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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_841_Библиотеки_им_академика_М_И_Перельмана.pdf
182
F.P. Prete et al.
23
signs at the intraoperative exploration suggesting
presence of stones spilled in the biliary tree.
Typically, these patients are either asymptomatic (but liver function tests are not normal) and
undergoing elective cholecystectomy or had recent
episodes of jaundice or gallstone pancreatitis and are
showing mild dilatation of the common bile duct,
with the lower end not seen well on ultrasonography.
Sometimes there is history of multiple gallstones and recurrent attacks of jaundice but preoperative US, MRCP and bilirubin are normal. A
wide cystic duct seen during laparoscopic dissection may be the only evidence.
We prefer intraoperative laparoscopic cholangiogram to laparoscopic biliary ultrasound to
assess the presence of stones in the extrahepatic
biliary tree; it allows a better denition of the biliary
anatomy, which may be limited on ultrasound; the
pancreas also may obscure the views on ultrasound,
although ultrasound is highly specic for stones.
When CBD stones are found intraoperatively,
we proceed to clearance in one time, either by
laparoscopically guided ERCP (“rendezvous”
procedure) or through laparoscopic bile duct
exploration, either transcystic or by choledochotomy. If a laparoscopically assisted approach
fails, we convert to open surgical CBD clearance.
One-stage treatment combining laparoscopic
cholecystectomy with laparoscopic common bile
duct exploration is cost-eective, with no signicant increase in morbidity or mortality from different approaches. Both single-stage laparoscopic
and combined laparoscopic/intraoperative endoscopic approaches require time, equipment, skills
and experience to be performed.
Choice of the treatment is inuenced not only by
patient’s condition, CBD calibre, stone load, size and
eventual impaction but also the availability of laparoscopic and endoscopic facilities, level of expertise
of endoscopist performing ERCP and experience of
surgeon performing laparoscopic biliary surgery.
23.9.2 Laparoscopic Transcystic
Approach (Diculty II-III)
is is applicable when the calibre of the cystic duct is compatible to the size of the stones
targeted (up to 6mm), when there is not much
discrepancy between the size of the cystic duct
and the size of the CBD stones.
e cystic duct is incised up to 50 % of its diameter to preserve its wall strength. If stones are found
in the cystic duct, they can be “milked” out of it
before positioning the catheter for cholangiogram.
en a guide wire is passed from the cystic duct
opening into the CBD, and sequential dilation
of the cystic duct follows, with either balloon or
bougie; dilation is functional to the use of instrumentation. Although surgeons may operate wire
baskets under uoroscopic control, an approach
to CBD stones by means of wire basket entrapment under direct choledochoscope guidance is
safer. Inserting the choledochoscope through the
cystic duct requires sucient dilation, and, if this
is too vigorous or too close to the common bile
duct while excessive tension is applied to the gallbladder, the cystic duct might be avulsed, making
impossible the use of instruments. In general, this
approach is accepted for stones within 6mm and
a cystic duct calibre larger than 4mm, although
the combination of stones and wire basket might
result in entrapment of this complex in the CBD,
with necessity to cut the guide wire free and open
the CBD to retrieve the basket. is is an important
limiting factor to the success of the procedure and
bears a relatively high incidence of retained stones
and complications. Otherwise, successful transcystic approach has the intrinsic benet of eliminating
risk of CBD stricture when closing a choledochotomy. Another limiting factor depends on anatomical variability of the cystic-to-CBD junction, being
straight and lateral entry the ideal situation, while
posterior insertion or CBD stone proximal to cystic insertion are contraindications to this approach.
23.9.1 Intraoperative
Laparoscopically Guided
ERCP (Diculty II)
It is usually retrograde, with sphincterotomy performed through the duodenoscope, as opposed to
antegrade (which we don’t use); antegrade is usually
performed during open surgery with the sphincterotome introduced through the choledochotomy.
23.9.3 Laparoscopic
Choledochotomy forCBD
Stones (Diculty II-IV)
is approach is indicated when the CBD stones
are large or impacted and may require lithotripsy, when transcystic approach is not feasible
because of insucient dilation of the cystic duct
Surgical Technique andDicult Situations fromFrancesco Crafa
183
23
a
b
Ductus hepaticus communis
Ductus cysticus
. Fig. 23.13 Preparation for choledochotomy through
the cystic duct loop and the proximal clamping of hepatic
duct
1 cm lange Längsinzesion
a
b
. Fig. 23.15 Suction (a) and irrigation of the common
bile duct (b)
. Fig. 23.14 Choledochotomy
or transcystic approach fails. CBD must be dilated
beyond 6mm to allow for this procedure.
Aer applying a tie to the proximal cystic
duct, the common hepatic duct upstream the
junction with the cystic duct is closed with a so
clamp (. Fig. 23.13). One cm longitudinal incision (preserves the CBD vascular supply) is taken
on the anterior surface of supraduodenal portion
of CBD (
. Fig.23.14). Aer sucking sludge and
stones eventually creeping through the incision,
CBD is washed with warm saline (
. Fig.23.15).
A choledochoscope is inserted through the epigastric port and then carefully advanced into the
ductal system (. Fig.23.16). Continuous infusion
of warm saline maintains the choledochoscopic
view clear. A balloon catheter can be used to drag
stones (. Fig.23.17), or a wire basket may be care-
. Fig. 23.16 Intraoperative choledochoscopy
. Fig. 23.17 Insertion of the balloon catheter for the
extraction of common bile duct stones
23
F.P. Prete et al.
184
. Fig. 23.18 Insertion of the Dormia basket for stone
extraction
. Fig. 23.19 Insertion of the Dormia under
choledochoscopical control
a
b
. Fig. 23.21 Choledochoscopic control after the stone
extraction
fully inserted under choledochoscopic guidance
(. Figs.23.18 and 23.19) and advanced beyond the
stones, opened and withdrawn with the captured
stones that can thus be removed (. Fig.23.20).
If a calculus is impacted or too large (>2cm) to be
relieved, we prefer converting the procedure to open
CBD exploration than using rigid choledochoscope.
Aer conrming CBD clearance, we proceed to
explore the proximal portion of the common hepatic
duct and the biliary conuence (. Fig.23.21). Our
preferred method for closure of a choledochotomy
is direct continuous monolament suture (4/0, 5/0)
without internal stent (“ideal” choledochotomy)
(. Fig. 23.22), but it mandates verifying that no
single residual fragment of stone is present in the
CBD as well as there is no distal biliary stricture.
We leave a transcystic biliary drain aer closing the
choledochotomy (. Fig.23.23) through which it is
still possible to perform a cholangiogram.
Postoperative Diagnosis
If diagnosis of CBD stones is postoperative,
ERCP is the preferred choice of treatment today.
If this is not available, then laparoscopic CBD
exploration may become an option provided that
CBD is adequately dilated. Another option is classical open CBD exploration with T-tube drainage.
Example of dicult laparoscopic choledochotomy for CBD stones clearance:
. Fig. 23.20 (a) extraction of common bile duct stones
(b) put it in extraction bag
Situation A 70-year-old female, ASA-
III.Intraoperative laparoscopic
guided choledochoscopy and
attempted (failed) clearance of
a 1.5cm stone, found impacted
in the distal third of the CBD,
cannot be overcome by a basket
and is not moved by irrigation
ab
cd
Surgical Technique andDicult Situations fromFrancesco Crafa
185
23
. Fig. 23.22 Closure of choledochotomy with a running suture
Dilemma Conversion to open surgery–
open CBD exploration and
stone retrieval?
Solutions Laparoscopic Kocher manoeu-
vre, with freeing of the head of
the pancreas and the relative
intrapancreatic tract of the distal
CBD.CBD is gently “milked” from
behind the pancreas, and the
Outcome No complications
Analysis Expertise in advanced laparo-
stone is freed and retrieved
scopic and pancreatobiliary surgery is necessary to manipulate
the pancreas safely by laparoscopy; experience in biliary tract
surgery is necessary to anticipate
which scenario is likely to be
positively aected by a modication to a standard technique. It is
possible to safely retrieve large
stones initially looking impacted
and not amenable to laparoscopic CBD clearance
. Fig. 23.23 Insertion of transcystic common bile duct
drain
Reference
1. Overby DW, Apelgren KN, Richardson W, Fanelli R;
Society of American Gastrointestinal and Endoscopic
Surgeons. SAGES guidelines for the clinical application
of laparoscopic biliary tract surgery. Surg Endosc.
2010;24(10):2368–86.
Surgical Technique
andDicult Situations
fromBenoit Navez
BenoitNavez
24.1 Laparoscopic Management ofCommon
Bile Duct Stones (CBDS) – 188
24.2 Subtotal Cholecystectomy andthe“Inside
Approach”: ASafe Option inSevere
Cholecystitis – 188
24.2.1 Introduction – 188
24.2.2 Surgical Technique – 188
24.2.3 Indications – 189
24.2.4 Results – 189
187
24
24.3 Laparoscopic Management
ofCholecysto-enteric Fistula – 189
24.4 Classication ofIntraoperative Diculties – 190
References – 190
© Springer-Verlag Berlin Heidelberg 2017
M. Korenkov et al. (eds.), Gastrointestinal Operations and Technical Variations,
DOI10.1007/978-3-662-49878-1_24
188
B. Navez
24
24.1 Laparoscopic Management
ofCommon Bile Duct Stones
(CBDS)
Laparoscopic management of CBDS is less and
less a commonly used technique because the
learning curve is long and advanced technology
like exible choledocoscopy is required. Most
of the surgeons prefer an endoscopic sphincterotomy performed by themselves or by the
gastroenterologists. However, there are some
clinical conditions where the latter approach
fails and where surgical CBD desobstruction is
necessary.
During laparoscopic exploration of the common bile duct (CBD), several technical diculties
can be encountered.
5 For stone extraction, a Dormia basket with a
exible tip must be used. It will avoid the
“classical” perforation of CBD wall when
using a Dormia with a rigid tip. Stones grasping and extraction need to be done under uoroscopic and/or choledocoscopic control. If
not, impaction of Dormia basket within the
papilla can occur.
5 Transcystic approach (TA) is indicated in case
of a limited number (<5) of small-size CBDS
located below the junction between the cystic
duct and CBD.Ideally, the cystic duct should
be short and dilated with a right implantation into the middle third of CBD.In all other
cases or aer failure of TA, choledocotomy is
indicated. is approach is also preferable in
case of multiple CBDS (>5) with at least one
stone larger than the cystic duct and in case
of a low implantation of the cystic duct. e
CBD diameter should be 7mm or more.
5 It is necessary to ensure the complete clear-
ance of the biliary tract before the end of the
procedure, with an intraoperative cholangiography and a choledocoscopy.
5 Impacted papillary stone remains the main
cause of failure. Lithotripsy under choledoscopic control could help.
5 Biliary drainage is indicated in case of doubt-
ful complete clearance of CBD either with a
T-tube in case of choledocotomy or with a
transcystic drain. Anyway, external biliary
drainage raises signicantly the rate of complications (drain pulled out or ruptured, biliary stula aer removal …) and the length of
hospital stay.
24.2 Subtotal Cholecystectomy
andthe“Inside Approach”:
ASafe Option inSevere
Cholecystitis
24.2.1 Introduction
In severe cholecystitis with dense brosis of the
Calot’s triangle, the “inside approach” of the gallbladder combined with subtotal cholecystectomy
(SC) is a safe alternative technique to classical dissection of the cystic duct and cystic artery which
are frequently embedded in severe inammation
(. Fig. 24.1). In a recent multicenter study, it has
been shown that in case of cholecystitis, the rate of
bile duct injury could reach 2.7 % in open surgery
and 1.1 % in laparoscopic surgery [1]. erefore,
by avoiding to dissect close to the important biliary
ducts, the risk to damage them is lower. e main
advantage of this strategy is to decrease dramatically
the CBD injury rate. It is also helpful when a dicult
case is suspected to have an MRI in the preoperative
workup. It allows to identify before the procedure
biliary anomalies like a posterolateral biliary duct
entering the common bile duct near the cystic duct
24.2.2 Surgical Technique
5 e rst step is laparoscopic exploration of
the subhepatic area and mostly the porta
hepatis. Technical diculties of dissection will
be suspected if the transition area between the
Hartman pouch of the gallbladder and the
right side of the porta hepatis is rigid and
Inflamation
Fibrosis
. Fig. 24.1 Schematic representation of the subtotal
cholecystectomy
Surgical Technique andDicult Situations fromBenoit Navez
inammatory without any anatomical landmark visible. In that situation, to “force” the
passage through the Calot’s triangle could lead
to severe damage to a biliary duct or the right
branch of the hepatic artery.
5 Before any dissection, the gallbladder is lon-
gitudinally opened on its peritoneal surface
from the fundus to Hartmann’s pouch (HP).
Bile is aspirated and stones are placed in an
endobag.
5 en the gallbladder wall is dissected from
the liver bed. By checking the plane of dissection from the inside and outside of the
gallbladder, it allows an easier determination
of the precise limits of the gallbladder wall.
However, sometimes it is dicult to separate the gallbladder from the liver bed, and
in order to avoid a liver parenchyma injury
that can lead to severe venous hemorrhage, a
small part of the gallbladder wall can be le
in place attached to the liver. Anyway, the
dissection should be kept close to the gallbladder wall.
5 At the level of the HP, the dissection is stopped
and the gallbladder is incised circularly leaving
in place a part or all of the HP.e resected
gallbladder is placed in the bag. e cystic
artery is usually encountered at the superior
border of the HP and secured by clips or cauter y.
5 Finally, HP is le opened and the cystic duct
is approached from the inside of the HP.It is
catheterized with a special cholangiography
catheter having a balloon on its tip. e latter
is inated inside the cystic duct in order to
avoid any leakage of contrast material, and the
intraoperative cholangiogram is performed.
5 Cystic duct is closed by suturing intracorpore-
ally the outlet of HP taking care not to widely
anchorage and damage the CBD.
5 e residual mucosa of HP is then super-
cially destroyed by using argon beam coagulator (. Fig.24.2).
189
remaining part of the
gallbladder wall
Argon-Beamer
suture of the cystic duct
. Fig. 24.2 Coagulation of remaining mucosa with
argon beamer
5 Impacted stone in an inamed Hartmann’s
pouch
5 Dicult plane of dissection in the liver bed
or between HP and right part of the hilum
5 Cirrhosis and portal hypertension
5 Mirizzi syndrome type I
24.2.4 Results
In a consecutive series of 39 patients with local
dicult conditions in the triangle of Calot which
represents 7.1 % of all cholecystectomies, an
endovascular approach was performed. Intraoperative cholangiography was feasible in 79.5 %,
and only minor complications occurred in 15.4 %.
ere were no postoperative biliary or infectious
complications [2].
24.3 Laparoscopic Management
ofCholecysto-enteric Fistula
24
24.2.3 Indications
5 Severely inamed GB with severe inamma-
tory or brotic changes
5 Acute gangrenous cholecystitis, empyema
5 Severe brosis from scleroatrophic gall-
bladder
Various communications can occur between
the gallbladder and the digestive tract. There
are internal biliary fistulas like a cholecystocholedochal fistulas (Mirizzi syndrome type
II) and cholecysto-enteric fistulas. Classically,
surgical management of such complicated cases
should be done by open surgery, but for some
190
B. Navez
24
surgeons skilled in laparoscopic techniques and
with a huge experience in biliary surgery, the
procedure can be attempted endoscopically.
e most frequent biliary stulas are
cholecysto- duodenal stula and cholecystocolic stula. Usually, the gallbladder is severely
and chronically inamed (scleroatrophic cholecystitis). Intraoperatively, there are a lot of dense
adhesions between the gallbladder and the
neighboring stulized organ. Do not hesitate to
switch to an inside approach if dense brosis in
the Calot’s triangle makes the dissection dangerous. e stula has to be clearly individualized,
and the digestive side of the stulous path has to
be divided by using a linear endo-stapler. When
closing and locking the stapler, it is important
to verify that it does not cause a stenosis of the
duodenum or the colon.
24.4 Classication ofIntraoperative
Diculties
e operative diculties for surgery of benign
gallbladder and biliary tract diseases can be classied as summarized in . Table24.1.
. Table 24.1 Grading of operative diculties for
benign gallbladder and biliary tract diseases
I. Biliary colics, no cholecystitis, no stone
migration
II. Acute edematous cholecystitis.
Sclero-atrophic gallbladder
III. Acute purulent cholecystitis. Associated
common bile duct stones
IV. Gangrenous cholecystitis. Cholecysto-enteric
stula. Mirizzi syndrome
References
1. Navez B, Ungureanu F, Michiels M, Claeys D, Muysoms
F, Hubert C, Vanderveken M, Detry O, Detroz B, Closset
J, Devos B, Kint M, Navez J, Zech F, Gigot JF; The Belgian Group for Endoscopic Surgery (BGES) and the
Hepatobiliary and Pancreatic Section (HBPS) of the
Royal Belgian Society of Surgery. Surgical management of acute cholecystitis: results of a 2-year prospective multicenter survey in Belgium. Surg Endosc.
2012;26(9):2436–45. Epub 2012 Mar 10.
2. Hubert C, Annet L, van Beers BE, Gigot JF. The “inside
approach of the gallbladder” is an alternative to the classic Calot’s triangle dissection for a safe operation in severe
cholecystitis. Surg Endosc. 2010;24(10):2626–32.
Individual Surgery
for Inflammatory
Bowel Disease
Contents
Chapter 25 Surgical Technique and Difficult
Situations for Ulcerative Colitis
from Adrian Greenstein – 193
AlexanderJ.Greenstein andAdrianJ.Greenstein
Chapter 26 Surgical Technique and Difficult
Situations for Crohn Disease from
Adrian Greenstein – 201
AlexanderJ.Greenstein andAdrianJ.Greenstein
191
VI
Chapter 27 Surgical Technique and Difficult
Situations from Karl-Heinz
Vestweber – 209
Karl-HeinzVestweber
193
Surgical Technique
andDiicult Situations
forUlcerative Colitis
fromAdrian Greenstein
AlexanderJ.Greenstein andAdrianJ.Greenstein
25.1 Introduction – 194
25.2 Preoperative Strategy andPlanning – 194
25.3 Laparoscopic Technique – 195
25.3.1 Positioning – 195
25.3.2 Trocar Placement – 195
25.3.3 Distal Left Colon andTransection atRectosigmoid
Junction – 195
25.3.4 Proximal Left Colon andSplenic Flexure – 196
25.3.5 Completion ofSplenic Flexure andLateral Dissection
ofTransverse Colon – 197
25.3.6 Right Hemicolectomy – 197
25.3.7 Completion ofTransection oftheMesentery
oftheTransverse Colon – 197
25.3.8 Intestinal Extraction andTransection oftheTerminal
Ileum – 198
25
25.4 Conclusions – 198
References – 199
© Springer-Verlag Berlin Heidelberg 2017
M. Korenkov et al. (eds.), Gastrointestinal Operations and Technical Variations,
DOI10.1007/978-3-662-49878-1_25