How do I do it: laparoscopic cholecystectomy - Majumder

Although not every patient with gallstones will manifest symptoms or require intervention, laparoscopic cholecystectomy (LC), which accounts for ... Home / Vol5(April2020) / HowdoIdoit:laparoscopiccholecystectomy HowdoIdoit:laparoscopiccholecystectomy Video1HowIdoit:laparoscopiccholecystectomyandintraoperativecholangiogram. Introduction IntheUnitedStates,gallstonediseaseremainsaprevalentconditionaffectingover20to25millionAmericans,representing10–15%ofthepopulation(1,2).Althoughnoteverypatientwithgallstoneswillmanifestsymptomsorrequireintervention,laparoscopiccholecystectomy(LC),whichaccountsfor90%ofallcholecystectomies,remainsoneofthemostcommonlyperformedprocedures—conservativelynumbering750,000peryear(3).Sinceitsintroductioninthe1980sandsubsequentadoption,LChasbecomethestandardofcareduetoitsadvantagesofreducedcostandhospitallengthofstay,andincreasedpatientsatisfaction(4,5).Overall,LCisconsideredasafeprocedure,asmorbiditycanoccurinapproximately6–8%ofthepatients(6),includingbleeding,abscess,bileleak,bowel/vascularinjury,woundcomplication,andbileductinjury(BDI)(6,7).Althoughbileductinjuryhasbeenbecomelessfrequentovertheyears,occurringinapproximately0.2–0.4%ofcases,thefrequencyisstillsomewhathigherthanintheeraofopencholecystectomy(8,9).Thus,performinglaparoscopiccholecystectomysafelyandembracingtheprinciplesoutlinedbelowiscrucial. BDIhasbeenassociatedwithothercomplicationsandthenecessityforfurtherprocedures/interventions,highermortality,lowerqualityoflifeanddisability,increasedhealthcareburdenandlitigation(10,11).Studieshaveshownbothincreasedshortandlong-termmortalityduetoBDI(12).Inordertoenhancethesafetyofcholecystectomyandreducetherateofbiliaryinjury,in2014theSocietyofGastrointestinalandEndoscopicSurgeons(SAGES)formedtheSafeCholecystectomyTaskForcewiththegoalofenhancingacultureofsafetyaroundthisprocedure(13).TheauthorsreportthesurgicaltechniquesthatfollowtheprinciplesespousedbySAGESduringlaparoscopiccholecystectomyinordertoensureasafeprocedure. Operativetechnique Thepatientisplacedinsupinepositionwiththeleftarmtuckedtofacilitateintraoperativecholangiography. Withthesurgeonstandingtotheleftofthepatientandfirstassistantstandingonthepatient’srightside,abdominalaccessisobtainedandpneumoperitoneumisestablished.Inourpractice,wegenerallyperformanopencutdowntechniqueandHassoncannulaplacementattheumbilicus(T1position)(Figure1).Inpatientswithpriorperiumbilicalmidlineincisions,analternativeaccesssiteisused,eitherclosedwithaVerresneedleintherightupperquadrantmid-clavicularbelowtheliverorleftupperquadrant(Palmer’spoint)orviaanopenepigastricincision.Intheobesepatient,aclosedVerresneedleaccessisobtainedjusttotherightofthemidline15cmbelowthexiphoidsincetheumbilicusisdisplacedinferiorlyinthesepatients;thisallowsthecameraporttobepositionedforadequatevisualizationofthedissectionsite.Aftercreationofthepneumoperitoneum,5mmportsareplacedintherightlateralsubcostalposition(T2)andrightsubcostalmid-clavicularline(T3),alongwitha5mmepigastricport(T4),whichisinsertedjusttotherightedgeofthefalciformligament.AgrasperintroducedfromT2isusedtoapplycephaladtractiononthefundustoelevatethegallbladderandagrasperthroughthemid-clavicularportretractstheinfundibulumlaterallyandinferior.TheworkingtrocarsthatareusedbythesurgeonareT3andT4. Figure1Laparoscopiccholecystectomyportpositioning. Step1:Dissectionofthehepatocystictriangle Thegallbladderisretractedovertheliverwithcephalictractionwhileinferior-lateraltractionontheneckofthegallbladderisappliedthroughthemidclavicularportsite.Theassistantcanusuallymaintainconstanttensiononthisretractorunlessadjustmentsarerequiredforchangesinvisualization.UsingT3,thesurgeoncanmanipulatetheneckofthegallbladdertoexposeanterior(medial)andposterior(lateral)aspectsasneeded.Ifthegallbladderisdistended,werecommenddecompressingitwithaneedleaspirationdevicetoavoidperforationwithspillageofbileandgallstones.Ifadhesionsarepresent,thesearetakendownbluntlyorwithmonopolarenergytakingcaretoavoidenergyuseneartheduodenumwhichcanbeadherenttothegallbladder.Thedissectionbeginsbyincisingperitoneumalongtheedgeofthegallbladderonbothsidestoopenupthehepatocystictriangle.Thiscanbecarriedupposteriorlyalongthewallofthegallbladderatitsinterfacewiththeliver.Acombinationofbluntdissectionandjudicioususeofcauteryareneededwithagoalofclearingthetriangleoffatandfibroustissue. Step2:Establishingthecriticalviewofsafety Thecriticalviewofsafetyrequiresthreecriteriatobemet:(I)thehepatocystictriangle(definedasthetriangleformedbythecysticduct,thecommonhepaticduct,andinferioredgeoftheliver)isclearedofallfatandfibroustissue.Thecommonbileductandcommonhepaticductarelookedforbutnotexposedbydissection;(II)theloweronethirdofthegallbladderisseparatedfromthelivertoexposethecysticplate.Thecysticplateisdefinedastheliverbedofthegallbladderandrepresentsthegallbladderfossa;and(III)twoandonlytwostructuresshouldbeseenenteringthegallbladder,representingthecysticductandthecysticartery.Oncethisviewisestablished,werecommendapauseandconfirmationamongsttheoperatingsurgeonandassistantpriortoclippingorcuttingofanystructures.Atthisjuncture,identificationofaberrantanatomyiscritical.Variationsincysticductpositionandentryintothecommonbileductarecommon,asarevariantsinarterialanatomy.Athoroughunderstandingandappreciationofaberrantanatomyisimportanttominimizetheriskofaninjury.Onecommonconsiderationisensuringtherighthepaticarteryisnotmistakenforthecysticarteryoraccessorybranchposteriorlyintheareaofthecysticplate. Step3:Cysticarteryisclippedanddivided Inourinstitutiontominimizecosts,areusableclipapplierwith8mmclipsisutilizedtoclipthecysticartery,twoclipsontheproximalsideandonecliponthedistal(specimen)sidewithanadequategapbetweentoallowfordivision.Hookscissorsareusedtodividetheartery.Careshouldbetakenduringthisprocessnottodislodgetheproximalclips.Werecommendleavingasmallcuffoftissuebeyondtheedgeoftheclipstopreventaccidentaldislodgementeitherduringthecaseorafter.Aclipisplacedontheneckofthegallbladderattheupperendofthecysticduct-GBjunction.Divisionrightattheclipcanpredisposethedistalspecimencliptobecomedislodged. Step4:Operativecholangiographyanddivisionofthecysticduct Itisourpracticetoperformcholangiographyroutinely.CholangiographyismorecommonlyperformedselectivelybutcompellingindicationsaresuspicionofCBDstones(historyofabnormalliverfunctiontestsorgallstonepancreatitis),adilatedcommonbileduct,uncertaintyofanatomyorconcernforbiliaryinjury,andahistoryofRouxYgastricbypasswhichprecludessubsequentERCP.Ifnocholangiogramisperformed,similartothecysticartery,thecysticductcanbeclippedwiththreetitaniumclips,twoonthestaysideandoneonthegallbladderspecimenside.Incasesinwhichthecysticductisdilatedorthickenedortherearebileductstones,apre-tiedendoloopsutureshouldbeusedtosecuretheductontheproximalside. Ifanintraoperativecholangiogramistobeperformed,asingleclipisplacedatthejunctionofthecysticductandinfundibulumofthegallbladder.Thecysticductispartiallyincisedwithhookscissors.Thecysticductotomyisthendilatedwithamicroscissorsinordertodisruptanyvalvesinthecysticduct.A4FrenchureteralcatheteristheninsertedintothecysticductusinganOlsoncholangioclamptosecureit.SinglespotfilmsareusedtoadjustthepositionoftheC-armsothatboththeentirebiliarytreeandduodenumcanbevisualizedinthecenteroftheframe.Weutilizetwo20mLsyringes,onecontainingsalineandtheothera50-50mixtureofsalineandiodinatedcontrastmediaattachedviaathree-waystopcockforinjection.Theductisinitiallyflushedwithsalineandthencontrastunderfluoroscopy.Oneshouldseeretrogradefillingintothecommonhepaticductaswellasrightandleftbranchesintotheliverandcontrastshouldflowfreelyintotheduodenum,ensuringapatentbiliarytree.Ifthereisnoentryofcontrastintotheduodenum,glucagon1mgshouldbegivenintravenouslytorelaxthesphincterofOddiandtheinjectionrepeatedin2–3minutes.Ifdifficultyisencounteredwithretrogradefillingoftheduct,placingthepatientinTrendelenburg,gentlycompressingthedistalductwithanatraumaticgrasper,orinjectionofmorphineintravenouslycanbegiventofacilitatecontractureofthesphincter.Ifastoneisvisualizedinthebileduct,thenthedecisionshouldbemadewhethertoattemptatrans-cysticcommonbileductexploration,laparoscopiccholedochotomy,orreferralforpostoperativeERCP,accordingtosurgeonexpertiseandpreference. Onceasatisfactorycholangiogramisobtained,thecholangiogramcatheterisremoved,andthecysticductisdoublyclippedanddivided.Asstatedabove,ifthereisconcernaboutthesecurityoftheclipsonthecysticduct,apre-tiedloopsutureshouldbeusedtosecuretheductinstead. Step5:Gallbladderseparationfromtheliverbed Followingdivisionofthecysticduct,retrogradedissectionofthegallbladderfromtheliverbedisperformed.Inourinstitution,weuseanL-hookmonopolarenergydevicetodissectgallbladderofftheliver.Careshouldbetakentostayintheplanebetweenthegallbladderandliverbed.Entryintotheliverbedmayresultinbleedingand/orbileleakagefromasuperficialsubparenchymalduct.Entryintothegallbladderwithspillageofbileandstonesmakesubsequentdissectionmoredifficult,butshouldnothaveanyadverseconsequencesaslongasallbileandstonesareremovedfromthefield.Maintainingappropriateretractionbymovingtheneckofthegallbladderbackandforthtooptimizevisualizationandmaintainingtensiononthedissectionlinefacilitatesthisstepintheoperation.Forthedifficultgallbladderinthesettingofacutecholecystitis,anadvancedenergydevicesuchasanultrasoniccoagulatormaymaintainhemostasisbasisbetterandproducelesssmokeplume,whichmakesthedissectioneasierandmoreefficient.Justpriortocompletedisassociationofthegallbladderfromitsbed,thelastattachmentshouldbeleftinplacetoallowforretractionofthelivercephaladandclearvisualizationofthecysticplatetoallowforanyneededhemostasis.Theliverbedisirrigatedandanybloodorbileoraspiratedfromthefield.Thegallbladderisthenplacedinanentrapmentbagandremovedatthe10–12mmportsite. Step6:Specimenandportremoval Oncethespecimenisinthebag,itcanberemovedatthe10mmportsitewhetherattheumbilicusorepigastricregion.Thesestepsaresummarizedinourvideo(Video1).Someenlargementoftheskinandfascialopeningmaybeneeded,especiallyiftherearemultipleorlargerstonesorathickenedgallbladder.Oncethespecimenisremoved,allportsareventedtoeliminateanyresidualCO2gas.Thefasciaattheextractionportsiteshouldbeclosedwith0-Vicrylorsimilarsutureandtheskinclosedwithanabsorbablemonofilamentsubcuticularsuture. Acknowledgments Funding:None. Footnote ConflictsofInterest:AllauthorshavecompletedtheICMJEuniformdisclosureform(availableathttp://dx.doi.org/10.21037/ales.2020.02.06).Theauthorshavenoconflictsofinteresttodeclare. EthicalStatement:Theauthorsareaccountableforallaspectsoftheworkinensuringthatquestionsrelatedtotheaccuracyorintegrityofanypartoftheworkareappropriatelyinvestigatedandresolved.Allproceduresperformedinstudiesinvolvinghumanparticipantswereinaccordancewiththeethicalstandardsoftheinstitutionaland/ornationalresearchcommittee(s)andwiththeHelsinkiDeclaration(asrevisedin2013).Writteninformedconsentwasobtainedfromthepatientforpublicationofthismanuscriptandanyaccompanyingimages. OpenAccessStatement:ThisisanOpenAccessarticledistributedinaccordancewiththeCreativeCommonsAttribution-NonCommercial-NoDerivs4.0InternationalLicense(CCBY-NC-ND4.0),whichpermitsthenon-commercialreplicationanddistributionofthearticlewiththestrictprovisothatnochangesoreditsaremadeandtheoriginalworkisproperlycited(includinglinkstoboththeformalpublicationthroughtherelevantDOIandthelicense).See:https://creativecommons.org/licenses/by-nc-nd/4.0/. References EverhartJE,RuhlCE.BurdenofDigestiveDiseasesintheUnitedStatesPartIII:Liver,BiliaryTract,andPancreas.Gastroenterology2009;136:1134-44.[Crossref][PubMed] ShafferEA.Epidemiologyandriskfactorsforgallstonedisease:Hastheparadigmchangedinthe21stcentury?CurrGastroenterolRep2005;7:132-40.[Crossref][PubMed] RussoMW,WeiJT,ThinyMT,etal.DigestiveandLiverDiseasesStatistics,2004.Gastroenterology2004;126:1448-53.[Crossref][PubMed] SheaJA,BerlinJA,BachwichDR,etal.Indicationsforandoutcomesofcholecystectomy:AcomparisonofthepreandpostlaparoscopicEras.AnnSurg1998;227:343-50.[Crossref][PubMed] CallandJF,TanakaK,FoleyE,etal.Outpatientlaparoscopiccholecystectomy:Patientoutcomesafterimplementationofaclinicalpathway.AnnSurg2001;233:704-15.[Crossref][PubMed] MurphyMM,NgSC,SimonsJP,etal.PredictorsofMajorComplicationsafterLaparoscopicCholecystectomy:Surgeon,Hospital,orPatient?JAmCollSurg2010;211:73-80.[Crossref][PubMed] GigerUF,MichelJM,OpitzI,etal.RiskFactorsforPerioperativeComplicationsinPatientsUndergoingLaparoscopicCholecystectomy:Analysisof22,953ConsecutiveCasesfromtheSwissAssociationofLaparoscopicandThoracoscopicSurgeryDatabase.JAmCollSurg2006;203:723-8.[Crossref][PubMed] FlumDR,DellingerEP,CheadleA,etal.IntraoperativeCholangiographyandRiskofCommonBileDuctInjuryduringCholecystectomy.JAMA2003;289:1639-44.[Crossref][PubMed] PucherPH,BruntLM,DaviesN,etal.Outcometrendsandsafetymeasuresafter30yearsoflaparoscopiccholecystectomy:asystematicreviewandpooleddataanalysis.SurgEndosc2018;32:2175-83.[Crossref][PubMed] KernKA.Malpracticelitigationinvolvinglaparoscopiccholecystectomy:Cost,cause,andconsequences.ArchSurg1997;132:392-7;discussion397-8.[Crossref][PubMed] CarrollBJ,BirthM,PhillipsEH.Commonbileductinjuriesduringlaparoscopiccholecystectomythatresultinlitigation.SurgEndosc1998;12:310-3;discussion314.[Crossref][PubMed] BooijKAC,DeReuverPR,VanDierenS,etal.Long-termImpactofBileDuctInjuryonMorbidity,Mortality,QualityofLife,andWorkRelatedLimitations.AnnSurg2018;268:143-50.[Crossref][PubMed] TheSAGESSafeCholecystectomyProgram.Availableonline:https://www.sages.org/safe-cholecystectomy-program/. doi:10.21037/ales.2020.02.06Citethisarticleas:MajumderA,AltieriMS,BruntLM.HowdoIdoit:laparoscopiccholecystectomy.AnnLaparoscEndoscSurg2020;5:15. 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