STRATEGIES

TO PREVENT COMPLICATIONS IN
LAP CHOLECYSTECTOMY
CAUSES-BILE DUCT INJURY
 ACUTE CHOLECYSTITIS
 ANATOMICAL VARIATIONS
 BLEEDING FROM CYSTIC /HEPATIC
 UNCLEAR CALOT’S TRIANGLE
 ANATOMICAL ILLUSIONS
 MISIDENTIFICATION
 SHORT / ABSENT CYSTIC DUCT
 IMPACTED STONE
 EXCESSIVE DIATHERMY
FACTORS PREDICTING DIFFICULTY

 ACUTE CHOLECYSTITIS
 EMPYEMA GALL BLADDER
 PREVIOUS ABDOMINAL SURGERY
 CIRRHOSIS LIVER
 AGE MORE THAN 65 YEARS
 MALE PATIENT
 OBESE PATIENTS B.M.I > 27.5
ULTRASONOGRAPHIC INDICATORS

 WALL THICKENING > 4 MM

 CONTRACTED GALL BLADDER
 PERICHOLECYSTIC COLLECTION
 CALCULUS > 20 MM, PACKED G.B
 STONE IMPACTED IN HARTMANS
 C.B.D > 6 MM DIAMETER
 EVIDENCE OF PANCREATITIS
 STEPS

 IDENTIFY THE CALOT’S & CYSTIC

DUCT
 CRANIAL TRACTION OF FUNDUS
 LATERAL TRACTION OF
HARTMAN’S POUCH
 ALWAYS START DISSECTION
LATERAL TO INFUNDIBULUM
CRANIAL TRACTION LATERAL TRACTION

LATERAL DISSECTION MEDIALDISSECTION

LATERAL TRACTION OF CYSTIC DUCT
 STEPS
 TRACE THE CYSTIC DUCT
UNINTERRUPTED TO GB
 MAKE A BIG WINDOW BEHIND GB
 CLEAR ALL TISSUES BETWEEN CYSTIC
DUCT AND GB
 AVOID BLIND DIATHERMY OR CLIPS TO
CONTROL BLEEDING
 USE LIBERAL SUCTION IRRIGATION TO
KEEP FIELD CLEAR
SAFE ZONE & DANGER ZONE
WINDOW (QUADRANGLE )
? CYSTIC DUCT / ??C B D

 INCOMPLETE ENCOMPASSMENT OF CLIP

 STRUCTURE COURSING TO BEHIND
DUODENUM
 PRESENCE OF ANOTHER DUCTAL
STRUCTURE
 LARGE ARTERY BEHIND / HEPATIC
 EXTRA LYMPHATIC & VASCULAR
STRUCTURES ON DISSECTION
OBESE PATIENT WITH INVISIBLE CALOT’S

• PLACE THE PATIENT IN STEEP REVERSE

TRENDELENBERG

• INSERT AN EXTRA 5 MM TROCAR IN LEFT

UPPER ABDOMEN

• USE A FAN RETRACTOR / SUCTION CANNULA

• PUSH DOWN THE DUODENUM & GREATER

OMENTUM
BLEEDING FROM CALOT’S TRIANGLE
RETRACT THE TELESCOPE FOR WIDER VIEW

COMPRESS THE BLEEDER WITH GUAZE

CLEAR THE CLOTS WITH SUCTION & IRRIGATION

BLEEDING FROM CALOT’S TRIANGLE

IDENTIFY BLEEDER & CLIP PRECISELY

BIPOLAR DIATHERMY CAN BE SAFELY USED

AVOID BLIND CLIPPING AND PARTIAL CLIPPING

LAPAROTOMY IF CONTROL MEASURES FAIL

INDICATIONS FOR CONVERSION TO OPEN

1. ADHESIONS

2. CIRRHOTIC LIVER

3. THICKENED CONTRACTED GALL

BLADDER

4. ABNORMAL ANATOMY

5. SEVERE CHOLECYSTITIS WITH FRIABLE

GB
PLEASE REMEMBER

CONVERSION
IS
NOT
A FAILURE
 WHAT NOT TO DO ?

 STARTING DISSECTION AT DANGER

ZONE
 EXCESS CAUTERY
 BLIND AND INCOMPLETE CLIP
APPLICATION
 CUTTING BEFORE FULL
DISSECTION AND IDENTIFICATION
 WHAT NOT TO DO ?
 EXCESSIVE LATERAL TRACTION ON
INFUNDIBULUM
 INCOMPLETE CLIPS ON LARGE CYSTIC
DUCT
 DEEP DISSECTION OF LIVER BED
 DISSECTION OF SCARRED TISSUE IN
INFLAMMATION
 DISSECTION OF CBD
 HANDLING CLIPS AFTER APPLICATION
VIDEO