laparoscopic cholecystectomy cara lawrence university of kentucky college of medicine

LAPAROSCOPIC CHOLECYSTECTO

MY CARA LAWRENCE

UNIVERSITY OF KENTUCKYCOLLEGE OF MEDICINE

Symptoms

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

Blood tests: Amylase and Lipase- digestive enzymes

made by the pancreas Bilirubin- jaundice (typically measures both

BC/BU) CBC Liver function

Abdominal Ultrasound 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

Useful for detecting gallstones and location

Abdominal Ultrasound Example

From St. Luke’s Health System Resource Library

Diagnosis1

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

Biliary dyskinesia: (chronic acalculous gallbladder disease)

Diagnosis1

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

From Telepathology.com

Laparoscopic Cholecystectomy

Low mortality Shorter hospital

stay Quicker recovery Decreased cost

Gall Bladder or Bile duct tumors

Portal Hypertension Acute pancreatitis Biliary fistula Mirizzi’s Syndrome Pregnancy in the final

trimester Cardiopulmonary or

Coagulation disorders

Advantages Contraindications2

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

Metzenbaum Scissors L-hook electrocautery 5 mm/10mm,

irrigation & suction Cholangiogram

depending on location of stones

extraction bag

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

Anatomy in the Operating Room

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)

Trocar placementSurgical Trocar (both are often

5mm)

Optical

TrocarRetraction

of gall bladder/liv

er


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)

Cystic Duct

Cystic Artery

Infundibulum of Gall Bladder


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


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


Dissect away the posterior wall of the gall bladder using an L-Hook. Make sure L-hook does not come in contact with other instrumentation to prevent tissue damage

(45 min 9 sec)

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

2 and steri-strip or

suture trocar incisions


Post-operative care

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

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

laparoscopic cholecystectomy cara lawrence university of kentucky college of medicine

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