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Bhavesh Devkaran
BY
Dr. RAKSHAY KAUL
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“Gall bladder in our part are far more difficult
than what you see”
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Laparoscopic Cholecystectomy is the most popular & most accepted minimal access
surgery worldwide
It is the most commonly performed minimal access surgery by general surgeons
worldwide
By the age of 75 years, gallstones would have developed in 35% of women and 20%
of men
Most patients with gallstones are asymptomatic and only 10 % will become
symptomatic about years after diagnosis .
Gall Stones incidence is fairly high in North India (>60% have cholesterol stones)
and in south India( >90% have pigment and mixed variety stones) 3
Alexander of tralles (526-605)- a physician in BYZANTINE empire- 1st one to
mention gallstones –described calculi in human liver
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Cholelithiasis
A) Ssymptomatic
1. Biliary colic
2. acute cholecystitis <72 hrs & >72 hrs
3. Mucocele/empyema gall bladder
B) Asymptomatic
1. Sickle cell disease
2. Tpn
3. Chronic immunosupression
4. No immidiete access to health care
facilities
5. Incidental for patients undergoing sx for
other indications i.e. whipple’s procedure
Choledocholithiasis
Acalculous cholecystitis
Gall bladder dyskinesia
Gall bladder polyps > 10mm in diameter
Porcelain gb
Cholesterosis
Tyhphoid carriers
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Absolute
I. Refractory coagulopathy
II. Suspicion of Ca gall bladder
III. Hemodynamic instability
Relative
I. Cholangitis
II. Diffuse peritonitis
III. Cirrhosis/portal htn
IV. Copd
V. Cholecystoenteric fistula
VI. Morbid obesity
VII. Late pregnancy*
VIII. Multiple previous upper abdominal surgeries
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Investigations
Cbc
Rbs
Rft/serum electrolyte
Lft
Pt/inr
S. Amylase
S. Lipase
CXR-PA & ECG (IF AGE >45yr OR medicaly indicated)
AXR (10 % GS are radio opaque)
ultrasound abdomen
BG/CM
Antibiotic prophylaxis
DVT prophylaxis
Informed consent
2. Light source
3. Co2 insufflator
4. Trocars
•A pair of scissors
Insertion of ports
Diagnostic laparoscopy
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Irrigation and suction of the operating field
Closure of wound
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At the time of introduction of Ports – supine position
At the time of cholecystectomy- reverse trendelenberg(30 degree) with rotation of
operating table to left by 15 degree
Surgeon
1. North american technique
2. French/european technique
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Ports
1. 10mm trocar (camera) - umbilicus
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•Modification of supine
position
•This position displaces
abdominal organs caudally to
provide better view of surgical
site
•It also helps by reducing
blood flow to upper body and
facilitating respiration
•Important to apply knee
straps 2 inches distal to knee
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Gases used
1. Co2
2. Nitrous oxide
3. Helium
4. Argon
Techniques
1. Closed technique(using veress needle)
2. Hassons open laparoscopic access.
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Ideal insufflating agent characteristics
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1) Carbon dioxide (m/c used )
# Odourless, colourless .
# Rapidly dissolves in blood stream but associated
with low risk of venous embolism
# Does not support combustion with electrocautery
Disadvantage – hypercarbia and acidosis
2) Nitrous oxide
# Colourless, found freely in air
# Absorbtion in blood faster than that of co2
# Minimum effect on acid base balance in blood
# Associated with lesser post operative pain in comparison to co2
Disavantage – supports combustion and poses an inherent hazard to the
operating personel
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CLOSED TECHNIQUE
•The Umbilicus is the ideal site for insertion as
a) It has the thinnest area
b) It has minimal Sub Cutaneous Fat even in Obese Women
c) There is fusion of Fascial layers with the Peritoneum
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CLOSED TECHNIQUE
1. It is done with the help of veress needle
2. Patient positioned supine with 10-20 degree head-up tilt
3. Peri umbilical site – most prefered location for verres needle insertion
4. Umbilical puncture is made using n.o.11 stab knife and curved artery forceps used for
exposing the sub-umbilicus
5. The lower abdominal wall is lifted and verres needle is inserted at
(a) 45 degree caudal angle in asthenic/minimaly obese patients
(B) 90 degree angle in markedly obese patients
6. As needle enters peritoneal cavity, a distinct click can often be heard as blunt tip portion of
veress needle springs forward into the cavity(spring test)
CONFIRMATION
1. Hiss test
2. Drop test
3. Syringe with partialy filled saline is attached to verress & aspirated
4. Instill 5 ml of saline into peritoneal cavity & aspirate
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HASSON’S OPEN CUTDOWN TECHNIQUE
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2 clamps used for lifting linea alba and a 1.5 cm
incision made
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2 absorbable sutures(e.g. vicryl) placed on either
sides of fascial defect and hassons cannula with
obturator introduced into peritoneal cavity
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ALTERNATE PUNCTURE SITES
Indication - presence of scar in or around the umbilicus,
leading to substantial risk of bowel injury due to
adhesions
Sites-
1. Palmars point – 4-5 cm( 3 finger width) below left costal
margin in mid clavicular line
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Anomalies are the rule ,not the exception. Classic anatomy
of the biliary tree is present in 30% of the individuals
Landmarks of safe cholecystectomy
1. Hartmann’s pouch
2. Cystic node of lund
3. Calot’s triangle
4. Union of cystic duct with bile duct
5. Cystic artery and right hepatic artery
6. Rouviere’s sulcus
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Tortuous Right hepatic Artery
with short cystic Artery
Tortuous Common
Hepatic Artery
MOYNIHAN’S
HUMP 29
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EXPOSURE OF GALL BLADDER
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ADHESIOLYSIS
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Closure:
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DIFFICULT LAPAROSCOPIC
CHOLECYSTECTOMY
•Difficult dissection of gall bladder or difficult dissection of calots triangle due to
various risk factors is considered as difficult laparoscopic cholecystectomy
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RISK FACTORS
B) ultrasound criteria
A) difficult access
B) exposure difficulties
C) abnormal anatomy
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CLINICAL RISK FACTORS PREDICTING
DIFFICULT CHOLECYSTECTOMY :
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Ultrasound Criterion of Difficult
cholecystectomy :
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1. Difficult Access due to Adhesions
2. Exposure difficulties due to diseased gall bladder
i. Abnormality of the liver
ii. Tense acutely inflammed gall bladder
iii. Gall bladder packed with stones
iv. Thick walled gall bladder
v. Sclero-atrophic gall bladder
vi. Inflammatory mass due to previous pancreatitis
3. Abnormal Anatomy
i. Situs Inversus
ii. Malposition of Gall bladder
iii. Arterial abnormalities
iv. Biliary tract abnormalities
a) Short cystic duct
b) stone impaction in cystic duct
c) Hartmann’s Pouch adherent to common duct
d) Foreshortened cystic pedicle
e) Anomalous insertion of cystic duct
ACCESS PROBLEMS
ADHESIONS
INCISIONAL MALPOSITION
HERNIA LIVER
OBESITY
DISORDER
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ADHESIONS POST OPERATIVE – Depends on magnitude of previous
surgery
• Scars often encountered – (a)cesarian section scar
(b)open appendicectomy
SOLUTION-
(a) The needle is inserted at epigastric port (slighlty above
transpyloric line) & directed towards the left in order to avoid
falciform ligament insufflation
(b) Open hassons method
(c) Veress needle insertion in palmer’s point if scar is midline or
right paramedian
(d) Use additional ports
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Key points for Adhesiolysis
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Incisional Hernia
1. Problems to be dealt with based on site and size of defect
2. Upper abdominal incisional hernia- small defect –L/C with intra corporeal suturing
3. Lower abdominal incisional hernia - L/C followed by completion by same method
or conversion to open cholecystectomy
OBESITY
1. Safety measures to be followed
i. Adequate padding and snug restraints needed to prevent the arms from
shifting from its position and resulting in nerve injuries
ii. Lanz Transumbilical Veress needle technique * this technique takes
advantage of thinness of base of umbilicus
iii. Patients with pendulous abdomen- The needle and camera trocar are inserted
cranial to the umbilicus. In order to achieve this the Intra abdominal pressure
can be increased upto 20 mmHg but once the camera is introduced , the
pressure can be dropped to 14mmHg
iv. Angled scope and additional ports for retraction to counter visual road block
exaggerated by the increased retroperitoneal fat , lifting the C loop anteriorly
and non mobile fat laden omentum are required
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v. The falciform ligament can be lifted selectively by using
percutaneous silk stitch in difficult situations
vi. Abundant fat in the Calots triangle : the yellow blue junction
indicating the medial margin if the neck of the gall bladder is the
safest area to begin dissection
vii. In cases where left lobe of lliver is enlarged and obscuring the
operating field the left lateral tilting of the operating table along
with placement of sandbag behind the right costal marginmoves the
enlarged lobe away from the field
NOTE- In dissecting the calot’s triangle, the bulky fatty liver especially
the segment IV will obstruct the exposure of calot’s triangle so this
may require retraction of the quadrate lobe of liver by a blunt tipped
retractor to obtain proper exposure
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MALPOSITION OF GALL BLADDER
1. Needs additional ports and changing of patient & operating Table
2. SITUS INVERSUS
A. Surgeon stands between the legs and port placement is mirror image of routine
ports
B. Epigastric Port shifted to right side -5mm size (10mm size for left Handed)
C. Left subcostal port- 10mm size for Right handed to facilitate clip application and
5mm size for Left handed
3. Left Lobe Gall Bladder(same arrangement of ports as SITUS INVERSUS)
4. Lateral Lie of GB – Requires more left lateral tilt of operating table
5. Medial Lie of GB – Gall Bladder just under Falciform Ligament – Right 10mm and
left 5mm working ports created on either side of midline in epigastrium with
patient and monitor in routine Laparoscopy Position
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TECHNICAL
DIFFICULTIES
GB RETRACTION BLEEDING
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GALL BLADDER EXPOSURE
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GALL BLADDER RETRACTION
•Thick walled Gall bladder – when wall thickness >4mm
•Opened jaw of such graspers can be used as pushing device to expose calot’s triangle
•Elongated GB- Lateral Graspers to hold body(not FUNDUS) to lift GB up and cranially
for exposure of Calot’s
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BLEEDING
Cystic Artery
Due to Injury to
Branches of portal Endosuturing
Vein(running in GB bed)
Right Hepatic Artery
Arteries of Calots triangle
Diffuse Ooze
FAILS
Clipping of vessel Open Conversion
•Electrocautery
•Gel Foam soaked in Hemostatic
solution
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DUCTAL INJURY
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1. The duct when clipped is not fully encompassed by a 9mm clip
2. Any duct that can be traced without interruption to course behind the
duodenum is probably cbd
3. The presence of another unexpected ductal structure after cutting the first
one
4. Large artery behind the duct
5. Extra lymphatic and vascular structures encountered in the
dissection(hence more bleed during its dissection)
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1. Use a 30 degree laparoscope &high quality imaging equipment
2. Apply firm cehalic traction on fundus and lateral traction on infundibulum
so that cystic duct is perpendicular to cbd
3. Dissect cystic duct where it joins gall bladder
4. Expose the critical view of safety prior to dividing the cystic duct
5. Convert to open procedure if
A) infundibulum cannot be mobilised
Or
B) bleeding /inflammation obscures the calot’s
triangle
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• Unclear Anatomy
•Failure to Progress in dissection (MAXIMUM – 1HR)
•Inury to major blood vessel
•Injury to Abdominal Viscus
•Inury to Bile duct
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PROBLEMS IN CONCOMITANT PATHOLOGY
CA GB
MUCOCELE CHOLE-CYSTOENETERIC
GALL BLADDER
GANGRENOUS
CHOLECYSTITIS PORCELAIN GALL BLADDER
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MUCOCELE GB– most frequent inflammatory disease of gall bladder next to acute
cholecystitis .
C/F – Minimal acute inflammatory signs
Palpable GB
Normal blood investigation
USG abdomen- impacted stone at neck/in cystic duct of GB with mild
thickening of GB wall
Type II
Infundibular
Type I
Generalized biliary Localized peri- type
peritonitis with Sub cholecystic fluid Cystic duct
hepatic, sub collection M.C type, obstruction with
diaphragmatic, & intra increased intra severe infection
peritoneal fluid collection GB pressure-> d/t pressure changes
+ perforation ischemia by stone at Hartmann’s
; M.C a/w perforation
MANAGEMENT
DIFFICULTIES 1. Gentle Traction on Hartmann’s pouch to avoid avulsion of cystic
1. DIFFICULTY IN GRASPING duct(should be done by surgeon himself)
2. LOSS OF TISSUE PLANE 2. A 5mm suction cannula used for dissection and aspiration & helps in
3. DIFFICULT EXPOSURE OF identifying proper dissection plane btw the GB, colon and
CALOT’S duodenum. Keep the dissection plane on gall bladder to avoid entry
4. DIFFICULTY PERFORMING into liver bed
INTRA-OP CHOLANGIOGRAM 3. Dissection of calots similar to standard procedure but if edema
5. SPILLAGE OF present, do gentle blunt dissection by suction cannula
STONES/INFECTED BILE 4. Cystic artery thrombosed usualy so dissect artery with extreme care
to prevent bleed.Cystic duct closure by pretied loop or suture closure
5. After removing necrotic mucosa, pus and tissue from cavity, irrigation
done & GB bed electro-fulgurated for hemostasis
6. Removal of spilled stones(placed in sterile endobag) done by dilating
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epigastric port(using artery forceps)
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EMPYEMA GALL BLADDER
Inflammatory adhesions present released by blunt dissection
GB too thick walled, too tense to grasp Right MCL 5mm trocar inserted directly
and fluid inside highly viscous so into GB, suction cannula inserted, pus
percutaneous aspiration may not be effective aspirated, repeated suction & irrigation
done
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CHOLECYSTOENTERIC FISTULA
Diagnosis – presence of air in biliary tree with contracted GB (other D/D)
M.C site for internal Fistula – Duodenum> colon> stomach
M.C.C of internal fistula – Gall stones(90%)
•Additional trocars are placed – downward traction of omentum/colon & lifting quadrate lobe
•Duodenum carefully dissected from GB, fistulous tract identified, detached and defect sutured
with vicryl & covered with omental flap(similar to Grahams patch repair
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SCLEROATROPHIC GALLBLADDER
Management strategy
1. Identify GB by releasing adhesions
2. Additional Ports for duodenal and colon retraction and quadrate lobe lifting
in difficult cases
3. Slow/meticulous dissection starting medially or laterally at junction of liver
and GB(not at Fundus)
4. Retrograde technique can be performed
5. Cystic duct tied with Pre-tied endoloop. Any impacted stone in cystic duct
milked out
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MIRRIZZI SYNDROME
Difficulties
1. Contracted Gb with extensive adhesions makes visualization of biliary anatomy
difficult
2. CBD mistaken for cystic duct thereby increasing chances of its injury
3. If fistula not recognized during surgery, can lead to biliary peritonitis
Management
1. Type I MIRRIZZI- GB opened at level of impacted stone & stone is dislodged
Infundibulum is carefully seperated from CHD and cystic duct
is sutured.
2. Type II MIRRIZZI – Fistula can be repaired over ‘T’ Tube . Intra Op cholangiogram
done in all cases
Solution-
1. Cranial push of GB done by opened jaws of toothed forceps
2. If cystic duct free from calcification- occlude by clipping else
Endosuturing/Endoloops needed to ligate the duct
ACUTE BILIARY PERITONITIS
BACK
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CYSTIC ARTERY BLEED
1. Do not Panic and DO NOT apply clips without adequate VISION
2. Release the cranial Traction on Fundus & use the infundibulum/Gauze piece
to compress the bleeder. The bleed should stop in some time due to SPASM
3. If bleed continues - Right Hand Suction The
accumulated
Left Hand blood
BACK
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