Biliary Tract Surgery
0039-6109/90 $0.00 + .20
Laparoscopic Cholecystectomy Thomas R. Gadacz, MD, * Mark A. Talamini, MD, t Keith D. Lillemoe, MD,t and Charles]. Yeo, MDt.
Laparoscopy has been a standard procedure for the gynecologist for many years. General surgeons have had limited experience with the procedure, but considerable enthusiasm for it has developed recently because of the increasing interest in laparoscopic cholecystectomy. As a result, laparoscopy will likely become a common procedure for most general surgeons, and laparoscopic cholecystectomy will become a common operation. Laparoscopic cholecystectomy was popularized over the past 2 years by Dubois and associates' and Reddick and Olsen" when they published their individual series of patients. The initial results in these two reports were good, and the principal advantages described were a short hospital stay and early return to normal activity. Since these initial reports, several hundred laparoscopic cholecystectomies have been performed by various groups. The volume of and enthusiasm for the procedure are escalating, and adequate training is necessary for its appropriate and safe application. The selection and evaluation of patients, equipment and instruments, operative procedure and its complications, results, training, and credentialing are discussed in this article.
SELECTION AND EVALUATION OF PATIENTS The indications for laparoscopic cholecystectomy are the same as for a standard cholecystectomy (Table 1). These include symptomatic gallstones and complications of gallstones such as recurrent episodes of pancreatitis. Patients with gallstones and biliary colic are ideal candidates for the procedure. Patients with acute as well as chronic cholecystitis are candidates provided the operative team is experienced. The contraindications to the *Professor of Surgery, The Johns Hopkins University; and Chief, Surgical Service, Baltimore VA Medical Center, Baltimore, Maryland t Assistant Professor of Surgery, Department of Surgery, The Johns Hopkins University, Baltimore, Maryland :j:Associate Professor of Surgery, Department of Surgery, The Johns Hopkins University, Baltimore, Maryland
Surgical Clinics of North America-Vol. 70, No.6, December 1990
1249
1250
THOMAS
R.
GADACZ ET AL.
operation are gradually evolving and depend on the experience of the operative team. Morbidly obese patients present many technical difficulties and should be avoided. The absolute and relative contraindications are listed in Table 1. Patients with symptoms compatible with gallstone disease usually have the diagnosis confirmed with a sonogram or an oral cholecystogram. A 99mTc-HIDA scan is most useful in confirming acute cholecystitis. Endoscopic retrograde cholangiopancreatography (ERCP) is indicated in those patients with abnormal liver function studies suggesting common duct stones and those patients with an elevated serum amylase concentration suggesting gallstone pancreatitis. Liver function tests, amylase measurements, and clotting studies are obtained in all patients. In addition to the assessment of gallstones and gallbladder disease, the overall operative risk of the patient is evaluated. The options for the treatment of gallstone and gallbladder disease are explained to the patient. Those patients offered laparoscopic cholecystectomy are specifically informed that a laparotomy and standard cholecystectomy may be necessary. Even with strict selection criteria, technical problems may be encountered, and the patient as well as the surgeon must be prepared for a standard cholecystectomy.
EQUIPMENT Several pieces of equipment are required for laparoscopic cholecystectomy: a high-flow insufflator, light source, high-resolution camera, and video monitor, an irrigation device, and an electrocautery unit or laser. These individual pieces of equipment have various specifications and are manufactured by several companies. Specifications for these essential components are described below. High-Flow Insufflator As a safeguard for laparoscopy, the carbon dioxide insufflator must constantly monitor the intra-abdominal pressure, stop flow once a certain pressure is achieved, indicate the rate of flow of gas into the abdomen, and record the total volume of gas delivered. The high-flow insufflator must Table 1. Indications and Contraindications for Laparoscopic Cholecystectomy Indications Cholelithiasis and biliary colic Symptomatic gallbladder polyps Resolved gallstone pancreatitis Symptomatic chronic cholecystitis Relative Contraindications Acute cholecystitis Prior upper abdominal operation Minor bleeding disorder Common duct stones
Absolute Contraindications Acute cholangitis Severe acute-cholecystitis Acute pancreatitis Peritonitis Portal hypertension Pregnancy Serious bleeding disorder Morbid obesity
LAPAROSCOPIC CHOLECYSTECTOMY
1251
deliver at least 6 L of gas per minute, and 8 L per minute is ideal. This high flow is required to maintain an adequate pneumoperitoneum during the exchange of the various instruments and to compensate for the evacuation of smoke generated by the electrocautery or laser. Continuous pressure monitoring is a critical feature of the insufRator and is used to confirm the location of the Verres needle in the free abdominal cavity before initiating the pneumoperitoneum and then to ensure a safe pressure during the procedure. Light Source A xenon light source with variable intensity and a light filter provides adequate visibility in the abdominal cavity at various distances. Xenon produces considerable heat, and the end of the endoscope or fiberoptic light cable must therefore be handled with care. If blood and other residue is allowed to accumulate on the end of the endoscope, the debris can encrust on the surface and be difficult to remove. Once the lens becomes cloudy, the endoscope must be removed and the lens cleaned. When the endoscope is removed from the abdominal cavity, it must not rest on the surgical drapes; if it does, the heat that is generated could result in a burn or fire. High-Resolution Camera and Monitor It is imperative that visibility of the structures be maximized. A onechip end-viewing camera has 480 pixels and is a minimum requirement for adequate vision (Fig. 1). The camera is attached to the endoscope and the cable to a processor that transmits the image to a video monitor. An endviewing camera is used rather than a split-beam camera, as the former transmits the entire image from the endoscope directly to the camera, whereas the latter significantly compromises visibility because part of the image is transmitted to the camera and part to the lens of the endoscope for direct observation. Because the operation is performed by watching the video monitor and not by viewing through the lens of the endoscope, the split-beam camera is undesirable, as it produces a poor-quality image on the video monitor. The three-chip camera (700 pixels) provides the best image. This hightech and high-quality camera maximizes the visibility of the operative field but is expensive (about $18,000). The chief advantage of the three-chip camera is the sharp image, which enhances anatomic details.
Figure 1. High-resolution camera has a rotating lock to secure it to the lens of the endoscope. The cable relays the signal to a processor, which transmits the image to a video monitor.
1252
THOMAS
R.
GADACZ ET AL.
To complement the high-resolution camera, a high-resolution video monitor is essential. This monitor should be capable of 480 horizontal lines for a two-chip camera and 700 horizontal lines for a three-chip camera.
Irrigation Device Various models of irrigation devices that will instill fluid at a high flow rate and a high pressure are available. Some of these devices (also named hydroxylators) digitally control the pressure. The device is powered by a tank of pressurized carbon dioxide and is connected to 1-L containers of irrigating solution. The device has off and on controls and two pressure gauges. One measures the pressure directly from the carbon dioxide tank, and the other gauge is adjustable to regulate the irrigating pressure of the fluid between 0 and 600 mm Hg. A pressure of 300 mm Hg generally is used to irrigate the abdomen, as it allows a relatively rapid flow of fluid into the abdomen with the capabilities of dislodging loose particulate material and identifying any bleeding points in the bed of the liver and portal area.
Electrocautery or Laser Either electrocautery or a laser can be used to dissect the gallbladder from its bed. Either unit also will provide hemostasis of small vessels and the liver bed. Electrocautery uses electrons to produce heat to dissect and coagulate tissue and is familiar to most general surgeons. The power setting is tested on the liver to ensure adequate but not excessive coagulation. A power setting of 20 to 25 W is sufficient. Although coagulation is used primarily, a mixed blend of cutting and coagulation may be useful. Electrocautery must be used with caution, because sparking may injure the bowel. The tip of the electrocautery must not be pulled inside the metal cannula, as injury to other tissue, including the skin, may occur. The laser uses photons to dissect and coagulate tissue. The advantage of the laser is that there is less tissue damage compared with electrocautery. The two principal laser sources used for laparoscopic cholecystectomy are the Nd:YAG (neodymium:yttrium-aluminum-garnet), which has a wavelength of 1064 nm, and the KTP (potassium titanyl phosphate), which has a wavelength of 532 nm. Laser units are of two principal types: a free beam and a contact laser. The Nd:YAG can be used either way, whereas the KTP is a free-beam laser. The free beam has a maximum power output of 150 W. It requires careful manipulation of the fiber to control the focal point. The depth of penetration is 3 to 5 mm. Essential structures must not be in the path of the beam; if they are, serious injuries can occur. When dissecting the gallbladder, the liver must be maintained in the background of the beam to prevent injury to the colon and portal structures. It is critical that the surgeon remain cognizant of the path of the beam. The contact Nd:YAG laser delivers the laser energy to a synthetic sapphire (garnet) probe. Endoscopic procedures can be performed with a power setting of 15 W. The probe has a penetration depth of 0.2 to 1.0 mm and is not dependent on focal point control. The probe must come in contact with the tissue. It is critical to allow the tip to cool before it is used as a dissector. Otherwise,
LAPAROSCOPIC CHOLECYSTECTOMY
1253
a thermal perforation of the gallbladder may occur. The cost of a laser unit ranges from $60,000 to $100,000.
INSTRUMENTS The instruments used for laporoscopic cholecystectomy are not only standard and modified pelviscopy instruments but also highly specialized and innovative instruments. Some of the essential ones are the Verres needle, cannulas (with a trumpet or trap-door valve), a trocar to introduce the cannula, endoscopes, retractors (graspers), dissectors, scissors, a clip applier, a cholangiocatheter clamp, an irrigator-aspirator instrument, coagulators, and a laser probe or fiber. The purpose of these instruments is to perform the operative procedure in a safe manner. The instruments differ in size according to the diameter of the cannulas. Generally, the diameters are either 5.5, 10, or 11 mm. A reducer can be inserted into a Ll-mm cannula to use a 10- or 5.5-mm instrument. The Verres needle is used to insufflate the abdomen (Fig. 2A). A metal sheath covers the tip of the needle and retracts as the needle penetrates the abdominal wall. The metal sheath springs to cover the tip once the needle is in the abdomen to prevent laceration of the abdominal organs
Figure 2. Instruments for laparoscopic cholecystectomy. A, Verres needle used for insuffiation. B, Verres needle (upper left). Cannulas with trocar: disposable (upper left); reusable (upper right). Endoscopes (below trocars): Ll-mm, 30-degree (top); Ll-rnm, O-degree imiddle); and 5.5-mm, O-degree (bottom). Retractors, or graspers, are below endoscopes.
1254
THOMAS
R.
GADACZ ET AL.
during insufflation. The Verres needle is connected to the tubing from the insufflator to establish the pneumoperitoneum. The cannulas are introduced into the abdomen with a trocar (Fig. 2B). They provide access to the abdominal cavity for the endoscope and instruments. The reusable cannulas have a trumpet valve to prevent gas from escaping from the abdominal cavity and to allow introduction of instruments into the cavity. The Surgiport cannulas are disposable and have some unique features: (1) the channel is occluded by a trapdoor mechanism (flapper valve); (2) the trocar has a protective sheath; and (3) the barrel of the cannula is either stainless steel or fiberglass (translucent). The plastic sheath rapidly covers the trocar once the free peritoneum is entered and prevents injury to the abdominal organs by the sharp trocar. The translucent barrel is advantageous when obtaining an intraoperative cholangiogram, because it does not obscure the contrast material in the bile duct. The endoscope is used to transmit light into the abdomen and to transmit an image to the lens (Fig. 2B). The cable from the light source is attached to the side of the endoscope, and the camera is attached to the lens. Although endoscopes with operating channels are available, the field of vision and amount of light are markedly reduced, resulting in a poor image on the video screen. Endoscopes are either end-viewing (O-degree) or angled (30-degree). The 30-degree endoscope is more versatile but initially difficult to orient. Retractors or graspers are instruments (usually 5.5 mm in diameter) with jaws at the tip; the handle usually has a spring or ratchet mechanism that apposes the jaws (Fig. 2B). These instruments are used to grasp tissue or the gallbladder and position the tissue or organ to maximize exposure. The retractors usually are inserted through the two most lateral ports to retract the dome of the gallbladder cephalad and the fundus anteriorly, laterally, or medially. The spring handle maintains a constant grasp and relieves the assistant of the fatiguing task of maintaining a constant grip on the handle. Dissectors are used to free structures from one another or the surrounding tissue. They generally have thin or elongated jaws and are able to grasp fragments of tissue and separate structures when gently opened. The Maryland dissector (10 and 11 mm) is a modified needle-nose dissector with the tip of the jaws slightly bent to form a curve. This instrument is very useful to encircle the cystic duct and artery and free these structures from the surrounding peritoneal attachments. The clip applier, in 10- and Ll-mm diameters, is a crucial instrument, as it places a titanium clip that occludes the cystic duct and artery (Fig. 3). The reusable clip applier dispenses individual clips. It is durable and economical but does require extraction and reloading after each clip is applied. The disposable clip applier (Endo clip) contains 20 8.8g-mm titanium clips. A clip can be loaded into the jaws without removing the instrument. This instrument saves time but is more expensive. The cholangiocatheter clamp is used for cholangiograms (Fig. 3). It has flexible jaws that extend beyond a hollow channel. The catheter is inserted through the channel, threaded into the cystic duct, and held in place by the clamp. A ratchet mechanism at the handle secures the jaws and holds
LAPAROSCOPIC CHOLECYSTECTOMY
1255
Figure 3. Two types of clip appliers (top). Cholangiocatheter clamp (below clip appliers). Irrigator-aspirator (below clamp). Coagulators (hooked; below irrigator-aspirator), and spatula
ibottomi.
the catheter in place. The irrigation-aspiration instrument (5.5-mm diameter) is used to wash away blood and particulate material and aspirate the irrigant or blood. Tubing from the irrigator is connected to a 5.5-mm irrigation-aspiration instrument, which has trumpet valves or stopcocks to irrigate as well as aspirate. The aspiration port of the instrument is connected to a standard wall suction cannister. The formation of blood clots can be alleviated by initially instilling about 200 ml of heparinized saline (5000 units of heparin in 1 L of saline). There are various designs for the irrigation-aspiration instrument. Coagulators (usually 5.5 mm in diameter) are used to coagulate or cut attachments and coagulate vessels or bleeding areas. The hook and spatula can be used not only for coagulation but also for dissection. Other instruments that are insulated such as scissors can be used to coagulate tissue. Laser fibers or probes coagulate tissue by delivering the energy of the laser. The fiber focuses the energy on the tissue from a distance (free beam laser), whereas the probe must come in direct contact with the tissue (contact laser). Both are used to separate tissue, coagulate small vessels, and control bleeding areas.
OPERATIVE PROCEDURE Preoperative antibiotics, such as a first-generation cephalosporin, can be used routinely or reserved for patients with medical risk factors and those with evidence of recent cholecystitis. The procedure is performed under general or epidural anesthesia. Two video monitors are used; these are placed on the right and left side of the operating table to allow the surgical team members on the opposite side an adequate view of the procedure. It is best if the monitors are placed as close to the head of the patient as possible and at the eye level of the operating surgeons. They
1256
THOMAS
R.
GADACZ ET AL.
lUUSt be carefully positioned to ensure that the anesthesiologist has adequate access to the patient and anesthesia monitoring equipment and that the surgeons have a direct and unobstructed view of the monitors. Because the entire procedure is guided by the view provided by the video monitors, it is essential that the monitors be positioned to maximize visibility. The insufflator must be in view of the surgeon or first assistant to allow constant monitoring of the intra-abdominal pressure. When the equipment is in the proper position, the procedure is begun. The urinary bladder and stomach are decompressed with a Foley catheter and a nasogastric tube, respectively, to avoid injury during insertion of the Verres needle and trocar and to facilitate exposure. The sites for insertion of the cannulas are marked on the abdominal wall (Fig. 4). The pneumoperitoneum is established with the patient in the Trendelenburg position. A O.5-inch incision is made just above the umbilicus, and a Verres needle is introduced into the abdominal cavity. Several drops of sterile saline are placed in the hub of the needle; they will be drawn into the needle by the negative intra-abdominal pressure if the tip of the needle is in the free abdominal cavity (positive drop test). The needle is aspirated to ensure that no vessel or bowel has been entered. The Verres needle is then connected to the insufflator, and a negative pressure of 0 to - 5 mm Hg reconfirms the position of the needle in the abdominal cavity. After the insufflator is set to 12 mm Hg, carbon dioxide is instilled at a low flow rate (1 L/minute) into the abdominal cavity through the Verres needle. The quadrants of the abdomen are gently percussed to ensure that there is an even distribution of the pneumoperitoneum. Once an adequate pneumoperitoneum is established (about 1 L), a higher flow rate of 2 to 3 L/minute is used. When 3 to 5 L of carbon dioxide has been instilled into the abdomen, the maximum intra-abdominal pressure of 12 mm Hg is usually reached, and flow ceases. The Verres needle is removed, and an Ll-mm cannula is inserted above the umbilicus. The insufflator is attached to this cannula and set to a maximum flow rate of 6 to 8 L/minute. It is critical that the cannula delivering the pneumoperitoneum be maintained in the abdominal cavity
Upper Midline
Mid-Clavicular
Umbilicus
La.paroscope Anterior Axillary
Figure 4. The approximate position of the cannulas. The exact location depends on the size of the liver and the location of the gallbladder.
LAPAROSCOPIC CHOLECYSTECTOMY
1257
and not in the subcutaneous tissue; otherwise subcutaneous emphysema may occur. The endoscope is then inserted, and the abdominal cavity is inspected. The patient is placed in the extreme reverse Trendelenburg position to allow the colon and omentum to fall inferiorly. Tilting the patient to the left may also improve the exposure. After a visual inspection of the pelvis and upper abdomen, a second Ll-mm cannula (the surgeon's position) is inserted two thirds of the way between the umbilicus and the xiphisternum just to the right of the midline. A 5.5-mm cannula is inserted 3 to 4 em below the costal margin in the midclavicular line (the first assistant's position), and a second 5.5-mm cannula is inserted 4 to 5 em below the costal margin in the midaxillary line. These cannulas are inserted according to the position of the liver and gallbladder. All three cannulas are inserted with a trocar under direct endoscopic vision. The umbilical cannula is used for the endoscope and carbon dioxide inflow, and the other Ll-mm port is used for dissection. The two 5.5-mm ports are used to retract and expose the gallbladder. Adhesions are dissected off the gallbladder, and the cystic duct and artery are identified by removing the peritoneum overlying these structures. Cholangiograms are performed selectively (Fig. 5). This study is performed by isolating the cystic duct and applying two clips near the neck. The cystic duct is partially transected with microscissors, and the cholangiocatheter clamp is used to insert and secure a cholangiocatheter or a 5-Fr urethral catheter. If the cholangiogram is normal, the distal part of the cystic duct is doubly clipped, and the cystic duct is transected. If a cholangiogram is not planned, the cystic duct is isolated, two clips are placed proximally and
Figure 5. Monitoring of procedure. A, Operative cholangiogram showing a normal common bile duct. Note instruments: grasper (left), cholangiocatheter clamp (middle), distal bile duct, and the epigastric (top) and supraumbilical cannulas (bottom). B, Later phase of the cholangiogram demonstrating intrahepatic ducts, contrast in the duodenum, and instruments described above.
1258
THOMAS
R.
GADACZ ET AL.
two distally, and the duct is divided between the middle clips. The cystic artery is clipped and divided in a similar manner. The infundibulum and neck of the gallbladder are elevated, and the gallbladder is dissected from its bed using either electrocautery or the laser. Before transection of the final attachments to the fundus, the gallbladder is retracted cephalad, and the gallbladder fossa is inspected for any bleeding. The bed of the gallbladder and portal area are irrigated, and the solution is aspirated. When hemostasis has been ensured, the remaining attachments between the gallbladder and the liver are divided. The endoscope and camera are then moved to the upper midline (11mm) cannula, and, under visual guidance, the claw forceps are inserted into the abdominal cavity through the umbilical cannula to extract the gallbladder. If the gallbladder is distended, bile is aspirated with a needle through a side cannula. Large stones are crushed with a clamp, or the fascial incision is enlarged slightly to accommodate them. The umbilical fascia is closed with a Vicryl suture and the skin approximated with SteriStrips. The nasogastric tube is removed in the operating room, and the Foley catheter is removed in the recovery room. The patient is monitored in the recovery room and given pain medication as needed, although generally, none is required. The hematocrit is usually checked in the evening, and a specimen for liver function tests is sent to the laboratory at the time of discharge. By the following morning, most patients are eager to be discharged, and they leave after breakfast. The patient is seen 7 to 10 days later for evaluation and inspection of the incisions.
REVIEW OF RESULTS Experience with laparoscopic cholecystectomy is being gained rapidly. To date, reports by three groups': 3, 4 have established the procedure as being safe. A report submitted for publication by Fitzgibbons and associates and our own data are summarized in Table 2. Most of the procedures have been performed for symptomatic gallstones. Experience with acute cholecystitis and gallstone pancreatitis is too limited at this time to make a statement about efficacy. Operative time has been acceptable. The chief advantages include a short hospital stay and early return to work. Standard laparotomy has been required in less than 5% of patients because of bleeding, bile leak, bile duct injury, or technical difficulties. Thus far, the complication rate is 5%, and the mortality rate O. More data will be necessary to determine whether the incidence of bile duct injury will be higher or similar to that of open cholecystectomy. Because there are only three published reports on laparoscopic cholecystectomy, the incidence of complications has not been well documented. There are anecdotal reports of serious complications, but these have not been published. In the series of 220 patients described by Dubois and coworkers, 1 no complications occurred in the last 180 patients. Among the first 36 patients, two complications were reported: bleeding from avulsion of the cystic artery and a bile collection. The first patient was treated with
1259
LAPAROSCOPIC CHOLECYSTECTOMY
Table 2. Results of Laparoscopic Cholecystectomy
No. of patients Mean age (range) Indications (%) Biliary colic Cholecystitis Polyps Pancreatitis Asymptomatic Average operative time (min) Average hospital stay (days) Return to normal activity (days) Complication rate (%) No. of open procedures Deaths
DUBOIS
REDDICK
ZUCKER
ETAL1
& OLSEN 3
ET AL4
FITZGIBBONS ET AL*
ET AL
220 36 (29-86)
25 40 (NA)
100 53 (17-85)
100 44 (15-87)
60 54 (33-83)
72
100
91 6 2 1
88 12
90 9
NA
95
104
110
100
3-7 3-7
1.96 6.5
0039-6109/90 $0.00 + .20
Laparoscopic Cholecystectomy Thomas R. Gadacz, MD, * Mark A. Talamini, MD, t Keith D. Lillemoe, MD,t and Charles]. Yeo, MDt.
Laparoscopy has been a standard procedure for the gynecologist for many years. General surgeons have had limited experience with the procedure, but considerable enthusiasm for it has developed recently because of the increasing interest in laparoscopic cholecystectomy. As a result, laparoscopy will likely become a common procedure for most general surgeons, and laparoscopic cholecystectomy will become a common operation. Laparoscopic cholecystectomy was popularized over the past 2 years by Dubois and associates' and Reddick and Olsen" when they published their individual series of patients. The initial results in these two reports were good, and the principal advantages described were a short hospital stay and early return to normal activity. Since these initial reports, several hundred laparoscopic cholecystectomies have been performed by various groups. The volume of and enthusiasm for the procedure are escalating, and adequate training is necessary for its appropriate and safe application. The selection and evaluation of patients, equipment and instruments, operative procedure and its complications, results, training, and credentialing are discussed in this article.
SELECTION AND EVALUATION OF PATIENTS The indications for laparoscopic cholecystectomy are the same as for a standard cholecystectomy (Table 1). These include symptomatic gallstones and complications of gallstones such as recurrent episodes of pancreatitis. Patients with gallstones and biliary colic are ideal candidates for the procedure. Patients with acute as well as chronic cholecystitis are candidates provided the operative team is experienced. The contraindications to the *Professor of Surgery, The Johns Hopkins University; and Chief, Surgical Service, Baltimore VA Medical Center, Baltimore, Maryland t Assistant Professor of Surgery, Department of Surgery, The Johns Hopkins University, Baltimore, Maryland :j:Associate Professor of Surgery, Department of Surgery, The Johns Hopkins University, Baltimore, Maryland
Surgical Clinics of North America-Vol. 70, No.6, December 1990
1249
1250
THOMAS
R.
GADACZ ET AL.
operation are gradually evolving and depend on the experience of the operative team. Morbidly obese patients present many technical difficulties and should be avoided. The absolute and relative contraindications are listed in Table 1. Patients with symptoms compatible with gallstone disease usually have the diagnosis confirmed with a sonogram or an oral cholecystogram. A 99mTc-HIDA scan is most useful in confirming acute cholecystitis. Endoscopic retrograde cholangiopancreatography (ERCP) is indicated in those patients with abnormal liver function studies suggesting common duct stones and those patients with an elevated serum amylase concentration suggesting gallstone pancreatitis. Liver function tests, amylase measurements, and clotting studies are obtained in all patients. In addition to the assessment of gallstones and gallbladder disease, the overall operative risk of the patient is evaluated. The options for the treatment of gallstone and gallbladder disease are explained to the patient. Those patients offered laparoscopic cholecystectomy are specifically informed that a laparotomy and standard cholecystectomy may be necessary. Even with strict selection criteria, technical problems may be encountered, and the patient as well as the surgeon must be prepared for a standard cholecystectomy.
EQUIPMENT Several pieces of equipment are required for laparoscopic cholecystectomy: a high-flow insufflator, light source, high-resolution camera, and video monitor, an irrigation device, and an electrocautery unit or laser. These individual pieces of equipment have various specifications and are manufactured by several companies. Specifications for these essential components are described below. High-Flow Insufflator As a safeguard for laparoscopy, the carbon dioxide insufflator must constantly monitor the intra-abdominal pressure, stop flow once a certain pressure is achieved, indicate the rate of flow of gas into the abdomen, and record the total volume of gas delivered. The high-flow insufflator must Table 1. Indications and Contraindications for Laparoscopic Cholecystectomy Indications Cholelithiasis and biliary colic Symptomatic gallbladder polyps Resolved gallstone pancreatitis Symptomatic chronic cholecystitis Relative Contraindications Acute cholecystitis Prior upper abdominal operation Minor bleeding disorder Common duct stones
Absolute Contraindications Acute cholangitis Severe acute-cholecystitis Acute pancreatitis Peritonitis Portal hypertension Pregnancy Serious bleeding disorder Morbid obesity
LAPAROSCOPIC CHOLECYSTECTOMY
1251
deliver at least 6 L of gas per minute, and 8 L per minute is ideal. This high flow is required to maintain an adequate pneumoperitoneum during the exchange of the various instruments and to compensate for the evacuation of smoke generated by the electrocautery or laser. Continuous pressure monitoring is a critical feature of the insufRator and is used to confirm the location of the Verres needle in the free abdominal cavity before initiating the pneumoperitoneum and then to ensure a safe pressure during the procedure. Light Source A xenon light source with variable intensity and a light filter provides adequate visibility in the abdominal cavity at various distances. Xenon produces considerable heat, and the end of the endoscope or fiberoptic light cable must therefore be handled with care. If blood and other residue is allowed to accumulate on the end of the endoscope, the debris can encrust on the surface and be difficult to remove. Once the lens becomes cloudy, the endoscope must be removed and the lens cleaned. When the endoscope is removed from the abdominal cavity, it must not rest on the surgical drapes; if it does, the heat that is generated could result in a burn or fire. High-Resolution Camera and Monitor It is imperative that visibility of the structures be maximized. A onechip end-viewing camera has 480 pixels and is a minimum requirement for adequate vision (Fig. 1). The camera is attached to the endoscope and the cable to a processor that transmits the image to a video monitor. An endviewing camera is used rather than a split-beam camera, as the former transmits the entire image from the endoscope directly to the camera, whereas the latter significantly compromises visibility because part of the image is transmitted to the camera and part to the lens of the endoscope for direct observation. Because the operation is performed by watching the video monitor and not by viewing through the lens of the endoscope, the split-beam camera is undesirable, as it produces a poor-quality image on the video monitor. The three-chip camera (700 pixels) provides the best image. This hightech and high-quality camera maximizes the visibility of the operative field but is expensive (about $18,000). The chief advantage of the three-chip camera is the sharp image, which enhances anatomic details.
Figure 1. High-resolution camera has a rotating lock to secure it to the lens of the endoscope. The cable relays the signal to a processor, which transmits the image to a video monitor.
1252
THOMAS
R.
GADACZ ET AL.
To complement the high-resolution camera, a high-resolution video monitor is essential. This monitor should be capable of 480 horizontal lines for a two-chip camera and 700 horizontal lines for a three-chip camera.
Irrigation Device Various models of irrigation devices that will instill fluid at a high flow rate and a high pressure are available. Some of these devices (also named hydroxylators) digitally control the pressure. The device is powered by a tank of pressurized carbon dioxide and is connected to 1-L containers of irrigating solution. The device has off and on controls and two pressure gauges. One measures the pressure directly from the carbon dioxide tank, and the other gauge is adjustable to regulate the irrigating pressure of the fluid between 0 and 600 mm Hg. A pressure of 300 mm Hg generally is used to irrigate the abdomen, as it allows a relatively rapid flow of fluid into the abdomen with the capabilities of dislodging loose particulate material and identifying any bleeding points in the bed of the liver and portal area.
Electrocautery or Laser Either electrocautery or a laser can be used to dissect the gallbladder from its bed. Either unit also will provide hemostasis of small vessels and the liver bed. Electrocautery uses electrons to produce heat to dissect and coagulate tissue and is familiar to most general surgeons. The power setting is tested on the liver to ensure adequate but not excessive coagulation. A power setting of 20 to 25 W is sufficient. Although coagulation is used primarily, a mixed blend of cutting and coagulation may be useful. Electrocautery must be used with caution, because sparking may injure the bowel. The tip of the electrocautery must not be pulled inside the metal cannula, as injury to other tissue, including the skin, may occur. The laser uses photons to dissect and coagulate tissue. The advantage of the laser is that there is less tissue damage compared with electrocautery. The two principal laser sources used for laparoscopic cholecystectomy are the Nd:YAG (neodymium:yttrium-aluminum-garnet), which has a wavelength of 1064 nm, and the KTP (potassium titanyl phosphate), which has a wavelength of 532 nm. Laser units are of two principal types: a free beam and a contact laser. The Nd:YAG can be used either way, whereas the KTP is a free-beam laser. The free beam has a maximum power output of 150 W. It requires careful manipulation of the fiber to control the focal point. The depth of penetration is 3 to 5 mm. Essential structures must not be in the path of the beam; if they are, serious injuries can occur. When dissecting the gallbladder, the liver must be maintained in the background of the beam to prevent injury to the colon and portal structures. It is critical that the surgeon remain cognizant of the path of the beam. The contact Nd:YAG laser delivers the laser energy to a synthetic sapphire (garnet) probe. Endoscopic procedures can be performed with a power setting of 15 W. The probe has a penetration depth of 0.2 to 1.0 mm and is not dependent on focal point control. The probe must come in contact with the tissue. It is critical to allow the tip to cool before it is used as a dissector. Otherwise,
LAPAROSCOPIC CHOLECYSTECTOMY
1253
a thermal perforation of the gallbladder may occur. The cost of a laser unit ranges from $60,000 to $100,000.
INSTRUMENTS The instruments used for laporoscopic cholecystectomy are not only standard and modified pelviscopy instruments but also highly specialized and innovative instruments. Some of the essential ones are the Verres needle, cannulas (with a trumpet or trap-door valve), a trocar to introduce the cannula, endoscopes, retractors (graspers), dissectors, scissors, a clip applier, a cholangiocatheter clamp, an irrigator-aspirator instrument, coagulators, and a laser probe or fiber. The purpose of these instruments is to perform the operative procedure in a safe manner. The instruments differ in size according to the diameter of the cannulas. Generally, the diameters are either 5.5, 10, or 11 mm. A reducer can be inserted into a Ll-mm cannula to use a 10- or 5.5-mm instrument. The Verres needle is used to insufflate the abdomen (Fig. 2A). A metal sheath covers the tip of the needle and retracts as the needle penetrates the abdominal wall. The metal sheath springs to cover the tip once the needle is in the abdomen to prevent laceration of the abdominal organs
Figure 2. Instruments for laparoscopic cholecystectomy. A, Verres needle used for insuffiation. B, Verres needle (upper left). Cannulas with trocar: disposable (upper left); reusable (upper right). Endoscopes (below trocars): Ll-mm, 30-degree (top); Ll-rnm, O-degree imiddle); and 5.5-mm, O-degree (bottom). Retractors, or graspers, are below endoscopes.
1254
THOMAS
R.
GADACZ ET AL.
during insufflation. The Verres needle is connected to the tubing from the insufflator to establish the pneumoperitoneum. The cannulas are introduced into the abdomen with a trocar (Fig. 2B). They provide access to the abdominal cavity for the endoscope and instruments. The reusable cannulas have a trumpet valve to prevent gas from escaping from the abdominal cavity and to allow introduction of instruments into the cavity. The Surgiport cannulas are disposable and have some unique features: (1) the channel is occluded by a trapdoor mechanism (flapper valve); (2) the trocar has a protective sheath; and (3) the barrel of the cannula is either stainless steel or fiberglass (translucent). The plastic sheath rapidly covers the trocar once the free peritoneum is entered and prevents injury to the abdominal organs by the sharp trocar. The translucent barrel is advantageous when obtaining an intraoperative cholangiogram, because it does not obscure the contrast material in the bile duct. The endoscope is used to transmit light into the abdomen and to transmit an image to the lens (Fig. 2B). The cable from the light source is attached to the side of the endoscope, and the camera is attached to the lens. Although endoscopes with operating channels are available, the field of vision and amount of light are markedly reduced, resulting in a poor image on the video screen. Endoscopes are either end-viewing (O-degree) or angled (30-degree). The 30-degree endoscope is more versatile but initially difficult to orient. Retractors or graspers are instruments (usually 5.5 mm in diameter) with jaws at the tip; the handle usually has a spring or ratchet mechanism that apposes the jaws (Fig. 2B). These instruments are used to grasp tissue or the gallbladder and position the tissue or organ to maximize exposure. The retractors usually are inserted through the two most lateral ports to retract the dome of the gallbladder cephalad and the fundus anteriorly, laterally, or medially. The spring handle maintains a constant grasp and relieves the assistant of the fatiguing task of maintaining a constant grip on the handle. Dissectors are used to free structures from one another or the surrounding tissue. They generally have thin or elongated jaws and are able to grasp fragments of tissue and separate structures when gently opened. The Maryland dissector (10 and 11 mm) is a modified needle-nose dissector with the tip of the jaws slightly bent to form a curve. This instrument is very useful to encircle the cystic duct and artery and free these structures from the surrounding peritoneal attachments. The clip applier, in 10- and Ll-mm diameters, is a crucial instrument, as it places a titanium clip that occludes the cystic duct and artery (Fig. 3). The reusable clip applier dispenses individual clips. It is durable and economical but does require extraction and reloading after each clip is applied. The disposable clip applier (Endo clip) contains 20 8.8g-mm titanium clips. A clip can be loaded into the jaws without removing the instrument. This instrument saves time but is more expensive. The cholangiocatheter clamp is used for cholangiograms (Fig. 3). It has flexible jaws that extend beyond a hollow channel. The catheter is inserted through the channel, threaded into the cystic duct, and held in place by the clamp. A ratchet mechanism at the handle secures the jaws and holds
LAPAROSCOPIC CHOLECYSTECTOMY
1255
Figure 3. Two types of clip appliers (top). Cholangiocatheter clamp (below clip appliers). Irrigator-aspirator (below clamp). Coagulators (hooked; below irrigator-aspirator), and spatula
ibottomi.
the catheter in place. The irrigation-aspiration instrument (5.5-mm diameter) is used to wash away blood and particulate material and aspirate the irrigant or blood. Tubing from the irrigator is connected to a 5.5-mm irrigation-aspiration instrument, which has trumpet valves or stopcocks to irrigate as well as aspirate. The aspiration port of the instrument is connected to a standard wall suction cannister. The formation of blood clots can be alleviated by initially instilling about 200 ml of heparinized saline (5000 units of heparin in 1 L of saline). There are various designs for the irrigation-aspiration instrument. Coagulators (usually 5.5 mm in diameter) are used to coagulate or cut attachments and coagulate vessels or bleeding areas. The hook and spatula can be used not only for coagulation but also for dissection. Other instruments that are insulated such as scissors can be used to coagulate tissue. Laser fibers or probes coagulate tissue by delivering the energy of the laser. The fiber focuses the energy on the tissue from a distance (free beam laser), whereas the probe must come in direct contact with the tissue (contact laser). Both are used to separate tissue, coagulate small vessels, and control bleeding areas.
OPERATIVE PROCEDURE Preoperative antibiotics, such as a first-generation cephalosporin, can be used routinely or reserved for patients with medical risk factors and those with evidence of recent cholecystitis. The procedure is performed under general or epidural anesthesia. Two video monitors are used; these are placed on the right and left side of the operating table to allow the surgical team members on the opposite side an adequate view of the procedure. It is best if the monitors are placed as close to the head of the patient as possible and at the eye level of the operating surgeons. They
1256
THOMAS
R.
GADACZ ET AL.
lUUSt be carefully positioned to ensure that the anesthesiologist has adequate access to the patient and anesthesia monitoring equipment and that the surgeons have a direct and unobstructed view of the monitors. Because the entire procedure is guided by the view provided by the video monitors, it is essential that the monitors be positioned to maximize visibility. The insufflator must be in view of the surgeon or first assistant to allow constant monitoring of the intra-abdominal pressure. When the equipment is in the proper position, the procedure is begun. The urinary bladder and stomach are decompressed with a Foley catheter and a nasogastric tube, respectively, to avoid injury during insertion of the Verres needle and trocar and to facilitate exposure. The sites for insertion of the cannulas are marked on the abdominal wall (Fig. 4). The pneumoperitoneum is established with the patient in the Trendelenburg position. A O.5-inch incision is made just above the umbilicus, and a Verres needle is introduced into the abdominal cavity. Several drops of sterile saline are placed in the hub of the needle; they will be drawn into the needle by the negative intra-abdominal pressure if the tip of the needle is in the free abdominal cavity (positive drop test). The needle is aspirated to ensure that no vessel or bowel has been entered. The Verres needle is then connected to the insufflator, and a negative pressure of 0 to - 5 mm Hg reconfirms the position of the needle in the abdominal cavity. After the insufflator is set to 12 mm Hg, carbon dioxide is instilled at a low flow rate (1 L/minute) into the abdominal cavity through the Verres needle. The quadrants of the abdomen are gently percussed to ensure that there is an even distribution of the pneumoperitoneum. Once an adequate pneumoperitoneum is established (about 1 L), a higher flow rate of 2 to 3 L/minute is used. When 3 to 5 L of carbon dioxide has been instilled into the abdomen, the maximum intra-abdominal pressure of 12 mm Hg is usually reached, and flow ceases. The Verres needle is removed, and an Ll-mm cannula is inserted above the umbilicus. The insufflator is attached to this cannula and set to a maximum flow rate of 6 to 8 L/minute. It is critical that the cannula delivering the pneumoperitoneum be maintained in the abdominal cavity
Upper Midline
Mid-Clavicular
Umbilicus
La.paroscope Anterior Axillary
Figure 4. The approximate position of the cannulas. The exact location depends on the size of the liver and the location of the gallbladder.
LAPAROSCOPIC CHOLECYSTECTOMY
1257
and not in the subcutaneous tissue; otherwise subcutaneous emphysema may occur. The endoscope is then inserted, and the abdominal cavity is inspected. The patient is placed in the extreme reverse Trendelenburg position to allow the colon and omentum to fall inferiorly. Tilting the patient to the left may also improve the exposure. After a visual inspection of the pelvis and upper abdomen, a second Ll-mm cannula (the surgeon's position) is inserted two thirds of the way between the umbilicus and the xiphisternum just to the right of the midline. A 5.5-mm cannula is inserted 3 to 4 em below the costal margin in the midclavicular line (the first assistant's position), and a second 5.5-mm cannula is inserted 4 to 5 em below the costal margin in the midaxillary line. These cannulas are inserted according to the position of the liver and gallbladder. All three cannulas are inserted with a trocar under direct endoscopic vision. The umbilical cannula is used for the endoscope and carbon dioxide inflow, and the other Ll-mm port is used for dissection. The two 5.5-mm ports are used to retract and expose the gallbladder. Adhesions are dissected off the gallbladder, and the cystic duct and artery are identified by removing the peritoneum overlying these structures. Cholangiograms are performed selectively (Fig. 5). This study is performed by isolating the cystic duct and applying two clips near the neck. The cystic duct is partially transected with microscissors, and the cholangiocatheter clamp is used to insert and secure a cholangiocatheter or a 5-Fr urethral catheter. If the cholangiogram is normal, the distal part of the cystic duct is doubly clipped, and the cystic duct is transected. If a cholangiogram is not planned, the cystic duct is isolated, two clips are placed proximally and
Figure 5. Monitoring of procedure. A, Operative cholangiogram showing a normal common bile duct. Note instruments: grasper (left), cholangiocatheter clamp (middle), distal bile duct, and the epigastric (top) and supraumbilical cannulas (bottom). B, Later phase of the cholangiogram demonstrating intrahepatic ducts, contrast in the duodenum, and instruments described above.
1258
THOMAS
R.
GADACZ ET AL.
two distally, and the duct is divided between the middle clips. The cystic artery is clipped and divided in a similar manner. The infundibulum and neck of the gallbladder are elevated, and the gallbladder is dissected from its bed using either electrocautery or the laser. Before transection of the final attachments to the fundus, the gallbladder is retracted cephalad, and the gallbladder fossa is inspected for any bleeding. The bed of the gallbladder and portal area are irrigated, and the solution is aspirated. When hemostasis has been ensured, the remaining attachments between the gallbladder and the liver are divided. The endoscope and camera are then moved to the upper midline (11mm) cannula, and, under visual guidance, the claw forceps are inserted into the abdominal cavity through the umbilical cannula to extract the gallbladder. If the gallbladder is distended, bile is aspirated with a needle through a side cannula. Large stones are crushed with a clamp, or the fascial incision is enlarged slightly to accommodate them. The umbilical fascia is closed with a Vicryl suture and the skin approximated with SteriStrips. The nasogastric tube is removed in the operating room, and the Foley catheter is removed in the recovery room. The patient is monitored in the recovery room and given pain medication as needed, although generally, none is required. The hematocrit is usually checked in the evening, and a specimen for liver function tests is sent to the laboratory at the time of discharge. By the following morning, most patients are eager to be discharged, and they leave after breakfast. The patient is seen 7 to 10 days later for evaluation and inspection of the incisions.
REVIEW OF RESULTS Experience with laparoscopic cholecystectomy is being gained rapidly. To date, reports by three groups': 3, 4 have established the procedure as being safe. A report submitted for publication by Fitzgibbons and associates and our own data are summarized in Table 2. Most of the procedures have been performed for symptomatic gallstones. Experience with acute cholecystitis and gallstone pancreatitis is too limited at this time to make a statement about efficacy. Operative time has been acceptable. The chief advantages include a short hospital stay and early return to work. Standard laparotomy has been required in less than 5% of patients because of bleeding, bile leak, bile duct injury, or technical difficulties. Thus far, the complication rate is 5%, and the mortality rate O. More data will be necessary to determine whether the incidence of bile duct injury will be higher or similar to that of open cholecystectomy. Because there are only three published reports on laparoscopic cholecystectomy, the incidence of complications has not been well documented. There are anecdotal reports of serious complications, but these have not been published. In the series of 220 patients described by Dubois and coworkers, 1 no complications occurred in the last 180 patients. Among the first 36 patients, two complications were reported: bleeding from avulsion of the cystic artery and a bile collection. The first patient was treated with
1259
LAPAROSCOPIC CHOLECYSTECTOMY
Table 2. Results of Laparoscopic Cholecystectomy
No. of patients Mean age (range) Indications (%) Biliary colic Cholecystitis Polyps Pancreatitis Asymptomatic Average operative time (min) Average hospital stay (days) Return to normal activity (days) Complication rate (%) No. of open procedures Deaths
DUBOIS
REDDICK
ZUCKER
ETAL1
& OLSEN 3
ET AL4
FITZGIBBONS ET AL*
ET AL
220 36 (29-86)
25 40 (NA)
100 53 (17-85)
100 44 (15-87)
60 54 (33-83)
72
100
91 6 2 1
88 12
90 9
NA
95
104
110
100
3-7 3-7
1.96 6.5
