Laparoscopic Cholecystectomy

• There are no absolute contraindications to laparoscopic cholecystectomy
• Relative contraindications include cirrhosis and portal hypertension, bleeding diathesis, pregnancy
• Technical modifications can be made to suit these three problems

Preoperative investigations include liver function tests and typically an ultrasound examination. If the laparoscopic cholecystectomy is being performed for acalculouscholecystitis, patients may have had nuclear studies to assess gallbladder function. If there is the suspicion of gallbladder cancer or big polyps, a CT scan is required. There is no place for routine preoperative endoscopic retrograde cholangiopancreatography (ERCP) in laparoscopic cholecystectomy. The patient should have prophylactic antibiotics on induction and appropriate anti-thromboembolic measures.

The procedure should be performed on a table allowing operative cholangiography. There is no routine need for a nasogastric tube or Foley catheter. Typically there is no requirement for invasive anesthetic monitoring. Patients are placed supine, legs together with a slight reverse Trendelenburg position. There is little to gain by using a steep reverse Trendelenburg position. Safe access: Open insertion of a Hasson cannula through a transumbilical incision. Eversion of the umbilicus creates access via the gap in the lineaalba at the base of the umbilicus. The Hasson cannula can be sat directly in the peritoneal cavity. There is no need for stay sutures nor to suture the port in place. A 30° telescope is used; insufflation pressures are set at 15mmHg.

Bleeding

The major intraoperative complication is bleeding. This is typically from a very short cystic artery or from the right hepatic artery itself. Bleeding from the portal vein is very rare, but in contrast to hepatic and cystic artery bleeding, it is always torrential and the patient must be opened. Failure to Progress the second major complication is failure to progress. If the surgeon is not making any progress, the patient should be converted to an open cholecystectomy. Bile Duct Injury Proper retraction, careful dissection, steady control of hemorrhage and recognition of an appropriate time to convert to open cholecystectomy should minimize the chance of the most feared intraoperative complication – bile duct injury or bile duct resection. If a duct injury is recognized the surgeon should just stop, collect his or her thoughts, and ring a hepatobiliary colleague immediately.

Postoperative Complications

• Most bile leaks are low volume and will settle spontaneously.
• High volume bile leak is suggestive that the clip has come off the cystic duct or there is a major unrecognized duct injury. ERCP will determine this, allowing appropriate management.
• Subphrenic collection may require percutaneous drainage.
• Pneumonia – best treated with physiotherapy and antibiotics.
• Jaundice suggests major duct obstruction or excision – ERCP or referral to a hepatobiliary specialist.

Retraction and dissection of Calot’s triangle Once caudad retraction of the fundus is established, the crucial maneuver is lateral retraction of Hartmann’s pouch by the upper lateral 5-mm port. This places Calot’s triangle on the stretch and will greatly reduce the chance of injury of the common bile duct.

Then incise the posterior peritoneal attachment behind Hartmann’s pouch to separate Hartmann’s pouch from the liver to further stretch out Calot’s triangle.

Once these two maneuvers are instituted, hook dissection can be performed, staying close to the gallbladder to incise the anterior sheet of peritoneum over Calot’s triangle. This will expose one or two cystic arteries and the cystic duct . Windows should be developed between all these structures before anything is divided. Once the anatomy is determined (see anatomical variations and tricks), the cystic arteries are divided between clips and a clip is placed below Hartmann’s pouch to the proximal end of the cystic duct. Cystic duct is divided.

Removal of gallbladder: The gallbladder is then removed from the liver bed using hook diathermy. This is done through a combination of elevating the peritoneum, burning with the hook and pushing so that the gallbladder is removed toward the fundus and finally separated from the liver at the fundus. There is very little place for fundus-first laparoscopic cholecystectomy.

• The major anatomical variations are involved with the common bile duct and the right hepatic artery.
• A very small common bile duct can be mistaken for the cystic duct and completely excised. Even more worrisome is the variant of a low junction of the left and right hepatic ducts (A) or a low junction of the right anterior and right posterior hepatic ducts (B). In these situations the cystic duct can enter the right hepatic duct or the right posterior hepatic duct. The right or right posterior ducts can therefore be mistaken for the cystic duct and divided.
• More rarely, but even more difficult, particularly in the setting of acute cholecystitis, is when there is no cystic duct and Hartmann’s pouch opens directly underneath the right hepatic duct or the common duct.