+Model
ARTICLE IN PRESS
JVS-463; No. of Pages 5
Journal of Visceral Surgery (2015) xxx, xxx—xxx
Available online at
ScienceDirect www.sciencedirect.com
SURGICAL TECHNIQUE
Anterograde cholecystectomy by laparotomy for acute cholecystitis B. Le Roy , F. Prunel , K. Slim ∗ Service de chirurgie digestive, CHU Estaing, 1, place Lucie-Aubrac, 63003 Clermont-Ferrand, France
KEYWORDS Cholecystectomy; Acute cholecystitis; Laparoscopy; Bile duct injury
∗
Introduction For the last 20 years, open cholecystectomy by laparotomy for acute cholecystitis has been indicated only when there are contra-indications for laparoscopy or when conversion to an open approach is necessitated by operative difficulties [1]. Contra-indications to laparoscopy include: lack of availability of adequate equipment, the cardio-respiratory complications of prolonged pneumoperitoneum (patients with septic shock, hypovolemia, decompensated congestive heart failure, or bullous emphysema), suspicion of gallbladder cancer, portal hypertension, and coagulopathies. Conversion to laparotomy should not be considered a failure and, in fact, delay in conversion is tied to an increased risk for bile duct injury [2]. Open cholecystectomy for acute cholecystitis is not a rare procedure; data from the PMSI (French national data bank) in September 2014 showed that cholecystectomy for acute cholecystitis was performed through an open approach in 12% of cases during the preceding three years. It is therefore important for recently-trained surgeons to know the open operative technique and the rules for preventing complications in this setting [3].
Corresponding author. E-mail address: [email protected] (K. Slim).
http://dx.doi.org/10.1016/j.jviscsurg.2015.01.010 1878-7886/© 2015 Elsevier Masson SAS. All rights reserved.
Please cite this article in press as: Le Roy B, et al. Anterograde cholecystectomy by laparotomy for acute cholecystitis. Journal of Visceral Surgery (2015), http://dx.doi.org/10.1016/j.jviscsurg.2015.01.010
+Model JVS-463; No. of Pages 5
ARTICLE IN PRESS
2
B. Le Roy et al.
1
Incisions
2
Exposure of the sub-hepatic space
Patient position and incisions should take into consideration body habitus, history of upper abdominal surgery, and the need for associated abdominal surgery procedures. A right subcostal, transverse or upper midline incision can be used. A right subcostal incision, 3 cm below the lower costal margin, is best suited for emergency cholecystectomy for acute cholecystitis. Incisions: 1: right subcostal; 2: transverse; 3: supraumbilical midline.
To expose the sub-hepatic region, a malleable retractor covered by a laparotomy pad is used to lift Segment IV and affixed to an autostatic subcostal retractor. A second abdominal pad is placed on the duodenum allowing the first assistant to retract the duodenum downward verticalizing the hepatic pedicle. Careful finger or instrumental dissection is necessary to free the omentum, which is often adherent to the gallbladder and hepatic pedicle. For a tensely distended gallbladder, needle aspiration of bile (a sample should be sent for bacteriologic culture) may be necessary to decompress the gallbladder, allowing the fundus to be grasped while minimizing the risk of perforation.
Please cite this article in press as: Le Roy B, et al. Anterograde cholecystectomy by laparotomy for acute cholecystitis. Journal of Visceral Surgery (2015), http://dx.doi.org/10.1016/j.jviscsurg.2015.01.010
+Model JVS-463; No. of Pages 5
ARTICLE IN PRESS
Anterograde cholecystectomy via laparotomy for acute cholecystitis
3
Gallbladder dissection
4
Dissection of the cystic pedicle
The operator grasps the gallbladder fundus with a Duval or fenestrated grasper. The gallbladder peritoneum is incised ½ cm from the liver, proceeding from the fundus towards the infundibulum. The gallbladder is retracted caudad, exposing the avascular space between the gallbladder and the gallbladder bed for dissection. Dissection can be performed with electric cautery or with scissors and bipolar coagulation. If bleeding is encountered, the plane of dissection may be too deep, into the liver parenchyma, and the dissection plane should be corrected to remain closer to the gallbladder wall. Caution is warranted as the dissection approaches the infundibulum where the cystic artery and duct are located.
The Duval grasper is now repositioned a bit lower on the gallbladder neck. Division of the cystico-duodenal ligament allows the gallbladder to be freed from the duodenum. The peritoneum is incised at the level of the neck, successively on the posterior and anterior aspects while the gallbladder is retracted caudad and to the right, distancing it from the common bile duct. When all the peritoneum is divided, the operator exposes the structures within Calot’s triangle (classically defined by the cystic artery above, the cystic duct below and the common bile duct to the left). The only remaining attachments of the gallbladder are the cystic artery, which should be dissected, ligated and divided as close as possible to the gallbladder, and the cystic duct, which is ligated and divided in the same manner.
Please cite this article in press as: Le Roy B, et al. Anterograde cholecystectomy by laparotomy for acute cholecystitis. Journal of Visceral Surgery (2015), http://dx.doi.org/10.1016/j.jviscsurg.2015.01.010
3
+Model JVS-463; No. of Pages 5
ARTICLE IN PRESS
4
B. Le Roy et al.
5
Cholangiography
6
Prevention of haemorrhagic risk
If intra-operative cholangiography is performed, the cystic duct is ligated proximally, near the infundibulum. The cystic duct is then incised and intubated with a catheter, taking care to flush any air bubbles beforehand. Since the catheter tip can abut Heister valves, the cystic duct may need to be dissected free from its peritoneal attachments distally to facilitate the introduction of the catheter into the duct. A return of bile into the distal catheter confirms correct placement. Usually three injections of contrast are made under fluoroscopic C-arm control; static images should be obtained for the patient’s record. Cholangiograms should be read from peripheral to central, checking to ensure that the entire biliary tree is opacified and that no calculi are present. The gallbladder bed and the cystic duct are swabbed with a dry sponge to check for bile leak. Prior to closure, hemostasis is carefully checked. Drainage after cholecystectomy is not necessary as long as hemostasis and biliostasis are perfect, and/or, if thorough lavage is carried out after accidental gallbladder spillage [4].
If there is no clear cleavage plane between the gallbladder and liver or if planes are haemorrhagic due to portal hypertension, it may be prudent to leave part of the gallbladder attached to the liver bed, electrocoagulating the retained mucosa. This last procedure is often associated with subtotal cholecystectomy (cf. below). There are many anatomic variations of the bile ducts and hepatic arteries and the surgeon must be on the alert for a short, double, or early dividing cystic artery, or for an anomalous right hepatic artery arising from the superior mesenteric artery and coursing behind (or in front of) the cystic duct in Calot’s triangle. Whenever a ‘‘cystic artery’’ with a diameter exceeding 5 mm is encountered, dissection should follow the artery or its two divisional branches closer to the gallbladder wall, ligating the artery or its two branches in contact with the gallbladder neck. When intra-operative bleeding does occur, ‘‘blind’’ efforts to control bleeding may lead to bile duct injury.
Please cite this article in press as: Le Roy B, et al. Anterograde cholecystectomy by laparotomy for acute cholecystitis. Journal of Visceral Surgery (2015), http://dx.doi.org/10.1016/j.jviscsurg.2015.01.010
+Model JVS-463; No. of Pages 5
ARTICLE IN PRESS
Anterograde cholecystectomy via laparotomy for acute cholecystitis
7
5
Subtotal cholecystectomy
In addition to the technical precautions published by the French Federation of Visceral and Gastro-intestinal Surgery (Fédération de Chirurgie Viscérale et Digestive) [3], it may be prudent to avoid routine exploration and dissection of the cystic pedicle when the presence of severe inflammation makes dissection difficult. Dissection must proceed in contact with the gallbladder neck and the infundibulum in order to maintain distance from the common bile duct. One technical variation consists of opening the gallbladder at the level of the neck, or slightly higher, well away from the hepatic pedicle. If a cleavage plane cannot be clearly identified, it may be safer to divide the gallbladder and leave an infundibular remnant. This can be closed by several figure-of-eight sutures, after intra-operative cholangiography. Drainage is indicated in this setting.
Disclosure of interest The authors declare that they have no conflicts of interest concerning this article.
References [1] Gurusamy KS, Davidson C, Gluud C, Davidson BR. Early versus delayed laparoscopic cholecystectomy for people with acute cholecystitis. Cochrane Database Syst Rev 2013;6:CD005440. [2] de Mestral C, Rotstein OD, Laupacis A, et al. Comparative operative outcomes of early and delayed cholecystectomy for acute
cholecystitis: a population-based propensity score analysis. Ann Surg 2014;259(1):10—5. [3] Fédération de chirurgie viscérale et digestive. Risk management to decrease bile duct injury associated with cholecystectomy: measures to improve patient safety. J Visc Surg 2014;151(3): 241—4. [4] Park JS, Kim JH, Kim JK, Yoon DS. The role of abdominal drainage to prevent intra-abdominal complications after laparoscopic cholecystectomy for acute cholecystitis: prospective randomized trial. Surg Endosc 2014, http://dx.doi.org/10.1007/ s00464-014-3685-5.
Please cite this article in press as: Le Roy B, et al. Anterograde cholecystectomy by laparotomy for acute cholecystitis. Journal of Visceral Surgery (2015), http://dx.doi.org/10.1016/j.jviscsurg.2015.01.010
ARTICLE IN PRESS
JVS-463; No. of Pages 5
Journal of Visceral Surgery (2015) xxx, xxx—xxx
Available online at
ScienceDirect www.sciencedirect.com
SURGICAL TECHNIQUE
Anterograde cholecystectomy by laparotomy for acute cholecystitis B. Le Roy , F. Prunel , K. Slim ∗ Service de chirurgie digestive, CHU Estaing, 1, place Lucie-Aubrac, 63003 Clermont-Ferrand, France
KEYWORDS Cholecystectomy; Acute cholecystitis; Laparoscopy; Bile duct injury
∗
Introduction For the last 20 years, open cholecystectomy by laparotomy for acute cholecystitis has been indicated only when there are contra-indications for laparoscopy or when conversion to an open approach is necessitated by operative difficulties [1]. Contra-indications to laparoscopy include: lack of availability of adequate equipment, the cardio-respiratory complications of prolonged pneumoperitoneum (patients with septic shock, hypovolemia, decompensated congestive heart failure, or bullous emphysema), suspicion of gallbladder cancer, portal hypertension, and coagulopathies. Conversion to laparotomy should not be considered a failure and, in fact, delay in conversion is tied to an increased risk for bile duct injury [2]. Open cholecystectomy for acute cholecystitis is not a rare procedure; data from the PMSI (French national data bank) in September 2014 showed that cholecystectomy for acute cholecystitis was performed through an open approach in 12% of cases during the preceding three years. It is therefore important for recently-trained surgeons to know the open operative technique and the rules for preventing complications in this setting [3].
Corresponding author. E-mail address: [email protected] (K. Slim).
http://dx.doi.org/10.1016/j.jviscsurg.2015.01.010 1878-7886/© 2015 Elsevier Masson SAS. All rights reserved.
Please cite this article in press as: Le Roy B, et al. Anterograde cholecystectomy by laparotomy for acute cholecystitis. Journal of Visceral Surgery (2015), http://dx.doi.org/10.1016/j.jviscsurg.2015.01.010
+Model JVS-463; No. of Pages 5
ARTICLE IN PRESS
2
B. Le Roy et al.
1
Incisions
2
Exposure of the sub-hepatic space
Patient position and incisions should take into consideration body habitus, history of upper abdominal surgery, and the need for associated abdominal surgery procedures. A right subcostal, transverse or upper midline incision can be used. A right subcostal incision, 3 cm below the lower costal margin, is best suited for emergency cholecystectomy for acute cholecystitis. Incisions: 1: right subcostal; 2: transverse; 3: supraumbilical midline.
To expose the sub-hepatic region, a malleable retractor covered by a laparotomy pad is used to lift Segment IV and affixed to an autostatic subcostal retractor. A second abdominal pad is placed on the duodenum allowing the first assistant to retract the duodenum downward verticalizing the hepatic pedicle. Careful finger or instrumental dissection is necessary to free the omentum, which is often adherent to the gallbladder and hepatic pedicle. For a tensely distended gallbladder, needle aspiration of bile (a sample should be sent for bacteriologic culture) may be necessary to decompress the gallbladder, allowing the fundus to be grasped while minimizing the risk of perforation.
Please cite this article in press as: Le Roy B, et al. Anterograde cholecystectomy by laparotomy for acute cholecystitis. Journal of Visceral Surgery (2015), http://dx.doi.org/10.1016/j.jviscsurg.2015.01.010
+Model JVS-463; No. of Pages 5
ARTICLE IN PRESS
Anterograde cholecystectomy via laparotomy for acute cholecystitis
3
Gallbladder dissection
4
Dissection of the cystic pedicle
The operator grasps the gallbladder fundus with a Duval or fenestrated grasper. The gallbladder peritoneum is incised ½ cm from the liver, proceeding from the fundus towards the infundibulum. The gallbladder is retracted caudad, exposing the avascular space between the gallbladder and the gallbladder bed for dissection. Dissection can be performed with electric cautery or with scissors and bipolar coagulation. If bleeding is encountered, the plane of dissection may be too deep, into the liver parenchyma, and the dissection plane should be corrected to remain closer to the gallbladder wall. Caution is warranted as the dissection approaches the infundibulum where the cystic artery and duct are located.
The Duval grasper is now repositioned a bit lower on the gallbladder neck. Division of the cystico-duodenal ligament allows the gallbladder to be freed from the duodenum. The peritoneum is incised at the level of the neck, successively on the posterior and anterior aspects while the gallbladder is retracted caudad and to the right, distancing it from the common bile duct. When all the peritoneum is divided, the operator exposes the structures within Calot’s triangle (classically defined by the cystic artery above, the cystic duct below and the common bile duct to the left). The only remaining attachments of the gallbladder are the cystic artery, which should be dissected, ligated and divided as close as possible to the gallbladder, and the cystic duct, which is ligated and divided in the same manner.
Please cite this article in press as: Le Roy B, et al. Anterograde cholecystectomy by laparotomy for acute cholecystitis. Journal of Visceral Surgery (2015), http://dx.doi.org/10.1016/j.jviscsurg.2015.01.010
3
+Model JVS-463; No. of Pages 5
ARTICLE IN PRESS
4
B. Le Roy et al.
5
Cholangiography
6
Prevention of haemorrhagic risk
If intra-operative cholangiography is performed, the cystic duct is ligated proximally, near the infundibulum. The cystic duct is then incised and intubated with a catheter, taking care to flush any air bubbles beforehand. Since the catheter tip can abut Heister valves, the cystic duct may need to be dissected free from its peritoneal attachments distally to facilitate the introduction of the catheter into the duct. A return of bile into the distal catheter confirms correct placement. Usually three injections of contrast are made under fluoroscopic C-arm control; static images should be obtained for the patient’s record. Cholangiograms should be read from peripheral to central, checking to ensure that the entire biliary tree is opacified and that no calculi are present. The gallbladder bed and the cystic duct are swabbed with a dry sponge to check for bile leak. Prior to closure, hemostasis is carefully checked. Drainage after cholecystectomy is not necessary as long as hemostasis and biliostasis are perfect, and/or, if thorough lavage is carried out after accidental gallbladder spillage [4].
If there is no clear cleavage plane between the gallbladder and liver or if planes are haemorrhagic due to portal hypertension, it may be prudent to leave part of the gallbladder attached to the liver bed, electrocoagulating the retained mucosa. This last procedure is often associated with subtotal cholecystectomy (cf. below). There are many anatomic variations of the bile ducts and hepatic arteries and the surgeon must be on the alert for a short, double, or early dividing cystic artery, or for an anomalous right hepatic artery arising from the superior mesenteric artery and coursing behind (or in front of) the cystic duct in Calot’s triangle. Whenever a ‘‘cystic artery’’ with a diameter exceeding 5 mm is encountered, dissection should follow the artery or its two divisional branches closer to the gallbladder wall, ligating the artery or its two branches in contact with the gallbladder neck. When intra-operative bleeding does occur, ‘‘blind’’ efforts to control bleeding may lead to bile duct injury.
Please cite this article in press as: Le Roy B, et al. Anterograde cholecystectomy by laparotomy for acute cholecystitis. Journal of Visceral Surgery (2015), http://dx.doi.org/10.1016/j.jviscsurg.2015.01.010
+Model JVS-463; No. of Pages 5
ARTICLE IN PRESS
Anterograde cholecystectomy via laparotomy for acute cholecystitis
7
5
Subtotal cholecystectomy
In addition to the technical precautions published by the French Federation of Visceral and Gastro-intestinal Surgery (Fédération de Chirurgie Viscérale et Digestive) [3], it may be prudent to avoid routine exploration and dissection of the cystic pedicle when the presence of severe inflammation makes dissection difficult. Dissection must proceed in contact with the gallbladder neck and the infundibulum in order to maintain distance from the common bile duct. One technical variation consists of opening the gallbladder at the level of the neck, or slightly higher, well away from the hepatic pedicle. If a cleavage plane cannot be clearly identified, it may be safer to divide the gallbladder and leave an infundibular remnant. This can be closed by several figure-of-eight sutures, after intra-operative cholangiography. Drainage is indicated in this setting.
Disclosure of interest The authors declare that they have no conflicts of interest concerning this article.
References [1] Gurusamy KS, Davidson C, Gluud C, Davidson BR. Early versus delayed laparoscopic cholecystectomy for people with acute cholecystitis. Cochrane Database Syst Rev 2013;6:CD005440. [2] de Mestral C, Rotstein OD, Laupacis A, et al. Comparative operative outcomes of early and delayed cholecystectomy for acute
cholecystitis: a population-based propensity score analysis. Ann Surg 2014;259(1):10—5. [3] Fédération de chirurgie viscérale et digestive. Risk management to decrease bile duct injury associated with cholecystectomy: measures to improve patient safety. J Visc Surg 2014;151(3): 241—4. [4] Park JS, Kim JH, Kim JK, Yoon DS. The role of abdominal drainage to prevent intra-abdominal complications after laparoscopic cholecystectomy for acute cholecystitis: prospective randomized trial. Surg Endosc 2014, http://dx.doi.org/10.1007/ s00464-014-3685-5.
Please cite this article in press as: Le Roy B, et al. Anterograde cholecystectomy by laparotomy for acute cholecystitis. Journal of Visceral Surgery (2015), http://dx.doi.org/10.1016/j.jviscsurg.2015.01.010
