65

Pictorial Laparoscopic

cholecystectomy

is a recent

surgical

Essay

innovation

American Journal of Roentgenology 1992.159:65-67.

Operative Cholangiography in Patients Undergoing Laparoscopic Cholecystectomy: Unique Radiographic Findings Suppiah

Balachandran,1

in which

a cholecystectomy

Philip

Goodman,1

Rami Saydjari,2

Mark

the

(

is performed

through

four

ports

in

W. Hogge,1

anterior

Unlike

abdominal

conventional

and Morton

wall

under

cholecystectomy,

H. Leonard,

direct

vision no

Jr.1

via a laparoscope.

abdominal

incision

Is

-

#{174}_

0-

1 Fig. 1.-Four abdominal ports are created during gallbladder also occurs through this port. Cannulas

laparoscopic in remaining

cholecystectomy. Port i I5 created for passage of the laparoscope. Final removal of the ports admit various surgical instruments for dissection, irrigation, and cholangiography.

Fig. 2.-Cholangiogram shows hardware used during laparoscopic cholecystectomy. All four plastic disposable cannulas have flush ends. Cannulas 1 and 2 are 10 mm in diameter and allow entry of laparoscope and surgical instruments, respectively. A metal clamp overiies cholangiographic catheter, which enters through port 2, upper midline port. Laparoscope that was inserted through lower midline umbilical port was withdrawn before film exposure. Cannulas 3 and 4 enter through lateral (subcostal) ports, are 5 mm in diameter, and are mainly Intended for grasping and retracting gallbladder during dissection. A nasogastric tube is used in all cases to deflate stomach, which would otherwise obstruct operative field. Cholangiographic catheter usually Is inserted Into abdomen through Intracath sheath placed beside lower lateral cannula (arrow). Surgical instrument constantly present in operative field is cholangiographic clamp that Is inserted through port 2. Jaws of clamp placed over cystic duct secure cholangiographic catheter and prevent leakage of contrast material. Fig. 3.-Cholangiogram shows beveled to plastic cannulas. Use of metal 1 and 2 are also seen.

identical

metal rather

cannulas (arrows) used during laparoscopic cholecystectomy. They are similar in size and have function than plastic cannulas is a personal preference of surgeon. Larger 10-mm plastic cannulas through ports

Received December 9, 1991 ; accepted February 5, 1992. 1 Department of Radiology, University of Texas Medical Branch, 301 University Blvd., Galveston, 2

Department

AJR 159:65-67,

of Surgery,

University

of Texas

July 1992 0361-803X/92/1591-0065

Medical

Branch,

0 American

Galveston,

Roentgen

TX 77550.

Ray SOciety

TX 77550. Address reprint requests to S. Balachandran.

66

BALACHANDRAN

made,

the abdomen

radiographs

lateral to the second subcostal cannula under direct visualization. A cholangiogram catheter is introduced into the ab-

The

seen on operative cholecystectomy. to avoid mistaken

American Journal of Roentgenology 1992.159:65-67.

performed

before

are made.

purpose

Operative

is

large

July 1992

moperitoneum, four puncture wounds (ports) are made in the anterior abdominal wall with trocars (Fig. 1). The first trocar is introduced supraumbilically. The remaining trocars are introduced under direct visualization by using the laparoscope. The trocars are withdrawn, and the cannulas are left in the abdominal ports to allow passage of instruments and the laparoscope (Figs. 2-5). Blunt dissection is used to find and

and cholangiography

with

AJR:159,

amounts of carbon the gallbladder is removed. These differences lead to several findings on operative cholangiograms that are not seen on cholangiograms obtamed in patients undergoing conventional cholecystectomy. In patients having the laparoscopic procedure, the extensive pneumoperitoneum causes the falciform ligament and the gallbladder to be visible on operative cholangiograms. Subcutaneous emphysema can be seen on the cholangiogram if carbon dioxide leaks into the abdominal wall via the abdominal ports. Also, the instruments used in the laparoscopic procedure are visible on the cholangiograms because they must remain in the field when the

dioxide,

is distended

ET AL.

of this essay

is to illustrate

cholangiograms

Recognition impressions

these

obtained

during

unique

findings

laparoscopic

of these differences is important that abnormalities exist.

Procedure

Laparoscopic cholecystectomy is performed in the operating room with the patient under general anesthesia [1]. After carbon dioxide is insufflated in the abdomen to create pneu-

Fig. 4.-Photographs

of hardware

A, I = irrigator, 2 = atraumatic B, i and 2 = metal cannulas,

used

in laparoscopic

isolate the cystic duct and cystic artery. The cystic artery is ligated with surgical clips and divided. The cystic duct is then partially transected sheath-over-needle

domen

this

sheath.

The

catheter

is grasped

and

directed into the opening in the cystic duct. A self-retaining clamp is used to hold the catheter in place, and cholangiograms are obtained. All other instruments are removed from the abdomen when the cholangiograms are obtained. After the radiographs are exposed, the catheter is withdrawn. The cystic duct is then ligated proximal and distal to the opening and divided by using microscissors. Electrocautery and blunt dissection are used to dissect the gallbladderfrom the liver.

cholecystectomy.

grasping forceps, 3 = cholangiographic 3 and 4 = plastic cannulas.

through

by using microscissors. A 1 2-gauge catheter is introduced into the abdomen

clamp.

Fig. 5.-Radiograph of hardware used in Iaparoscopic cholecystectomy: I and 2 = trocars with plastic cannulas, 3 = Irrigator, 4 = cholangiographic clamp, 5 = atraumatic grasping forceps, 6 and 7 = trocars with metal cannulas.

Fig. 6.-Subcutaneousemphysema.

Cholangio-

gram obtained during laparoscopic cholecystectorny shows leakage of carbon dioxide at port, resulting in subcutaneous emphysema (arrow). This

feature

cystectomy obtained

is

unique

to

laparoscopic

chole-

and is not seen on cholanglograms during

open

cholecystectomy.

All four

cannulas in their abdominal ports are visible. Cholangiogram catheter within its sheath is seen below arrow.

Fig. 7.-Cholangiogram

obtained during lapacholecystectomy shows gallbladder as pear-shaped structure (arrow) with density of soft tissue. Contrast Is provided by surrounding intense, artificial pneumoperitoneum. This feature is not readily appreciated on a cholangiogram during roscopic

open

cholecystectomy

because

pneumoperito-

neum is naturally occurring, open, and less intense. Three plastic cannulas in their abdominal ports are visible. Cholangiogram catheter enters cystic

duct.

AJR:159,

CHOLANGIOGRAPHY

July 1992

DURING

LAPAROSCOPIC

CHOLECYSTECTOMY

67

American Journal of Roentgenology 1992.159:65-67.

Fig. 8.-Extravasation of contrast material. Cholangiogram obtained during laparoscopic cholecystectomy shows collection of extravasated contrast material in subhepatic space (straight arrows). 5tones are seen in common bile duct (curved arrow). These features may also be seen on cholangiograms obtained during open cholecystectomy. Cholangiographic clamp is seen entering cannula in port 2. Two other cannulas are present, one each In ports 3 and 4. Cholangiogram obtained during laparoscopic cholecystectomy shows falciform ligament (arrows), which is easily visible pneumoperitoneum is artificially Introduced, and maintained throughout operative procedure by continuous flow of carbon is open, naturally occurring, and not very intense, intraabdominal structures such as faiciform ligament are not readily

Fig. 9.-Pneumoperitoneum. because surrounding contained dioxide. As pneumoperitoneum appreciated on cholangiograms

obtained during open cholecystectomy.

Cholangiographic

The gallbladder is usually removed intact via the supraumbilical port under direct vision. Bile and small gallstones in the gallbladder may be removed by suction to reduce the size of large

or distended

gallbladders

before

they

are withdrawn

through the abdominal port. The abdomen is irrigated with normal saline. The instruments and cannulas are removed, and the wounds are closed. Discussion Cholangiograms

obtained

during

tomy have several

features

that are not commonly

cholangiograms

These

include

obtained

during

an open

include

and filling defects The falciform

extravasated

ligament

of the large amount

contrast

dioxide

on intraoperative [3] is not seen.

laparosIntraoper-

ative Iaparoscopic cholangiograms help the surgeon correctly identify the common bile duct or its anatomic variations so that injury to the duct can be avoided or minimized [4]. On the basis

of the cholangiographic

findings,

the surgeon

may

elect to proceed with the laparoscopic cholecystectomy, cornplete the laparoscopic cholecystectomy and later attempt endoscopic retrograde retrieval of stones through the cornmon bile duct, or convert the Iaparoscopic cholecystectomy cholecystectomy.

cholecystectomy.

material

(Fig. 8)

bile duct.

(Fig. 9) is frequently

of carbon

is not included the urachus

seen on

displays

in the common

Because the pelvis copic cholangiograms,

to an open

cholecystec-

of pneumoperitoneum and subcutaneous emphysema (Fig. 6) and visualization of the unresected gallbladder (Fig. 7) and of unique hardware that must remain in the operative field during the film exposure. Findings seen on cholangiograms obtained during both types of procedures

unusual

laparoscopic

clamp is seen entering cannula in port 2.

visible

because

in the abdomen

[2].

REFERENCES 1 . Gradacz TR, Talamini MA. Traditional tomy. Am J Surg 1991;161 :336-338

versus laparoscopic

cholecystec-

2. Han SY. Variation in falciform ligament with pneumoperitoneum.

J Can Assoc Radio! 1980;31 : 171 -1 73 3. Jelaso DV, Schultz EH Jr. The urachus: an aid to diagnosis of pneumoperitoneum. Radiology 1969;92:295-296 4. Berci G. Sackier JM, Paz-Partlow M. Routine or selected intraoperative cholangiography during laparoscopic cholecystectomy? Am J Surg i991;161 :355-360