Standard Laparoscopic Cholecystectomy

The pneumoperitoneum is obtained in the usual fashion. The trocars are inserted
as indicated.
STEP 1: Exposing the Cystic Duct and Artery
The stationary grasper [1: lateral position] is utilized to grasp the tip of the
gallbladder and push it over the anterior edge of the liver by progressive traction.
Hartmann's pouch is pulled upward. This exposes the cystic duct and artery as
well as the common bile duct. It is important to constantly maintain this traction.
In most cases, the scrub nurse or assistant hold this retractor. In difficult, longer
cases, the handle of the grasper is clamped onto the skin of the abdomen or onto
the protective field. The patient is now positioned head down.

CAUTION: It is not always possible to push the tip of the gallbladder (Re:
cirrhotic patients) over the anterior hepatic edge. In these cases, gently push its
tip against the liver, being very meticulous not to penetrate the parenchyma of
the liver.

STEP 2: Dissecting the Cystic Duct and Artery

Once the field is exposed, Hartmann's pouch is grasped with the lateral working
grasper and pulled laterally, further exposing Calot's triangle. The operator will
then pass a dissecting grasper through the subxyphoid trocar and begin to

identify the cystic duct. In acute cholecystitis, edematous layers of tissue will
have to be stripped downward to expose the cystic duct.

The subxyphoid Dolphin Nose Grasper instrument is passed behind the cystic
duct or actually between the cystic duct and the cystic artery. In most cases, the
duct is anterior to the artery.
CAUTION : Hartmann's pouch should always be identified and visualized. The
dissection of Calot's triangle can be done safely starting from the pouch and
moving toward the cystic duct. This is particularly important in acute cases, when
anatomical landmarks are difficult to find. It is essential to visualize Calot's
triangle, which includes the cystic artery, cystic duct and the common bile duct. If
visualization of this area becomes difficult, always check the tension on the
stationary grasper and the intra-abdominal pressure.

STEP 3: Routine Intra-operative Cholangiogram

To view the technique of Routine Intra-operative Cholangiography.

STEP 4: Transecting the Cystic Duct and Artery
At this juncture, the cystic window is created (i.e., free space behind the cystic
duct and the cystic artery). The clip applier is inserted via the subxyphoid trocar.
The cystic duct and artery are clipped (three clips) as close as possible to the
gallbladder. The ENDO CLIP* Applier is then withdrawn and the EndoShears
instrument is inserted to cut them.

CAUTION: Be very careful to clearly identify the junction of the gallbladder and
cystic duct and plan your transection from this anatomical landmark. In doubt,
always check with an IOC.

STEP 5: Dissecting the Body of the Gallbladder

Hartmann's pouch is now retracted upward. Using the EndoShears* instrument,
the most lower lateral aspect of Hartmann's pouch should be dissected
meticulously.

The ENDO SHEARS*instrument is withdrawn and replaced by the electrocautery

hook. The gallbladder is retracted upward and tension is placed on the surgical
plane between the gallbladder and its liver bed. The dissection is extended to the
top of the gallbladder. Occasionally the grasper holding the cystic duct stump can
be used to flip the body of the gallbladder around the stationary grasper which is
still holding the fundus of the gallbladder.
In most instances, this dissection will generate smoke which can impair the
surgeon's visualization. This smoke can be aspirated by opening the insufflation
of the lateral trocar.
STEP 6: Extracting the Gallbladder
A 10 mm, large grasper is introduced via the sub-xyphoid trocar. The two lateral
graspers holding the gallbladder present the gallbladder to the newly introduced
large grasper. The gallbladder is pulled from the the intra-abdominal cavity
through the same trocar site. This trocar site can enlarged bluntly with a peon
clamp of a few millimeters. An Endocatch Instrument can be used to remove
the specimen.

The intra-abdominal cavity is then thoroughly irrigated with normal saline. All
stones that have dropped into the intra-abdominal cavity are retrieved with a
morcilator or stone retrieving forceps.
The abdomen is deflated; the trocars removed, and the trocar insertion sites are
closed in the usual fashion.

Laparoscopic Common Bile Duct Exploration: Trans-cystic

duct
As previously mentioned, the number of laparoscopic common bile duct
explorations performed on our surgical service has dramatically decreased over
the past few years. These explorations are now rare and usually performed in
post-cholecystectomy patients with Choledocholithiasis who have failed
endoscopic retrieval. We strongly believe Choledocholithiasis is best treated by
non-surgical methods such as an Endoscopic Retrograde Cholangiography and
Papillotomy.
Two techniques are used to perform a common bile duct exploration via
laparoscopy. These are 1) the cystic duct dilatation and retrieval and, 2) the
anterior choledochotomy. Nowadays, we almost exclusively use the laparoscopic
anterior choledochotomy.
Pre-exploration Work-up: A correct diagnosis should be made prior to the
actual initiation of the procedure. An intraoperative cholangiogram or another
imaging study should demonstrate common bile duct pathology unequivocally.
Operating Room Set-up:

Additional Instruments and Hardware:

A second Storz Camera with a monitor
1 - 5 mm trocar (available)
Additional Instruments
1 Storz Ureteroscope- 3.0 mm or 3.5 mm with a 1.5 mm working channel
1 Phantom 5 Plus Balloon Catheter (Microvasive /75cm, 5 Fr./6 mm, 18 Fr.)
with Catheter Introducer

1 LeVeen Inflator 10 cc with Pressure Gauge

1 Glide Wire 0.35/150 cm with straight tip
1 Segura Stone Retrieval Stone Basket 2.4F Mini (120 cm)
The Technique

STEP 1: The Intra-operative Cholangiogram

This technique is used at the time of a laparoscopic cholecystectomy. An
operative cholangiogram has confirmed the presence of a common bile duct
stone. At this point, a clip has been placed at the junction of the gallbladder and
the cystic duct. The cholangio-catheter has been removed. The cystic duct should
not be cut. An intact common bile duct is necessary to maintain sufficient tension
for easy access into the cystic duct and the common bile duct.

STEP 2: Cannulating the Cystic Duct

The Phantom 5 Plus Catheter is connected to the LeVeen Inflator with Pressure
Gauge. The catheter is inserted via the lateral 5 mm trocar into the
intraabdominal cavity. A long 4.5 mm sealed, steel shaft is used to minimize air
leaks and to facilitate insertion of the catheter into the cystic duct.

A glide wire is inserted into the central channel of the Phantom 5 Plus Catheter.
This glide wire is inserted into the Cystic duct and into the common bile duct
using direct vision. The dilating catheter is then passed over the glide wire into

the common bile duct. The balloon of the catheter entering the cystic duct is
positioned at the entrance of the cystic duct. The balloon is inflated for five
minutes at 12 atmospheres of pressure. The entrance of the cystic duct has now
been dilated to accommodate a standard 3.0 mm ureteroscope.
STEP 3: Inserting the Choledochoscope
The Phantom 5 Plus Catheter is then removed and replaced by the ureteroscope.
This scope is either connected to an additional camera and monitor, or to an
additional camera with a image splitter. The ureteroscope is inserted into the
cystic duct with a high pressure saline flow. It is pushed into the common bile
duct which is visualized and fully explored.

STEP 4: Retrieving the CBD Stones

Once a stone is seen, the tip of the ureteroscope is placed proximal to the stone.
A Segura Basket is inserted into the working channel of the ureteroscope,
advanced into the common bile duct and passed beyond the stone. It is then
opened and slowly withdrawn under direct vision. When the stone is in the
basket, the basket is closed and the stone grasped. The entire apparatus,
including the ureteroscope and the wire basket, is pulled out of the common bile
duct and the cystic duct. The stone is then released into the intraabdominal cavity
and retrieved in the usual manner.

Laparoscopic Common Bile Duct Exploration:

Choledochotomy
Additional Instruments and Hardware:
A second Storz Camera with a monitor
1 - 5 mm trocar (available)
Biliary Fogarty Catheters (5, 6 F)
Zsabo-Berci Needle Driver or EndoStitch Instrument
Laparoscopic Sutures
T Tube ( Sizes 12 - 18 should be available)
The Technique
This can be performed at the time of a laparoscopic cholecystectomy or in the
post-cholecystectomy patient. In the latter group, the trocars used are the same
as for a standard laparoscopic cholecystectomy.

STEP 1: Exposing the CBD

The common bile duct should be equivocally identified. We rarely proceed with a
common bile duct exploration if the duct is 1cm or less in diameter. A
confirmation of the diagnosis is imperative either via an intra-operative
cholangiography or with an intra-operative sonographic study. A meticulous
dissection of the common bile duct is performed using the ENDO SHEARS*
Instrument and a non traumatic grasper from the hepatic bifurcation to the
superior aspect of the pancreas. A section of the common bile duct of about 2 cm
should be exposed. In some cases, the gallbladder is used to give additional
retraction as demonstrated in the following picture. An endoscopic suture can be
placed on the lower portion of the gallbladder and the lateral aspect of the
common bile duct. In most cases however, we perform a choledochotomy without
retraction sutures.

STEP 2: The Anterior Choledochotomy

The anterior choledochotomy is performed by inserting the ENDO SHEARS*
Instrument via the subxyphoid trocar, grasping the common bile duct with an

ENDO DISSECT* Instrument (via the lateral trocar) and incising the CBD (15 to
20mm).
STEP 3: Clearing the CBD
Once the choledochotomy is done, the common bile duct is flushed using our
high pressure irrigation device. A Biliary Fogarty Catheter is then used. It is
inserted via the subxyphoid trocar and into the common bile duct, run proximally
and distally. This step usually retrieves most of the common bile stones.

STEP 4: The Choledochoscopy

A Choledochoscopy is performed. An additional camera and monitor are used to
connect the flexible 3 mm choledochoscope or ureteroscope. In this setting,
larger ureteroscopes can be utilized as the choledochotomy can accommodate
larger sizes. Stones are retrieved using a Secura Basket via the working channel
of the telescope.

STEP 5: inserting the T Tube

Once the common bile duct is shown to be free of stones, a T Tube is inserted.
The T Tube is usually inserted via the subxyphoid trocar after its limbs have been
cut (each should be 1.0 cm in length). It is then inserted entirely into the intra-

abdominal cavity. An additional 5 mm trocar is inserted in the RUQ. A grasper is

inserted via this new trocar to grasp the long limb of the T Tube. The T Tube is
then pulled through the anterior abdominal wall along with the trocar. The T Tube
is then inserted into the common bile duct, using two graspers or ENDO
DISSECT*. The common bile duct is sutured closed with endoscopic sutures. A
completion Cholangiogram is then obtained.

Subtotal or Anterior Laparoscopic Cholecystectomy

Indications: Acute, severe, gangrenous Cholecystitis and the inability to

complete a safe standard laparoscopic Cholecystectomy.
Operating Room Setup: Same as Standard LapChole
Hardware: Same as Standard LapChole
Instruments: Same as Standard LapChole
Additional Instruments: Two Blake drains with drainage reservoir
All patients are given Toradol (Roche Pharmaceuticals) and Cefizox (Fujisawa
USA) during induction.

The Technique
A standard laparoscopic cholecystectomy has been initiated by the surgeon, at
which time he assesses an anterior laparoscopic cholecystectomy should be
performed.

Using the stationary or lateral 5 mm grasper, the tip of the fundus of the
gallbladder is grasped and retracted cephalad. An ENDO SHEARS* Instrument is
inserted via the sub-xyphoid trocar (with electrocautery connection). Using the
other lateral grasper, the anterior aspect of the gallbladder is dissected
meticulously. The dissection should be extended as low as possible toward the
cystic duct without compromising the safety of the procedure.
Using the ENDO SHEARS* Instrument, the gallbladder is entered and the anterior
wall of the gallbladder should be resected. Hemostasis should be controlled with
the ENDO SHEARS* Instrument connected to an electrocautery source. Spilled
gallstones should be retrieved and removed with a morcilator-type grasper (10
mm). The specimen should be removed via the sub-xyphoid trocar. The
gallbladder fossa should be flushed thoroughly with normal saline.

Two Blake drains are inserted into the intra-abdominal cavity. The best method
for the insertion of these drains is to insert a 5 mm grasper via one of the lateral
trocars into the intra-abdominal cavity and out through the sub-xyphoid trocar.
The sub-xyphoid trocar is removed. The end of the Blake drain is grasped by the
grasper outside the abdominal cavity and pulled back into the intra-abdominal
cavity. The lateral grasper pulls it via the 5 mm trocar site. One drain is inserted
into the open gallbladder fossa and the other into the sub-hepatic fossa.
The procedure is completed as usual.
Technical Notes
Postoperative Management: Postoperatively, the clinical behavior of these
patients is the same as for all patients undergoing a minimally invasive
procedure. The next day they usually are on a regular diet and ambulatory.
Unless they have associated medical problems, most patients can be discharged
within 48 hours. They are discharged with Blake drains in place. Interestingly,
some patients will have a bile leak-drainage noticeable on postoperative day one,
and others will not. This is most likely secondary to a blocked cystic duct
secondary to an impacted gallstone. Nonetheless, these drains are to remain in
place for two weeks or until they cease to drain.
Bile Leak-Drainage: Most patients will have significant bile drainage, as this
procedure effectively creates a controlled bilio-cutaneous fistula. The average or
mean bilious drainage is two days. The longest recorded drainage has been 21
days. As a rule, in the absence of a distal common bile duct obstruction, all
bilious drainage or leaks will cease within three weeks.
Associated Complications: This procedure does not allow the performance of
an intra-operative cholangiogram or the placement of a cystic duct cannula. One
patient was found postoperatively to have a retained common bile duct stone
requiring an Endoscopic Retrograde Cholangiography and Papillotomy. Another
patient developed a sub-phrenic abscess and eventually required a laparotomy.
Impact of Anterior-subtotal Laparoscopic Cholecystectomy On the
Conversion Rate: Prior to introducing this procedure, most conversions occurred
in patients with acute, severe, and gangrenous cholecystitis. This procedure
effectively decreased our conversion rate as soon as it was introduced. Actually,

since its introduction, 896 LapCholes were done with only one conversion. This
reduction in the conversion rate is probably the most significant advantage of this
technique.

Management of Choledocholithiasis with a Cystic Duct

Catheter
Stephen Levinson, MD
Philippe J. Quilici, MD
Dept. of Surgery
Dept. of Gastroenterology
Providence Saint Joseph Medical Center, Burbank, CA

Controversies in the Management of CBD Stones

In the United States, surgeons perform approximately 600,000 laparoscopic
cholecystectomies (LC) per year. LC's have largely superceded open
cholecystectomies (OC) as the preferred method of gallbladder removal,
accounting for 80% of such procedures in this country. One limitation of LC as
compared to OC is the difficulty in dealing with common bile duct (CBD) stones.
CBD stones are present in approximately 15% of patients, and are responsible for
considerable morbidity and mortality (specifically pancreatitis and ascending
cholangitis) which mandates the removal of such stones.

In OC, surgeons can routinely remove CBD stones via common bile duct
exploration (CBDE), a natural extension of the operative procedure. In LC
however, techniques for detection of CBD stones (intraoperative cholangiography
or IOC) and subsequent removal are beset with pitfalls. IOC, performed by
injection of dye via a cystic duct catheter placed surgically, adds significant time
to the operative procedure. It also requires commitment of additional equipment
and personnel to the operating room, and has a false positive rate of stone
detection of up to 12%, sometimes resulting in unnecessary CBDE. Furthermore,
the finding of stones on operative cholangiogram obligates the surgeon to
perform CBDE, either laparoscopic or open . A laparoscopic CBDE is a time
consuming, hardware intensive procedure, has a steep learning curve, is
associated with up to a 50% failure rate, and risks injury to the CBD. Conversion
to open CBDE negates the value of a laparoscopic procedure. Another alternative
in patients with stones seen on IOC is to refer the patient postoperatively for
ERCP, papillotomy, and stone removal. However, a technical failure rate of up to
15% in some series could lead to a second operative procedure, open CBDE.
A number of researchers have attempted to define parameters which could be
useful in preoperative prediction of CBD stones. This includes the presence of any
of several parameters: 1) Increased liver enzymes, 2) Preoperative pancreatitis,
jaundice, or cholangitis, 3) A dilated CBD or intraductal stone on ultrasound, is
predictive of CBD stones 25-48% of the time. Furthermore, stones can be present

up to 8% of the time in the absence of such parameters or risk factors. Strategies

to deal with possible CBD stones in patients with risk factors are complex. One
strategy is to do preoperative ERCP with removal of stones (if present). The
problem is that 50-75% of ERCP's performed because of the presence of a risk
factor will show no stones. Thus, a large number of unnecessary ERCP's will be
performed, with a complication rate of 5-10%, and a technical failure rate of up
to 15% (i.e. failure to cannulate CBD). A second strategy is to do IOC on patients
with risk factors, and to do intraoperative stone removal if stones are detected.
The problem with this, as mentioned is that IOC, is time-consuming and
associated with up to 12% false positive rate. Subsequent intraoperative stone
removal is both time consuming and risky, and often subjects the patient to an
open procedure. A third strategy is to do postoperative ERCP if the IOC shows
stones. Again, the problem here is that up to a 15% failure risk associated with
ERCP would subject the patient to another surgical procedure to remove the
stones.
Using a CDC for a post-operative Cholangiogram
We have developed a new and simple technique for cholangiography that we
believe will largely supplant existing complicated algorithms for dealing with CBD
stones. In this laparoscopic technique, in lieu of performing IOC, we secure a
standard ERCP catheter (Microvasive, tapered tip) in the cystic duct
intraoperatively and leave the catheter in place after surgery.

Postoperatively, all patients undergo a cholangiogram in the x-ray department via

the catheter. If no stones are demonstrated, then the catheter is pulled. If stones
are present, then the endoscopist performs postoperative ERCP and papillotomy
to remove the stones, and then pulls the transcystic catheter.
The LapChole with CDC Placement
Operating Room Setup:Same as Standard LAPCHOLE
Hardware: Same as Standard LAPCHOLE
Instruments: Same as Standard LAPCHOLE
Additional Instruments:
1 Blake Drain with drainage reservoir
1 Ureteral 7 French Ureteral Catheter or
1 Fluoro Tip ERCP Cannula Tapered Tip
(210 cm - 5 French 1.7 mm with stainless steel stylet)
Technique
The procedure is initiated as described in the Standard LAPCHOLE Chapter.
1. Inserting the Cystic Duct Cannula in the Intraabdominal Cavity

The cystic duct is exposed and clipped at its junction with the gallbladder with an
endoclip. Traction is maintained on Hartmann's pouch to expose the cystic duct.
An anterior incision is made with the ENDO SHEARS* instrument.
The cystic duct cannula is inserted via the subxyphoid trocar site. First, the trocar
is quickly removed from the subxyphoid site. The site is plugged with a finger and
the cannula is inserted bluntly into the intraabdominal cavity under direct vision.
When 10 to 15 cm of the cannula is in the intraabdominal cavity, the
VERSAPORT* trocar is reinserted bluntly next to the cystic duct cannula. Both the
cannula and the trocar are now side by side in the subxyphoid insertion site. The
cannula can be advanced, withdrawn and manipulated very easily from the
outside of the abdominal cavity.
2. Placing the Cannula in the Biliary Tree
An ENDODISSECT* Instrument or an atraumatic grasper is inserted via the
subxyphoid trocar and grasps the tip of the cystic duct cannula. It is inserted into
the cystic duct under direct vision and advanced into the common bile duct.
We routinely advance the cannula for about 5-6 cm, and then withdraw the
cannula to leave approximately 1.5 to 2 cm inside the cystic duct.
3. Securing the Cannula in the Cystic Duct
The ENDO DISSECT*or grasper is removed from the intraabdominal cavity and
replaced with the ENDO CLIP* Applier. It is essential to use a USSC ENDO CLIP*
or a SURGICON applier. They are the only instruments that will allow the
performance of the next maneuver.
Two clips are placed on the cystic duct. It is essential NOT to close the entire clip
around the cystic duct so as not to entirely obliterate the duct and cannula. The
partial closing of the clip can only be performed with the USSC ENDO CLIP*
applier. ( The Ethicon clip Applier does not have this capability.) Another clip is
tightly placed behind the cannula. If using the SURGICON clip applier, only one
clip is used on the cannula and behid it.

The ENDO CLIP* applier is now replaced with the ENDO DISSECT* Grasper. The
Cannula is grasped outside the cystic duct and pulled .5 cm to check that the
cannula is not crushed or locked onto the cystic duct. Then additional cannula is
inserted into the intraabdominal cavity to provide slack, so it can be placed
laterally to allow for the completion of the laparoscopic cholecystectomy. A Blake
Drain is inserted at the end of the procedure.
An intraoperative cholangiogram can be performed. If negative, the cannula is
removed. We routinely do not perform an intraoperative cholangiogram. We order
it a few hours after the procedure.
Post-op ERCP
Scenario 1: Choledocholithiasis is demonstrated on the Transcystic
Cholangiogram: an ERCP is planned.
ERCP Technique
The cystic duct catheter provides a portal through which a guidewire can be
directed into the duodenum at the time of ERCP. The ability to place a guidewire
greatly facilitates cannulation of the CBD during ERCP, especially in technically
difficult cases.
Equipment
Pentax ERCP scope
Microvasive Ultratome XL
Zebra wire
Balloon Retrieval Catheters--8.5 mm. and 11 mm.(Microvasive Extractor XL)
Stone retrieval basket
Technique

STEP 1. A cholangiogram is first performed via transcystic

catheter. This helps identify CBD and facilitates cannulation of
papilla.
STEP 2. ERCP is then performed in the standard fashion.
STEP 3. If cannulation takes longer than 15 minutes, then a
400 cm Zebra wire is advanced through the transcystic
catheter and directed by fluoroscopy into the CBD and through
the papilla.
STEP 4. The endoscopist passes a snare through the biopsy
channel of the ERCP scope, snares the end of the Zebra wire,
and pulls it out of the scope.
STEP 5. The papillotomy is flushed with saline and advanced
over the wire, through the scope, and into position in the
papilla and CBD.
STEP 6. Endoscopist performs papillotomy over the guidewire
and removes guidewire/papillotomy assembly.
STEP 7. The duct is then swept with an 8.5 mm or 11 mm
balloon or a stone retrieval basket to remove stone(s).

The transcystic cannula is removed by firmly pulling on it at the bedside or in the

ERCP suite. The Blake drain is left in place and the patient is discharged. The
Blake drain is then removed a few days later as an outpatient.
NOTE: There has been no reported leak following this protocol. However, the
Blake drains are left in place should a bile leak occur.
Scenario 2: No Common Bile Duct Stone demonstrated.
The Cannula is removed by exerting firm traction. The Blake Drain is left in place
and removed 48 hours later as an outpatient.
Advantages
This technique offers many advantages over existing strategies for dealing with
CBD stones. First, ERCP's will be limited only to those patients who have a stone

visualized on transcystic cholangiogram. For those surgeons or

gastroenterologists who currently stratify patients' need for ERCP according to
preoperative risk factors for CBD stones, the TCC approach will eliminate the
need to perform ERCP on up to 80% of patients with positive risk factors but who
have no stones (False Positives). The ERCP associated complications will thereby
be eliminated. Second, the 15% risk of postoperative ERCP failure to cannulate or
clear stones (even up to 10% in biliary referral centers) will be largely eliminated
by the ability to place a transcystic, transpapillary guidewire. This safety valve
will greatly facilitate endoscopic access to the bile duct, eliminate the need for a
risky precut papillotomy to gain access to the CBD, and reduce the potential need
for a second operation in patients in whom ERCP was a technical failure. Third,
the TCC should eliminate the need for IOC and CBDE. Since the TCC/ERCP
technique reduces the risks associated with ERCP and optimizes the chance of a
successful outcome, the need for IOC and /or CBDE (laparoscopic or open) is
greatly reduced (including those CBDE's done for false positive IOC's). Fourth, if
this technique is applied to all laparoscopic cholecystectomies, then all CBD
stones will be detected including up to 8% of patients who have no preoperative
risk factors for stones.