Ch. 54 – Biliary System

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1564 Section X Abdomen Gallbladder Cystic artery Cystic duct Figure 54-16 View obtained after dissection within the triangle of Calot demonstrating the cystic duct and cystic artery clearly entering the gallbladder. At this point, it is safe to ligate and divide the cystic duct. Visualization of the common bile duct is not necessary. (From Strasberg SM, Hertl M, Soper NJ: An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg 180:101-125, 1995.) duct enables identifi cation of all the anatomy and minimizes risk for bile duct injury. The next step is ligation of the cystic artery. The artery is usually encountered running parallel to and behind the cystic duct. Clips are placed proximally and distally on the artery, which is then divided. If indicated, an intraoperative cholangiogram may now be performed by placing a hemoclip proximally on the cystic duct, incising the anterior surface of the duct, and passing a cholangiogram catheter into the cystic duct. Once the cholangiogram is completed, two clips are placed distally on the cystic duct, which is then divided. A large cystic duct may require placement of a pretied loop ligature or a standard suture tied laparoscopically for secure closure. Finally, the gallbladder is dissected out of the gallbladder fossa with electrocautery. Just before removing the gallbladder from the liver, the operative fi eld is carefully searched for hemostasis. The gallbladder is then dissected off the liver and removed through the umbilical port. If the gallbladder is acutely infl amed, gangrenous, or entered during the dissection, a plastic specimen retrieval bag should be used for removal from the abdominal cavity. Any bile or blood that has accumulated should be irrigated and sucked away, and if stones were spilled, they should be retrieved. Any concern about bile accumulation or leak should prompt placement of a closedsuction drain through one of the 5-mm ports and left underneath the right lobe of the liver close to the gallbladder fossa. Elective laparoscopic cholecystectomy can be safely performed as an outpatient procedure, and most centers in the United States have demonstrated a strong trend toward ambulatory cholecystectomy. 22 Among patients selected for outpatient management, 77% to 97% of patients can be successfully discharged without hospital admission. 23 Intraoperative Cholangiogram or Ultrasound Use of routine cholangiogram or ultrasound to identify so-called silent common bile duct stones is controversial. Routine intraoperative cholangiography will detect stones in about 7% of patients, outline the anatomy, and identify potential biliary injuries, 24 although it does not prevent them. A selective intraoperative cholangiogram should be performed when the patient has a history of abnormal liver function tests, a large duct and small stones, or a dilated common bile duct, or if preoperative endoscopic cholangiography was not performed in a patient with suspected choledocholithiasis (Box 54-4). Laparoscopic ultrasonography is as accurate as intraoperative cholangiography in detecting common bile duct stones but is operator dependent and requires expertise with ultrasound and interpretation of results. 25 Open Cholecystectomy Open cholecystectomy has become an uncommon procedure. It is now usually performed either as a conversion from an attempted laparoscopic cholecystectomy or as a second procedure in patients who require laparotomy for another reason. It should be performed in any patient who cannot tolerate pneumoperitoneum because of poor pulmonary or cardiac reserve (Box 54-5). An important consideration for open cholecystectomy is in patients in whom gallbladder cancer is suspected preoperatively. From a technical standpoint, open cholecystectomy can be performed similarly to the laparoscopic approach. After the cystic artery and duct have been identifi ed, the
Box 54-4 Indications for Intraoperative Cholangiogram Elevated preoperative liver enzymes (AST, ALT, ALP, bilirubin) Unclear anatomy during laparoscopic dissection Suspicion of intraoperative injury to biliary tract Dilated common bile duct on preoperative imaging Gallstone pancreatitis without endoscopic clearance of common bile duct Jaundice Large common bile duct and small stones Unsuccessful preoperative endoscopic retrograde cholangiopancreatography for choledocholithiasis gallbladder is dissected from the liver bed, starting with the fundus. Alternatively, the retrograde technique can be used where the dissection is initiated with the fundus and the artery and duct identifi ed, ligated, and divided as a fi nal step. It is important to keep the dissection as close to the gallbladder as possible, to avoid dissection into the liver and subsequent bleeding. The dissection is carried proximally toward the cystic artery and the cystic duct, which are then ligated and divided. Common Bile Duct Exploration In patients with large and multiple stones or dilated ducts, and when endoscopic therapy fails, laparoscopic common bile duct exploration is indicated. If unsuccessful, conversion to open surgery is necessary, whereas postoperative ERCP should be used as the last resource. After intraoperative cholangiogram indicates the presence of choledocholithiasis, the surgeon is faced with many options. A wide array of techniques and tools are at a surgeon’s disposal. The initial step is to determine the important factors regarding which modality of treatment will best serve the patient. Factors such as diameter and anatomy of the cystic and common bile ducts, number and size of CBD stones, clinical status of the patient, and most importantly, technical skill of the surgeon should all be considered. Laparoscopic Approach If the stones are small, use of saline irrigation through the cholangiogram catheter to fl ush the stones into the duodenum is all that is necessary. Relaxation of the sphincter of Oddi with glucagon may be helpful. If irrigation is unsuccessful, a balloon catheter may be passed through the cystic duct and down the common bile duct, where it is infl ated and withdrawn to retrieve the stones. The next attempt should be made with a wire basket passed under fl uoroscopic guidance to catch the stones. If needed, a fl exible choledochoscope is inserted directly into the cystic duct (Fig. 54-17). The cystic duct may have to be dilated to allow its passage. Although most authors advocate fi rst attempting a transcystic access, there are clear indications for a direct common bile duct exploration fi rst. The most common scenarios are the presence of more than fi ve common bile duct stones, stones larger than 9 mm, and common hepatic duct stones. Once in the common bile duct, the stones may be caught into Chapter 54 Biliary System 1565 Box 54-5 Indications for Open Cholecystectomy Poor pulmonary or cardiac reserve Suspected or known gallbladder cancer Cirrhosis and portal hypertension Third-trimester pregnancy Combined procedure a wire basket under direct vision or pushed into the duodenum. When the duct has been cleared, the cystic duct is ligated and cut and the cholecystectomy is completed. If the cystic duct cannot be dilated, a longitudinal choledochotomy should be made on the anterior wall. After adequate dissection, anterior choledochotomy can be used. A longitudinal incision is favored because of the pattern of terminal arterioles supplying the common bile duct. Postoperative biliary drainage with a T tube may then be necessary. Clearance of all common bile duct stones is achieved in 75% to 95% of cases with laparoscopic common bile duct exploration. 19 Many studies have shown similar effi cacy of laparoscopic common bile duct exploration as endoscopic sphincterotomy and laparoscopic cholecystectomy, while demonstrating signifi - cant cost analysis in favor of common bile duct exploration at one setting. Open Approach With the increased use of endoscopic, percutaneous, and laparoscopic techniques to treat common bile duct stones, the open common bile duct exploration is rarely performed today. It is now commonly used as a last resort if the above therapies fail. The techniques and operative manipulations are similar to the laparoscopic approach. In patients with a nondilated bile duct (>4 mm), a transduodenal sphincterotomy should be performed and the duct explored through the sphincteroplasty. This avoids the need for a postoperative T tube and the potential for a late bile duct stricture. With the use of intraoperative choledochoscopy, the rate of retained common bile stones is less than 5%. Drainage Procedures If the stones cannot be cleared or when the duct is very dilated (>1.5 cm in diameter), a choledochal drainage procedure should be performed. Options for biliary drainage include a side-to-side choledochoduodenostomy or a choledochojejunostomy with a Roux-en-Y limb of jejunum. Surgeon preference dictates which approach is used. Use of the duodenum is preferred if the duodenum can be fully mobilized (Kocher maneuver) and there is minimal scarring. Any concerns about tension should prompt use of the jejunum either as an end-to-side or side-to-side confi guration. Transduodenal Sphincterotomy In the current era, endoscopic sphincterotomy has replaced open transduodenal sphincterotomy. If an open procedure for common bile duct stones is being done in which the stones are impacted, recurrent, or multiple, the
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Ch. 54 – Biliary System

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