Transcript Laparoscopic Cholesectomy - University of Kentucky | Medical Center

LAPAROSCOPIC
CHOLECYSTECTOMY
CARA LAWRENCE
UNIVERSITY OF KENTUCKY
COLLEGE OF MEDICINE
Symptoms
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pain located URQ to upper
middle of the abdomen.
Pain occurs within minutes
of a meal
clay colored stools
Jaundice
(obstructive/conjugated)
Nausea
Vomiting
Mild fever
Work up
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Blood tests:
 Amylase and Lipase- digestive enzymes made by the
pancreas
 Bilirubin- jaundice (typically measures both BC/BU)
 CBC
 Liver function
Abdominal Ultrasound Useful for detecting
gallstones and location
Abdominal CT scan
Abdominal X-ray
Oral cholecystogram -Eat high fat meal at noon, low fat
meal at night, take tablets and then NPO until the x-ray the
next day
Gallbladder radionuclide scan- 1-2 hr scan that takes
pictures to detect inflammation or gallstones
Abdominal Ultrasound Example
From St. Luke’s Health System Resource Library
Diagnosis
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Acute/Chronic cholecystitis:
 Cholelithiasis
-90% of cases & often obstruction of the
cystic duct, in chronic it is not understood if gall stones are
what first initiate symptoms
 Rarely tumors: cholangiocarcinoma freq: 0.6/100,000
malignancy of the biliary tree
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Biliary dyskinesia: (chronic acalculous
gallbladder disease)
Diagnosis
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Cholelithiasis (gallstones)- 10-20% of the population
Pigment stones and Cholesterol stones
 Women 2x more likely to have, aging also plays a role
 Choledocholithiasis- if gallstone(s) located in the common
bile duct
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From
Telepathology.com
Laparoscopic Cholecystectomy
Advantages
Contraindications2
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Low mortality
Shorter hospital stay
Quicker recovery
Decreased cost
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Gall Bladder or Bile duct
tumors
Portal Hypertension
Acute pancreatitis
Biliary fistula
Mirizzi’s Syndrome
Pregnancy in the final
trimester
Cardiopulmonary or
Coagulation disorders
Instrumentation
2 or 3 5mm trocars
 1 or 2 10mm trocars
 10mm 30° scope
 liver retractor/
 grasper(s)
 straight dissectors
 clip applier
 Scalpel and Suture
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Metzenbaum Scissors
 L-hook electrocautery
 5 mm/10mm,
irrigation & suction
 Cholangiogram
depending on location
of stones
 extraction bag
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Structures to avoid
Duodenum and colon on trocar
placement
 Common bile duct (2-7% chance of injury)
 Common Hepatic Duct (can be mistaken
for cystic artery in anatomical variations)
 Liver and other instruments with L-Hook
 Also note any variations such as an
accessory hepatic ducts
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Anatomy in the Operating Room
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Falciform Ligament
Fundus of Gallbladder
Infindibulum of Gall bladder
Calot’s Triangle
 Cystic
Duct (connecting from Common Bile Duct)
 Common Hepatic Duct
 Liver
 Cystic Artery (often arises from the right hepatic artery,
but note that there are variations
 Calot’s (Lund’s) Node
Operating Room Setup
Placed in a reverse
Trendelenburg and
tilted slightly to the
left after insertion
of optic trocar
Retrograde Laparoscopic Cholecystectomy Steps
Prep the patient
 Placement of first trocar (midline navel)
 Creation of Pneumoperitinium
 Final Diagnosis (2 min 47 sec)
 Place patient in Reverse Trendelenburg position
slightly rotated to the left
 Apply local anesthetics and 2-3 other trocars
under visualization of scope (4 min 50 sec)
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Trocar placement
Surgical Trocar (both
are often 5mm)
Optical
Trocar
Retraction of
gall
bladder/live
r
Retrograde Laparoscopic Cholecystectomy Steps
Assistant grasps fundus of gallbladder and
retract superiorly
 Grasp infundibulum of the gallbladder (may
need some dissecting)
 Create tension by pulling slightly superior and
laterally on the infundibulum of the gall
bladder
 Dissect Calot’s Triangle starting towards the
infundibulum of the gall bladder and working
your way to the common bile duct (12 min 51 sec)
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Infundibulum
of Gall Bladder
Cystic Artery
Cystic Duct
Retrograde Laparoscopic Cholecystectomy Steps
Using the
gallbladder as
point of reference,
place 2 distal clips
and 1 proximal clip
along the cystic
duct. (30 min 3 sec)
 Divide making sure
both jaws are
visible to prevent
vascular injury
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Retrograde Laparoscopic Cholecystectomy Steps
Using the gallbladder
as point of reference,
place 2 distal clips
and 1 proximal clip
along the cystic
artery. (39 min 21 sec)
 Divide and
cauterize/clip any
necessary collateral
arteries
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Retrograde Laparoscopic Cholecystectomy Steps
(45 min 9 sec)
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Dissect away
the posterior
wall of the gall
bladder using
an L-Hook.
Make sure Lhook does not
come in contact
with other
instrumentation
to prevent
tissue damage
Retrograde Laparoscopic Cholecystectomy Steps
Remove gallbladder via bag or trocar
 Irrigate and Suction
 Final visualization check
 Deroofing of ovarian cyst (55 min 28 sec)
 Irrigate and suction
 Release of CO and steri-strip or suture
2
trocar incisions
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Post-operative care
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Transfer to PACU
Discharge typically within 24 hours
Post-operative pain can typically be relieved with
OTC pain medications
Patient can resume normal daily activities in roughly
24 hours
Heavy lifting should be avoided for a few weeks
Watch for drainage, bleeding, swelling around
incision sites, and for mild fever, as this could
indicate complication
References
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1. Kumar , V., Abbas, A., & Fausto, N. (7th Ed.). (2005). Robbins and
Cotran: Pathologic basis of disease. Philidelphia, PA: Elsevier
Saunders.
2. Kremer, K., Platzer, W., Schreiber, H., Steichen, F.M. (2001).
Minimally Invasive Abdominal Surgery. New York, NY: Theime.
3. Berci, G., Nobuto, T., Phillips, E.H. (2008). A pocket atlas of
laparoscopic surgery. Tuttlingen, Germany: Endo:Press.
4. Longstreth, G.F. (2009, July 6). Acute cholecystitis. Retrieved from
http://www.nlm.nih.gov/medlineplus/ency/article/000264.htm
5. Swierzerski, III, S.J. (2001, November 1). Cholecystectomy:
preoperative procedures, postoperative procedures, complications.
Retrieved from
http://www.surgerychannel.com/cholecystectomy/preop.shtml