Laparoscopic Cholecystectomy

CHAPTER 1

This is a young female patient who came in with a few months of abdominal pain after eating fatty foods, and the pain would last for hours, would sometimes radiate to her- was primarily in the right upper quadrant, sometimes radiate to her back. And imaging was consistent with either gallbladder sludge, or small stones, or potentially a polyp. And so, because she was having these symptoms that were really affecting her quality of life, we agreed to perform a laparoscopic cholecystectomy to remove the gallbladder. So, the positioning of the patient is generally supine. Once the case starts, we generally place the patient in reverse Trendelenburg with their head up, and rotate the patient to their left side, so that the gallbladder is at the highest point possible in the operative field, and everything else kind of falls away from it, and it's easier to access the gallbladder. We use, in general, four ports for these procedures. So there's usually one right around the umbilicus for the camera, and then three other ones along the right costal margin for dissection purposes. The key steps of operation are obtaining safe entry into the abdominal cavity, insufflating with carbon dioxide, and then gaining exposure to the gallbladder, and dissecting out the cystic duct and cystic artery safely, clipping and dividing them, and then taking the gallbladder off the liver, placing it in a bag, and removing it.

CHAPTER 2

Make a little slit here. Veress needle, please. All right, gas on. So our opening pressure was about 4 mmHg. We're going to go up to 15.

So we're going to start by placing a 5-mm laparoscope at the umbilicus. And we'll use an optical viewing trocar for that. So I'll start with a knife, please. Thank you. So as we go in, I zoom out, so we can see. Slowly advance the trocar. There's the fascia. And then we're coming through the peritoneum. And then once we get in here, and we see the dark space, that's the pneumo. So I actually re-angle, so that we don't… We aren't at risk of going into any vital structures, and we're just advancing into the pneumo. And there we are. Take that cannula in. Okay, our needle is up here. Everything looks good. I pull the Veress needle out. So now let's see where we are. We could actually pull the OG tube back a little bit. Okay, pulling back. Great, okay. So… Is that better? A little more is fine. Yeah, more, more, more, more. You probably can- Yep, there you go, all right, you're good Okay, so I put a - my larger trocar up here. Can I have a knife, please? And this is an 11 mm. Thanks. Come in, and I skive a little bit, so that I come out just to the right of falci. Of the falciform ligament. There. Then my next two trocars… Let me switch sides. I put a 5 mm all the way out laterally, and then I kind of split the difference and I put another 5 mm right here, right above where the gallbladder is. This a good spot? Let's see. Yeah, probably right about there is good. Great.Knife back.The bed is all the way down. All right, great, so can we get a little bit of reverse Trendelenburg? And then rotate the bed towards the patient's left, towards me.

CHAPTER 3

So we use this lateral retractor to retract up and over the gallbladder towards the patient's right shoulder. And then if you can hold the camera, I'll take a blunt and a pointy.

Okay. So I'm grabbing the infundibulum and I'm retracting laterally and a little bit towards the patient's feet. And come in a little bit with the camera. And down here, where we're not sure what we're looking at and what we're dissecting yet, I usually don't use a lot of energy, and I just carefully peel. So we have to open up the peritoneum on both sides. So, this appears to be - potentially the cystic duct. Remember, come in with your camera. Great. So… Yeah, all right. This might be a little- Come on in closer. This seems to be an artery right here. Do you have a hook on cautery, please? This must be the posterior branch. Yeah, right there. Cystic artery, there. Yep. This might be just a small branch of the artery. The patient has a long mesentery to the gallbladder, so that was pretty thin and opened up pretty easily. All right, so let's see here.

Come in a little bit more closely. Perfect. So in these choles, I always look for the critical view. And so, the critical view - is basically, you have the liver out here. You see the duct here. You see the liver here, and then here, the arteries - there's a branch of the artery here - it's small. Then there's a larger artery back here. I'd like to open this space all up, if possible. And to obtain the true critical view, you have to lift the gallbladder - almost a third of the way up the liver bed, to expose the cystic plate. Right up here. This back side - we'll open up the peritoneum here. Just a little bit less tension. Yep, perfect. Great, all right. So, let's see here. All right. So we've got the gallbladder hanging up over here. At this part, we've got a branch, a posterior branch here. And then this is all dissected up off the liver. I'd like to open up that a little bit more. I'm just dissecting out this posterior vessel a little bit. It looks like we're pretty open here, right? There we go. Can I have that hook again, please? All right, so now we've got gallbladder hung up over here. Liver is here, liver back here. A posterior branch of the cystic artery. Another branch of the cystic artery. And presumable duct here. And we don't see any common bile duct or anything kind of tenting behind here. You think we're safe to clip? I think so. All right, I'll just do this while I'm here. When it's easy, I always take this peritoneum and free up more of this because it just kind of saves you time on the back end. And it's, you have it anyways, and you can see it. If you're struggling, then I wait until after I clip. But that way, like, the more you lift this up, the surer you are that there's nothing traveling behind here. So this guy, I wonder if we could even just Bovie it. But I might just clip it. Just to be safe. All right. Actually, I'm going to take this one little lymphatic, that's right here if it's easy to take. Yeah, I think the duct's small enough that we can clip it all together. Okay. Clip, please. And there it goes, bleeding.

You want to take the branch first? Yeah, I'm going to take this branch first. Okay, let's get that back one. You can see the lumen's what we just divided. Right there. And then I always try to make sure I see the back… Back tongs of the clip. Free this up. I'm caught a little bit. Let's see here. Yep, now I can- Perfect. Great. This all looks good, so now we'll do the duct.

Clip, please. Yep. So, I put 1 clip on the bottom and 1 clip on the top for the vessels. But for the duct, I put 2 on the bottom and 2 on the top. Flip this around. Let's sneak under there. Can you see my back tong? Yep, I can see your back. There you go. All right, there's this. Scissors. Let go, great.

And now, we can, yep. Now I just use the hook to take the gallbladder off the liver bed. And I use a combination of hooking it versus backing - backing the Bovie in. Grab over here. Work on the lateral side? Yeah, I'm going to do the lateral side. Her gallbladder is a bit intrahepatic. There's a very thin layer between - gallbladder and liver. Okay. Now, let's look down for a second and make sure there's no active bleeding. I don't think there is. And look all the way down at the clips, make sure they look okay. Good. And then we take off the last little bit. Can you pull out a little bit? Yeah, perfect. And I'm just going to come around the back. Yep. Let's see. Great. Perfect.

CHAPTER 4

So now - I'll let go. I have it. And I'll put the gallbladder into the bag that I put in through the 11-mm port. Push it in there. Great. Now I - give this back to you. You good? Mm hmm. All right, so once it's in… Scissors, please. Airflow out. SNaP. Kelly. All right, I'll take a - I actually won't need that. I'll take a blunt grasper. And is our irrigation hooked up, or no? So then, we'll just irrigate so we can look at the liver bed, or the gallbladder bed, which looks good and dry. Right? Locking grasper is fine. Just lift the liver up for you. Good. Yeah, I think we're good. Yeah, I think we are. Yeah, all right. So lay that down. Let's level the bed, please. Grasper back. Okay, so… The final step is to get the gallbladder out, which can sometimes be the most difficult part of the operation. Let's see, here. That to you. See if it comes out easily or not. Sometimes the fascia needs to be dilated here. Do you have a long Kelly? Yep. Stretch it open a little. And go. Here's the gallbladder. Okay, thank you. And then because the fascial defect is often buried within falci, I don't always close this port. Yeah, you want to just suction over there and just make sure that… Yeah, that was from that cystic artery that was bleeding earlier. And just lift up gently. Oh, that's the old clot. Let's suction some of this clot. Yeah, that looks good. That was just the bleeding from before. Yeah, from before. The old clot. All right, great. Okay.

CHAPTER 5

So then we pull out all our ports. Here's the scope. Release the gas. And I'll take some local anesthetic. So we infiltrate each of these incisions with a little bit of local. More local. Some more? Did you do this one already? You can just split it between your two incisions, and then I'll inject through mine. Can I have some dry laps, please? Or dry sponges? Needle back. And here's the needle. And then we just closed with buried, subcuticular 4-0 Monocryl sutures. Thank you. Thank you. I'll take an Adson, please.

CHAPTER 6

Today's procedure was pretty straightforward. And so, she did have a posterior cystic artery which is something to look out for when you perform the operation. Sometimes, the main cystic artery, when it looks smaller than you would expect, there's oftentimes another artery that's - that you need to look for posteriorly. Other than that, it was pretty straightforward. I think the same principles of identifying the critical view - the critical view of safety is very important regardless of whether the operation is straightforward or not in order to make sure that you don't damage any vital structures. Postoperatively, the patients can start on a PO diet, and go slowly in the beginning. They're able to move around as usual, and usually are able to perform their general activities of daily living. We ask them for no heavy lifting for approximately 4 to 6 weeks after the operation, but otherwise there are no real restrictions. In general, patients recover pretty quickly and quite well from this operation. They may have a little bit of pain in the beginning, but that generally is very manageable with medications and they recover probably within a week or two they're probably back to baseline. Patients should assume very normal quality of life and be back to their baseline. Some patients have a little bit of loose stools in the beginning, but usually that improves over time. So some of the complications that occur after this operation include a bile leak. And so, if the cystic duct is not clipped completely, or if there's a duct of Luschka that's leaking from the liver bed, patients can develop a bile leak or biloma. And in those cases, they would present with pain in the right upper quadrant. And - if they came into the hospital and an ultrasound would be performed, then you would notice a fluid collection. That would be concerning for a biloma. The other, more devastating complication would be injury to the common bile duct, And usually patients, hopefully most of the time, this is identified during the operation, and then it would be repaired at the same time. But otherwise, patients may come in with just pain and discomfort as well as elevated liver function tests, in which case, imaging can be performed to identify that problem. An MRCP can be obtained. And if that's what is found, then they would need to taken back to the operating room to have it repaired.