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148
5.6 Laparoscopic Cholecystojejunostomy
5.6 Laparoscopic Cholecystojejunostom y
L. U. Jung, M. S. Rangraj, C.A. Schneider, V. Maffucci
Introduction
Endoscopic implantation of a biliary stent provides an effective
palliation for an unresectable malignant biliary obstruction.
However, this procedure is associated with a high rate of late
complications such as stent occlusion and cholangitis. Laparoscopic biliary-enteric bypass can also provide efficient decom-
pression in patients with malignant biliary obstruction. The la-
paroscopic procedure avoids endoprosthesis-related complica-
tions, therefore reducing morbidity and the need for hospital
readmissions. The patient’s quality of life is improved. The pro-
cedure is best suited as the last step in a laparoscopic explora-
tion of a patient with malignant biliary obstruction in whom
tumor assessment and staging have demonstrated unequivocal
inoperability. If this conclusion can be reached before, the la-
paroscopy may not even be necessary and cholecystojejunos-
tomy can be performed even under local or regional anesthesia.
Indications
쐌 Unresectable malignant biliary obstruction.
Contraindications
쐌 Severe coagulopathy.
쐌 Respiratory failure.
쐌 Cardiac failure.
쐌 Cholelithiasis.
쐌 Involvement of the common bile duct with disease within
two cms of the cystic duct junction.
Instruments
쐌 General purpose laparoscopic setup.
쐌 4 10−12 mm trocars.
쐌 1 Endo GIA stapler.
쐌 1 TA stapler.
쐌 1 GIA stapler.
쐌 1 Laparoscopic fan retractor.
Anesthesiology
General endotrachal.
Positioning
Supine.
Intraoperative Risks
쐌 Trocar Injur y
− Bowels,
− Solid organs,
− Vascular structures.
Step-by-Step Procedure (Fig. 5.6.9 to 5.6.11 )
1. The patient is placed on the operating table in supine position. The surgeon stands to the right and assistant to the left
of the patient.
2. A 2 cm vertical skin incision is made intraumbilically. The fascia is incised vertically at the linea alba and the peritoneal cav-
ity is entered. A 10 mm blunt trocar is placed under direct vi-
sion and secured. Pneumoperitoneum up to 15 mm Hg is established.
3. A 0° scope is inserted at the umbilical port. Two other trocars
are placed under direct vision: A 10−12 mm trocar lateral to
the left rectus and another 10−12 mm trocar lateral to the
right rectus muscle (Fig. 5.6.1).
4. Exploratory laparoscopy is performed and inoperability of the
disease is confirmed.
5. The ligament of Treitz is identified and a loop of jejunum distal to the ligament is identified.
6. The loop distal to the ligament is brought next to the gallbladder using an Endo-Babcock.
7. The right upper quadrant trocar site is enlarged to the appro-
priate size.
8. The loop of jejunum and the gallbladder are brought up into
the operating field.
9. Stay sutures are placed to hold the jejunum and gallbladder
and a small opening is made in the jejunum and gallbladder
using electrocautery and scissors.
10. Cholecystojejunostomy is performed using the GIA stapler
(Fig. 5.6.2).
11. The GIA introduction site is closed using the TA stapler
(Fig. 5.6.3).
12. The anastomosis is inspected and returned to the peritoneal
cavity. The fascia is closed and pneumoperitoneum is reestab-
lished.
13. The final inspection is done laparoscopically (Fig. 5.6.4).
14. For total intraabdominal cholecystojejunostomy, another 10−
12 mm trocar is placed lateral to the right rectus muscle
below the umbilicus (Fig. 5.6.5).
15. A loop of jejunum distal to the ligament of Treitz is brought
next to the gallbladder.
16. Stay sutures are placed to hold them in contact and a small
opening is made in the jejunum and gallbladder.
17. Anastomosis is made using Endo GIA stapler (Fig. 5.6.7).
18. The Endo GIA introduction site is closed with another Endo
GIA application (Fig. 5.6.).
19. The final inspection is done laparoscopically (Fig. 5.6.8).
Operative Technique
Postoperative Course
149
Fig. 5.6.1 The patient is prepped and draped in routine fashion. A naso-
gastric tube is placed by the anesthesiologist. Urinary catheter is not essential for the operation. After insertion of the umbilical port, a
pneumoperitoneum is established using CO
Generally three trocars are placed for laparoscopically assisted cholecys-
tojejunostomy. A 10−12 mm trocar at the umbilicus for the laparoscope,
10−12 mm working ports at either side of the rectus muscle above the
umbilical level (Fig. 5.6.1).
up to 15 mm Hg of pressure.
2
Postoperative Risks
쐌 Anastomotic leak.
쐌 Wound infection.
쐌 Bleeding.
쐌 Recurrent jaundice.
Fig. 5.6.2 Once the pneumoperitoneum is established and trocars are in
place, exploratory laparoscopy is performed. The ligament of Treitz is
identified. A loop of jejunum distal to the ligament is brought up next to
the gallbladder using an Endo Babcock. The right upper quadrant trocar
site is enlarged to the appropriate size and the loop of jejunum is brought
up next to the gallbladder. Stay sutures are placed to hold the jejunum
and gallbladder in contact and a small opening is made in the jejunum and
gallbladder. Cholecystojejunostomy is performed using the GIA stapler.
Postoperative Course
A nasogastric tube is used during the intra- and postoperative
period until bowel function returns. Diet is started slowly. Liver
function tests are ordered postoperatively until they level
towards normal values.
150
5.6 Laparoscopic Cholecystojejunostomy
Fig. 5.6.3 Hemostasis of the anastomotic line is inspected and the GIA
introduction site is closed using the TA stapler. Excessive tissue is excised
using scissors above and parallel to the TA stapler.
Fig. 5.6.4 Once the anastomosis is completed, the fascia is closed and
the pneumoperitoneum is reestablished. Final inspection is done laparoscopically.
Fig. 5.6.5 The laparoscopic cholecystojejunostomy can also be done
totally intraabdominally. Here, we recommend placement of another 10−
12 mm trocar lateral of the right rectus muscle below the umbilicus.
a b
Fig. 5.6.6a, b A laparoscopic fan retractor is used to retract the liver su-
periorly. A loop of jejunum is brought next to the gallbladder and stay su-
tures are used to hold them. Then a small opening is made at the apex of
Postoperative Course
the gallbladder and the loop of jejunum, using electrocauterey scissors.
The anastomosis is made using the Endo GIA stapler. It might take more
than one Endo GIA application to assure a patent anastomosis.
151
Fig. 5.6.7 The Endo GIA introduction site is closed with another applica-
tion of the Endo GIA.
Fig. 5.6.8 Completed view of cholecystojejunostomy. One must make
sure that there are no kinks in the jejunal loop.
152
6
3
7
8
3
2
5.6 Laparoscopic Cholecystojejunostomy
54
1
Fig. 5.6.9 Fig. 5.6.10
Bibliography
6
Cotton PB. Endoscopic methods for relief of malignant obstructive jaundice.
World Journal of Surgery 1984; 8:854−861.
5
Matsuda Y, Shimakura K, Akamatsu T. Factors affecting the patency of stents
in malignant biliary obstructive disease: Univariate and Multivariate
Analysis. The American Journal of Gastroenterology 1991; 86:843−849.
Rangraj M, Mehta M, Zale G, Maffucci, Herz B. Laparoscopic Gastrojejunos-
tomy: A case presentation. Journal of Laparoscopic Surgery 1994; 81−87.
Shimi S, Banting S, Cuschieri A. Laparoscopy in the management of pan-
creatic cancer: endoscopic cholecystojejunostomy for advanced disease.
Br. J. Surg. 1992; 79:317−319.
Soehendra N, Rejnders-Frederix V. Palliative bile duct drainage. A new endo-
scopic method of introducing a transpapillary drain. Endoscopy 1979;
12:8−11.
Tytgat GNJ, Bartelsman JFWM, DeaHartog Jager FCA, Hailbregtse K, Mathus-
Vliegea EMH. Upper intestinal and biliary tract endoprosthesis. Dig. Dis.
Sci. 1986; 31:57S−76S.
VandenBosch R, VanderSchelling G, Klinkenbiji F, Mulder P, Van Bankenstein
M, Jeekel J. Guidelines for the application of surgery and endoprosthesis in
the palliation of obstructive jaundice in advanced cancer of the pancreas.
Annals of Surgery 1994; 219:18−24.
Watanapa P, Williamson RCN. Surgical palliation for pancreatic cancer:
developments during the past two decades. Br. J. Surg. 1992; 79:8−20.
Fig. 5.6.11
5.7 Comments on Laparoscopic Biliary Operations
5.7 Comments on Laparoscopic Biliary Operations
E. Bodner
153
Classic gallstone treatment by open operation has undergone
many changes in a relatively short time. First came endoscopic
papillotomy for the extraction of stones from the bile ducts,
then chemical litholysis and extracorporeal shock-wave
lithotripsy. Litholysis and lithotripsy did not fulfill surgeons’ expectations because acceptable results could only be achieved
for a few carefully selected patients (Strasberg and Clavien,
1993). Laparoscopic surgical methods were introduced in 1988
by Mouret in Lyon and have enjoyed unprecedented popularity.
For the patient, laparoscopic cholecystectomy represents close
to ideal surgical treatment: minimal pain, rapid healing, high
rate of therapeutic success, and, as an added benefit, good cosmetic results. From a surgical viewpoint, the goal of treatment,
removal of the stone-laden gallbladder is achieved without laparotomy, in a procedure that leaves the anatomy and function
of the abdominal wall largely intact. Reduced operative trauma,
a shorter hospitalization period, accelerated recovery, and, apparently, lower treatment costs (Lee et al., 1993) give laparoscopic cholecystectomy a competitive edge over the traditional
operation.
The risks specific to this method are now known, and surgeons
have largely learned to avoid them. This applies to injuries from
trocar insertion and complications involving the pneumoperi-
toneum, the risks of using high-frequency electrocautery in
Calot’s triangle, potential injuries to neighboring organs, and
possible sequelae of a stone lost in the abdomen. In quantitative
terms, the incidence of complications is comparable to other
operative procedures of a similar degree of difficulty. Morbidity
is less than 10% (Gadacz, 1993) in the hands of a trained, experienced surgeon; mortality is comparable to open cholecys-
tectomy (Siewert et al., 1993).
The enthusiasm with which laparoscopic cholecystectomy was
first received has become somewhat subdued in light of a rela-
tively high incidence of injuries to the biliary tract. At 0.6%, they
occur three times as frequently as in the open method. Each injury to the biliary tract represents a serious complication be-
cause even if promptly diagnosed and treated, such an injury
still has a considerable potential for late sequelae. Routine in-
traoperative cholangiography appears unable to solve this problem (Gadacz, 1993). This risk of injury can only be reduced if
surgeons increase their willingness to convert to an open pro-
cedure or, better, resist the trend and increase the use of the
traditional open procedure as primary therapy. If the laparoscopic method cannot achieve the significantly lower risk of the
traditional procedure, these few isolated cases could jeopardize
the otherwise positive overall assessment of laparoscopic
cholecystectomy. It is not a matter of what percentage of all
gallstone operations are performed laparoscopically; the crucial
point is to achieve the lowest possible incidence of operative injuries.
Acute cholecystitis must also be viewed in this light when considering whether a laparoscopic procedure is indicated. Tissue
inflammation and the spread of infected bile pose additional
risks. In the choice of operative strategy for any specif ic patient,
safety must take precedence over any technical advantages a
procedure is thought to offer.
Certain reservations have arisen regarding the treatment
strategy for bile duct stones, which are to be expected in 15−20%
of all cholecystectomies. In the open method, the procedure was
standardized: Involvement of the bile duct was demonstrated
by intraoperative cholangiography, and the stone was removed
during the same operation by choledochotomy. The declared
goal was to eliminate symptomatic cholelithiasis with a single
operative intervention, and this goal was achieved in 99% of all
patients. Laparoscopic cholecystectomy required a departure
from this concept because only very few surgeons have previously been able to perform laparoscopic common bile duct
exploration and stone removal. Although isolated studies have
reported high rates of success (Millat et al., 1995), this technically demanding procedure can hardly be expected to prove
equally successful in widespread use. The choice remains between the traditional open procedure and two-step operative
management: endoscopic extraction of the bile duct stones followed by laparoscopic cholecystectomy. This two-step therapy
may preserve the advantages of laparoscopic cholecystectomy,
but it is not yet known whether it has any advantage over the
traditional single-step procedure when one considers the cumulative complications and costs of both treatment steps. The
traditional procedure has proven superior to the combination of
endoscopic sphincterotomy and open cholecystectomy (Neoptolemos et al., 1987).
Since only about 90% of stones can be removed in a transpapillary endoscopic procedure (Graham et al., 1994), exploration of
and stone removal from the common bile duct is recommended
as the initial step before laparoscopic cholecystectomy is performed. If stone extraction is unsuccessful, the surgeon can convert to an open operation. This strategy requires that the diagnosis of choledocholithiasis be made preoperatively. This entails intravenous cholangiography or, better, diagnostic endoscopic retrograde cholangiography (ERC). There is not yet consensus about which patients should undergo these examinations (Bonatsos et al., 1996). On the one hand, systematic intraoperative cholangiography reveals bile duct stones by chance
in 5−10% of all cases even where clinical examination and medical history are negative. On the other hand, every preoperative
bile duct exploration performed because of an overly wide
range of permissible indications represents an unnecessary
burden for many patients and increases costs.
Whether cholangiography should be performed as a matter of
course in laparoscopic cholecystectomy (as is done in classic
open cholecystectomy) is, understandably, also controversial. If
no immediate therapeutic consequences follow from the results
of this examination, it may be deemed superfluous. Presumably,
the advantages of laparoscopic cholecystectomy are achieved at
the cost of a higher incidence of residual stones, although many
of these stones may be subsequently removed endoscopically.
The dynamic development of recent years has raised many
questions, some of which still lack a precise answer. However,
even classic gallstone surgery struggled for many decades to
achieve a clear strategic treatment concept, one which, at least
in complicated cases of choledocholithiasis, has retained its
merit to this day.
154
5.7 Comments on Laparoscopic Biliary Operations
Bibliography
Bonatsos G, Leandros E, Polydorou A, Romanos A, Dourakis N, Birbas C, Gole-
matis B. ERCP in association with laparosopic cholecystectomy. Surg. Endosc. 1996; 10:37−40.
Gadacz Th. Experience with laparoscopic cholecystectomy. Am. J. Surg.
1993; 165:450−454.
Graham SM, Flowers JL, Scott TH, Bailey RW, Scovill WA, Zucker KA, Im-
bembo AL. Laparoscopic cholecystectomy and common bile duct stones.
Ann. Surg. 1993; 218:61−67.
Lee VS, Chari RS, Cucchiaro G, Meyers WC. Complications of laparoscopic
cholecystectomy. Am. J. Surg. 1993; 165:527−532.
Millat B, Fingerhut A. Deleuze A, Briandet H, Marrel E. de Seguin C, Soulier P.
Prospective evaluation in 121 consecutive unselected patients undergoing
laparoscopic treatment of choledocholithiasis. Br. J. Surg. 1995; 82:1266−
1269.
Neoptolemos JP, Carr-Locke DL, Fossard DP. Prospective randomised study of
preoperative endoscopic sphincterotomy versus surgery alone for common bile duct stones. Br. Med. J. 1987; 294:470−474.
Siewert JR, Feussner H, Scherer MA, Brune IB. Fehler und Gefahren der la-
paroskopischen Cholecystektomie. Chirurg 1993; 64:221−229.
Strasberg SM, Clavien PA. Overview of therapeutic modalities for the treat-
ment of gallstone diseases. Am. J. Surg. 1993; 165:420−426.
6. Laparoscopic Approach to the Spleen and Liv er
6.1 Splenectomy
F. Köckerling, C. Zornig
155
Goals and Methods
Laparoscopic splenectomy represents a logical additional
development in the field of minimally invasive surgery. The essential prerequisites for laparoscopic splenectomy were fulfilled when the use of linear staplers for suturing major vascular
structures (inferior mesenteric artery and vein) was successfully demonstrated in laparoscopic colorectal surgery and reli-
able extraction techniques using sterile bags and extractor tro-
cars were developed.
Indications
Elective laparoscopic splenectomy may be indicated primarily
for treatment of benign hematologic disorders in the presence
of hypersplenism and small to medium sized splenomegaly. The
etiology involves pathologically increased splenic sequestration
of blood cells. Clinically significant disorders include idiopathic
thrombocytopenic purpura (Werlhof’s disease), hemolytic anemia in the presence of hereditary spherocytosis, and throm-
bocytopenia as can occur following HIV infection. Further in-
dications for laparoscopic intervention may include staging
operations in the presence of lymphoproliferative and myeloproliferative disorders involving the spleen. Laparoscopy can be
used in staging Hodgkin’s disease, for example. It remains to be
seen whether laparoscopic surgery will become an option in repairing traumatic ruptures of the spleen. The suturing, coagula-
tion, and adhesive techniques used in open operations can also
be used in laparoscopy.
Contraindications
Patients with severe splenomegaly (over 500 g; normal dimensions are 12× 8 × 4 cm, weight 120−200g) are not suitable can-
didates for laparoscopic splenectomy. The same applies to
patients with portal hypertension in the presence of proximal
prehepatic or intrahepatic blockage and previous upper abdominal surgery. Establishing the pneumoperitoneum may cause
problems in patients with cardiopulmonary risk factors (see
chapter 2.5).
jury to the pancreas, stomach, or colon. Also inform the patient
of possible postoperative complications such as pancreatic
fistula, perforation of the colon accompanied by peritonitis and
abscess, postoperative bleeding, and pleural effusion. Patients
must also be informed about the prevention and management
of postoperative sepsis following splenectomy. An informative
brochure may be of use to the patient and his or her familiy doctor.
Special Preparations
Due to the risk of injury to the left colon flexure, we recommend
a preoperative bowel preparation. As in all laparoscopic operations, placement of a nasogastric tube and urinary catheter is
indicated.
Note: Due to the risk of serious bleeding in laparoscopic splenic
surgery, be prepared for immediate conversion to open laparotomy at any time during the procedure.
Anesthesia
General anesthesia.
Positioning
(See Figs. 6.1.1 and 6.1.2).
Experience with laparoscopic nephrectomy has demonstrated
the advantages of right lateral decubitus and left side up positioning for laparoscopic splenectomy (see Fig. 6.1.1). This pro-
vides a good approach to the spleen, the left colon flexure, the
stomach, and the left hepatic lobe. Other surgeons prefer supine
positioning with the left side slightly elevated.
Trocar Placement
(Fig. 6.1.3).
Surgical Risks and Patient Information
The patient should be informed of possible complications that
may occur during laparoscopic splenectomy. These include injuries to hollow organs and major vascular structures caused by
insertion of the Veress needle and blind percutaneous insertion
of the laparoscope/camera trocar. Other complications that re-
quire conversion to open laparotomy include bleeding and in-
Complications
Intraoperative Complications
쐌 Perforation of hollow organs with the Veress needle or the
laparoscope/camera trocar.
쐌 Arterial or venous bleeding caused by puncture from the
Veress needle or laparoscope/camera trocar.
쐌 Subcutaneous emphysema.
쐌 Bleeding from the spleen.
156
6.1 Splenectomy
쐌 Bleeding from the short gastric arteries or veins, or from the
splenic artery or vein.
쐌 Perforation of the small intestine or colon.
Corrective action: If one of these complications occurs, immediate conversion to laparotomy is indicated.
Postoperative Complications
쐌 Wound infection.
쐌 Thrombosis or embolism.
쐌 Postoperative bleeding.
쐌 Pancreatic fistula.
쐌 Undetected injury to the colon accompanied by peritonitis
and abscess.
Operative Technique
Step-by-Step Procedure
1. Insert trocars under laparoscopic visualization.
2. Explore the peritoneal cavity, make diagnosis, and determine
indication.
3. Divide the splenocolic, splenorenal, and phrenicosplenic ligaments.
4. Gradually dissect, coagulate, and ligate or clip the gastro-
splenic ligament containing the short gastric arteries and veins.
5. Transect the splenic artery and vein or their branches with a
vascular multifire stapler. Dissection and ligation with extracor-
poreal tying of vascular branches is another option. Sometimes
a combination of both is useful.
6. Place the resected spleen in a sterile specimen bag.
7. Extract the spleen from the abdomen after bluntly breaking it
in a sterile extraction bag.
Fig. 6.1.1 Splenectomy. Right lateral decubitus positioning of the
patient.
Reclining the thoracic section of the operating table extends the left flank
and provides good exposure to the left upper flank. Shoulder and pelvic
support cushions help immobilize the patient and permit inclining the
table for intraoperative repositioning. An alternative is to position the
patient supine with the left side slightly elevated.
st
surgeon
1
Fig. 6.1.2 Splenectomy. Equipment and position of the
operating team.
The surgeon and the assistant holding the laparoscope
stand to the right of the patient. Another assistant stands to
the left of the patient. The monitor, light source, and insufflator are located opposite the surgeon behind the left side
of the patient’s head. The operating team looks past the
surgical site to the monitor. This positioning permits a
coordinated approach with one monitor. The operating
room nurse and the instrument table are to the left of the
operating table between the monitor and the second assistant. The aspirator/irrigator and bipolar electrocautery
unit can be positioned as desired.
Assistant holding
laparoscope
Electrocautery
unit
Insufflator
Monitor
Aspirator/
Irrigator set
nd
surgeon
2
Instrument
table
T2
T1
T4
T3
T2
Complications
157
Fig. 6.1.3 Splenectomy. Trocar placement.
T1 10/12-mm laparoscope/camera trocar inserted a few centimeters
inferior to the umbilicus, left of and lateral to the midline.
T2−4 10/12-mm instrument trocars: The right instrument trocar (T2) is
inserted in the left upper abdomen at about the nipple line. The left
instrument trocar (T3) is inserted as far lateral as possible in the
posterior axillary line. The middle instrument trocar (T4) is inserted
inferior to the costal arch between the medial and lateral instrument trocars.
Alternative: open trocar placement.
T2
Fig. 6.1.4 Splenectomy. Exposing the spleen.
The right lateral decubitus position provides good access to the spleen
and exposes splenic ligaments under tension. Expose the adjacent structures with an atraumatic swab (port T2) and explore the site. Right lateral
positioning places tension on the splenocolic and splenorenal ligaments.
T2
T4
Fig. 6.1.5 Splenectomy. Transecting the splenic ligaments.
Lift the inferior pole of the spleen to improve exposure of the splenocolic,
splenorenal, and phrenicosplenic ligaments. Transect them one by one
with electrocautery, using either a hooked electrode or electrocautery
scissors. Be careful not to damage the wall of the colon or the adjacent tail
of the pancreas. You can reduce the risk of these complications by proceeding gradually and dissecting close to the spleen (see Fig. 6.1.3 for key
to instrument numbers).
Fig. 6.1.6 Splenectomy. Transecting the splenic ligaments.
Once you have transected the splenic ligaments, the spleen is held only by
the gastrosplenic ligament with the short gastric arteries and veins, and
by the vascular pedicle of the splenic artery and vein. Using a swab to
move the spleen, verify that the other ligamentous connections have
been sufficiently transected (see Fig. 6.1.3 for key to instrument numbers).