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Moderator – Prof.

Bhavesh Devkaran

BY
Dr. RAKSHAY KAUL

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“Gall bladder in our part are far more difficult
than what you see”

– All Indian Surgeons

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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

Laparoscopic cholecystectomy is the current Gold standard for treatment of gall


stone disease [Ann Surg. 1996 nov; 224(5): 689-690]

Currently >80% cholecystectomies are performed using the laparoscopic approach

 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

Jean louis petit – 1st cholecystostomy* – 1743

Carl langenbuch - 1ST open cholecystectomy– 1882

Erich muhe in boblingen,germany(1985) & Philippe mouret of lyon, france(1987)


– 1ST Laparoscopic cholecystectomy

Professor mouret – used key hole approach

Prof. Jacques perissat(france) – presented 1st paper on Laparoscopic


Cholecystectomy during SAGES congress in 1988 in USA

Dr eddie reddick – 1st to describe 4 port Laparoscopic Cholecystectomy

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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

Parts prepared- particular care to remove debris from


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umbilicus
1. Video-laparoscope

2. Light source

3. Co2 insufflator

4. Trocars

5. Specialised laproscopic hand instruments


•Monopolar electrode with l-hook

•A fine tipped dissector

•Gall bladder graspers

•Large gall bladder extractor

•A pair of scissors

•Medium to large hemoclip applier

•Suction and irrigation 8


Preparation of position

Creation of pneumo peritoneum

Insertion of ports

Diagnostic laparoscopy

Dissection of visceral peritoneum

Dissection of calot’s triangle

Clipping and division of cystic duct and artery

Dissection of gall bladder from liver bed

Extraction of gall bladder and any spilled stone

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Irrigation and suction of the operating field

Final diagnostic laparoscopy

Removal of instrument with complete exit of co2

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

2. 10 mm trocar (operating) - epigastrium, left to


falciform ligament

3. 5mm trocar (operating) - right subcostal- 2-3cm below


costal margin in the mid
clavicular line

4. 5mm trocar (assissting) - RLQ , right anterior


axillary line

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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.

Target pressure - 13 – 15mmhg

Target flow rate


initialy – 2 l/min f/b 5 l/min

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 Ideal insufflating agent characteristics

Should be colourless , inert, and non explsoive


 Should have low solubility in peritoneal cavity
Should have high solubility in blood
Should be readily available, non expensive and non toxic

Q) why air cannot be used?

Due to risk of air embolism and inflammability during electro cauterization

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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

3) Helium – colourless, tasteless, non combustible with no risk of hypercarbia or


acidosis
Risk - minimal risk of gas embolism

4) Hrgon - colourless , odourless, non combustible, chemicaly non reactive.


Good alternative to co2 in patients with decreased respiratory reserve

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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

Infraumbilical incision made (1-3cm)

Sub Cutaneous tissue bluntly dissected and


retracted

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2 clamps used for lifting linea alba and a 1.5 cm
incision made

Peritoneal fat bluntly dissected till peritoneum


is reached which is held with hemostat and
incised

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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

Obturator removed, sutures firmly


attached to create a seal with fascia
followed by insertion of laparoscope

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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

•A ratcheted grasper is used through the right lower 5mm


Trocar to grasp gall bladder fundus
• Retract the gall bladder over the liver edge in cranial
direction(towards right shoulder) to expose the entire length of gall bladder
•Carefully examining the anatomy would reveal whether the gall bladder is
intrahepatic, on a mesentry or posesses phyrigian cap
•It is important to identify hartmanns pouch
•Cystic artery can be seen running along undersurface of gall bladder
•A lymph node may be seen anterior to cystic artery

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ADHESIOLYSIS

•Any adhesion should be cleared from the gall bladder


•Using a dissector through the epigastric trocar the peritoneal attachments are
torn down from the undersurface of liver and gall bladder
•The attachments are taken down from high on the gall bladder beginning
lateraly in order to help avoid injury to the common bile duct
•Sharp dissection may be carried out with help of scissors attached with
monopolar current
•Adhesions should be retracted downwards with left hand grasper to expose
the plane of division

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Closure:

Trocar are removed under direct vision.


Pneumoperitoneum is evacuated.
Fascia of 10 mm ports closed with vicryl 2826 port closure.
Skin closure with metal clips.

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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

•Advanced skills in laparoscopic surgery especially in intra-corporeal suturing and


knotting are essential to perform difficult cholecystectomy

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RISK FACTORS

1. Pre-operative risk factors

A) clinical risk factors

B) ultrasound criteria

2. Per-operative risk factors

A) difficult access

B) exposure difficulties

C) abnormal anatomy

D) complications during dissection

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CLINICAL RISK FACTORS PREDICTING
DIFFICULT CHOLECYSTECTOMY :

1. Stocky male patients-


(a) tall
(b) short
2. Multiparous women with flabby abdomen – thinned out lower abdomen
3. Previous upper abdominal surgery
4. Cirrhosis of liver –
(a) adhesions with increased neovascularity
(B) difficult traction of liver
(c) inadequate exposure of hilum
(d) high risk gb bleed
(e) high risk hilum(approach to cystic pedicle difficult)
5. Present or previous acute cholecystitis and acute severe pancreatitis
6. Previous treatment – percutaneous drainage or cholecystostomy

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Ultrasound Criterion of Difficult
cholecystectomy :

1. Thick walled Gall Bladder(>4mm)


2. Contracted (non functioning) gall bladder
3. Packed stones and large calcified gall bladder
4. Polyp or mass lesion without any acoustic shadow
5. Evidence of Acute cholecystitis
a) Impacted stone
b) Edematous gall bladder wall
c) Pericholecystic fluid collection
d) Air in the Gall Bladder(Emphysematous cholecystitis)
e) Subphrenic collection
f) Intra-peritoneal fluid collection due to perforated gall bladder
6. Fatty liver with hepatomegaly
7. Cirrhosis of liver
8. Portal Vein thrombosis

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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

4. Complications during dissection


i. Bleeding
ii. Bile duct injury
iii. Gall bladder perforation and stone loss
iv. Visceral injury 68
PROBLEMS FACED IN DIFFICULT CHOLECYSTECTOMY

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

INFLAMMATORY- Due to Acute cholecystitis/pancreatitis


Adhesions can be released using suction nozzle but if adhesions are organized
then sharp dissection is needed to release them

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Key points for Adhesiolysis

1. Proper amount of traction needed downwards.


2. Stay in the avascular plane
3. Atraumatic instruments will prevent bowel injury
4. Use of angled scope in difficult situations
5. Sharp dissection is preferred in dense, chronic fibrous adhesions and
blunt dissection(e.g. suction nozzle) in acute inflammatory adhesions
6. Monopolar cautery dissection for adhesiolysis should be AVOIDED if
close to bowel or bile duct

NOTE- In patients with dense adhesions, L/C may be performed successfully


by adopting the following maneuvers
1. Additional ports
2. Retrograde fundus first technique
3. Modified cholecystectomy

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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 EXPOSURE DUCTAL INJURY

GB RETRACTION BLEEDING

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GALL BLADDER EXPOSURE

1. Release of Adhesions (by careful sharp & Blunt dissection) between


i. Anterior abdominal wall with colon
ii. Inferior surface of liver & parietal peritoneum
iii. Duodenum & infundibulum of GB

2. Decompression – facilitates the approach to tense gall bladder(In acute


cholecystitis)

3. A 5mm long toothed grasper to hold the infundibulum and a figure of


8 suture at Hartmann’s pouch for Lateral Traction when GB is too
Rigid

4. Additional ports –downward traction of duodenum & upward lift of


quadrate lobe liver

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GALL BLADDER RETRACTION
•Thick walled Gall bladder – when wall thickness >4mm

•Considered difficult to retract with conventional graspers so Specialized toothed


graspers with Long & wide mouth are helpful

•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

E/o Portal Vein


Liver - Normal
Thrombosis

Diffuse Ooze

FAILS
Clipping of vessel Open Conversion

•Electrocautery
•Gel Foam soaked in Hemostatic
solution

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DUCTAL INJURY

Recognized Intra-op and Good prognosis


Treated Immediately

Not recognized Intra-op Presentation

Biloma (POD 10-12) Biliary Peritonitis


(POD 7-9)

Percutaneous Drainage technique with Laproscopy with PT/PD with


ERCP,sphincterotomy and stenting ERCP with stenting

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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

EMPYEMA MIRRIZZI’S SYNDROME

SCLERO ATROPHIC ACUTE BILIARY PANCREATITIS

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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 I mucocele GB Type II Mucocele


•Contains mucus due to block at gb neck, •h/o acute severe
preceded by brief attack of pain symptoms/symptoms of
•GB is non functioning and grossly dilated cholangitis/sepsis
•Clinically diagnosed as acute
Difficulty - To grasp with forceps and cholecystitis
Right subcostal trocar
retract
introduced into
fundus via which
Treatment strategy Preliminary decompression
infected bile is cleared
Dislodge impacted Toothed graspers preferred for
stone into GB, if retraction of infundibulum
fails, open cystic Severe case of inflammation in calots - restrict
duct over stone dissection to GB-cystic duct junction & avoid cystic
partialy & milk it out duct-common duct junction 84
Gangrenous Cholecystitis (a relative contra-indication)
Pathological Types
Clinically classified as Fundus
type Entire GB

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

Duodenum firmly adherent to GB plane of dissection – subserosa of GB

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

Post decompression, puncture site grasped


& GB retracted cranially to avoid further
spillage
If dissection of calot’s triangle is difficult Modified subtotal cholecystectomy

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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

Gall bladder is completely contracted, fibrosed and densely covered by extensive


adhesions.

1. Repeated attacks of inflammation- loss of tissue planes


2. Adhesions of duodenum/colon common
3. GB filled with stones & hence difficult to decompress
4. Foreshortening of calot’s triangle due to fibrous scarring and contracted GB
together make Cholecystectomy prone for CBD injury

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

Gall stones impacted in hartmann’s pouch /cystic duct causing compression of


common Hepatic duct leading to Obstructive jaundice

Predisposing factors 1.Long cystic duct running parallel to CHD


2. low insertion of cystic duct

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

Intra corporeal suturing and knotting essential in laparoscopic management if


MIRRIZZI syndrome
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PORCELAIN GALL BLADDER
Gall bladder wall is deposited with calcium.Risk to develop CA- 12.5 to 60%
More in elderly; F : M = 5 : 1 ; Diagnosis on AXR ; CT to r/o associated Carcinoma

Difficulty- calcified wall does not allow decompression or grasping

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

Initial presentation - 10-15% cases- pancreatitis with or without CBD stones


Patients with
1. Mild episode with Ransons score<3 and pain resolves within S4 days with
normalization of liver enzymes
Treatment- L/C with Intra-op cholangiogram(CBD stone detected is removed by
post-op ERCP)
2. Severe episode- cholecystectomy done in recovery phase(10-60 days)- Interval
cholecystectomy
MANAGEMENT
DIFFICULTY
1. Limited adhesiolysis required just enough for reaching
1. Extensive adhesions(33% cases) the gall bladder
2. Visual Road block d/t 2. Difficult exposure d/t swollen head of pancreas dealt
inflammatory phlegmon in by Camera Port Placement at Supra umbilical
head region of pancreas(56%
region, On right of midline
cases)
3. Highly Edematous Cystic 30 degree angled scope to visualize calot’s
pedicle and HDL(75% cases)
3 prong flat blade- to retract the duodenum
4. Ascitic fuid +
& greater omentum
5. Pseudocyst Pancreas (retro
gastric position) Quadrate lobe lift- when cranial traction of
fundus dangerous/not possible
3. Modified sub-total cholecystectomy when cystic
pedicle cannot be dissected d/t extensive phlegmon 94
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Differential for Air in biliary tree
1. infection with gas producing organism
2. incompetent sphincter of oddi
3. ercp with lateral sphincterotomy

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

Apply Clips to Grasp the


the identified bleeder with
bleeder Forceps

BACK

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