Cholecystectomy, laparoscopic

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  • General anatomy

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    The bile duct drains bile from the liver into the duodenum. This way, bile aids in the digestion of lipids in the food. The intrahepatic biliary tract comprises the right and left hepatic duct (ductus hepaticus dexter et sinister) which descend from the liver. Their union forms the common hepatic duct (CHD – ductus hepaticus communis). Along its course to the duodenum it is joined by the cystic duct (ductus cysticus) from the gallbladder (vesica biliaris). The union of the common hepatic duct and the cystic duct forms the common bile duct (CBD – ductus choledochus) which drains into the duodenum. The major duodenal papilla (papilla of Vater) is a sphincter muscle controlling the bile flow from the common bile duct into the duodenum.

  • Specific anatomy

    In 75% of cases, the sole arterial blood supply for the gallbladder is a single cystic artery, arising from the right hepatic artery which courses posterior to the right hepatic duct (see figure above). In all other cases, the cystic artery arises from other branches of the hepatic arteries, and even the gastroduodenal artery, and courses anterior to the common hepatic duct, or the gallbladder is supplied by several arterial branches. Many times, hemorrhage obscuring the view of the surgical field can be controlled by compressing the hepatic artery within the hepatoduodenal ligament or by clamping of the hepatic pedicle (Pringle maneuver). Persistent bleeding may be indicative of an accessory hepatic artery arising from the superior mesenteric artery!

    While anomalies of the cystic duct are less common than vascular variants, their impact in terms of injuries to the common bile duct is more severe. The cystic duct may join the biliary tree at any point, including the duodenal papilla. Therefore, the length of the cystic duct may vary significantly, from being very short to complete absence, and it may spiral anterior or posterior to the common hepatic duct or may even share a common wall (duplicated common bile duct). In addition, accessory bile ducts from the liver may drain into the cystic duct, gallbladder or right hepatic duct. Whenever the anatomy of the cystic duct is in doubt, there is always the option of opening up the gallbladder and probing the cystic duct from within the gallbladder. Option: In case of doubt perform intraoperative cholangiography!

    Injuries of the common bile duct are mostly due to anatomical anomalies or disease-induced tissue changes. Excessive traction on the cystic duct may result in knuckling of the common duct and applying the forceps too low, thereby catching and ligating part of the edge of the common bile duct. This will result in stenosis or even complete transection of the CBD.

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  • Indications

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  • Contraindications

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  • Preoperative diagnostic work-up

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  • Special preparation

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  • Informed consent

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  • Anesthesia

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  • Positioning

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  • Operating room setup

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  • Special instruments and fixation systems

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  • Postoperative management

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date of publication: 12.07.2008

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  • Establish pneumoperitoneum

    • 15-5

    Small skin incision inferior to left lower costal arch near the xiphoid. Introduce the Verres needle through this incision and establish the pneumoperitoneum. Limit maximum pressure to 12 mm Hg.

    Optionally establish pneumoperitoneum by introducing the Verres needle through a 1 cm periumbilical skin incision or opt for open insertion of the first trocar and establish the pneumoperitoneum through the trocar.

  • Trocar positioning

    • 15-6

    Bluntly insert the trocar for the laparoscope (10 mm) through a small umbilical incision. Tilt the table to the reverse Trendelenburg position and slightly to the left; this ensures better exposure of Calot’s triangle. Inspect the abdominal cavity. Now insert three additional trocars in the following sequence and under direct vision:

    5 mm working trocar (T2) inferior to the xiphoid and right of the midline; 10 mm working trocar (T3) in left medioclavicular line (superior to the umbilicus); 5 mm working trocar (T4) in right anterior axillary line (inferior to the costal arch)

    Tip: For better cosmesis of any 10 mm incisions, the umbilical incision may be placed directly in the umbilicus and the left lateral trocar could be reduced to a 5 mm trocar, if a 5 mm laparoscope is used.

  • Exposing the gallbladder

    • 15-7

    Grasp the gallbladder at its fundus (forceps through T2) and retract it cephalad over the liver margin. With another forceps (through T4) grasp the infundibulum and retract it laterally. This will stretch out Calot’s triangle.

  • Dissecting Calot’s triangle

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  • Exposing the cystic duct and cystic artery

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  • Clipping and transecting the cystic artery

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  • Clipping and transecting the cystic duct

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  • Retrograde dissection of the gallbladder

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  • Hemostasis of the gallbladder bed

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  • Retrieving the gallbladder

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  • Inserting drains

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  • Wound closure

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  • Intraoperative complications

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  • Postoperative complications

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  • mibeg-Institut Medizin

    PD Dr. med. Stefan Sauerland

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  • Literature summary

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  • Ongoing trials on this topic

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  • References on this topic

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  • Literature search

    Literature search under: http://www.pubmed.com

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