Laparoscopic Douglas 0. Olsen,
Cholecystectomy MD, FAG, Nashville.~ennessee
With more than 500,000 cholecystectomies performed per year, great interest has developed in laparoscopic cholecystectomy. The procedure offers the patient reduced hospital stay, faster return to work, less pain, and improved cosmetic results. In September 1988, we developed a technique of performing laparoscopic cholecystectomy that we have now performed in more than 800 cases with good results. The technique allows the surgeon to fully evaluate the common duct via operative cholangiography and has allowed us to use a laparoscopic approach in all patients who were candidates for cholecystectomy. The technique offers a minimally invasive alternative to open cholecystectomy.
M
ore than a half million patients underwent totalcholecystectomy in 1988, and with the increasing number of elderly patients, this number is expected to rise. In an attempt to reduce the morbidity and cost of the surgical treatment of gallbladder disease, a minimally invasive approach to the surgical removal of the gallbladder was developed [I]. Herein, we present a technique for performing laparoscopic cholecystectomy that we have used in more than 800 cases and that has been shown to be effective and safe [2]. From the Department of Surgery, West Side Branch, Centenial Medical Center, and the HCA Center for Research and Development, Nashville, Tennessee. Requests for reprints should be addressed to Douglas 0. Olsen, MD, FACS, 2021 Church Street, Suite 502, Baptist Medical Plaza II, Nashville, Tennessee 37203. Presented as part of a postgraduate course on interventional laparoscopy during the American College of Surgeons 1990 Clinical Congress, San Francisco, California, October 12, 1990.
TECHNIQUE
The procedure is based on a four-puncture technique using a clip applier to control the duct and artery and laser or cautery to cut and coagulate. A primary lo-mm trocar is placed at the umbilicus for the video laparoscope, and three accessory trocars are placed in the right upper quadrant for grasping the gallbladder and operating (Figure 1). A 5-mm trocar is placed along the anterior axillary line midway between the costal margin and the anterior iliac spine, and another 5-mm trocar is placed along the midclavicular line just below the costal margin. The operating port is a lo-mm trocar that is placed in the midline 2 to 4 cm below the xyphoid process, aiming at approximately a 45” angle to just pass lateral to the falciform ligament. Placing the trocar left of the falciform ligament can cause difficulties if the patient has a large redundant falciform ligament. If the patient has had previous surgery, an alternate primary approach is made to avoid injuring possible underlying adhesed bowel. If the previous surgery was in the lower abdominal area, then a primary puncture is made at the midclavicular site with a 5-mm trocar, and using a 5-mm laparoscope for visualization, the umbilical port is placed under direct vision. If adhesiolysis is needed prior to placement of the umbilical port, then one of the other accessory ports is placed under direct vision to allow placement of instruments for the lysis of the adhesions. If upper abdominal surgery has been performed, then an open laparoscopic technique is used to gain access to the abdominal cavity. Once access to the abdominal cavity has been achieved, exploration is performed, checking for any sign of visceral injury secondary to trocar insertion. The accessory ports are placed under direct vision, and placement is “adjusted” to the body habitus. If the patient’s liver is not mobile, but edematous or swollen, then special care is taken to ensure that all the ports are below the liver edge. This is also important for the patient with a low-lying liver. Liver adhesions to the diaphragm should be removed to not only facilitate the retraction on the gallbladder, but also to prevent tearing of the liver capsule during traction on the liver. Placement of the patient in a reverse Trendelenberg position with a slight roll to the left will help bring the transverse colon and the omentum out of the right upper quadrant. The gallbladder is grasped at the fundus and retracted above and “over” the liver (Figure 2). This move elevates the portal triangle, aIlowing visualization. Lateral and upward retraction of Hartman’s pouch will splay out Charcot’s triangle and aid in visualizing the portal structures for a safe dissection. Common mistakes are: (1) insufficient upward retraction on the fundus, and (2) retraction on Hartman’s pouch upward and into the liver, not lateral and away from the liver. Blunt dissection of
THE AMERICAN JOURNAL OF SURGERY
VOLUME 161 MARCH 1991
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-I
iI/ -~
tempted. If the portal area is particularly inflamed, or the artery is not easily found at this point, it is left until the duct has been fully identified and divided. It is especially easy to identify the artery as the cystic duct and neck of the gallbladder are retracted upward in the process of dissecting the gallbladder off the liver bed. Care is taken to identify any posterior branches of the cystic artery. If cholangiography is not going to be performed, then it is mandatory to identify not only the cystic duct-common duct junction, but also identify the common hepatic duct before any tissue is ligated or divided. If the artery is identified, it is ligated but not divided until after the cholangiogram is performed, so if the cystic duct is inadvertently transected during the attempted cholangiography, the portal area is still “tented” by the intact artery and will help in recovering the cystic duct stump and controlling it. Several techniques for performing cholangiograms are available. It is important to learn a technique of “cystic duct” cholangiography so as to be able to evaluate the ductal system for not only stones, but also anatomy in those difficult cases of acute cholecystitis and hydrops. In these cases, cholangiography through the gallbladder cannot be done due to cystic duct occlusion. After identifying the cystic duct, a clip is placed distal on the duct at the neck of the gallbladder. A small incision is made in the duct using scissors, and a catheter (either a mushroom tip or ureteral catheter) is introduced into the abdominal cavity. This can be done through a cholangiogram clamp, needle guide, or a 1Cgauge angiocath sheath inserted through the lateral abdominal wall. The cystic duct is intubated and the catheter is secured with the clamp (or a clip if the clamp is not used) (Figure 4). Use of radiolucent ports will facilitate performing cholangiography by eliminating overlying “hardware.” The cholangiogram is performed in a standard fashion. After the cholangiogram is performed, the catheter is removed and the cystic duct stump is doubly ligated and
1
I
~~~~
igure 1. Trocar placement.
the porta is started from the lateral aspect of the neck of the gallbladder and carried down to the common duct (Figure 3). Dissection of the porta is avoided until the lateral edge of the cystic duct is identified. Attempts are made to identify the duct high up on the neck of the gallbladder and then carry the dissection down to the common duct. This will minimize the risk of mistakenly dissecting the common duct instead of the cystic duct. Cautery and sharp dissection of the tissues in the portal area should be avoided so as to minimize the risk of injuring the common duct or common hepatic duct. After the cystic duct is identified and dissected free, dissection and identification of the cystic artery are at-
Figure 2. The gallbladder is lifted and
p 340
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JOURNAL
OF SURGERY
VOLUME
161
MARCH
1991
cephalad above the edga of the
Figure 3. The cystic duct and cystic ar tery are dissected free using blunt dis section.
divided (Figure 5). If the stump is short, or there is a question of a tenuous clip closure, a Roeder loop ligature is performed for additional security of closure. If the artery has not been previously identified, it is identified and dissected free at this time. An artery that is difficult to identify with the cystic duct intact will easily be found as the neck of the gallbladder is now retracted upward. Dissection of the gallbladder off the liver bed is performed in an orthograde fashion (from the neck to the fundus) (Figure 6). If the dissection is performed from the fundus down to the neck, the traction on the liver is lost at a time when the exposure is the most crucial. The dissection is performed using either the laser or the cautery. The keys to a safe dissection are (1) maintain good traction/countertraction on the gallbladder; (2) dissect from the lateral or medial serosal attachment of the gall-
bladder toward the middle of the bed to help keep within the proper plane of dissection; and (3) successively reposition the gallbladder and graspers to maximize the exposure and traction on the gallbladder. Before removing the last attachments of the gallbladder to the liver, the bed and porta are checked for hemostasis (Figure 7). Once the gallbladder is off the liver bed, it can be difficult to expose the deeper recesses of the bed. After the gallbladder is off the liver bed, the last area of the bed is checked for any bleeding that may have occurred with the final division of the tissues. While holding the gallbladder with one of the graspers, the other two ports are used to elevate the edge of the liver to irrigate the tissues and aspirate dry all fluid. By placing 5,000 U of heparin in each liter of irrigating fluid, any blood that pools will remain fluid and can be easily aspirated at the end of the procedure. After
Flgure4.Acholangtogamcatheter clipped securely in the cystic duct. THE AMERICAN
JOURNAL
OF SURGERY
VOLUME
161
MARCH
1991
341
Flgure 5. The cystic duct and cystic ar-
Itery are dividedafter ligatingwlth clips.
checking for final hemostasis and aspirating all fluid, the camera is placed in the lo-mm epigastric port, and a grasping instrument is placed through the umbilical port to grab the “neck” of the gallbladder. The gallbladder is brought out through the umbilical puncture for three reasons: (1) it is the thinnest point on the patient’s abdominal wall; (2) there is a single facial layer, so if a facial extension is required, it can be done simply; and (3) the patient tolerates any facial extension or manipulation of the tissues at the umbilicus much easier than up in the epigastrium. After pulling the neck of the gallbladder up into the umbilical sheath (Figure S), both are brought out through the umbilical puncture site. With control of the neck outside the abdominal cavity, the neck can be opened and the gallbladder decompressed of both bile
and stones (Figure 9). This eases the extraction of the gallbladder from the abdominal cavity. If the gallbladder can still not be delivered after decompression, a fascial extension can be performed millimeter by millimeter until the gallbladder can be delivered. Under direct vision, the accessory ports are removed to check for hemostasis, and the abdomen is deinflated of all carbon dioxide. The epigastric port and scope are removed, and the facia at the umbilicus closed with a figure-of-eight absorbable suture. The skin incisions are closed with subcuticular suture and Steristrips. The wounds are sterily dressed, the nasogastric tube and Foley catheter are removed, and the patient is then taken to the recovery room. If the surgeon desires to drain the liver bed, this can be easily performed at the end of the case by bringing a
Flgure 6. Tha gallbladder is dissected from the gallbladderfossa using either laser or cautery. 342
THE AMERICAN
JOURNAL
OF SURGERY
VOLUME
161
MARCH
1991
LAPAROSCOPIC CHOLECYSTECTOMY
Figure 7. The gallbladder fossa checked for hemos&sis prior to dividil the last attachments.
Figure 9. The gallbladderneck Is brow cal puncture.
out through the umbiliTHE AMERICAN
Fbgure9. The neck of the gallbladder is opened and drained; stones are removed with a spoon if necessary.
JOURNAL
OF SURGERY
VOLUME
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1991
343
suction drain through one of the ports into the abdominal cavity and pulling it out through the lateral puncture site. The drain is positioned with the remaining ports prior to removing them. In summary, laparoscopic cholecystectomy is an alternative to standard cholecystectomy that offers the patient (1) reduced ho&al Shy, with than 24 hours postoperatively; (2)
3&
discharge usually less
faster return to work,
THE AMERICAN JOURNAL OF SURGERY
with a return to unrestricted activities in less than 7 day and (3) improved cosmetic results. REFERENCES l. Reddick EJ, Olsen DO, Daniel1 JF, et al. Laparoscopic las cholecystectomy. Laser Medicine and Surgery News and Advance 1989; 7: 38-40. 2. Reddick EJ, Olsen DO. Laparoscopic laser cholecystectom Surg Endosc 1989; 3: 131-3.
VOLUME 161
MARCH 1991
Cholecystectomy MD, FAG, Nashville.~ennessee
With more than 500,000 cholecystectomies performed per year, great interest has developed in laparoscopic cholecystectomy. The procedure offers the patient reduced hospital stay, faster return to work, less pain, and improved cosmetic results. In September 1988, we developed a technique of performing laparoscopic cholecystectomy that we have now performed in more than 800 cases with good results. The technique allows the surgeon to fully evaluate the common duct via operative cholangiography and has allowed us to use a laparoscopic approach in all patients who were candidates for cholecystectomy. The technique offers a minimally invasive alternative to open cholecystectomy.
M
ore than a half million patients underwent totalcholecystectomy in 1988, and with the increasing number of elderly patients, this number is expected to rise. In an attempt to reduce the morbidity and cost of the surgical treatment of gallbladder disease, a minimally invasive approach to the surgical removal of the gallbladder was developed [I]. Herein, we present a technique for performing laparoscopic cholecystectomy that we have used in more than 800 cases and that has been shown to be effective and safe [2]. From the Department of Surgery, West Side Branch, Centenial Medical Center, and the HCA Center for Research and Development, Nashville, Tennessee. Requests for reprints should be addressed to Douglas 0. Olsen, MD, FACS, 2021 Church Street, Suite 502, Baptist Medical Plaza II, Nashville, Tennessee 37203. Presented as part of a postgraduate course on interventional laparoscopy during the American College of Surgeons 1990 Clinical Congress, San Francisco, California, October 12, 1990.
TECHNIQUE
The procedure is based on a four-puncture technique using a clip applier to control the duct and artery and laser or cautery to cut and coagulate. A primary lo-mm trocar is placed at the umbilicus for the video laparoscope, and three accessory trocars are placed in the right upper quadrant for grasping the gallbladder and operating (Figure 1). A 5-mm trocar is placed along the anterior axillary line midway between the costal margin and the anterior iliac spine, and another 5-mm trocar is placed along the midclavicular line just below the costal margin. The operating port is a lo-mm trocar that is placed in the midline 2 to 4 cm below the xyphoid process, aiming at approximately a 45” angle to just pass lateral to the falciform ligament. Placing the trocar left of the falciform ligament can cause difficulties if the patient has a large redundant falciform ligament. If the patient has had previous surgery, an alternate primary approach is made to avoid injuring possible underlying adhesed bowel. If the previous surgery was in the lower abdominal area, then a primary puncture is made at the midclavicular site with a 5-mm trocar, and using a 5-mm laparoscope for visualization, the umbilical port is placed under direct vision. If adhesiolysis is needed prior to placement of the umbilical port, then one of the other accessory ports is placed under direct vision to allow placement of instruments for the lysis of the adhesions. If upper abdominal surgery has been performed, then an open laparoscopic technique is used to gain access to the abdominal cavity. Once access to the abdominal cavity has been achieved, exploration is performed, checking for any sign of visceral injury secondary to trocar insertion. The accessory ports are placed under direct vision, and placement is “adjusted” to the body habitus. If the patient’s liver is not mobile, but edematous or swollen, then special care is taken to ensure that all the ports are below the liver edge. This is also important for the patient with a low-lying liver. Liver adhesions to the diaphragm should be removed to not only facilitate the retraction on the gallbladder, but also to prevent tearing of the liver capsule during traction on the liver. Placement of the patient in a reverse Trendelenberg position with a slight roll to the left will help bring the transverse colon and the omentum out of the right upper quadrant. The gallbladder is grasped at the fundus and retracted above and “over” the liver (Figure 2). This move elevates the portal triangle, aIlowing visualization. Lateral and upward retraction of Hartman’s pouch will splay out Charcot’s triangle and aid in visualizing the portal structures for a safe dissection. Common mistakes are: (1) insufficient upward retraction on the fundus, and (2) retraction on Hartman’s pouch upward and into the liver, not lateral and away from the liver. Blunt dissection of
THE AMERICAN JOURNAL OF SURGERY
VOLUME 161 MARCH 1991
339
-I
iI/ -~
tempted. If the portal area is particularly inflamed, or the artery is not easily found at this point, it is left until the duct has been fully identified and divided. It is especially easy to identify the artery as the cystic duct and neck of the gallbladder are retracted upward in the process of dissecting the gallbladder off the liver bed. Care is taken to identify any posterior branches of the cystic artery. If cholangiography is not going to be performed, then it is mandatory to identify not only the cystic duct-common duct junction, but also identify the common hepatic duct before any tissue is ligated or divided. If the artery is identified, it is ligated but not divided until after the cholangiogram is performed, so if the cystic duct is inadvertently transected during the attempted cholangiography, the portal area is still “tented” by the intact artery and will help in recovering the cystic duct stump and controlling it. Several techniques for performing cholangiograms are available. It is important to learn a technique of “cystic duct” cholangiography so as to be able to evaluate the ductal system for not only stones, but also anatomy in those difficult cases of acute cholecystitis and hydrops. In these cases, cholangiography through the gallbladder cannot be done due to cystic duct occlusion. After identifying the cystic duct, a clip is placed distal on the duct at the neck of the gallbladder. A small incision is made in the duct using scissors, and a catheter (either a mushroom tip or ureteral catheter) is introduced into the abdominal cavity. This can be done through a cholangiogram clamp, needle guide, or a 1Cgauge angiocath sheath inserted through the lateral abdominal wall. The cystic duct is intubated and the catheter is secured with the clamp (or a clip if the clamp is not used) (Figure 4). Use of radiolucent ports will facilitate performing cholangiography by eliminating overlying “hardware.” The cholangiogram is performed in a standard fashion. After the cholangiogram is performed, the catheter is removed and the cystic duct stump is doubly ligated and
1
I
~~~~
igure 1. Trocar placement.
the porta is started from the lateral aspect of the neck of the gallbladder and carried down to the common duct (Figure 3). Dissection of the porta is avoided until the lateral edge of the cystic duct is identified. Attempts are made to identify the duct high up on the neck of the gallbladder and then carry the dissection down to the common duct. This will minimize the risk of mistakenly dissecting the common duct instead of the cystic duct. Cautery and sharp dissection of the tissues in the portal area should be avoided so as to minimize the risk of injuring the common duct or common hepatic duct. After the cystic duct is identified and dissected free, dissection and identification of the cystic artery are at-
Figure 2. The gallbladder is lifted and
p 340
THE AMERICAN
JOURNAL
OF SURGERY
VOLUME
161
MARCH
1991
cephalad above the edga of the
Figure 3. The cystic duct and cystic ar tery are dissected free using blunt dis section.
divided (Figure 5). If the stump is short, or there is a question of a tenuous clip closure, a Roeder loop ligature is performed for additional security of closure. If the artery has not been previously identified, it is identified and dissected free at this time. An artery that is difficult to identify with the cystic duct intact will easily be found as the neck of the gallbladder is now retracted upward. Dissection of the gallbladder off the liver bed is performed in an orthograde fashion (from the neck to the fundus) (Figure 6). If the dissection is performed from the fundus down to the neck, the traction on the liver is lost at a time when the exposure is the most crucial. The dissection is performed using either the laser or the cautery. The keys to a safe dissection are (1) maintain good traction/countertraction on the gallbladder; (2) dissect from the lateral or medial serosal attachment of the gall-
bladder toward the middle of the bed to help keep within the proper plane of dissection; and (3) successively reposition the gallbladder and graspers to maximize the exposure and traction on the gallbladder. Before removing the last attachments of the gallbladder to the liver, the bed and porta are checked for hemostasis (Figure 7). Once the gallbladder is off the liver bed, it can be difficult to expose the deeper recesses of the bed. After the gallbladder is off the liver bed, the last area of the bed is checked for any bleeding that may have occurred with the final division of the tissues. While holding the gallbladder with one of the graspers, the other two ports are used to elevate the edge of the liver to irrigate the tissues and aspirate dry all fluid. By placing 5,000 U of heparin in each liter of irrigating fluid, any blood that pools will remain fluid and can be easily aspirated at the end of the procedure. After
Flgure4.Acholangtogamcatheter clipped securely in the cystic duct. THE AMERICAN
JOURNAL
OF SURGERY
VOLUME
161
MARCH
1991
341
Flgure 5. The cystic duct and cystic ar-
Itery are dividedafter ligatingwlth clips.
checking for final hemostasis and aspirating all fluid, the camera is placed in the lo-mm epigastric port, and a grasping instrument is placed through the umbilical port to grab the “neck” of the gallbladder. The gallbladder is brought out through the umbilical puncture for three reasons: (1) it is the thinnest point on the patient’s abdominal wall; (2) there is a single facial layer, so if a facial extension is required, it can be done simply; and (3) the patient tolerates any facial extension or manipulation of the tissues at the umbilicus much easier than up in the epigastrium. After pulling the neck of the gallbladder up into the umbilical sheath (Figure S), both are brought out through the umbilical puncture site. With control of the neck outside the abdominal cavity, the neck can be opened and the gallbladder decompressed of both bile
and stones (Figure 9). This eases the extraction of the gallbladder from the abdominal cavity. If the gallbladder can still not be delivered after decompression, a fascial extension can be performed millimeter by millimeter until the gallbladder can be delivered. Under direct vision, the accessory ports are removed to check for hemostasis, and the abdomen is deinflated of all carbon dioxide. The epigastric port and scope are removed, and the facia at the umbilicus closed with a figure-of-eight absorbable suture. The skin incisions are closed with subcuticular suture and Steristrips. The wounds are sterily dressed, the nasogastric tube and Foley catheter are removed, and the patient is then taken to the recovery room. If the surgeon desires to drain the liver bed, this can be easily performed at the end of the case by bringing a
Flgure 6. Tha gallbladder is dissected from the gallbladderfossa using either laser or cautery. 342
THE AMERICAN
JOURNAL
OF SURGERY
VOLUME
161
MARCH
1991
LAPAROSCOPIC CHOLECYSTECTOMY
Figure 7. The gallbladder fossa checked for hemos&sis prior to dividil the last attachments.
Figure 9. The gallbladderneck Is brow cal puncture.
out through the umbiliTHE AMERICAN
Fbgure9. The neck of the gallbladder is opened and drained; stones are removed with a spoon if necessary.
JOURNAL
OF SURGERY
VOLUME
161
MARCH
1991
343
suction drain through one of the ports into the abdominal cavity and pulling it out through the lateral puncture site. The drain is positioned with the remaining ports prior to removing them. In summary, laparoscopic cholecystectomy is an alternative to standard cholecystectomy that offers the patient (1) reduced ho&al Shy, with than 24 hours postoperatively; (2)
3&
discharge usually less
faster return to work,
THE AMERICAN JOURNAL OF SURGERY
with a return to unrestricted activities in less than 7 day and (3) improved cosmetic results. REFERENCES l. Reddick EJ, Olsen DO, Daniel1 JF, et al. Laparoscopic las cholecystectomy. Laser Medicine and Surgery News and Advance 1989; 7: 38-40. 2. Reddick EJ, Olsen DO. Laparoscopic laser cholecystectom Surg Endosc 1989; 3: 131-3.
VOLUME 161
MARCH 1991
