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108
T3
4.1 Retrograde Cholecystectomy
T2
T2
T4
Fig. 4.1.68 Cholecystectomy. Complication: clip slippage corrected
with Roeder knot.
We recommend using metal clips to ligate the cystic duct or control a ves-
sel 1−2.5 mm in diameter. Where clips are used to ligate structures of
larger diameters, the wider vascular wall and tissue tension can cause slippage.
Prevention:
쐌 Only use clips on structures with a diameter greater than 1 mm and
less than 2.5 mm.
쐌 After placing the clips, inspect the operative site to verify hemostasis
and proper seating.
Corrective action:
쐌 Ligate structure with Roeder knot (chapter 2.2).
쐌 Manipulate pre-tied knot with the grasper.
쐌 Grasp the stump of the vessel.
쐌 Place the Roeder knot near the base of the vessel.
쐌 Cut the suture tail about 5−7 mm above the knot.
See Fig. 4.1.28 for key to instrument numbers.
T3
Fig. 4.1.69 Cholecystectomy. Complication: bleeding in the area of the
bifurcation fo the common hepatic duct.
After you identify and control the cystic artery, there is a risk of injuring a
more posterior gallbladder vessel during further dissection. The vascular
structures in this area are often so fine that clips are contraindicated (see
Fig. 4.1.71). Generally hemostasis can only be achieved with bipolar electrocautery. Observe the safety precautions listed below.
Prevention:
Safety precautions for bipolar electrocautery:
쐌 Use low power setting.
쐌 Coagulate in short bursts (less than one second).
쐌 Maintain a safe distance to adjacent tissue.
You can avoid this complication by performing further dissection
bluntly (with a swab dissector) after ligating the cystic artery and cystic
duct. Insert the swab dissector at the infundibulum to open up a hollow space between the gallbladder and the liver bed (see Fig. 4.1.42).
This allows you to expose any posterior vessels while minimizing the
risk of damaging them. We recommend rotating the swab dissector
and applying gentle, even pressure as you advance it. Dissect medially
toward the common bile duct (see Fig. 4.1.34).
Corrective action:
쐌 Bipolar electrocautery
1. Low power setting.
2. Short bursts (less than one second).
3. Be careful of the common hepatic duct (maintain safe distance).
쐌 Apply compression.
쐌 Use clips on larger vessels.
쐌 Ligate if necessary.
쐌 When in doubt, immediate conversion to laparotomy is indicated.
See Fig. 4.1.28 for key to instrument numbers.
Complications
109
.
r
Fig. 4.1.70 Cholecystectomy. Complication: bleeding from the cystic
artery.
Dissection of Calot’s triangle is improved by applying tension to the infun-
dibulum. However, if you apply excessive tension while dissecting toward
the gallbladder with the swab dissector, you can avulse the cystic artery.
Prevention:
쐌 The tension applied to the infundibulum must not elongate the entire
length of the vessel.
쐌 Dissect gently with the swab dissector.
쐌 Use a grasper to try to dissect the artery so that it is completely ex-
posed.
쐌 Good exposure of all the anatomy is helpful.
Corrective action:
쐌 Remove blood with suction.
쐌 Place the suction tube at the puncture site.
쐌 If you cannot identify the puncture site, place temporary clips, remove
the remaining blood with suction, place permanent clips as necessary,
and remove the temporary clips.
쐌 Identify the cystic artery.
쐌 Expose the entire artery.
쐌 Locate and expose the puncture site.
쐌 Ligate with clips distal and proximal to the puncture site.
쐌 When in doubt, convert to laparotomy.
Fig. 4.1.71 Cholecystectomy. Complication: faulty clip placement.
A closed metal clip will apply the least pressure at its open end. Some clips
have an aperture at their curvature. If the vessel to be ligated is less than
1 mm in diameter, there is a risk that the clip might not securely ligate the
vessel. Loose clips can easily slip off the structure to be ligated.
Prevention:
Ligate vessels less than 1 mm in diameter with internal ligatures or coagulate them with bipolar electrocautery.
Corrective action:
쐌 Remove improperly placed clips.
쐌 Bipolar electrocautery.
쐌 Alternative: internal ligature.
쐌 Apply compression to smaller vessels.
쐌 When in doubt, convert to laparotomy.
110
4.1 Retrograde Cholecystectomy
a
a
b
Fig. 4.1.72a Cholecystectomy. Complication: severed vein in the liver
bed.
Superficial veins of the liver bed can be injured if the surgeon dissects the
gallbladder sharply from the liver bed. The resulting bleeding can be difficult to control. Using scissors or monopolar electrocautery for dissection
of a well vascularized area increases the risk of injuring superficial vessels.
Prevention:
쐌 Apply tension to tissue by holding it with a grasper placed as close as
possible to the dissection site.
쐌 Always clean blood from tissue with a swab dissector. Only use electro-
cautery or scissors as the second step in dissecting.
쐌 Continue dissection with a swab dissector after identifying a vein in the
liver bed.
Corrective action:
쐌 Ligate if necessary.
쐌 Coagulation.
쐌 Compression.
Fig. 4.1.72b Cholecystectomy. Complication: bleeding vein of the liver
bed. Ligature.
bc
Fig. 4.1.73a Cholecystectomy. Complication: penetration into the liver
bed.
After the gallbladder has been removed, inspect the operative site again.
Use the grasper inserted through port T4 to open up the liver bed. If you
do not grasp the remaining peritoneal cover of the gallbladder, but instead attempt to lift the liver directly with the grasper as shown here, the
grasper can penetrate the bed of the liver and cause bleeding.
Prevention:
쐌 Grip the tip of the liver capsule at the edge of the gallbladder bed.
쐌 Use a swab dissector (mini dissecting swab dissector or larger swab
dissector inserted through 15- or 20-mm trocar) to directly lift the
liver.
쐌 Always use atraumatic graspers.
Corrective action:
쐌 Electrocautery (see Fig. 4.1.73b).
쐌 Irrigating the operative site cools the surface of the liver bed and helps
achieve deeper coagulation.
쐌 Minor bleeding from the liver bed can be additionally treated with a
hemostatic agent. This may be used in conjunction with fibrin glue.
쐌 Apply compression to the source of bleeding (see Fig. 4.1.73 c).
쐌 Ligature (see Fig. 4.1.72 b).
쐌 Apply hemostatic agent.
Fig. 4.1.73b Cholecystectomy. Complication: bleeding vein in the liver
bed.
Bipolar electrocautery.
Fig. 4.1.73c Cholecystectomy. Complication: bleeding vein in the liver
bed.
Compression.
Complications
111
Fig. 4.1.74 Cholecystectomy. Sealing the liver bed.
Occasionally dissection of the gallbladder off the liver bed may result in injury to the liver parenchyma. This may occur in the presence of acute
cholecystitis. Bleeding from such a lesion is difficult to control with bipolar
electrocautery. In addition to tamponading the liver bed, you may seal it
with fibrin glue using a double-lumen application catheter approximately
20 cm long. Place a high-volume suction drain, see Fig. 4.1.50.
Fig. 4.1.75 Cholecystectomy. Complication: perforation of the diaphragm.
After dissecting one-third of the gallbladder off the liver bed, the surgeon
transfers the traction on the infundibulum to the first assistant. The first
assistant now pushes the gallbladder past the margin of the liver toward
the diaphragm. This often requires applying considerable force, because
about two-thirds of the gallbladder are still fixed in the liver bed. Here,
there is a risk that the grasper might slip off the tissue and penetrate the
diaphragm.
Prevention:
쐌 Inspect all instrument jaws for signs of wear.
쐌 Extend your index finger along the shaft of the instrument (see
Fig. 4.1.76).
Corrective action:
쐌 Depending on the size of the perforation, placement of an underwater
chest drain may be indicated.
쐌 Convert to laparotomy and repair the perforation.
컅 Fig. 4.1.76 Cholecystectomy. Safety precautions when handling the
grasper.
As described in Fig. 4.1.75, the force required to move the infundibulum
can result in perforation of the diaphragm. Extending the index finger
along the shaft prevents uncontrolled instrument movement if the tissue
slips out of the jaws of the grasper.
112
4.1 Retrograde Cholecystectomy
Fig. 4.1.77 a Cholecystectomy. Complication: improper use of scissors.
Due to the fixed viewing angle of the laparoscope, only one jaw of the
scissors may be visible on the monitor. This entails a risk of vascular injury.
Fig. 4.1.77 b Cholecystectomy. Complication: improper use of the scissors.
To avoid inadvertent tissue injury, make sure that both jaws of the scissors
are visible on the monitor before you cut.
Fig. 4.1.78 Cholecystectomy. Complication: improper use of scissors.
The illustration shows improper use of the scissors as the surgeon transects the cystic duct. If the cystic duct and the cystic artery lie close together and the surgeon opens the scissors too wide, vascular structures
can be injured and serious bleeding from the cystic artery or right hepatic
artery can result.
Prevention:
쐌 Completely dissect the vascular structures to be transected.
쐌 Expose the posterior aspect of the structure as much as possible with a
mini dissection swab.
쐌 Only open the jaws of the scissors slightly.
쐌 If necessary, transect the structure by making a series of small cuts.
쐌 Mobilize adherent vessels with a grasper and move them out of the
scissors’ way.
Corrective action:
쐌 Apply suction to identify the source of bleeding.
쐌 Place clips as necessary.
쐌 Coagulate small vessels (less than 2 mm) with bipolar electrocautery
(see Fig. 4.1.44b).
쐌 Place ligature if necessary.
쐌 Apply swab dissector compression if necessary, and then place clips.
쐌 Control a profusely bleeding stump with grasper, and then place clips.
Complications
113
Fig. 4.1.79 Cholecystectomy. Complication: trocar spreads contamina-
tion to subcutaneous fatty tissue.
Dissecting the gallbladder off the liver bed may result in perforation and
spillage of gallstones into the peritoneum. If this happens, retrieve the
gallstones with the grasper inserted through the 10.5-mm trocar
(port T2).
Extracting a stone through the converter sleeve can be difficult, since the
stone may fracture. If the end of the trocar becomes contaminated, with-
drawing the trocar can spread the contamination to the abdominal wall
and produce a subcutaneous abscess.
Prevention:
쐌 Before removing the trocars, inspect the incisions laparoscopically to
verify the absence of bleeding or contamination.
쐌 Collect concretions in a sterile plastic bag.
쐌 Use a three-prong grasping forceps for retrieving stones.
Corrective action:
Debridement.
Fig. 4.1.80 Cholecystectomy. Losing a swab dissector through the flap
valve.
If you do not first pull the swab dissector into the converter sleeve before
withdrawing it from the abdomen, it will invariably jam in the flap valve
mechanism. This can pull it out of the grasper jaws so that it falls back into
the abdomen. Locating and retrieving a mini dissection swab dissector
can considerably extend the length of the operation. (A C-arm unit should
be available for intraoperative fluoroscopy).
Prevention:
쐌 Before withdrawing a swab dissector from the abdomen, pull it
completely into the converter sleeve.
쐌 Remove converter sleeve together with the grasper.
쐌 Always exert pressure on the jaws when using a swab dissector.
쐌 Use swab dissectors with a radiolucent strip, and only sparingly at that.
Corrective action:
쐌 Insert a grasper into the abdominal cavity through the trocar fixed in
its last position.
쐌 Use the grasper to determine the direction in which the swab dissector
has fallen.
쐌 Remove any residual blood under laparoscopic visualization.
쐌 Do not irrigate.
쐌 Do not reposition the patient.
쐌 If necessary, use fluoroscopy to locate the swab dissector.
쐌 Conversion to laparotomy is an option.
쐌 If you lose a swab dissector, fix the trocar in its last position.
114
4.1 Retrograde Cholecystectomy
Fig. 4.1.81 Cholecystectomy. Handling the grasper with a swab dissector
attached.
When using a grasper to hold a swab dissector, there is the risk that the
surgeon may inadvertently open the grasper and lose the swab dissector
in the abdominal cavity.
Prevention:
Always hold the grasper as shown, resting the proximal handle against the
heel of your hand and wrapping your fingers around the distal handle.
Never put your thumb and index finger through the rings and hold the
grasper like a standard forceps.
쐌 Use swab dissectors with a radiolucent strip.
쐌 Corrective action:
쐌 If you lose the swab dissector, fix the trocar in its last position.
쐌 Insert a grasper into the abdominal cavity through the fixed trocar.
쐌 Use the grasper to determine the direction in which the swab dissector
has fallen.
쐌 Remove any residual blood under laparoscopic visualization.
쐌 Do not irrigate.
쐌 Do not reposition the patient.
쐌 If necessary, use fluoroscopy to locate the swab dissector.
쐌 Conversion to laparotomy is an option.
Fig. 4.1.82 Cholecystectomy. Handling the instrument trocars.
The assistant holds the instrument trocars in the desired position between the thumb and middle finger as shown, thus minimizing the risk of
pulling out the trocars when the surgeon changes instruments.
Fig. 4.1.83 Cholecystectomy. Handling the instrument trocars.
When a 10.5-mm trocar is used with a converter sleeve, the assistant
places the index finger on the end of the sleeve to prevent it from being
inadvertently pulled out when the surgeon changes instruments (see
Fig. 4.1.84). This also fixes the trocar in the desired position.
Fig. 4.1.84 Cholecystectomy. Handling the instrument trocars.
If the converter sleeve is not secured as shown in Fig. 4.1.83, the sleeve
can permaturely slide out of the trocar when the surgeon changes instruments. This may result in loss of a swab dissector or damage to the valve
mechanism.
Special Preparations
115
Fig. 4.1.85a, b Cholecystectomy. Rendezvous maneuver.
The rendezvous maneuver provides a simple method for placing a drain.
Bring two opposite trocars horizontally into line with each other (a). Ad-
vance a grasper through one trocar into the lumen of the opposing trocar,
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4.2 Anterograde Cholecystectomy
F. Köc kerling
Goals and Methods
The standard technique in laparoscopic cholecystectomy fol-
lows the conventional procedure of retrograde cholecys-
tectomy, in which the surgeon locates the cystic artery and the
cystic duct and dissects the gallbladder off the liver bed from its
neck to the fundus. In the presence of acute cholecystitis or a
long history of chronic cholecystitis involving extensive inflammatory changes in Calot’s triangle, locating the cystic duct and
artery can be difficult. Here, as in open procedures, anterograde
cholecystectomy is an alternative. It is regarded as a safer opera-
tive procedure if extensive scarring is present in Calot’s triangle.
The advantage of this procedure is that the gallbladder is dissected off the liver bed starting at the fundus. If the dissection
proceeds immediately along the wall of a gallbladder, the cystic
duct can be reached more safely by proceeding along the neck
of the gallbladder. The disadvantage of this procedure is that
more extensive bleeding may be encountered while dissecting
the gallbladder due to the inflammatory reaction and the fact
that the cystic artery has not been ligated first. Despite this
drawback, we have successfully employed this procedure as an
alternative to the retrograde approach in individual cases in-
volving difficult anatomic features.
Indications
Anterograde laparoscopic cholecystectomy can be used in the
presence of extensive inflammation of Calot’s triangle in
patients with acute cholecystitis or a long history of chronic
cholecystitis. If a clear exposure and safe dissection of the cystic
artery and duct are not possible, then the gallbladder can be
carefully dissected off the liver bed by starting at the fundus. If
this is possible without major bleeding, conversion to an open
procedure can be avoided.
Contraindications
If a detailed exposure and complete dissection of the gallbladder cannot be achieved in this fashion or major bleeding occurs,
conversion to an open procedure is indicated.