
lated (see Fig. 4.1.69).
Corrective action:
쐌 If intraoperative injury to the cystic duct occurs, remove all clips from
the biliary structures.
쐌 Extensive repeat dissection is indicated. Expose the confluence and the
common bile duct.
쐌 Place the first clip as close to the neck of the gallbladder as possible.
쐌 Perform postoperative ERC if transaminase and bilirubin values in-
crease.
쐌 Remedial laparotomy.
쐌 In the presence of necrosis, perform laparotomy to manage biliary sys-
tem defect.
쐌 Remove improperly placed clips.
쐌 Place common duct T-drain or internal drain in gallbladder bed.
Possible complications resulting from insufficient dissection with consequent inadequate overview of the bile ducts are discussed in
Figs. 4.1.65 and 4.1.66.
T3
T3
Complications
107
2
.
Fig. 4.1.65 Cholecystectomy. Complication: insufficient exposure of the
common bile duct.
If the surgeon incompletely dissects Calot’s triangle as shown in the illustration, neither the confluence nor the cystic artery can be identified.
Applying clips or ligating in this situation can result in serious complica-
tions such as a partial occlusion of the common bile duct as shown.
See Fig. 4.1.64 for prevention and corrective action.
Dissect the common bile duct so as to ensure positive identification of the
confluence and the union with the hepatic bile duct. This makes it easier
to positively identify the common hepatic duct and the common bile
duct.
When in doubt, intraoperative cholangiography is helpful. Where positive
identification is still not possible, intraoperative ERC or conversion to laparotomy is indicated (see Fig. 4.1.28 for key to instrument numbers).
.
1
Fig. 4.1.66 Cholecystectomy. Complication: partial ligature of the common bile duct.
The complication shown here is the result of a series of errors. The clips
were placed too far centrally; the tension on the infundibulum was too
great; and Calot’s triangle and the common hepatic duct have not been
sufficiently dissected. This is complicated by the presence of a short cystic
duct. Here, the structures of the extrahepatic biliary system have not
been positively identified.
See Fig. 4.1.66 for prevention and corrective action.
1 Cystic duct
2 Common hepatic duct
3 Common bile duct
.
3
Fig. 4.1.67 Cholecystectomy. Complication: transection of the common
hepatic duct in the presence of an anatomic variant.
If in the presence of an anatomic variant of the common hepatic duct the
surgeon fails to dissect the common bile duct far enogh centrally, the surgeon can mistake the common hepatic duct for the cystic artery and ligate it.
Prevention:
쐌 Dissect the common bile duct so that the confluence and the common
hepatic duct are visible.
쐌 Completely expose the structures to be ligated.
쐌 When in doubt about an anatomic variant, intraoperative cholangio-
graphy is indicated.
쐌 Compare the anatomic structure with preoperative cholangiograms.
쐌 Where intraoperative cholangiography is not feasible, intraoperative
ERC is indicated.
쐌 When in doubt, conversion to laparotomy is indicated.
Corrective action:
Laparotomy.
1 Right hepatic duct
2 Cystic duct
3 Cystic artery
4 Common hepatic duct
T2
4
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3
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