© Springer International Publishing Switzerland 2016
Abe Fingerhut, Ari Leppäniemi, Raul Coimbra, Andrew B. Peitzman, Thomas M. Scalea and Eric J. Voiglio (eds.)Emergency Surgery Course (ESC®) Manual10.1007/978-3-319-21338-5_1414. Cholecystectomy for Complicated Biliary Disease of the Gallbladder
(1)
Department of Surgical Research, Clinical Division for General Surgery, Medical University of Graz, Graz, Austria
(2)
Surgical Department of Surgery Hippokration Hospital, University of Athens, Athens, Greece
(3)
Department of Surgery, Weill Cornell Medical College, New York, NY, USA
(4)
Cornell Medical School, New York, NY, USA
(5)
1st Department of Surgery, Pavol Jozef Safarik University, Kosice, Slovak Republic
(6)
I chirurgicka klinika, Kosice, 04190, Slovak Republic
(7)
Department of Surgical Oncology, Moscow Clinical Scientific Center, Moscow, Russia
14.1 Safe Cholecystectomy
14.2 Special Settings
14.2.1 Acute Cholecystitis
14.2.2 Acute Biliary Pancreatitis
14.2.3 Biliary Peritonitis
14.2.4 Acalculous Cholecystitis
14.2.5 Cirrhosis
14.2.6 Bilioenteric Fistula
Objectives
Describe safe techniques of cholecystectomy
When to start or convert to open cholecystectomy
How to treat unexpected intraoperative findings or incidents
How to manage complicated gallbladder disease
Complicated biliary disease of the gallbladder includes biliary stone-related complications (acute cholecystitis, empyema, gangrene, common choledocholithiasis with cholangitis or biliary pancreatitis, bilioenteric fistula) as well as complications without lithiasis such as acalculous cholecystitis, or other settings (with or without lithiasis) such as atrophic or scleroatrophic gallbladder, liver cirrhosis, and/or cancer. Therapeutic procedures for complicated gallbladder disease include cholecystectomy, biliary drainage, subtotal cholecystectomy, removal of associated common bile duct stones, sphincterotomy, and treatment of biliary tract fistula.
14.1 Safe Cholecystectomy
Safe cholecystectomy means removal of the gallbladder without injuring the common bile duct or liver, undue bleeding, bile or stone spillage, or bile leak.
Whether performed openly or through a laparoscopic approach, many of the steps are the same.
The principles of “safety” are the same for all cholecystectomies, whether for simple, uncomplicated, or complicated disease.
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Exploration
First step: evaluationDetermine:
Degree of inflammation of the gallbladder.
whether there is associated peritonitis by a complete, 360° exploration of the abdomen.
Exposure and retraction
Take down adhesions between the gallbladder and omentum,
Sometimes freeing a pocket of pus or infected bile.
Puncturing the gallbladder to empty some of the bile enables the surgeon to place a toothed grasper on fundus to properly retract the gallbladder fundus to the right, especially useful when gallbladder wall is thick or inflamed, or gallbladder is distended.
Exposure can be enhanced by suspending the liver (by placing a trancutaneous suture through the falciform ligament so when tied, the round ligament lifts the liver, best achieved when the suspension is to the left of the midline, and the suture is as close as possible to the liver without undue tension that might tear the liver).
Small intestine is retracted from field of view.
Push down and hold by abdominal pads or retractors (open surgery).
Incline the table to a reverse Trendelenburg’s position with a left tilt (laparoscopy).
Initial traction should aim at exposure of the Calot’s triangle.
Caution (when freeing adhesions between the gallbladder and duodenum, small intestine, and the hepatic pedicle): look for fistula and do not create iatrogenic perforation.Several time-proven techniques of cystic duct identification:
Infundibular technique
Not recommended because can be difficult or even hazardous in acute or chronic cholecystitis when cystic duct is short, or with large stone in Hartmann’s pouch, or Mirizzi syndrome
Antegrade dissection
Can be difficult in acute cholecystitis, as the acute inflammation increases bleeding and dissection takes place before ligation of cystic artery
Increases risk of traction injuries to the common bile duct
Displaying lower confluence (cystic duct with the common hepatic duct)
Can be difficult (and dangerous) in acute cholecystitis for same reasons
Identification of Rouvière’s sulcus
Cleft running to the right of the liver hilum, anterior to caudate process containing the right portal pedicle (visible in more than 75 % of patients), and accurately identifies the plane of the common bile duct. Dissection should always be anterior to the sulcus.
“Critical view of safety”
Consists of identification of two (and only two) structures (cystic duct and artery) before any division, by initial dissection of the neck of the gallbladder, freeing the latter from the cystic plate (of the liver bed) (i.e., unfolding Calot’s triangle)
Safer to start dissection from behind (lateral), opening the peritoneum below the cholecystocystic junction and then moving to the anterior aspect of the triangle
Difficult with:
Variant anatomy
Inflammation
When the cystic duct is:
Short
Stumpy
Hidden or effaced by a large stone
Hidden because of difficulty in retracting the gallbladder
Infrared indocyanine green fluorescence
Requires specific equipment
Less irradiation than intraoperative cholangiography
Quicker to perform
Preventive measure that can be performed before dissection begins
Intraoperative cholangiography
Used routinely, reduces rate/severity of biliary injury
Early recognition
Prevents complete transection
Increases rate of good initial repair
Better view of ductal variations
Will only succeed if the cholangiogram is interpreted correctly
Complete upper bile duct fill essential, increases incidence of detection of biliary tract injury
Disadvantages
Radiation
Extra time
Intraoperative ultrasound
Operator dependent
Of note, the only techniques of cystic duct identification that can be performed before dissection begins include identification of Rouvière’s cleft, infrared indocyanine fluorescence, and Introperative ultrasound
Cystic artery and duct may now be divided safely (after correct identification of cystic structures, whatever the method).
Close the distal stump with either absorbable clip or ligation.
Avoid metallic clips (because of electric dangers, possible migration, and stone formation in the common hepatic duct).
If the diameter of the cystic duct is greater than the length of the autolocking clip, it may be necessary to use an Endoloop or suture-ligate the duct – and double check that you are not dealing with the main bile duct.
Dissection of gallbladder from its bed
Best by combined blunt and sharp dissection, in a retrograde fashion. There may be dense fibrotic or inflammatory tissues between the liver parenchyma and the gallbladder wall, making it difficult to find the correct plane of dissection.
Place the gallbladder in retrieval bag.
To avoid any contamination of the abdominal wall during extraction.
If many stones and large diameter,Open the bag from the outside, and remove as many stones as necessary to reduce the volume and allow extraction of the gallbladder,
rather than enlarging the extraction site, always possible.Related posts:
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