Safe laparoscopic cholecystectomy finale

1. 1. Safe Laparoscopic Cholecystectomy Presented by Dr Rahul Singh JR3 , General

Surgery K.G.M.U , Lucknow Moderator: Prof. Sandeep Tewari ( MS, FACS,
FIAGES,FICS) Professor Dept. Of General Surgery K.G.M.U , Lucknow
2. 2. • More than 1,00,000 laparoscopic cholecystectomies are performed every year in
India.1 • Reduced pain, faster return to normal activities, and reduced risk of surgical site
infection with a laparoscopic approach compared to an open operation.2 1.
http://www.thelaparoscopicsurgeon.in/service/laparoscopic-cholecystectomy/ 2.Keus F,
de Jong JAF, Gooszen HG, van Laarhoven CJHM. Laparoscopic versus open
cholecystectomy for patients with symptomatic cholecystolithiasis. Cochrane Database of
Systematic Reviews 2006:CD006231
3. 3. Indications • Symptomatic cholelithiasis • Biliary colic • Acute cholecystitis •
Asymptomatic cholelithiasis • Sickle cell disease Blumgart's Surgery of the Liver, Biliary
Tract and Pancreas, Chapter 34, 511531
4. 4. • Total parenteral nutrition • Chronic immunosuppression • Incidental cholecystectomy
for patients undergoing laparoscopic procedure for other indications • Acalculous
cholecystitis (biliary dyskinesia) Blumgart's Surgery of the Liver, Biliary Tract and
Pancreas, Chapter 34, 511531
5. 5. • Gallstone pancreatitis • Gallbladder polyps greater than 1 cm in diameter • Porcelain
gallbladder • Blumgart's Surgery of the Liver, Biliary Tract and Pancreas, Chapter 34,
511531.
6. 6. Contraindications • Absolute Unable to tolerate general anesthesia Refractory
coagulopathy Suspicion of carcinoma* Blumgart's Surgery of the Liver, Biliary Tract and
Pancreas, Chapter 34, 511531.
7. 7. • Relative Previous upper abdominal surgery Cholangitis Diffuse peritonitis Cirrhosis or
portal hypertension Blumgart's Surgery of the Liver, Biliary Tract and Pancreas, Chapter
34, 511531.
8. 8. Chronic obstructive pulmonary disease Cholecystoenteric fistula Morbid obesity
Pregnancy Blumgart's Surgery of the Liver, Biliary Tract and Pancreas, Chapter 34,
511531.
9. 9. Safe Laparoscopic Cholecystectomy • Preoperative Preparation • Basic operative
technique • Postoperative Care
10. 10. Preoperative Preparation • Antibiotic prophylaxis i. Antibiotics are not required in low
risk patients undergoing laparoscopic cholecystectomy. (Level I, Grade A).2 ii. Antibiotics
may reduce the incidence of wound infection in high risk patients (age > 60 years, the
presence of diabetes, acute colic within 30 days of operation, jaundice, acute
cholecystitis, or cholangitis). (Level I, Grade B).2,3 2.Choudhary A, Bechtold ML, Puli SR,
Othman MO, Roy PK. Role of prophylactic antibiotics in laparoscopic cholecystectomy: a
meta-analysis. J Gastrointest Surg 2008;12:1847-53; discussion 53. 3.Dervisoglou A,
Tsiodras S, Kanellakopoulou K, et al. The value of chemoprophylaxis against
Enterococcus species in elective cholecystectomy: a randomized study of cefuroxime vs
ampicillin-sulbactam. Arch Surg 2006;141:1162-7
11. 11. iii. If given, they should be limited to a single preoperative dose given within one hour
of skin incision. (Level II, Grade A).4 and re-dosed if the procedure is more than 4 hours
long .5 4.Chang WT, Lee KT, Chuang SC, et al. The impact of prophylactic antibiotics on
postoperative infection complication in elective laparoscopic cholecystectomy: a
prospective randomized study. Am J Surg 2006;191:721-5. 5.Steinberg JP, Braun BI,
Hellinger WC, et al. Timing of antimicrobial prophylaxis and the risk of surgical site
infections: results from the Trial to Reduce Antimicrobial Prophylaxis Errors. Ann Surg
2009;250:10-6.
12. 12. Deep Venous Thrombosis Prophylaxis • Increased risk : 1. Increased intra abdominal
pressure as a result of pneumoperitoneum, 2. Reverse Trendelenburg position, and 3.
Systemic vasodilation associated with general anesthesia. Blumgart's Surgery of the
Liver, Biliary Tract and Pancreas, Chapter 34, 511531
13. 13. • In the absence of convincing evidence in the literature, DVT prophylaxis with calf
length pneumatic compression devices in all patients undergoing laparoscopic
 cholecystectomy . ( Level III , Grade C ) • Blumgart's Surgery of the Liver, Biliary Tract
and Pancreas, Chapter 34, 511531 • Guidelines for deep venous thrombosis prophylaxis
during laparoscopic surgery. Surg Endosc 2007;21:1007-9. • Haas S, Flosbach CW.
Prevention of postoperative thromboembolism with Enoxaparin in general surgery: a
German multicenter trial. Semin Thromb Hemost. 1993;19 suppl 1:164-73 • Gonzalez
QH, ishler DS, Plata-Munoz JJ, Bondora A, Vickers SM, Leath T, Clements RH.
Incidence of clinically evident deep venous thrombosis after laparoscopic roux-en-Y
gastric bypass. Surg Endosc. 2004 jul;18(7):1082-4
14. 14. • In patients with additional risk factors— Previous DVT Cancer Obesity Exogenous
estrogens Blumgart's Surgery of the Liver, Biliary Tract and Pancreas, Chapter 34,
511531
15. 15. Projected operating time > 2 hrs Age over 40 yrs Recommend the addition of
pharmacologic prophylaxis.( Level III , Grade C ) Blumgart's Surgery of the Liver, Biliary
Tract and Pancreas, Chapter 34, 511531 • Guidelines for deep venous thrombosis
prophylaxis during laparoscopic surgery. Surg Endosc 2007;21:1007-9. • Haas S,
Flosbach CW. Prevention of postoperative thromboembolism with Enoxaparin in general
surgery: a German multicenter trial. Semin Thromb Hemost. 1993;19 suppl 1:164-73 •
Gonzalez QH, ishler DS, Plata-Munoz JJ, Bondora A, Vickers SM, Leath T, Clements
RH. Incidence of clinically evident deep venous thrombosis after laparoscopic roux-en-Y
gastric bypass. Surg Endosc. 2004 jul;18(7):1082-4
16. 16. Basic operative technique • Room set-up and patient positioning: With no data to
guide choices, surgeon preference should dictate room set-up. (Level III, Grade A).9
9.Scott-Conner CEH, ed. The SAGES manual: fundamentals of laparoscopy,
thoracoscopy, and GI endoscopy. 2 ed: Birkhäuser; 2005.
17. 17. • Using the “American” technique, the surgeon stands to the left of the patient, the
first assistant stands to the patient's right, and the laparoscopic video camera operator
stands to the left of the surgeon • Blumgart's Surgery of the Liver, Biliary Tract and
Pancreas, Chapter 34, 511531
18. 18. Blumgart's Surgery of the Liver, Biliary Tract and Pancreas, Chapter 34, 511531
19. 19. • In the “French” technique, the patient's legs are abducted, and the surgeon stands
between them.
20. 20. • Ergonomic assessment of the French and American position for laparoscopic
cholecystectomy in the MIS Suite. No statistical difference was observed in the mean
body angles or in the percentages of operation time within an acceptable range between
the French and the American position. • Kramp KH , van Det MJ, Totte ER, Hoff C, Pierie
JP. SurgEndosg. 2014 May;28(5):1571-8. doi: 10.1007/s00464-013-3353-1. Epub 2014
Jan 1
21. 21. • Equipment: In the absence of data, surgeon preference should dictate choice of
equipment. (Level III, Grade A). . ScottConner CEH, ed. The SAGES manual:
fundamentals of laparoscopy, thoracoscopy, and GI endoscopy. 2 ed: Birkhäuser; 2005.
22. 22. • Abdominal Access There are a variety of techniques for gaining initial abdominal
access for laparoscopic surgery i. Veress needle ii. The open Hasson’s technique. iii.
Direct trocar placement without prior pneumoperitoneum.
23. 23. iv. The optical view technique, in which the laparoscope is placed within the trocar so
that the layers of the abdominal wall are visualized as they are being traversed. In
general, all of the mentioned approaches to abdominal access are safe.
24. 24. • Abdominal access: No demonstrable differences in the safety of open versus closed
techniques for establishing access; Decisions regarding choice of technique are left to
the surgeon and should be based on individual training, skill, case assessment. (Level I,
Grade A). .Larobina M, Nottle P. Complete evidence regarding major vascular injuries
during laparoscopic access. Surg Laparosc Endosc Percutan Tech 2005;15:119-23.
.Ahmad G, Duffy JM, Phillips K, Watson A. Laparoscopic entry techniques. Cochrane
Database Syst Rev 2008:CD006583.
25. 25. • Sharp instruments should never be moved intracorporeally unless they are under
direct videoscopic vision. • Blumgart's Surgery of the Liver, Biliary Tract and Pancreas,
Chapter 34, 511531
26. 26. Low pressure versus standard pressure pneumoperitoneum in laparoscopic
cholecystectomy • No evidence is currently available to support the use of low pressure
pneumoperitoneum in low anaesthetic risk patients undergoing elective laparoscopic
cholecystectomy.(Level I,Grade A) • Kurinchi Selvan Gurusamy,Jessica Vaughan,Brian R
Davidson ; Low pressure versus standard pressure pneumoperitoneum in laparoscopic
cholecystectomy, Cochrane Database Syst Rev 2014: CD006930
27. 27. Monopolar electrocautery versus ultrasonic dissection of the gallbladder from the
gallbladder bed in laparoscopic cholecystectomy: a randomized controlled trial •
Ultrasonic Dissection Provides a superior alternative to high frequency monopolar
technology in terms of lower incidence of gallbladder perforation and a shorter duration of
surgery. • Varun Mahabaleshwar, Lileswar Kaman, Javid Iqbal, Rajinder Singh;
Monopolar electrocautery versus ultrasonic dissection of the gallbladder from the
gallbladder bed in laparoscopic cholecystectomy: a randomized controlled trial; J can
chir, Vol. 55, No 5, octobre 2012
28. 28. Safe laparoscopic cholecystectomy • 1. Critical View of Safety (CVS) Three criteria
are required to achieve the CVS: A. The hepatocystic triangle (triangle of
cholecystectomy) is cleared of fat and fibrous tissue. The hepatocystic triangle is defined
as the triangle formed by the cystic duct, the common hepatic duct, and inferior edge of
the liver. The common bile duct and common hepatic duct do not have to be exposed.
29. 29. B. The lower one third of the gallbladder is separated from the liver to expose the
cystic plate. The cystic plate is also known as liver bed of the gallbladder and lies in the
gallbladder fossa. C. Two and only two structures should be seen entering the
gallbladder. • Strasberg SM, Brunt LM. Rationale and use of the critical view of safety in
laparoscopic cholecystectomy. Journal of the American College of Surgeons 2010;
211:1328. • Yegiyants S, Collins JC. Operative strategy can reduce the incidence of
major bile duct injury in laparoscopic cholecystectomy. Am Surg 2008;74:985-7.
30. 30. A : Anterior view B: Posterior view
31. 31. Anterior view of CVS
32. 32. Posterior View of CVS
33. 33. Calot’s Vs Hepatocystic triangle
34. 34. 2. Consider an Intraoperative Time Out during laparoscopic cholecystectomy prior to
clipping, cutting or transecting any ductal structures. • The Intraoperative Time Out
should consist of a stop point in the operation to confirm that the CVS has been achieved
utilizing the Doublet View.
35. 35. 3. Understand the potential for aberrant anatomy in all cases. • Aberrant anatomy
may include a short cystic duct, aberrant hepatic ducts, or a right hepatic artery that
crosses anterior to the common bile duct . These are some but not all common variants. •
Strasberg SM. A teaching program for the “culture of safety in cholecystectomy” and
avoidance of bile duct injury. Journal of the American College of Surgeons 2013;
217:751.
36. 36. Cystic duct variability
37. 37. 4. Make liberal use of cholangiography or other methods to image the biliary tree
intraoperatively. • Cholangiography may be especially important in difficult cases or
unclear anatomy. • Several studies have found that cholangiography reduces the
incidence and extent of bile duct injury but controversy remains on this subject.10 10.
Traverso LW. Intraoperative cholangiography reduces bile duct injury during
cholecystectomy. Surg Endosc 2006;20:16591661.
38. 38. 5. Recognize when the dissection is approaching a zone of significant risk and halt
the dissection before entering the zone. • Failure to obtain adequate exposure of the
anatomy of the hepatocystic triangle or when the dissection is not progressing due to
bleeding, inflammation or fibrosis.
39. 39. • Consider laparoscopic subtotal cholecystectomy or cholecystostomy tube
placement, and/or conversion to an open procedure based on the judgment of the
attending surgeon.
40. 40. 6. Get help from another surgeon when the dissection or conditions are difficult. •
Advice of a second surgeon is helpful under conditions in which the dissection is stalled,
the anatomy is unclear or under other conditions deemed “difficult” by the surgeon.
41. 41. The safety of laparoscopic cholecystectomy requires correct identification of relevant
anatomy. (Level I, Grade A). • Avgerinos C, Kelgiorgi D, Touloumis Z, Baltatzi L,
Dervenis C. One Thousand Laparoscopic Cholecystectomies in a Single Surgical Unit
Using the “Critical View of Safety” Technique. J Gastrointest Surg 2008. • Singh K, Ohri
A. Anatomic landmarks: their usefulness in safe laparoscopic cholecystectomy. Surg
Endosc 2006;20:1754-8
42. 42. • Intraoperative cholangiogram may reduce the rate or severity of injury and improve
injury recognition. (Level II, Grade B). • Nuzzo G, Giuliante F, Giovannini I, et al. Bile duct
injury during laparoscopic cholecystectomy: results of an Italian national survey on 56
591 cholecystectomies. Arch Surg 2005;140:986-92. • Kholdebarin R, Boetto J, Harnish
JL, Urbach DR. Risk factors for bile duct injury during laparoscopic cholecystectomy: a
case- control study. Surg Innov 2008;15:114-9.
43. 43. Six anatomical landmarks for safe Laparoscopic Cholecystectomy 1. Hartmann’s
pouch 2. Cystic node of Lund (Mascagne’s Node ) 3. Calot’s triangle 4. Union of cystic
duct with bile duct 5. Cystic artery and right hepatic artery 6. Rouviere’s sulcus • Rachit
Arora, Bhavinder AroraI; Six anatomical landmarks for safeLaparoscopic
Cholecystectomy International Journal of Enhanced Research in Medicines & Dental
Care, ISSN: 2349-1590 Vol. 1 Issue 10, December-2014, pp: (30-34),
44. 44. Operative photograph of Calot node. This node is useful for identification of the
common location of the cystic artery.
45. 45. Rouviere Sulcus • The Rouviere’s sulcus is a fissure in the liver between the right
lobe and caudate process seen during posterior dissection in majority of patients. • It
corresponds to the level of porta hepatis where the right pedicle enters the liver.
46. 46. • All dissection be kept to a level anterior to this sulcus to avoid injury to bile duct. •
This is an extrabiliary landmark and does not get distorted due to retraction during
laparoscopic cholecystectomy. • Peti N, Moser MAJ. Graphic reminder of Rouviere’s
sulcus: a useful landmark in cholecystectomy.ANZ J Surg 2012;82(5):367- 8. • Nagral S.
Anatomy relevant to cholecystectomy. J Min Access Surg 2005;1:53-8.
47. 47. Dissection of the gallbladder from the liver bed • The more conventional approach
starting at the gallbladder infundibulum and working superiorly, or the top down
approach, may be used with electrocautery, ultrasonic dissection, or hydrodissection as
the surgeon prefers. (Level II, Grade B). • Neri V, Ambrosi A, Fersini A, Tartaglia N,
Valentino TP. Antegrade dissection in laparoscopic cholecystectomy. JSLS 2007;11:225-
8. • Cengiz Y, Janes A, Grehn A, Israelsson LA. Randomized trial of traditional dissection
with electrocautery versus ultrasonic fundus-first dissection in patients undergoing
laparoscopic cholecystectomy. Br J Surg 2005;92:810-3. • Fullum TM, Kim S, Dan D,
Turner PL. Laparoscopic “Dome-down” cholecystectomy with the LCS-5 Harmonic
scalpel. JSLS 2005;9:51-7. • Bessa SS, Al-Fayoumi TA, Katri KM, Awad AT. Clipless
laparoscopic cholecystectomy by ultrasonic dissection. J Laparoendosc Adv Surg Tech A
2008;18:593-8. • Caliskan K, Nursal TZ, Yildirim S, et al. Hydrodissection with
adrenaline-lidocaine-saline solution in laparoscopic cholecystectomy. Langenbecks Arch
Surg 2006;391:359-63.
48. 48. • Posterior dissection of Gall bladder from GB fossa followed by anterior dissection . •
Skeletonisation of cystic duct and artery . • Cystic duct & Cystic artery not to be clipped
together . • Guidelines for the Clinical Application of Laparoscopic Biliary Tract Surgery A
SAGES Guideline
49. 49. • Extraction of the gallbladder: With no data to guide choice of technique, the
gallbladder may be extracted as the surgeon prefers. (Level III, Grade C). • Guidelines for
the Clinical Application of Laparoscopic Biliary Tract Surgery A SAGES Guideline
50. 50. • Use of Drains: Drains are not needed after elective laparoscopic cholecystectomy
and their use may increase complication rates. (Level I, Grade A). Drains may be useful
in complicated cases particularly if choledochotomy is performed. (Level III, Grade C). •
Gurusamy KS, Samraj K, Mullerat P, Davidson BR. Routine abdominal drainage for
uncomplicated laparoscopic cholecystectomy. Cochrane Database Syst Rev
2007:CD006004. • Tzovaras G, Liakou P, Fafoulakis F, Baloyiannis I, Zacharoulis D,
Hatzitheofilou C. Is there a role for drain use in elective laparoscopic cholecystectomy? A
controlled randomized trial. Am J Surg 2009;197:759-63.
51. 51. Conversion to laparotomy: • Conversion should not be considered a complication and
surgeons should have a low threshold for conversion; The decision to convert to an open
procedure must be based on intraoperative assessment of anatomy and surgeon’s skill.
(Level II, Grade A). • Zhang WJ, Li JM, Wu GZ, Luo KL, Dong ZT. Risk factors affecting
conversion in patients undergoing laparoscopic cholecystectomy. ANZ J Surg
2008;78:973-6. • Visser BC, Parks RW, Garden OJ. Open cholecystectomy in the
laparoendoscopic era. Am J Surg 2008;195:108-14.
52. 52. Postoperative Management • Prophylactic antibiotics not necessary in low-risk
patients undergoing laparoscopic cholecystectomy. Should be given in high risk patients •
Turk Emin, Karagulle Erdal, Serefhanoglu Kivanc, Turan Hale, Moray Gokhan. Effect of
Cefazolin Prophylaxis on Postoperative Infectious Complication in Elective Laparoscopic
Cholecystectomy: A Prospective Randomized Study. Iranian red cresent med j.
2013;15(7):581–6. • Sanabria A, Dominguez LC, Valdivieso E, Gomez G. Antibiotic
prophylaxis for Patients undergoing elective laparoscopic cholecystectomy. Cochrane
Database Syst Rev. 2010;(12):CD005265. doi: 10.1002/14651858.cd005265.pub2 • Koc
M, Zulfikaroglu B, Kece C, Ozalp N. A prospective randomized study of prophylactic
antibiotics in elective laparoscopic cholecystectomy. Surg Endosc. 2003;17(11):1716-8
53. 53. Summary • Laparoscopic cholecystectomy is the treatment modality of choice for
cholelithiasis • Antibiotic prophylaxis is not required in low risk patients undergoing
laparoscopic cholecystectomy. • DVT prophylaxis is required in high risk cases. •
Surgeon preference should dictate Room set- up , patient positioning and choice of
equipment.
54. 54. • No demonstrable differences in the safety of open versus closed techniques for
establishing abdominal access . • Sharp instruments should never be moved
intracorporeally unless they are under direct videoscopic vision. • Ultrasonic Dissection
Provides a superior alternative to high frequency monopolar technology in terms of lower
incidence of gallbladder perforation and a shorter duration of surgery
55. 55. • The safety of laparoscopic cholecystectomy requires correct identification of
relevant anatomy , CVS & Rouvier Sulcus. • Intraoperative cholangiogram is Useful to
reduce the rate or severity of injury and improve injury recognition.
56. 56. • Drains are not needed after elective laparoscopic cholecystectomy and their use
may increase complication rates . • Surgeons should have a low threshold for conversion
to open cholecystectomy . • Use Of antibiotics in postoperative phase is not
recommended .
57. 57. • These strategies are based on best available evidence. They are intended to make
a safe operation safer. They do not supplant surgical judgment in the individual patient.
The final decision on how to proceed should be made by the operating surgeon,
according to his/her experience and judgment.
58. 58. Thanks