0016-5107/91/3701-0001$03.00
GASTROINTESTINAL ENDOSCOPY Copyright © 1991 by the American Society for Gastrointestinal Endoscopy
Laparoscopic cholecystectomy: an initial report Barry A. Salky, MD, Joel J. Bauer, MD Isadore Kreel, MD, Irwin M. Gelernt, MD Stephen R. Gorfine, MD New York, New York
Sixty consecutive patients underwent an elective attempt at laparoscopic cholecystectomy between March 15 and July 31, 1990 at the Mount Sinai Hospital in New York. Fifty-two patients had successful completion of the laparoscopic cholecystectomy (87%). The reasons for conversion to open cholecystectomy were acute cholecystitis (four patients), inability to define the cystic duct-common duct junction (three patients), and one patient with an unexpected choledochal cyst variant. Forty patients (77%) were discharged on the first post-operative day, and the remaining 12 patients on the second post-operative day. Thirty-three patients (63%) required only oral pain medication, and 11 patients (21%) needed no pain medication post-operatively. Fifty-one patients (98%) had resumed normal activities by the seventh post-operative day. Cholecystectomy remains the treatment of choice for biliary colic. Laparoscopic cholecystectomy minimizes length of stay in the hospital, lessens post-operative pain, allows quicker return to normal activities, and has a superior cosmetic result. (Gastrointest Endosc
1991;37:1-4)
Laparoscopy is an accurate diagnostic modality useful in the setting of many gastrointestinal diseases. 1, 2 Its use as a therapeutic instrument is less well known. A recent report by Dubois et a1. 3 of their initial series of 36 laparoscopic cholecystectomies (Lap GB) has thrust this procedure into prominence in the surgical and lay communities. Approximately 500,000 cholecystectomies are performed each year in the United States. The potential impact of this modality is enormous. This report details our initial experience with this new procedure. PATIENTS AND METHODS
Between March 15 and July 31, 1990, 60 consecutive patients underwent an elective attempt at Lap GB for symptomatic cholelithiasis. Patients presenting with known acute cholecystitis were excluded. There were 42 women and 12 men, 22 to 80 years old (mean, 31 years). Twelve patients had prior abdominal surgery. All patients had an abdominal sonogram that confirmed the presence of cholelithiasis. Pre-operative liver function tests were obtained in all patients. In 11 patients there was elevation of alkaline phosphatase or 'Y-glutamyl transpeptidase. Six patients had elevated transaminase, and one paReceived September 11, 1990. Accepted September 17, 1990. From Mt. Sinai Hospital, New York, New York. Reprint requests: Barry A. Salky, MD, 25 East 69 Street, New York, New York 10021. VOLUME 37, NO.1, 1991
tient with Gilbert's syndrome had an elevated bilirubin. Forty-five of 60 (75%) patients demonstrated both a normalsized, stone-free common bile duct and normal liver function tests. Lap GB was attempted without further testing. In 15 of 60 patients (25%) either dilation of the bile ducts or abdominal liver chemistries were noted pre-operatively. Intravenous cholangiography (lVC) was performed to assess the state of the extra hepatic biliary system in 13 patients. Two patients were allergic to iodine, so ERCP was undertaken instead. If the IVC or ERCP was negative for choledocholithiasis, Lap GB was undertaken (12 patients, 20%). In three patients a stone was identified in the bile duct by IVC pre-operatively. ERCP with papillotomy was performed to clear the common bile duct (three patients, 5%). Lap GB was carried out the day after the papillotomy. Histological pathology of the gallbladders included 46 with chronic cholecystitis, 3 with acute cholecystitis, and 3 with hydrops. TECHNIQUE
The patient is placed supine on the operating table in modified lithiotomy position. General anesthesia is induced. An oral-gastric tube is inserted to decompress the stomach. A 10-mm "smile" infra-umbilical incision is made. The subcutaneous tissue is bluntly separated down to the midline fascia. The 100-mm Veress insufflation needle is inserted with upward traction on the abdominal wall. Five milliliters of saline are in1
Figure 1. The ratchet forceps holding the dome of the gallbladder is seen entering from the right lateral port. The gallbladder is lifted cephalad. Several adhesions to the gallbladder are seen. The round ligament (falciform) is seen to the right of the gallbladder. Figure 2. The common bile duct-cystic duct junction is clearly seen. The cystic artery is crossing superiorly to the cystic duct.
The gallbladder is to the right. 2
GASTROINTESTINAL ENDOSCOPY
jected into the Veress. The meniscus at the hub of the Veress disappears into the abdominal cavity ensuring a correct intra-abdominal position. Maximum pressure on the high-flow insufflator is preset to 14 mm Hg. Insufflation is begun on low flow (1 liter/min). Once 100 ml of CO 2 gas are insufflated, high flow (6 liters/min) is instituted. After the abdomen is insufflated, the Veress is removed. The 11-mm laparoscopic trocar and sleeve are placed through the same umbilical incision. A forward viewing 10-mm laparoscope (Olympus Corporation of America, Lake Success, N.Y.) is then placed through the sleeve. The procedure is performed under video magnification using the Olympus CLV-10 light source and Olympus OTV-S2 video camera. Direct inspection of the structures underlying the umbilical puncture site is performed first to exclude inadvertent injury to the bowel. The scope is then positioned to visualize the gallbladder area. Two 5-mm second punctures are placed. The first is placed in the right anterior axillary line at the level of the umbilicus. The other is put in the right mid-clavicular line 2 em below the right costal margin. A rachet grasping forceps is then introduced through the anterior axillary port. The fundus of the gallbladder is grasped and lifted cephalad (Fig. 1). A lO-mm incision is made in the upper midline just to the right of the round ligament. A reducing sleeve (10 to 5 mm) is placed in the upper lO-mm port to allow placement of the various instruments needed to dissect the cystic duct, cystic artery, and gallbladder. Any adhesions present between the gallbladder and surrounding structures are lysed using either electrocautery or scissors. Filmy adhesions may be "pulled" away atraumatically from the gallbladder with a grasping forceps. Visualization of the cystic duct, cystic artery, and common bile duct is accomplished (Fig. 2). The cystic duct and artery are dissected by incising the anterior and posterior peritoneal envelope surrounding these structures. The cystic duct and artery are encircled with a hook electrode. Electrocautery current is used to dissect the lymphatic channels in the area to maintain a bloodless field. The common bile duct and common hepatic duct should be clearly vis-
ualized to prevent inadvertent injury. Once the cystic artery and duct have been isolated, they are doubly clipped with titanium clips (Fig. 3) and divided using a micro or hook scissors (Fig. 4). The gallbladder is then dissected from the liver bed in a retrograde fashion using the spatula or hook electrode (Fig. 5). The gallbladder, once detached from the liver, is placed above the right lobe of the liver (Fig. 6). This will allow inspection of the surgical field (Fig. 7). Irrigation and suction are performed if necessary. The laparoscope and video camera are moved to the upper lO-mm sleeve, and the gallbladder is visualized. A 10mm atraumatic grasping forceps is inserted through the umbilical sleeve. The gallbladder (cystic duct) is grasped and pulled into the sleeve of the umbilical port (Fig. 8). The forceps and sleeve are then extracted from the abdominal wall while holding the gallbladder with the forceps. The gallbladder is then grasped with hemostats extra-abdominally. It is opened, and the bile is aspirated. The fundus of the gallbladder is viewed from the abdomen while the aspiration takes place (Fig. 9). The collapsed gallbladder is extracted from the abdominal wall. The abdominal cavity is reinspected with special attention to hemostasis of the cystic artery, liver bed, and trocar puncture sites. The cystic duct is visualized to ensure its complete closure without bile leak. All gas and instruments are then removed. The 10-mm wounds are closed with buried absorbable sutures. Steri-strips are applied to all wounds after injection with 0.5% bupivicaine. RESULTS
Fifty-two of the 60 (87%) patients underwent Lap GB. Seven patients had an unexpected acute cholecystitis at the time of Lap GB, four of whom required open cholecystectomy (7%). In three patients the cystic duct-common duct junction could not be identified with certainty, and open cholecystectomy was performed (5%). In one patient, a choledochal cyst variant was identified, and open cholecystectomy was undertaken (1%). No patient required conversion to open cholecystectomy because of bleeding. One patient sustained a
Figure 3. The cystic artery is doubly clipped on its proximal side. The cystic duct with clips in place is inferior to the artery. The common bile duct is visualized to the left. Figure 4. The grasping forceps is lifting the gallbladder, and the microscissors is in place before cystic duct division. Notice the posterior peritoneal envelope has been divided. Figure 5. The anterior peritoneal attachment of the gallbladder to the liver has been dissected by the hook electrode that is seen on the left. Figure 6. The gallbladder is seen above the right lobe of the liver. The diaphragm is in the background. Figure 7. The gallbladder fossa is visualized. The cystic duct clip is at the bottom right. Note the lack of trauma of the surrounding viscera. The gallbladder is seen above the right lobe of the liver. Figure 8. The gallbladder is being pulled into the 11-mm umbilical sleeve. Figure 9. The gallbladder is extracted via the umbilical puncture site. After aspiration of bile, the stones in the gallbladder are clearly seen. The stones are removed from the gallbladder with forceps while exterior to the abdominal cavity. The 11-mm sleeve has already been removed. VOLUME 37, NO.1, 1991
3
laceration injury to the common bile duct that was recognized and repaired by open technique after Lap GB had been completed. The mean procedure time for Lap GB was 70 min. The average estimated blood loss for this procedure was 8 ml. Fifty of the 52 Lap GB patients (96%) began a liquid diet the night of the procedure. Fifty-one of 52 patients (98%) tolerated a low-fat diet the morning after the Lap GB. Forty patients (77%) were discharged on the first post-operative day and the remaining 12 patients on the day after. The post-operative pain medication requirements included parenteral medication (Demerol®) in 8 patients, oral medication (Percocet® or Tylenol®) in 33 patients, and none in 11 patients. Fifty-one of 52 patients (98%) had resumed normal activities by the seventh postoperative day. DISCUSSION
Lap GB is rapidly replacing the traditional open approach for elective patients with biliary colic. In this initial series, 87% of the patients selected for this procedure had the Lap GB completed. It is important to understand that not all patients are candidates, and informed consent for the traditional approach must be obtained before surgery. The 13% conversion rate in this series was secondary to unexpected acute cholecystitis (7%), inability to identify the cystic ductcommon duct junction (5%), and choledochal cyst variant in 1%. There were two complications in this series. The laceration of the common bile duct occurred in a patient in whom the cystic duct originated from the right hepatic duct. The aberrant origin of the cystic duct was not recognized causing an inadvertent laceration (not transection) of the common bile duct. It was repaired over a T-tube. This patient is well and had a normal cholangiogram 2 months after surgery. The other complication was a perforation of the back wall of the gallbladder with spillage of bile. The hole was small, and therefore, no stones fell into the peritoneal cavity. The bile was aspirated, and the right upper quadrant was irrigated with 1000 ml of saline. The Lap GB was completed uneventfully. The postoperative course was benign, and the patient was discharged on the first post-operative day. Pre-operative evaluation is one of the keys to proper patient selection for Lap GB. In this series, 13 patients had abnormal liver function tests in the presence of a sonographically normal common bile duct, and 2 patients had a dilated common bile duct in the face of normal liver function tests. This group was further evaluated before Lap GB. Three patients had choledocholithiasis. In the two patients allergic to iodine, pre-operative ERCP was normal in both. All three patients with a positive IVC had successful ERCP and papillotomy before Lap GB. 4
The authors feel strongly that in the group of patients with abnormal liver function tests or a dilated common bile duct (>7 mm on sonography), pre-operative evaluation of the common bile duct is important. The authors use IVC in this group of patients routinely. If the patient is allergic to iodine, ERCP is performed before Lap GB. The authors do not perform routine intra-operative cholangiography as the incidence of common bile duct stones in patients with normal liver function tests and a normal caliber common bile duct on sonography is
GASTROINTESTINAL ENDOSCOPY Copyright © 1991 by the American Society for Gastrointestinal Endoscopy
Laparoscopic cholecystectomy: an initial report Barry A. Salky, MD, Joel J. Bauer, MD Isadore Kreel, MD, Irwin M. Gelernt, MD Stephen R. Gorfine, MD New York, New York
Sixty consecutive patients underwent an elective attempt at laparoscopic cholecystectomy between March 15 and July 31, 1990 at the Mount Sinai Hospital in New York. Fifty-two patients had successful completion of the laparoscopic cholecystectomy (87%). The reasons for conversion to open cholecystectomy were acute cholecystitis (four patients), inability to define the cystic duct-common duct junction (three patients), and one patient with an unexpected choledochal cyst variant. Forty patients (77%) were discharged on the first post-operative day, and the remaining 12 patients on the second post-operative day. Thirty-three patients (63%) required only oral pain medication, and 11 patients (21%) needed no pain medication post-operatively. Fifty-one patients (98%) had resumed normal activities by the seventh post-operative day. Cholecystectomy remains the treatment of choice for biliary colic. Laparoscopic cholecystectomy minimizes length of stay in the hospital, lessens post-operative pain, allows quicker return to normal activities, and has a superior cosmetic result. (Gastrointest Endosc
1991;37:1-4)
Laparoscopy is an accurate diagnostic modality useful in the setting of many gastrointestinal diseases. 1, 2 Its use as a therapeutic instrument is less well known. A recent report by Dubois et a1. 3 of their initial series of 36 laparoscopic cholecystectomies (Lap GB) has thrust this procedure into prominence in the surgical and lay communities. Approximately 500,000 cholecystectomies are performed each year in the United States. The potential impact of this modality is enormous. This report details our initial experience with this new procedure. PATIENTS AND METHODS
Between March 15 and July 31, 1990, 60 consecutive patients underwent an elective attempt at Lap GB for symptomatic cholelithiasis. Patients presenting with known acute cholecystitis were excluded. There were 42 women and 12 men, 22 to 80 years old (mean, 31 years). Twelve patients had prior abdominal surgery. All patients had an abdominal sonogram that confirmed the presence of cholelithiasis. Pre-operative liver function tests were obtained in all patients. In 11 patients there was elevation of alkaline phosphatase or 'Y-glutamyl transpeptidase. Six patients had elevated transaminase, and one paReceived September 11, 1990. Accepted September 17, 1990. From Mt. Sinai Hospital, New York, New York. Reprint requests: Barry A. Salky, MD, 25 East 69 Street, New York, New York 10021. VOLUME 37, NO.1, 1991
tient with Gilbert's syndrome had an elevated bilirubin. Forty-five of 60 (75%) patients demonstrated both a normalsized, stone-free common bile duct and normal liver function tests. Lap GB was attempted without further testing. In 15 of 60 patients (25%) either dilation of the bile ducts or abdominal liver chemistries were noted pre-operatively. Intravenous cholangiography (lVC) was performed to assess the state of the extra hepatic biliary system in 13 patients. Two patients were allergic to iodine, so ERCP was undertaken instead. If the IVC or ERCP was negative for choledocholithiasis, Lap GB was undertaken (12 patients, 20%). In three patients a stone was identified in the bile duct by IVC pre-operatively. ERCP with papillotomy was performed to clear the common bile duct (three patients, 5%). Lap GB was carried out the day after the papillotomy. Histological pathology of the gallbladders included 46 with chronic cholecystitis, 3 with acute cholecystitis, and 3 with hydrops. TECHNIQUE
The patient is placed supine on the operating table in modified lithiotomy position. General anesthesia is induced. An oral-gastric tube is inserted to decompress the stomach. A 10-mm "smile" infra-umbilical incision is made. The subcutaneous tissue is bluntly separated down to the midline fascia. The 100-mm Veress insufflation needle is inserted with upward traction on the abdominal wall. Five milliliters of saline are in1
Figure 1. The ratchet forceps holding the dome of the gallbladder is seen entering from the right lateral port. The gallbladder is lifted cephalad. Several adhesions to the gallbladder are seen. The round ligament (falciform) is seen to the right of the gallbladder. Figure 2. The common bile duct-cystic duct junction is clearly seen. The cystic artery is crossing superiorly to the cystic duct.
The gallbladder is to the right. 2
GASTROINTESTINAL ENDOSCOPY
jected into the Veress. The meniscus at the hub of the Veress disappears into the abdominal cavity ensuring a correct intra-abdominal position. Maximum pressure on the high-flow insufflator is preset to 14 mm Hg. Insufflation is begun on low flow (1 liter/min). Once 100 ml of CO 2 gas are insufflated, high flow (6 liters/min) is instituted. After the abdomen is insufflated, the Veress is removed. The 11-mm laparoscopic trocar and sleeve are placed through the same umbilical incision. A forward viewing 10-mm laparoscope (Olympus Corporation of America, Lake Success, N.Y.) is then placed through the sleeve. The procedure is performed under video magnification using the Olympus CLV-10 light source and Olympus OTV-S2 video camera. Direct inspection of the structures underlying the umbilical puncture site is performed first to exclude inadvertent injury to the bowel. The scope is then positioned to visualize the gallbladder area. Two 5-mm second punctures are placed. The first is placed in the right anterior axillary line at the level of the umbilicus. The other is put in the right mid-clavicular line 2 em below the right costal margin. A rachet grasping forceps is then introduced through the anterior axillary port. The fundus of the gallbladder is grasped and lifted cephalad (Fig. 1). A lO-mm incision is made in the upper midline just to the right of the round ligament. A reducing sleeve (10 to 5 mm) is placed in the upper lO-mm port to allow placement of the various instruments needed to dissect the cystic duct, cystic artery, and gallbladder. Any adhesions present between the gallbladder and surrounding structures are lysed using either electrocautery or scissors. Filmy adhesions may be "pulled" away atraumatically from the gallbladder with a grasping forceps. Visualization of the cystic duct, cystic artery, and common bile duct is accomplished (Fig. 2). The cystic duct and artery are dissected by incising the anterior and posterior peritoneal envelope surrounding these structures. The cystic duct and artery are encircled with a hook electrode. Electrocautery current is used to dissect the lymphatic channels in the area to maintain a bloodless field. The common bile duct and common hepatic duct should be clearly vis-
ualized to prevent inadvertent injury. Once the cystic artery and duct have been isolated, they are doubly clipped with titanium clips (Fig. 3) and divided using a micro or hook scissors (Fig. 4). The gallbladder is then dissected from the liver bed in a retrograde fashion using the spatula or hook electrode (Fig. 5). The gallbladder, once detached from the liver, is placed above the right lobe of the liver (Fig. 6). This will allow inspection of the surgical field (Fig. 7). Irrigation and suction are performed if necessary. The laparoscope and video camera are moved to the upper lO-mm sleeve, and the gallbladder is visualized. A 10mm atraumatic grasping forceps is inserted through the umbilical sleeve. The gallbladder (cystic duct) is grasped and pulled into the sleeve of the umbilical port (Fig. 8). The forceps and sleeve are then extracted from the abdominal wall while holding the gallbladder with the forceps. The gallbladder is then grasped with hemostats extra-abdominally. It is opened, and the bile is aspirated. The fundus of the gallbladder is viewed from the abdomen while the aspiration takes place (Fig. 9). The collapsed gallbladder is extracted from the abdominal wall. The abdominal cavity is reinspected with special attention to hemostasis of the cystic artery, liver bed, and trocar puncture sites. The cystic duct is visualized to ensure its complete closure without bile leak. All gas and instruments are then removed. The 10-mm wounds are closed with buried absorbable sutures. Steri-strips are applied to all wounds after injection with 0.5% bupivicaine. RESULTS
Fifty-two of the 60 (87%) patients underwent Lap GB. Seven patients had an unexpected acute cholecystitis at the time of Lap GB, four of whom required open cholecystectomy (7%). In three patients the cystic duct-common duct junction could not be identified with certainty, and open cholecystectomy was performed (5%). In one patient, a choledochal cyst variant was identified, and open cholecystectomy was undertaken (1%). No patient required conversion to open cholecystectomy because of bleeding. One patient sustained a
Figure 3. The cystic artery is doubly clipped on its proximal side. The cystic duct with clips in place is inferior to the artery. The common bile duct is visualized to the left. Figure 4. The grasping forceps is lifting the gallbladder, and the microscissors is in place before cystic duct division. Notice the posterior peritoneal envelope has been divided. Figure 5. The anterior peritoneal attachment of the gallbladder to the liver has been dissected by the hook electrode that is seen on the left. Figure 6. The gallbladder is seen above the right lobe of the liver. The diaphragm is in the background. Figure 7. The gallbladder fossa is visualized. The cystic duct clip is at the bottom right. Note the lack of trauma of the surrounding viscera. The gallbladder is seen above the right lobe of the liver. Figure 8. The gallbladder is being pulled into the 11-mm umbilical sleeve. Figure 9. The gallbladder is extracted via the umbilical puncture site. After aspiration of bile, the stones in the gallbladder are clearly seen. The stones are removed from the gallbladder with forceps while exterior to the abdominal cavity. The 11-mm sleeve has already been removed. VOLUME 37, NO.1, 1991
3
laceration injury to the common bile duct that was recognized and repaired by open technique after Lap GB had been completed. The mean procedure time for Lap GB was 70 min. The average estimated blood loss for this procedure was 8 ml. Fifty of the 52 Lap GB patients (96%) began a liquid diet the night of the procedure. Fifty-one of 52 patients (98%) tolerated a low-fat diet the morning after the Lap GB. Forty patients (77%) were discharged on the first post-operative day and the remaining 12 patients on the day after. The post-operative pain medication requirements included parenteral medication (Demerol®) in 8 patients, oral medication (Percocet® or Tylenol®) in 33 patients, and none in 11 patients. Fifty-one of 52 patients (98%) had resumed normal activities by the seventh postoperative day. DISCUSSION
Lap GB is rapidly replacing the traditional open approach for elective patients with biliary colic. In this initial series, 87% of the patients selected for this procedure had the Lap GB completed. It is important to understand that not all patients are candidates, and informed consent for the traditional approach must be obtained before surgery. The 13% conversion rate in this series was secondary to unexpected acute cholecystitis (7%), inability to identify the cystic ductcommon duct junction (5%), and choledochal cyst variant in 1%. There were two complications in this series. The laceration of the common bile duct occurred in a patient in whom the cystic duct originated from the right hepatic duct. The aberrant origin of the cystic duct was not recognized causing an inadvertent laceration (not transection) of the common bile duct. It was repaired over a T-tube. This patient is well and had a normal cholangiogram 2 months after surgery. The other complication was a perforation of the back wall of the gallbladder with spillage of bile. The hole was small, and therefore, no stones fell into the peritoneal cavity. The bile was aspirated, and the right upper quadrant was irrigated with 1000 ml of saline. The Lap GB was completed uneventfully. The postoperative course was benign, and the patient was discharged on the first post-operative day. Pre-operative evaluation is one of the keys to proper patient selection for Lap GB. In this series, 13 patients had abnormal liver function tests in the presence of a sonographically normal common bile duct, and 2 patients had a dilated common bile duct in the face of normal liver function tests. This group was further evaluated before Lap GB. Three patients had choledocholithiasis. In the two patients allergic to iodine, pre-operative ERCP was normal in both. All three patients with a positive IVC had successful ERCP and papillotomy before Lap GB. 4
The authors feel strongly that in the group of patients with abnormal liver function tests or a dilated common bile duct (>7 mm on sonography), pre-operative evaluation of the common bile duct is important. The authors use IVC in this group of patients routinely. If the patient is allergic to iodine, ERCP is performed before Lap GB. The authors do not perform routine intra-operative cholangiography as the incidence of common bile duct stones in patients with normal liver function tests and a normal caliber common bile duct on sonography is
