COLECISTECTOMÍA

The Main Bile Duct and the Sphincter of Oddi

The main bile duct (Figure 2.6),

the mean diameter of which is about 6 mm, is divided into two segments: the
upper segment is called the common hepatic duct and is situated above the cystic
duct, which joins it to form the common bile duct. The common duct courses
downwards anterior to the portal vein in the free edge of the lesser omentum and is
closely applied to the hepatic artery which runs upwards on its left, giving rise to the
right branch of the hepatic artery which crosses the main bile duct usually posteriorly,
though sometimes anteriorly. The cystic artery, arising from the right branch of the
hepatic artery, may cross the common hepatic duct posteriorly or anteriorly. The
common hepatic duct constitutes the left border of the triangle of Calot, the other
borders of which were originally described as the cystic duct below and the cystic
artery above. However, the commonly accepted working definition of Calot's
triangle recognizes the inferior surface of the right lobe of the liver as the upper
border and the cystic duct as the lower. Dissection of Calot's triangle is of key
significance during cholecystectomy (see Chapter 44) since in this triangle runs the
cystic artery, often the right branch of the hepatic artery and occasionally a bile duct
which should be displayed prior to cholecystectomy. In the event of an anomalous
hepatic artery arising from the superior mesenteric trunk (see Chapter 3), this vessel
usually courses upwards in the groove posterolateral to the common biliary channel,
appearing on the medial side of Calot's triangle and usually running just behind the
cystic duct where it is vulnerable during cholecystectomy or portacaval shunt. The
union between the cystic duct and the common hepatic duct may be located at various
levels. At its lower extrahepatic portion the common bile duct crosses the pyloric
vessels and the retroduodenal artery (Figure 2.9)
 and then traverses the posterior aspect of the pancreas running in a groove or
tunnel. The retropancreatic portion of the common bile duct approaches the second
portion of the duodenum obliquely, accompanied by the terminal part of the duct of
Wirsung. This duct courses from left to right within the pancreas, curves downwards
approaching the common bile duct, and runs parallel with but separated from it by the
transampullary septum to enter the duodenum at the papilla of Vater after traversing
the sphincter of Oddi.

The sphincter of Oddi has been thoroughly studied; (see Chapter 9) and
consists of a unique cluster of smooth muscle fibres (Figure 2.10)
 distinguishable from the adjacent smooth muscle of the duodenal wall. The
papilla of Vater at the termination of the common bile duct is a small nipple-like
structure protruding into the duodenal lumen and marked by a longitudinal fold of
duodenal mucosa. The duct of Wirsung as it runs down parallel with the common bile
duct for some 2 cm joins it within the sphincteric segment in some 70–85% of cases,
enters the duodenum independently in 10–13% of patients and in only 2% is replaced
by the duct of Santorini. Further details of the anatomy and function of the sphincter
of Oddi are found in Chapter 9, 56 and 58.

Gallbladder and Cystic Duct

The gallbladder is a reservoir located on the undersurface of the right lobe of
the liver within the cystic fossa and separated from the hepatic parenchyma by the
cystic plate, which is constituted of connective tissue closely applied to Glisson's
capsule and prolonging the hilar plate (see Figure 2.7).

Sometimes the gallbladder is deeply embedded in the liver but occasionally

presents on a mesenteric attachment and may then be liable to volvulus. The
gallbladder varies in size and consists of a fundus, a body and a neck. The tip of the
fundus usually, but not always, reaches the free edge of the liver and is closely
applied to the cystic plate. The cystic fossa is a precise anterior guide mark to the
main liver scissura (see Chapter 1). This is of major importance in the performance of
right and left liver resection (see Chapter 1 and 100). The neck of the gallbladder
makes an angle with the fundus. A large gallstone lodged in this part of the neck of
the gallbladder creates a Hartmann's pouch, which may obscure the common hepatic
duct and constitute a real danger point during cholecystectomy (see Chapter 62).
Indeed, erroneous common hepatic duct resection has been recorded during this step
of the operation. Sometimes, freeing of the neck of the gallbladder during
cholecystectomy may threaten the right branch of the hepatic artery (or an aberrant
right hepatic artery) and, rarely, the right hepatic duct.

The cystic duct arises from the neck or infundibulum of the gallbladder and
extends to join the common hepatic duct. Its lumen usually measures some 1–3 mm.
Its length is variable, depending upon the type of union with the common hepatic duct
(see below). The mucosa of the cystic duct is arranged in spiral folds known as the
valves of Heister. Its wall is surrounded by a sphincteric structure called the
sphincter of Lutkens. While the cystic duct joins the common hepatic duct in its
supraduodenal segment in 80% of cases, it may extend downwards to the
retroduodenal or even retropancreatic area. Occasionally the cystic duct may join the
right hepatic duct or a right hepatic sectoral duct (see below and Chapter 62).

The blood supply of the gallbladder is by the cystic artery, which has multiple
variations (Figure 2.11).
 Ignorance of these may provoke unexpected haemorrhage during
cholecystectomy and may result in bile duct injury during efforts to secure
haemostasis (see Chapter 44 and 62).

Biliary Ductal Anomalies

Full knowledge of the frequent variations from the described normal biliary
anatomy is required while performing any hepatobiliary procedure.

The constitution of a normal biliary confluence by union of the right and left
hepatic ducts as described above is reported in only 57 to 72% of cases. This
difference in figures is probably due to the fact that the study of Healey & Schroy did
not recognize a triple confluence of the right posterior sectoral duct, the right anterior
sectoral duct and the left hepatic duct, recorded in 12% of instances by Couinaud
(Figure 2.12).

Anomalies of the Accessory Biliary Apparatus

A number of anomalies have been described by Gross 20 (Figure 2.15).

While rare, agenesis of the gallbladder, bilobar gallbladders with a single

cystic duct but two fundi and duplication of the gallbladder with two cystic ducts
have all been described. Finally, a double cystic duct may drain a unilocular
gallbladder as described by Perelman. Congenital diverticulum of the gallbladder
with a muscular wall is also to be found.
 More frequently reported are anomalies of position of the gallbladder, which
may lie either in an intrahepatic position completely surrounded by normal liver
tissue or may be found on the left of the liver. This may give rise to diagnostic and
technical problems.

The mode of union of the cystic duct with the common hepatic duct may be
angular, parallel or spiral (Figure 2.16).

An angular union is the most frequent and is found in 75% of patients. The
cystic duct may run a parallel course to the common hepatic duct in 20%, with
connective tissue ensheathing both ducts. Finally, the cystic duct may approach the
common bile duct in a spiral fashion curving about it usually from the posterior
aspect. All these anatomical variations may lead to biliary ductal injury during
cholecystectomy, especially if persistent attempts are made to display the union
between cystic duct and the common biliary channel — a practice to be discouraged
(see Chapter 44 and 62). The absence of a cystic duct is probably an acquired
anomaly representing a choledochocholecystic fistula (see Chapter 62).

Bile Duct Blood Supply

 The blood supply of the bile duct has received attention. Indeed, despite the
presence of a rich biliary ductal vasculature, it is proposed that arterial damage during
cholecystectomy may cause ischaemia and result in postoperative bile duct stricture.

It seems unlikely that ischaemia alone is a major mechanism in the causation

of bile duct stricture but may be contributory especially in the retraction of the
common hepatic duct seen after injury (see Chapter 62).

According to Northover & Terblanche , the bile duct may be divided into three
segments: hilar, supraduodenal and retropancreatic (lower common bile duct).
The blood supply of the supraduodenal duct is essentially axial (Figure 2.17):
most vessels to the supraduodenal duct arise from the retroduodenal artery, the right
branch of the hepatic artery, the cystic artery, the gastroduodenal artery and the
retroportal artery. On average, eight small arteries measuring each about 0.3 mm in
diameter supply the supraduodenal duct. The most important of these vessels run
along the lateral borders of the duct and have been called the 3 o'clock and 9 o'clock
arteries (Figure 2.17). Of the blood vessels vascularizing the supraduodenal duct,
60% run upwards from the major inferior vessels, and only 38% of arteries run
downwards, originating from the right branch of the hepatic artery and other vessels.
Only 2% of the arterial supply is non-axial, arising directly from the main trunk of the
hepatic artery as it courses up parallel to the main biliary channel. The hilar ducts
receive a copious supply of arterial blood from surrounding vessels, forming a rich
network on the surface of the ducts in continuity with the plexus around the
supraduodenal duct. The source of the blood supply of the retropancreatic common
bile duct is from the retroduodenal artery, which provides multiple small vessels
running around the duct to form a mural plexus.

The veins draining the bile ducts are satellites to the corresponding described
arteries, draining into 3 o'clock and 9 o'clock veins along the borders of the common
biliary channel. Veins draining the gallbladder empty into this venous system and not
directly into the portal vein. The biliary tree seems to have its own portal venous
pathway to the liver 31.

Biliary exposure is the most important step in any biliary operative

procedure. A thorough knowledge of the anatomy of the biliary tract is essential if
dissection is to be precise and error avoided. Thus, bile duct injury during
cholecystectomy is generally due to inadequate bile duct exposure or failure to
recognize variations in anatomy.

Cholecystectomy is usually performed for symptomatic cholecystolithiasis

and for related complications. Cholecystectomy for acalculous cholecystitis,
adenomyomatosis or gallbladder carcinoma is less frequent. Asymptomatic
cholecystolithiasis has been considered as an indication for cholecystectomy in
diabetes or immunocompromised patients, but this has recently been challenged.

There are two important areas where improvement in diagnosis is necessary.

First, patients with right upperquadrant abdominal pain may have symptoms
unrelated to the presence of stones in the gallbladder. Thus, postcholecystectomy
pain, which has been observed in up to 30% of cases, may be the consequence of an
operation performed for symptoms unrelated to the presence of gallstones. Secondly
and by contrast, patients with characteristic symptoms but with absence of stones in
the gallbladder and who may be cured by a cholecystectomy have been identified,
and improvement in selection of cases for operation is necessary.

Some clinical features should alert the surgeon to possible operative

difficulties. Repeated and prolonged attacks of biliary pain might be associated with
chronic inflammation and dense adhesions or fibrous obliteration of Calot's triangle.
Liver function tests should be performed systematically before cholecystectomy. Any
abnormality (elevation of the bilirubin or alkaline phosphatase levels) requires serious
attention, since the change may not be caused by the presence of stones in the bile
duct but may be an index of other extrahepatic biliary tract disease. Diagnoses such as
the Mirizzi syndrome, tumour of the gallbladder or of the bile duct, choledochus cyst
or sclerosing cholangitis are all possibilities. Although patients submitted to
cholecystectomy will usually have undergone ultrasonography, more detailed
investigations should be performed if there is any doubt as to the integrity of the bile
duct. Endoscopic retrograde cholangiography will usually allow identification of
stones or other abnormalities.

Perfect knowledge of the anatomy of the bile ducts and of the possible
variations (see Chapter 2) is necessary to perform safe cholecystectomy. Unidentified
anatomical anomalies during operation often result in iatrogenic lesions of the bile
duct. Therefore, precise intraoperative identification of the anatomy is necessary
before dividing or ligating any structure.

The normal localization of the neck of the gallbladder and the cystic duct is
between the peritoneal surfaces within the right anterior part of the hepatoduodenal
ligament. The cystic artery runs transversely, forming with the cystic duct and
bile duct the triangle described by Calot in 1891. The triangle of
cholecystectomy (often misnamed as Calot's triangle) has for its upper superior
limit not the cystic artery but the inferior surface of the liver. Dissection of this
area should clearly demonstrate the anatomical structures and allow safe dissection
Figure

The junction between the cystic and common hepatic duct has many variations
(Figure 44.3 and 44.4; see Chapter 2). The cystic duct may join the right side of the
common bile duct after a parallel course, or it may be very short and almost non-
existent. An apparently short cystic duct might, in reality, be a long duct fused and
running parallel to the choledochus or it may be connected to the right hepatic duct.
The cystic duct may also join the left side of the choledochus, having crossed it
anteriorly or posteriorly. The cystic duct may on occasion be contracted as a result of
a chronic inflammatory process such as seen in the Mirizzi syndrome.

An unappreciated abnormal confluence of the hepatic ducts probably

represents the most important source of error leading to damage to the biliary tract
during cholecystectomy (see Chapter 62). These variations may involve a direct
hepatocystic ductal junction or a sectoral duct joining the choledochus just above or
below the cystic duct. An abnormal confluence of the hepatic ducts has been reported
in up to 43% of cases and a low junction with a right sectoral duct in 20% of cases
(Figure 44.4); 8–10.
 Abnormalities of the anatomy of the cystic artery are also frequent, and the
right branch of the hepatic artery may inadvertently be transected if not clearly
identified. An origin of the right hepatic artery from the superior mesenteric artery
results in passage of the vessel posterolaterally to the common bile duct and behind
the cystic duct, where it may be vulnerable. Although the necessity to systematically
perform intraoperative cholangiography is still debated, the routine use of this
procedure is advocated by most surgeons. Besides demonstrating unidentified stones
or pathology in the intra- or extrahepatic bile ducts, intraoperative cholangiography
provides a precise view of the anatomy of the biliary ductal system. This may help in
avoiding operative errors resulting in biliary injury. Thus, a review of 78
postcholecystectomy strictures revealed that in only 29% of these was intraoperative
cholangiography performed. Good technique is important and is detailed in Chapter
28.
 The retrograde technique of cholecystectomy, which involves initial dissection
of the cholecystectomy triangle, should be chosen when there is clear visualization of
its anatomical limits. Whenever the features in this region are not perfectly clear as a
result of acute or chronic inflammation, the anterograde or 'fundus down' technique is
generally considered safer since initial dissection of the gallbladder from the fundus
allows progressive demonstration of the anatomy down to the infundibulocystic
junction. The basic principles of dissecting close to the gallbladder and demonstrating
clearly any structure before ligature or section is performed must be respected.
 Método gold-standard para extraer una vesícula = COLECISTECTOMIA
LAPAROSCOPICA.
 Aseo de la piel con Betadine o Gerdex iniciando en donde el cirujano hará la
incisión. Se limpia con Betadine desde la linea mamilar (horizontal) hasta los
muslos inclusive y a los lados hasta ambas líneas axilares posteriores. Se
culmina en el ombligo.
 INCISIÓN:
o SUBCOSTAL DERECHA = KOCHER. Inicia a 2cm por dentro de la
línea media y se extiende 6-8cm (longitud variable dependiendo de las
características del paciente).
o MEDIANA SUPRAUMBILICAL: desde el apéndice xifoides hacia el
ombligo.
o PARA-MEDIANA: se hace 2-4cm lateral a la línea media corporal y
dependiendo del sitio en donde se atraviese la aponeurosis (vaina) de
los rectos se subdivide en:
 Para-rectal interna
 Para-rectal externa
 Trans-rectal
 Diéresis por planos.
 Abordaje de cavidad.
 Visualización de hallazgos.
 Exposure of the Operative Field and Initial Assessment
o The inferior aspect of the liver is normally accessible without
dissection, but adhesions are often present and must be freed. Such
adhesions may be dense and inflammatory, obscuring the anatomy of
the region. Dissection should be performed close to the gallbladder,
keeping in mind that a cholecystocolic or cholecystoduodenal
fistula might be present. In this case, the fistula must be transected to
expose the gallbladder. The opening in the colon or duodenum is
subsequently sutured. If the gallbladder cannot be identified, one
should suspect that it is scarred and contracted or that it is located
within the liver. It might be safe in such a situation to identify first the
distal bile duct and dissect it from below until the infundibulum of the
gallbladder or cystic duct is encountered. Intraoperative ultrasound
examination may be useful.
o Palpation of the intra-abdominal organs should be performed
whenever possible, with special emphasis on the liver, hepatoduodenal
ligament and pancreas. The gallbladder must be gently palpated and
not emptied by compression even if stones are not detected because,
first, their presence has already been demonstrated by preoperative
investigations and, secondly, manual compression of the gallbladder
may result in migration of small stones into the common bile duct.
 Elaboración del campo quirúrgico. Se introducen tantas compresas húmedas
como sea necesario. En general son tres compresas que se colocan de la
siguiente manera: una, que rechaza el estómago (la más medial); otra que
rechaza el colon (la más lateral) y por último otra que rechaza el duodeno y
las vísceras (la del medio).
 Prehensión de la vesícula en su fondo con una pinza (Kelly, Triangular o aro).
 Colocación de otra pinza en el bacinete = bolsa de Hartmann (la parte de la
vesícula más próxima a los conductos. No es el cuello).
 Emptying of the Gallbladder
 o The dissection is usually eased by a slight distension of the
gallbladder, and for this reason puncture of the gallbladder and
aspiration of its content should not be performed systematically. Gross
distension may, however, obscure the cholecystectomy triangle and
grasping of the distended gallbladder with forceps might be
impossible. One should not hesitate in these circumstances to puncture
the fundus and aspirate bile; bile culture is indicated, and is mandatory
in cholecystitis or cholangitis.
 Disección de los elementos del triángulo que conforman el triángulo de Calot
(arteria cistica, conducto cistíco, ganglio, conducto hepático común). El
triángulo de Calot está delimitado por el conducto cístico (borde derecho del
triángulo); el conducto hepático común se corresponde con el borde izquierdo
del triángulo y constituyendo el límite superior está la arteria cística.

 Pinzamiento, sección y ligadura con seda 2-0 de arteria. Se diseca y deja

referido el conducto cístico (OJO, SOLO CUANDO SE ESTÁ SEGURO
ES QUE SE LIGA EL CONDUTO, DE LO CONTRARIO SE DEJA
REFERIDO para evitar ligar la vía biliar principal = conducto colédoco o
inclusive el conducto hepático común).
 COLECISTECTOMÍA PROPIAMENTE DICHA (extracción de la vesícula
del lecho vesicular hepático) que puede ser desde el fondo al bacinete
(ANTEROGRADA por lo que el cístico que fue previamente referido es
ligado al final, una vez que se libere la vesícula del lecho) o desde el bacinete
hacia el fondo vesicular (RETROGRADA; una vez disecado el cístico, se liga
y se empieza la disección de la vesícula separándola del lecho desde el cístico
ligado hacia el fondo) o resecando la vesícula por ambos lados de manera
simultanea (MIXTA).- Schwartz. Para otros autores, la colecistectomía
anterógrada se efectúa separando primero la vesícula del lecho desde el fondo
al bacinete y ligando a lo último, la arteria y el conducto cístico. (Blumgart
and Fong)
 Retrograde Cholecystectomy
o The peritoneum covering the hepatoduodenal ligament is incised
anteriorly across the region of Hartmann's pouch; this incision is
pursued posteriorly in the same way, giving easy access to the
infundibulum of the gallbladder. A Duval or similar forceps is placed
at the fundus of the gallbladder in the region of Hartmann's pouch
(Figure 44.5a)

and dissection of the cholecystectomy triangle is commenced. It is

important to keep close contact with the gallbladder and to
demonstrate the cholecystocystic junction. The lower limit of the
triangle is the cystic duct and a ligature is passed around it but not
tied. Slight tension produced by a clamp hanging on this ligature might
prevent migration of stones from the gallbladder into the cystic duct.
The cystic artery is normally above the cystic duct; it is important to
dissect it towards the gallbladder to see its final distribution into the
gallbladder wall (Figure 44.5b). This is the best way to prevent ligature
of an aberrant right hepatic artery. At this stage, the junction of the
gallbladder infundibulum with the cystic duct and the distribution of
the cystic artery into the gallbladder wall is clearly demonstrated. The
cystic duct is palpated to detect stones which could, at this stage, be
pushed back into the gallbladder (Figure 44.6).

The cystic artery can be ligated and transected (Figure 44.7).

o A ligature or clamp is placed at the cholecystocystic junction and the
cystic duct is opened transversely 3 mm distally. A suitable canula for
cholangiography is gently inserted into the cystic duct, taking care not
to tear it (Figure 44.8).
 If an obstacle is encountered, and if the presence of a stone has
been excluded by palpation, a valve or tortuous cystic duct is probably
the cause. It is useful in this event to insert the end of a long, fine
clamp into the cystic duct and to dilate it gently. This usually allows
easy subsequent placement of the canula.
o A variety of canulae are described; the author prefers a transparent
polyethylene catheter, which allows easy identification and removal of
air bubbles before insertion. This catheter is fixed by tying the ligature
previously passed around the cystic duct. Cholangiography is
performed using the technique of Bolton & Le Quesne 13. All
instruments and retractors are removed, and the patient is slightly
rotated to the right (20°) before the contrast medium is injected. It is
important to inject initially a small quantity (1–2 ml) of the contrast
 agent in order to be able to identify small stones in the bile duct. The
ductal system of the biliary tract should be fully displayed, and
fluoroscopy is valuable in this regard. Two or three films are taken.
Whilst awaiting the cholangiograms, the cystic duct may be divided,
leaving the catheter in place; the gallbladder is then dissected from its
fossa either by sharp dissection, diathermy, with the help of gentle
traction or, on occasion, finger dissection. The dissection should be
kept close to the gallbladder, within the cystic plate (see Chapter 2), in
order to avoid damage to the liver parenchyma, which may
nevertheless occur in cases of chronic cholecystitis. In cases of acute
cholecystitis with considerable oedema, this plane is best found by
sharp dissection using scissors.
o There may occasionally be small bile ducts connecting the gallbladder
to the intrahepatic bile ducts. Transection of these is without
consequence when the biliary tree is not obstructed. Haemostasis of
the gallbladder fossa does not pose any problem. However, if the liver
parenchyma has been lacerated, a gauze pack should be placed in the
gallbladder bed and held in place with a retractor for at least 5
minutes. If the haemorrhage is not controlled, deep haemostatic
sutures should be placed. Formal closure of the gallbladder bed is
probably more harmful than useful in preventing postoperative fluid
collection.
o The gallbladder should then be opened and checked for the presence of
tumours. Inspection of stones may help to interpret the
cholangiograms, which are then assessed according to the criteria of
Bolton & Le Quesne 13. If there is any doubt as to the presence of
stones or the normality of the bile duct, a further set of films should be
obtained, especially if the initial cholangiograms were of poor quality.
o The anatomy of the intrahepatic bile ducts may be obscured by
incomplete proximal filling because of early passage of the contrast
 agent through the papilla. Low clamping of the hepatoduodenal
ligament with an intestinal clamp may give better images if the cystic
duct joins the hepatic duct above the clamp. A leak may be detected,
and its origin should be identified. In most cases, it will originate from
the gallbladder bed and may then be secured by a suture.
o A small leak will be without consequence and will close spontaneously
within a few days if there is no obstruction of the distal bile duct. The
cholangiography catheter is then removed and the cystic duct suture
ligated, using resorbable suture material (Figure 44.9).

The insertion of a drain before closing the abdominal wall is

controversial, and in most cases is unnecessary. If a small bile leak is
identified, insertion of a drain positioned close to the gallbladder bed
will prevent collection of bile. Usually only 50 ml of haemoserous
 fluid will drain during the first 24 hours, after which the drain may be
removed; however, the drain should be retained if there is excessive
oozing or leakage of bile.
 Anterograde or 'Fundus Down' Cholecystectomy
o An incision of the gallbladder serosa is performed 0.5 cm from the
liver edge, and a plane is developed between the serosa and the
gallbladder wall by sharp dissection, so as to allow entry to the cystic
plate (see Chapter 2). The gallbladder is still vascularized via the
cystic artery (Figure 44.10).

In the region of the infundibulum, the cystic artery is seen to enter

the gallbladder wall (Figure 44.11).
 After ligature and section of the cystic artery close to the
gallbladder wall, the infundibulum is dissected free, down to the
junction with the cystic duct. This technique may cause migration of
stones from the gallbladder into the cystic duct, but careful palpation
should identify these stones after the cystic duct has been isolated. Not
more than 0.5–1 cm of cystic duct should be dissected.
Cholangiography and cystic duct ligature are performed in the same
way as described for the retrograde technique.
 Partial Cholecystectomy
o Cholecystectomy may be hazardous when only the fundus of the
gallbladder can be recognized and when the region of the
infundibulum cannot be delineated because of fibrosis and
inflammation obscuring the triangle of Calot (Figure 44.12).
 It is then judicious to open the fundus and to introduce a finger into
the gallbladder in order to guide the dissection (Figure 44.13a).
Impacted stones should be removed.
o If no bile appears, the cystic duct is probably occluded by fibrosis and
inflammation. A partial cholecystectomy is the safest procedure in this
situation. The use of this technique has also been advocated in cases
with severe portal hypertension (Cottier et al 1991).
o The anterior visible wall of the gallbladder is excised, but the posterior
wall in contact with the liver is left in place down to the region of the
infundibulum. The mucosa is removed by curettage and
electrocoagulation, and a drain is placed in the region of the
infundibulum (Figure 44.13b).
 No attempt at ligating the cystic duct should be made when the
region is severely altered by inflammation. If a gush of bile occurs
when a big impacted stone is removed from the infundibulum, a
cholecystocholedochal fistula is probably present (Mirizzi syndrome
type 11). It is then advisable to keep the opened distal part of the
gallbladder intact to allow a cholecystoduodenostomy or a
cholecystojejunostomy. Attempted direct repair of the fistula is
hazardous 14.
 Hemostasia.
 Intraoperative Problems
o Intraoperative problems have been related to three main causes,
namely dangerous surgery, dangerous anatomy and dangerous
pathology; (see Chapter 62). Insufficient preoperative assessment of a
 complicated situation is certainly another avoidable cause of
intraoperative difficulties.
o Dangerous surgery arises from inadequate or imprecise observation of
the technical principles of cholecystectomy, insufficient experience,
inadequate incision and exposure, or inadequate assistance. Some of
the anatomical variations which have previously been mentioned are
particularly dangerous and, in particular, a narrow common bile duct
can be mistaken for the cystic duct (see Chapter 62).
o Dangerous pathology includes chronic or acute inflammation which
results in obscured anatomy and increased vascularity in the region of
the cholecystectomy triangle (Figure 44.12). Portal hypertension is
associated with increased venous collateralization, which makes the
dissection haemorrhagic and dangerous. Partial cholecystectomy has
been advocated in both situations 6.
o Haemorrhage in the cholecystectomy triangle represents potential
danger since attempts at haemostasis by placing clamps with an
obstructed and insufficient view may result in inadvertent clamping of
the right or common hepatic artery, or of the bile duct (Figure 44.14).
 In this situation, one should first attempt to control the
haemorrhage by digital compression or by clamping the
hepatoduodenal ligament (Figure 44.15)
 in order to localize its precise origin. Grasping the bleeding vessel
should be done with precision so as to limit the risks of including
another structure in the ligature. Cholangiography, even if already
performed, may be repeated and carefully analysed after haemostasis,
as it may reveal an iatrogenic lesion of the bile duct (leak, incomplete
or complete occlusion). Methods to deal with a freshly recognized
iatrogenic lesion of the bile duct are discussed in Chapter 62.
 Cuenta completa de material quirúrgico metálico y no metálico.
 Síntesis por planos:
o Peritoneo (no todos los cirujanos lo cierran) con crómico 2-0 a sutura
continua.
o Aponeurosis con vicryl o prolene 0 o 1 a puntos continuos.
 o Sub-cutáneo (no todos lo aproximan) con simple 2-0 o 3-0 puntos
continuos o separados.
o Piel con prolene o ethylon 2-0 o 3-0, puntos continuos intradérmico.
 Cura final.

BIBLIOGRAFIA.
 Blumgart and Fong. Surgery of the liver and the biliary tract. CD.
 Schwartz. Principios de cirugía. Volumen II. 5º edición. Editorial
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