4.3 Alternate Method of Gallbladder Retrieval

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4.2 Anterograde Cholecystectomy

Surgical Risks and Patient Information

The retrograde technique does not involve any special con-

siderations with respect to surgical risks and patient informa-

tion. The decision to employ an anterograde approach cannot be predicted and is reached intraoperatively. This technique is intended to reduce complications in the occasional, exceptional case.

Special Preparations

No special preparation of the patient is required to use this technique in laparoscopic cholecystectomy.

Anesthesia

General anesthesia.

Patient Positioning

The patient is positioned as for the retrograde technique.

Trocar Placement

The trocar placement is also the same as in the retrograde approach.

Complications

Specific intraoperative complications in anterograde laparoscopic cholecystectomy include:

쐌 Major bleeding during dissection of the gallbladder from the

liver bed.

쐌 Injuries to the hepatic parenchyma when elevating the gall-

bladder from the surrounding liver.

쐌 Avulsing the gallbladder at the neck.

Corrective action: Since the anterograde approach in cholecystectomy is used in very difficult cases, the operating team should be prepared for early conversion to an open procedure if complications are encountered.

Step-by-Step Procedure

1. Insert the trocars under laparoscopic visualization.

2. Establish the diagnosis and indication that favor anterograde dissection.

3. Elevate the liver with a blunt dissector or fan retractor.

4. Dissect the gallbladder off the liver bed starting at the fundus.

5. Locate, ligate, and transect the cystic artery at the level of the

neck of the gallbladder.

6. Dissect the cystic duct beyond the neck of the gallbladder.

7. Remove any stones occluding the cystic duct.

8. Ligate the cystic duct with PDS clips and transect it.

Operative Technique

Fig. 4.2.1 Anterograde laparoscopic cholecystectomy. Dissection of the gallbladder from the liver bed starting at the fundus and proceeding toward the neck of the gallbladder. Elevating the liver with a blunt dissector is absolutely essential for the anterograde technique. This cannot be safely done with a grasper due to the extensive inflammatory changes in the liver bed. After immobilizing the liver with the blunt dissector, the surgeon grasps the fundus of the gallbladder and gradually incises the peritoneum of the gallbladder and the inflamed adhesions between the gallbladder and the liver bed using electrocautery with a hooked electrode. Extreme care is necessary to achieve hemostasis and to prevent the operative site from becoming obscured with blood. The dissection must proceed along the wall of the gallbladder to avoid penetrating the hepatic parenchyma. The acutely inflamed gallbladder often lacks a tissue layer separating the wall of the gallbladder from the hepatic parenchyma.

Complications

119

Fig. 4.2.2 Anterograde laparoscopic cholecystectomy. Exposure of the

cystic artery at the level of the neck of the gallbladder. After carefully dissecting the gallbladder off the liver bed to its neck, the surgeon exposes the bifurcation and main trunk of the cystic artery. The dissection to expose the cystic artery proceeds along the neck of the gall-

bladder. Clips are placed and the cystic artery is transected. The cystic

artery can be positively identified by carefully elevating the lower surface of the liver with a swab dissector.

Fig. 4.2.3 Anterograde laparoscopic cholecystectomy. Locating and transecting the cystic duct.

After transection of the cystic artery, the cystic duct can be safely exposed and identified by dissecting from the neck of the gallbladder toward the cystic and common duct junction. Since a stone occluding the cystic duct is a frequent cause of acute cholecystitis, dissection of the cystic duct should proceed far enough to exclude the presence of stones occluding it. Only then can the gallbladder be removed by placing PDS clips and transecting the cystic duct.

4.3 Alternate Method of Gallbladder Retrieval

F. Köc kerling

Goals and Methods

Retrieving the gallbladder can cause problems in laparoscopic

cholecystectomy.

Despite the use of proven methods such as extraction through

the umbilical incision or with the aid of a gallbladder extractor or retrieval sleeve (see chapter 4.1 for technique), gallstones can

escape from a distended full gallbladder and individual stones may be too large to pass through the extractor sleeve. Lost gallstones or gallstone fragments are foreign bodies

capable of producing infection and are regarded as a risk factor leading to postoperative complications. In situations such as these, we recommend the use of a sterile

specimen or retrieval bag. Using a bag helps to diminish the risk

of losing gallstones. The surgeon can safely reduce the volume

of the gallbladder by aspirating it within the bag. Large concre-

tions can be broken up under laparoscopic visualization within

the bag.

The bag and its contents are extracted through the right lateral

trocar without direct contact with the abdominal organs or

abdominal wall.

Indications

Using a bag to retrieve a gallbladder is always possible. This method is advantageous in the presence of numerous large concretions which will not pass through the trocars and incisions, and whenever suspicious tissue changes in the gallbladder wall are detected. Since there have been reports of abdominal wall implantations of cancer from silent, unsuspected gallbladder cancers, the gallbladder should always be removed inside a protective shield, extractor/retrieval sleeve, or specimen retrieval bag.

Contraindications

There are no known contraindications to using a sterile speci-

men bag.

Surgical Risks and Patient Information

With respect to risks, this technique is no different from any other extraction or retrieval technique in laparoscopic cholecystectomy. Despite the improvements this technique offers,

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4.3 Alternate Method of Gallbladder Retrieval

the surgeon must discuss all known complications with the patient (see chapter 4.1).

Special Preparations

The patient requires no special preparations when this technique is used in laparoscopic cholecystectomy.

Anesthesia

General anesthesia.

Patient Positioning

The patient is positioned supine with the right upper abdomen

slightly elevated as in standard open cholecystectomy. The left

arm is positioned at the patient’s side, and the right arm is extended to facilitate intravenous access. Af ter the trocar is in-

serted through an incision in the inferior margin of the umbili-

cus, the patient is moved into a reverse Trendelenburg position

so that the transverse colon, greater omentum, and small in-

testine fall into the lower abdomen. The operating team and equipment are positioned accordingly (Fig. 4.3.1).

Trocar Placement (Fig. 4.3.2)

Complications

Specific intraoperative complications of the alternate extraction or retrieval technique in laparoscopic cholecystectomy include:

쐌 Failure to break up stones sufficiently with the use of a la-

paroscopic crushing clamp in the sterile bag.

쐌 Bile and gallstone spillage from the bag due to poor surgical

technique.

쐌 Tearing the sterile bag when using sharp instruments. 쐌 Perforating the sterile bag when breaking up stones with in-

struments held outside the bag.

쐌 Twisting the bag, thus impeding ”hourglass” extraction of

the stones.

Corrective action: If the complication cannot be corrected laparoscopically, conversion to laparotomy is indicated.

Monitor

Assistant helping with the dissection

Surgeon

Assistant holding laparoscope

Fig. 4.3.1 Patient positioning

and position of the operating team and instruments. The surgeon stands to the left of the patient, looking past the operative site to the monitor on the opposite side of the patient. The assistant holding the laparoscope stands to the left of the patient and of the surgeon. Another assistant stands to the right of the patient and holds the gallbladder as the surgeon dissects it.

He or she turns to the left to

watch the procedure on the monitor. The operating room nurse and the instrument table are either at the patient’s feet or to the left behind the surgeon. The aspirator/irrigator set and bipolar electrocautery unit can be positioned more or less as desired.

Instrument table

Fig. 4.3.2 Alternate retrieval technique in

cholecystectomy. Trocar placement. T1 10-mm laparoscope/camera trocar in-

serted through transverse incision in the inferior umbilical fossa.

T2 5/7-mm instrument trocar inserted just

inferior to the right costal arch at about the level of the gallbladder.

T3 12-mm instrument trocar inserted as

far right and lateral as possible inferior to the right costal arch. The sterile bag is inserted and retrieved with the gallbladder through this trocar.

T4 12-mm instrument trocar inserted infe-

rior to the xiphoid process slightly to the right and lateral of the falciform ligament of the liver. The pursestring suture clamp used in intraoperative lithotripsy is inserted through this instrument trocar. Alternative: open trocar placement.

Complications

121

Step-by-Step Procedure

1. Insert the trocars under laparoscopic visualization.

2. Perform the laparoscopic cholecystectomy (see the section on laparosopic cholecystectomy).

3. Grasp the neck of the gallbladder after dissecting the gall-

bladder from the liver bed.

4. Introduce the sterile bag through the right lateral instrument trocar.

5. After unfolding the bag with graspers, pull the gallbladder

into the bag with the neck first.

6. Inside the bag, grasp the gallbladder by the fundus and incise the gallbladder with scissors.

7. Aspirate the bile from the gallbladder.

8. Extend the incision in the gallbladder wall to allow removal of gallstones; liberate impacted gallstones from the gallbladder wall.

9. Extract the gallstones from the gallbladder into the bag.

10. Contain larger gallstones within the bag for inside lithotripsy using a laparoscopic crushing clamp.

11. Grasp the gallbladder by the neck again, turn it around to “shake out” stones, and introduce the suction catheter into

the sterile bag to aspirate bile and small concretions.

12. Tighten the pursestring suture of the sterile bag around the neck of the gallbladder and around the suction tube.

13. After removing the suction tube from the sterile bag, pull the bag containing the gallbladder into the right lateral instrument trocar.

14. Extract the sterile bag together with the right lateral instrument trocar holding part of the sac within its lumen through

the abdominal wall. Multiple stones or stone debris contained within the tail end of the sac, beyond the trocar are pulled out through the trocar incision like sand running through an hourglass. If necessary, a “peanut” swab mounted on a curved clamp can be used inside the wound, along the end of the bag

in a “pull-push” maneuver.

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4.3 Alternate Method of Gallbladder Retrieval

Operative Technique

Fig. 4.3.3 Alternate retrieval technique after cholecystectomy.

Grasp the dissected gallbladder (sealed with a clip placed at the stump of

the cystic duct) with two grapsers, pull it onto the right surface of the liver, and place it so that the neck of the gallbladder faces to the left (see Fig. 4.3.2 for key to instrument numbers).

Fig. 4.3.4 Alternate retrieval technique after cholecystectomy. Introduce a transparent, waterproof, impermeable sterile bag equipped

with a pursestring suture throught the right lateral 12-mm instrument

trocar. Inside the abdomen, open the bag with two graspers (see Fig. 4.3.2 for key to instrument numbers).

Complications

123

Fig. 4.3.5 Alternate retrieval technique after cholecystectomy. Using one grasper, place the gallbladder into the sterile bag (held open

with the second grasper) with the neck going in first so that it lies at the bottom of the bag and fundus faces the opening (see Fig. 4.3.2 for key to instrument numbers).

Fig. 4.3.6 Alternate retrieval technique after cholecystectomy. Inside the bag, hold the fundus with a grasper and incise its wall with scissors. The initial incision should only be long enough to allow one to aspirate the bile (see Fig. 4.3.2 for key to instrument numbers).

Fig. 4.3.7 Alternate retrieval technique after cholecystectomy.

With the gallbladder open, aspirate the bile through a 5- or 10-mm suc-

tion tip. This method often allows one to empty the gallbladder

completely, which is rarely possible when decompressing the gallbladder in situ. Aspiration shrinks the gallbladder considerably, and reveals the number and size of individual gallstones (see Fig. 4.3.2 for key to instrument numbers).

Fig. 4.3.8 Alternate retrieval technique after cholecystectomy. Now extend the incision in the gallbladder wall to allow evacuation of the gallstones into the bag. Liberate impacted gallstones from the gallbladder

wall with scissors or a grasper (see Fig. 4.3.2 for key to instrument num-

bers).

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4.3 Alternate Method of Gallbladder Retrieval

Fig. 4.3.9 Alternate retrieval technique after cholecystectomy.

Grasp the gallbladder by the neck and turn it around to “shake out” the

gallstones. If the incision is large enough, one can use the suction tube to push the gallstones out the gallbladder inside the bag (see Fig. 4.3.2 for key to instrument numbers).

Fig. 4.3.10 Alternate retrieval technique after cholecystectomy. Gallstones larger than 0.5 cm in diameter are difficult to extract through a 10- or 12mm incision. These larger stones are broken up inside the sterile bag. To do this, introduce a laparoscopic crushing clamp through the instrument trocar located inferior to the xiphoid process and crush the individual stones. Extremely large stones will have to be broken into several fragments. Continue intracavitary lithotripsy until there are only fragments measuring less than 0.5 cm in diameter. Generally, this is easily accomplished. However, extremely calcified stones can be a problem. Grasp these stones peripherally and continue to break off pieces until the fragments are small enough to be extracted (see Fig. 4.3.2 for key to instrument numbers).

Complications

125

Fig. 4.3.11 Alternate retrieval technique after cholecystectomy.

After removing the gallstones from the gallbladder into the specimen bag and reducing them by mechanical lithotripsy, one can begin the actualbag extraction procedure. The pneumoperitoneum inflates the sterile bag with

gas whichhas tobeevacuatedthrough asuction tubeinserted intothe

bag when the pursestring suture is drawn tight. To prevent the gallbladder

from folding up inside the bag and impeding extraction, grasp the neck of the gallbladder. Pull the neck of the gallbladder slightly past the end of the

bag, and insert the suction tube into the bag along the gallbladder neck so

that thepursestringsutureonthesterilebagwilltightenaroundbothasitis drawn shut (see Fig. 4.3.2 for key to instrument numbers).

Fig. 4.3.12 Alternate retrieval technique after cholecystectomy.

As the pursestring suture on the sterile bag is tightened around the neck of the gallbladder and the suction tube, the gas within the bag is aspirated. The clipped stump of the cystic duct should project just beyond the bag. After completely evacuating the bag of all CO

, the suction tube

is pulled and the pursestring suture drawn tighter (see Fig. 4.3.2 for key to instrument numbers).

Fig. 4.3.13 Alternate retrieval technique after cholecystectomy. Pull the sterile bag into the right lateral trocar until the end of the bag

jams against the trocar (see Fig. 4.3.2 for key to instrument numbers).

Fig. 4.3.14 Alternate retrieval technique after cholecystectomy. Now withdraw the right lateral trocar together with the sterile bag through the abdominal wall. If there are too many gallstones or fragments in the bottom end of the bag, they will cause it to become impacted in the incision. If this happens, one can open the pursestring suture past the abdominal wall level and extract the stones and the gallbladder itself from the bag (see Fig. 4.3.2 for key to instrument numbers).

126

4.4 Comments on Laparoscopic Cholecystectomy

Fig. 4.3.15 Alternate retrieval technique after cholecystectomy. Use an “hourglass” technique to extract stones. Since the stones or fragments may impede extraction of the bag, they must be individually pulled

and pushed through the 10- or 12-mm incision of the port site. Use a

”peanut” swab to gradually push the stones one after the other through

the abdominal wall while putting gentle tension on the bag. This tech-

nique can be used effectively to remove almost any stone through the 10-

or 12-mm incision after intracavitary lithotripsy (see Fig. 4.3.2 for key to

instrument numbers).

Bibliography

Köckerling F, Gastinger I, Schneider I, Reck T. Verbesserte Bergetechnik bei

der laparoskopischen Cholezystektomie. MIC 1993; 4:130.

4.4 Comments on Laparoscopic Cholecystectomy

G. Berci

There are no other operativeprocedures in the history of surgery wherea new idea was so quickly accepted and disseminated than laparoscopic cholecystectomy (LC). The news media contributed to this speed as well as the biotechnical industry predicting new avenues for novel products, creating thereby a “patients’ demand” operation. There is no debate that the patient has less postoperative discomfort and can return to full activities much faster than with an open cholecystectomy. It was not easy for a

surgeon to work through keyholes, to become acquainted with

eye/hand coordination and to see the anatomy or pathology on a two-dimensional TV screen, etc. The number of ductal injuries unfortunately increased, initially. However, education and training after ten years have improved, and surgeons have become more conscious about the problems which are inherent to this closed technique versus the open one. Another factor has also played a role, which is the ego of the surgeon to delay or avoid conversion to open operation. Converting is not a mistake but rather a good judgment and could increase the safety margin of the procedure. Information to the patient also has to be provided at the first visit that there is a chance that he or she will end up with a traditional scar. This has nothing to do with surgeon’s ability but is related to the possible an-

atomic variations or to other difficulties requiring a different technique to assure the patient’s safety. Perforation of the gallbladder and the spillage of stones in a thin-walled gallbladder or cases of edematous, inflamed thick walls are not uncommon. A discharge of bile into the abdominal cavity can be easily dealt with by repeated irrigation and evacuation. However, if the gallbladder is full with a large number of small faceted calculi there could be a problem in recovering all of the stones that spilled into the abdominal cavity. There are many “tricks of the trade” which we have learned during the last ten years to thwart this problem pretty fast. To place a clip is not always the best solution but the endoloop can be extremely helpful if it’s done quickly. The prerequisite is that the edges of the perforated hole have to be grasped quickly and tented after the open loop is already placed over the hole. We found a small alligator forceps with teeth of great help because in case of a thin or thick wall, it is very difficult to grasp it with the standard grasper. The higher the number of unsuccessful attempts, the more stones to be evacuated, the larger will the perforation be. In general, it is important to remove as many disappearing calculi as possible because these foreign bodies can act as a “time bomb” and surface in a few

Bibliography

127

months or even a year later as the nucleus of an abscess, re-

quiring surgical care.

There are many modifications since the f irst published reports regarding techniques for trocar placements, number of trocars, size of trocars, etc. This is dependent on the surgeon’s familiarity with certain specific techniques. As long as the results are satisfactory, I don’t think we can claim that one is superior over

the other. At the start, whether the trocar placement should be

achieved after pneumoperitoneum is obtained or a small incision is done and the open laparoscopic trocar approach is used, is a matter of individual choice. The open technique has some

definite merits for teaching institutions and helps significantly

to eliminate vascular injuries in the previously operated abdomen. I would like to comment on two major issues.

1. Routine Operative Fluorocholangiography (ROF)

Intraoperative cholangiography has been debated since Mirizzi introduced it in 1933. The situation in LC is different than in

open procedures. We do not have the CBD between our finger-

tips, nor can the cystic duct junction be easily dissected. The fact is that patients with an acute, inflamed gallbladder or adhesions are in greater danger during LC to sustain an injury than

with the open operation. Using modern digital equipment, the fluoroscopic image is excellent and anomalies of surgical importance (10%) can be discovered in time. One such anomaly, is

the short cystic duct which if not recognized can cause signifi-

cant problems. If the short cystic duct is pulled up the CBD is

tented and can easily be partially or totally transsected. In 2% of

cases, a cystic duct can drain into the right hepatic duct and in

4−5% into the common hepatic duct. The prevention of iatro-

genic damage to the ducts is crucial. It is true that in performing

biliary surgery we probably cannot completely eliminate ductal injuries, but there is a chance by employing ROF that it can be reduced to a minimum by recognizing dangerous anomalies in

time. There are many reports that if ROF is performed routinely

and the duct is damaged incidentally or clipped, then the lack of progress or extravasation of contrast material is recognized and repair can be done immediately. Complications after primary injury repair are significantly less than if the patient is readmitted a few days later with biliary peritonitis. In case of bile leakage the symptoms on the first postoperative

day can be vague or minimal, but the surgeon should think

about it. If the patient does not eat his/her breakfast in the morning or does not feel “100%” or has no intention to move

around, bile leakage should be considered, A Hida-scan should

be ordered as an emergency investigation. This isotope examination has no risk, and it is very sensitive and specific to bile leakage. If positive, ERC should be done immediately, the anat-

omy and the problems delineated, and urgent remedial action

contemplated.

sideration also. On the other hand, there is no debate that when dealing with an elderly high-risk patient with severe underlying disease and cholangitis, preoperative diagnostic common duct assessment is of the essence, so as to make possible a one stage remedial operation for gallbladder and common duct stones, laparoscopically. If a stone has to be left knowingly behind, it is advisable to insert a guide wire and/or a French 4−5 catheter through cystic duct stump and common duct into the duodenum under fluoroscopic control and leave it in this position. In case a postoperative ERC or endoscopic sphincterotomy is required, it is a great help to the endoscopist to have an indwelling indicator protruding into the duodenum through the sphincter. Another alternative is if the patient is under the age of 60 without any comorbid condition, an open choledocholithotomy can be done safely and without mortality. It is crucial to understand that unnecessary ERCs or endoscopic sphincterotomy have to be eliminated, and the patient should be cured in one operative session, as we did it for 100 years by open operation. Laparoscopic cholecystectomy is a great step forward in patients’ care, but we have to be aware also of the problems with ductal injuries. This can be decreased by ROF; therefore, we should give it serious consideration. Every attempt should be made to treat and cure CBD stones with an efficient and safe modality in one operating session.

The transcystic approach does not carry a larger morbidity or mortality than endoscopic sphincterotomy. The majority of smaller calculi can be retrieved through the cystic duct or in a minority of cases through the CBD. The operator can achieve with ease a success rate of 60% at the beginning of the learning curve, which can be increased as experience is gained to over 90%.