LAPAROSCOPIC CHOLECYSTECTOMY

       The gold standard of gall stone disease management is laparoscopic cholecystectomy. After doing full evaluation of gall bladder and biliary system patient will be prepared for surgery. Commonly this procedure is done under general anaesthesia. All investigations relevant to general anaesthesia is done and in case of other systemic disease the concerned specialist opinion must be obtained. After anaesthesiologist evaluation patient will be submitted for laparoscopic cholecystectomy.

       Where ever facilities available for ICG study with compatible laparoscopic system, ICG is injected 45 minutes prior to surgery to delineate the common bile duct so that injury to CBD can be avoided. Forty-five minutes after injection of ICG intravenously, most of the ICG will be concentrated in the biliary system. This can be seen by compatible laparoscopic system.

       Under general anaesthesia with muscle relaxation patient will be prepared for surgery. After giving anaesthesia, an orogastric tube (Ryle’s tube) is placed to decompress the stomach which is very useful in laparoscopic gall bladder removal operation. This tube will be removed immediately after surgery. Intravenous antibiotics will be given.

       The first step is to create a pneumoperitoneum which will be done with Veress needle around the umbilicus. This means inflating the abdominal cavity with gas. This increases the space within the abdominal cavity which is very important for any laparoscopic surgery. The commonly used gas is carbon dioxide. The operative intra-abdominal pressure is 12mm Hg.

       Once the abdominal distension is uniform then a tubular instrument called trocar is placed through the same incision into the abdominal cavity. Trocar is a tubular instrument with a valve which allows the camera system to go in but will not allow the gas to leak back out of the abdominal cavity. Normally 10mm telescope with camera system is introduced through the 10mm trocar. This first trocar can be 5mm in size if 5mm telescope is available. Laparoscopic gall bladder surgery done through 5mm laparoscope is known as Mini Laparoscopic Cholecystectomy and usually done by the experienced laparoscopic surgeons. Commonly used trocar is 10mm in size.

       After placing the first trocar other three accessory trocars are placed. Two 5mm accessory trocars are placed in right lumbar region and right sub costal region. And one more 10 mm trocar is passed just below the Xiphi sternum (upper abdomen lower chest junction) of the patient.

       Once the trocars are placed then the actual procedure is started. Trocar around the umbilicus is for camera system. The right lumbar region trocar is to retract the gall bladder towards the right shoulder of the patient which also retracts the liver upwards. This exposes the actual operative area. Then the right sub costal trocar is used to hold the neck of the gall bladder with Hartman’s pouch. Finally, through the upper 10mm trocar harmonic scalpel or dissector with diathermy is introduced. Then the dissection will be started at the junction between gall bladder neck and cystic duct on superior and inferior aspects of the gall bladder. During this dissection, peritoneal covering over that Calot’s triangle will be dissected and structures in the Calot’s triangle will be exposed.

       Sometime there will be bowel or omental adhesions with gall bladder which have to be released before start of the procedure. In case of severe infection and if not able to identify this area, then the dissection is started just behind the body of gall bladder.

       There are lots of technical issues in performing this procedure. Sometime there will be stone in the cystic duct which has to be removed. Same time careful preservation of bile duct is very important and injury to bile duct should be avoided. But sometime it is very difficult to delineate these structures because of anatomical variations and also because of severe infection with adhesion. There are multiple reasons which can leads to technical difficulties. They are:

1). Anatomical variations.

 2). Severe infection

3). Associated bile duct stones

4). Associated biliary pancreatitis

5). Associated biliary fistulas

       These are the reasons for doing extensive evaluation before surgery. All these associated problems cannot be identified during surgery. But these issues have to be identified before surgery.

       Once the dissection is started at this area, an attempt is made to identify cystic artery and cystic duct which needs clipping and division. Cystic artery is usually present in between cystic duct and liver bed. If harmonic scalpel is used cystic artery is divided with harmonic scalpel. If harmonic scalpel is not used, then the cystic artery is managed by applying two LT300 (Titanium) clips proximally and one LT300 clip distally and cut in between them. Then cystic duct is clipped with titanium clips. The size of the commonly used clips is (Medium large) LT300. Usually proximally two clips and distally one clip is placed and then divided in between the clips. If cystic duct is wide then wider clip like (Large) LT400 can be used. But sometime there will be gross inflammation where the clips may not hold. Then sutures can be used to secure the cystic duct. There are various techniques like endo-loop, suture ligation and endo-staplers are used to secure the difficult cystic duct.

SAFE LAPAROSCOPIC CHOLECYSTECTOMY:

ROUVIERE’S SULCUS

       Rouviere’s sulcus is a depression noted at the level of the gall bladder neck in the right lobe of the liver. It can present as a Sulcus or slit or Scar. The surgical significance is that in laparoscopic cholecystectomy, safeguarding the Common bile duct is done by identifying Rouviere’s sulcus. The neck and body of the gall bladder are seen above Rouviere's sulcus and cystic duct, CBD junction and Common bile duct is present below the level of Rouviere’s sulcus. Rouviere’s sulcus is identified only in 90% of individuals. Rouviere’s sulcus is better seen in laparoscopic surgery than in open surgery.

LYMPH NODE OF LUND

       This is a lymph node present in the Calot’s triangle. This lymph node will be enlarged in case of any infection, inflammation or tumours involving gallbladder. In case of severe infection due to gall stone, Calot’s triangle area will be frozen and identification of structures will be difficult. The identification of structures in the calot’s triangle is very important because cystic artery is usually tackled at this area. In case of frozen Calot’s triangle where the identification of cystic duct is difficult, the presence of enlarged lymph node (Lund lymph node) is a guide to proceed further a safe laparoscopic cholecystectomy

SAFETY WINDOWS OF STRASBERG:

       During laparoscopic cholecystectomy, dissection is started at junction between neck and body of the gallbladder. The dissection is proceeded towards body of gallbladder and during dissection it is important to note that there are no abnormal structures crossing this area. The possible abnormal structures are aberrant bile duct or abnormal arteries arising from right hepatic artery. In case of any abnormal structure that has to be tackled accordingly.

FLAG MOVEMENT:

       This is a movement of gallbladder created by surgeon during laparoscopic cholecystectomy. During Calot’s triangle dissection the grasper holding Hartman’s pouch move the gallbladder upward to see the interior part of gallbladder and downward to see the superior part of Calot’s triangle. This movement looks like a flag movement and very useful to dissect the Calot’s triangle.

ELEPHANT TRUNK SIGN:

       During laparoscopic cholecystectomy, when dissection is proceeded towards body of gallbladder a wide gallbladder with narrowing cystic duct will resemble as elephant trunk. The perception of elephant trunk appearance signifies the safe laparoscopic cholecystectomy.

       There are some common anomalies in gall bladder area. First is that normally the cystic artery comes from right hepatic artery as a single artery. But sometime there can be multiple small arteries can come from the right hepatic artery. Normally right hepatic artery will be away from the gall bladder area. But sometime it will be in close relation with the body of the gall bladder known as Moynihan’s hump. There is a possibility of damage to this right hepatic artery during surgery if not identified carefully.

       The cystic duct usually joins at common hepatic duct on right side about 2cm below the junction between right and left hepatic duct. But sometime this junction happens on left side of common hepatic duct and sometime this junction will be far below than normal. Sometime the cystic duct joins with right hepatic duct. There are various similar anomalies may exist which can be identified to some extend by pre operative MRCP evaluation and these anomalies have to be tackled properly during surgery.

       Once the cystic duct and cystic artery division is over then the gall bladder has to be released from the gall bladder bed. There may be a small duct communicating the gall bladder lumen directly from the liver bed. The name of this duct is called duct of Luschka. This is a rare anomaly and if present it has to be tackled by putting clip on this accessory duct. If not clipped during surgery this may end up with post operative biliary fistula. Similarly, there can be multiple small accessory arteries and veins and same has to be secured carefully. Otherwise, this may end up with bleeding from the gall bladder bed.

       Once the gall bladder removal is over then the specimen has to be removed. This is done through the 10mm port placed in the upper abdomen. In case of severe infection an endo-bag is used to retrieve the specimen. The size of the port is only 10 mm. In case of multiple stones or thickened gall bladder may require extension of incision a little more.

       Once the specimen is removed out, the gall bladder area should be inspected for any fresh bleeding. In case of severe infection of the gall bladder, pus in the abdominal cavity or gall bladder fossa, the abdominal cavity will be washed with normal saline.

       Once this is over a decision is made whether to keep a drainage tube in the abdominal cavity or not. Presence of severe infection or any minor bleeding from the liver bed as in cases of chronic liver disease are main indications for keeping a drain in the abdominal cavity. This drain will be there for about 48 hours usually. After removing the specimen, the rectus sheath of 10 mm port will be closed with non-absorbable suture. Then the skin will be closed with non-absorbable suture material.

       Post operative recovery of laparoscopic cholecystectomy is good. Patient can be given oral liquids 6 hours after surgery. Solid food can be given on next day of surgery. These patients can be discharged 24 hours after surgery if there are no problems during surgery. The drainage tube if placed will be removed usually after 24 hours to 48 hours, once confirming that the drainage is non bilious and the drainage amount is less than 30 ml for a period of 24 hours. After drainage tube removal the patient will be discharged.

HIGH RISK FOR LAPAROSCOPIC CHOLECYSTECTOMY

       1.Patient with end stage liver disease.

       2.Severe portal hypertension with collaterals.

       3.Coagulopathy.

       4.Chronic obstructive pulmonary disease (COPD).

       5.Congestive heart failure.

       High risk is involved in this group of patients for general anaesthesia for laparoscopic cholecystectomy as in case of COPD. Coagulopathy and end stage liver disease patients have the tendency to bleed during surgery or during immediate post operative period.