Ch. 54 – Biliary System

Surgery for Calculous Biliary Disease
Laparoscopic Cholecystectomy
Since the introduction of laparoscopic cholecystectomy,
the number of cholecystectomies performed in the United
States has increased from about 500,000 per year to
700,000 per year. Contraindications to laparoscopic cholecystectomy
include coagulopathy, severe chronic
obstructive pulmonary disease, end-stage liver disease,
and congestive heart failure. Currently, the major contraindication
to completing a laparoscopic cholecystectomy
is inability to clearly identify all of the anatomic structures.
The conversion rate for elective laparoscopic
cholecystectomy should be around 5%, whereas the conversion
rate in the setting of acute cholecystitis may be
as high as 30%. Conversion to an open procedure is not
a failure, and the possibility should be discussed with the
patient preoperatively.
Patients undergoing laparoscopic cholecystectomy
should be prepared and draped in a similar fashion to
open cholecystectomy. The patient is supine on the operating
table with the surgeon standing on the patient’s left.
The pneumoperitoneum is created with carbon dioxide
gas, either with an open technique or by closed-needle
technique. With the open technique, a small incision is
made either above or below the umbilicus into the peritoneal
cavity. A special blunt-tipped cannula (Hasson)
with a gas-tight sleeve is inserted into the peritoneal
cavity and anchored to the fascia. This technique is often
used following previous abdominal surgery and should
Right
subcostal
lateral
and medial
instrument
positions
Fundus of
gallbladder
Chapter 54 Biliary System 1563
avoid infrequent but life-threatening trocar injuries. In the
closed technique, a special hollow insuffl ation needle
(Veress) with a retractable cutting sheath is inserted into
the peritoneal cavity through a periumbilical incision and
used for insuffl ation. There is no difference in inadvertent
bowel or tissue injury between the two techniques.
The laparoscope with the attached video camera is
then inserted into the umbilical port and the abdomen
inspected. The additional ports are inserted under direct
vision (Fig. 54-14). The medial 5-mm cannula is used
to grasp the gallbladder infundibulum (Fig. 54-15) and
retract it laterally with the pull toward the right pelvis, to
expose the triangle of Calot; it is important to widely
expose the triangle of Calot with this direction of retraction
to fully enable identifi cation of possible aberrant
biliary anatomy. This maneuver may require taking down
the adhesions between the omentum or duodenum and
the gallbladder. Most of the dissection can be performed
using a dissector, hook, or scissors. The junction of the
gallbladder and cystic duct is identifi ed and dissection
continued until the cystic artery and duct is clearly seen
entering the gallbladder (Fig. 54-16). A helpful anatomic
landmark is the cystic lymph node. Careful extended
dissection of the base of the gallbladder off the liver bed
is essential to defi ne the duct and artery. The outdated
infundibular technique of cystic duct dissection and identifi
cation does not fully expose the triangle of Calot and
leads to misidentifi cation and is a setup for bile duct
injury. Partial dissection of the base of the gallbladder off
the liver bed before dividing either the artery or cystic
Liver
Cystic duct
and
artery
Subxiphoid
instrument
position
Figure 54-15 The gallbladder is retracted cephalad using the grasper on the gallbladder fundus and at the infundibulum,
with the direction of pull toward the right pelvis. The peritoneum overlying the gallbladder infundibulum
and neck and the cystic duct is divided bluntly, exposing the cystic duct. (From Cameron J: Atlas of Surgery, vol
2. Philadelphia, BC Becker, 1994.)