Professional Documents
Culture Documents
and Cholecystostomy
George A. Fielding
Laparoscopic Cholecystectomy
Mouret performed the first laparoscopic cholecystectomy in Lyon in 1988, and the first
written report was by Dubois in 1989. Reddick popularized the procedure in the United
States in 1990.
Procedure
STEP 1 Access
Once caudad retraction of the fundus is established, the crucial maneuver is lateral retrac-
tion of Hartmann’s pouch by the upper lateral 5-mm port. This places Calot’s triangle on
the stretch and will greatly reduce the chance of injury of the common bile duct.
STEP 3
Then incise the posterior peritoneal attachment behind Hartmann’s pouch to separate
Hartmann’s pouch from the liver to further stretch out Calot’s triangle.
530 SECTION 4 Biliary Tract and Gallbladder
STEP 4
Once these two maneuvers are instituted, hook dissection can be performed, staying
close to the gallbladder to incise the anterior sheet of peritoneum over Calot’s triangle.
This will expose one or two cystic arteries and the cystic duct . Windows should be
developed between all these structures before anything is divided.
Once the anatomy is determined (see anatomical variations and tricks), the cystic
arteries are divided between clips and a clip is placed below Hartmann’s pouch to the
proximal end of the cystic duct.
Laparoscopic Cholecystectomy, Open Cholecystectomy and Cholecystostomy 531
STEP 5 Cholangiography
Once cholangiography is completed, the ureteric catheter is removed and the cystic
duct is clamped. The gallbladder is then removed from the liver bed using hook
diathermy. This is done through a combination of elevating the peritoneum, burning
with the hook and pushing so that the gallbladder is removed toward the fundus and
finally separated from the liver at the fundus. There is very little place for fundus-first
laparoscopic cholecystectomy.
Laparoscopic Cholecystectomy, Open Cholecystectomy and Cholecystostomy 533
Anatomical Variations
■ The major anatomical variations are involved with the common bile duct and the
right hepatic artery.
■ A very small common bile duct can be mistaken for the cystic duct and completely
excised. Even more worrisome is the variant of a low junction of the left and right
hepatic ducts (A) or a low junction of the right anterior and right posterior hepatic
ducts (B). In these situations the cystic duct can enter the right hepatic duct
or the right posterior hepatic duct. The right or right posterior ducts can therefore
be mistaken for the cystic duct and divided.
■ More rarely, but even more difficult, particularly in the setting of acute cholecystitis,
is when there is no cystic duct and Hartmann’s pouch opens directly underneath the
right hepatic duct or the common duct.
534 SECTION 4 Biliary Tract and Gallbladder
Complications
Bleeding
The major intraoperative complication is bleeding. This is typically from a very short
cystic artery or from the right hepatic artery itself. Bleeding from the portal vein is very
rare, but in contrast to hepatic and cystic artery bleeding, it is always torrential and the
patient must be opened.
Failure to Progress
The second major complication is failure to progress. If the surgeon is not making any
progress, the patient should be converted to an open cholecystectomy.
Postoperative Complications
■ Most bile leaks are low volume and will settle spontaneously.
■ A high volume bile leak is suggestive that the clip has come off the cystic duct
or there is a major unrecognized duct injury. ERCP will determine this, allowing
appropriate management.
■ Subphrenic collection may require percutaneous drainage.
■ Pneumonia – best treated with physiotherapy and antibiotics.
■ Jaundice suggests major duct obstruction or excision – ERCP or referral to a
hepatobiliary specialist.
■ In cases with portal hypertension and cirrhosis, patients should be considered for
a partial cholecystectomy, where the back wall of the gallbladder is left on the
liver bed. Failure to do so can result in life-threatening hemorrhage. Further-
more, with laparoscopic surgery, you simply will not be able to see the operative
field due to the blood.
■ In severe acute cholecystitis, the first step is to decompress the gallbladder by
inserting the trocar directly into the gallbladder and aspirating the contents.
This will convert a tense, unmanageable gallbladder to a collapsed thick-walled
gallbladder that can be grasped and maneuvered.
■ If there is a stone impacted in Hartmann’s pouch, it should be pushed back into
the gallbladder to allow safe manipulation of Calot’s triangle.
Laparoscopic Cholecystectomy, Open Cholecystectomy and Cholecystostomy 535
Open Cholecystectomy
Until 1989 open cholecystectomy was the procedure of choice for all the complications
of symptomatic gallstones. It has largely been supplanted by laparoscopic cholecystec-
tomy as a freestanding elective procedure. The principle of open cholecystectomy is
removal of the gallbladder and its contents with preservation of the biliary tree.
Procedure
Operative table allowing C-arm fluoroscopy. If done for patient choice, and there are no
other contraindications, a 5-cm transverse incision is centered over the lateral border
of the rectus sheath made.
STEP 2
STEP 3
The peritoneal cavity is elevated with the fingers and the wound incised along its full
length. Three packs are inserted – one behind the liver, one on the colon and one over
the gastroduodenal area and retractors are placed over the gastroduodenal area and
one over the liver to place Calot’s triangle on the stretch.
538 SECTION 4 Biliary Tract and Gallbladder
STEP 4
The key step in open cholecystectomy is division of the cystic artery, which allows
Hartmann’s pouch to swing out and allow clear definition of the biliary anatomy.
The cystic duct is clipped and the gallbladder is retracted inferiorly and dissected free
of the liver.
Cholangiography is typically performed through the cystic duct using the same
equipment as for laparoscopic cholecystectomy.
Once the anatomy has been determined and cleared, the gallbladder is removed.
This is typically done starting from Hartmann’s pouch, but in the case of severe
inflammation it may be better done with the fundus first dissection, carefully dividing
in the plane between the liver and the gallbladder (A-1, A-2).
A-1
A-2
Complications
Cholecystostomy
Indications ■ Percutaneous cholecystostomy is used most commonly in the setting of a severely ill
patient with underlying gallbladder sepsis.
■ Operative severe inflammation of Calot’s triangle at surgery where the safest option
is to decompress the gallbladder.
Procedure
Cholecystostomy may be performed open but this is much more typically found at
laparoscopic cholecystectomy.
STEP 1
The 5-mm lateral trocar is inserted directly into the gallbladder and the gallbladder
aspirated. The gallbladder will collapse, typically showing a large stone in Hartmann’s
pouch; if this can be milked back and removed it should be done.
STEP 2
A Foley catheter is inserted via the lateral port directly into the gallbladder.
Cholangiography can be completed via this if indicated.
STEP 3
The trocar is removed from the gallbladder, leaving the Foley catheter in place, which
is then insufflated. The gallbladder is sutured 2nd request around the Foley catheter.
The Foley catheter is then left on free drainage and should be left in place at least
6weeks to allow the gallbladder to settle prior to returning to complete the laparoscopic
cholecystectomy.
The Foley catheter should be irrigated twice daily with 20ml of saline.