HOW WE DO IT
Laparoscopic Cholecystectomy: Tricks Learned over a Decade and How We Do It
Corresponding Author: Balram Goyal, Department of Gastrointestinal Surgery, Command Hospital (Southern Command) Associated with Armed Forces Medical College, Pune, Maharashtra, India, Phone: +91 9599386202, +91 9401562326, e-mail: email@example.com
How to cite this article: Goyal B, Sharma S, Sreejith BNRD, et al. Laparoscopic Cholecystectomy: Tricks Learned over a Decade and How We Do It. World J Lap Surg 2023;16(1):61–66.
Source of support: Nil
Conflict of interest: None
Received on: 22 April 2023; Accepted on: 04 June 2023; Published on: 05 September 2023
Cholelithiasis is one of common health issues and about 10–20% population harboring the calculi without any clinical features. Only one-fifth of these asymptomatic individuals progress to develop clinical symptoms at a rate of around 5% per year. Laparoscopic cholecystectomy is indicated for symptomatic patients and considered to be a “Gold Standard’’ treatment for the last three decades. It is the commonest abdominal procedure performed globally in an elective setting. Myriad techniques have been evaluated with increasing experience, skills, need, and availability of laparoscopic instruments. We have witnessed lots of modifications in creating pneumoperitoneum, dissection of Calot’s triangle, division and securing cystic duct and artery, dissection of gallbladder (GB) from liver bed, retrieval of specimen, and port closure.
Here we are presenting our experience and modifications used over the last one and a half decades.
Keywords: Bile duct injury, Cirrhosis, Fundus first Approach, Gallbladder extraction, Laparoscopic cholecystectomy, Pneumoperitoneum.
MATERIALS AND METHODS
The surgical procedure was performed by an experienced surgeon at various tertiary care teaching centers. We have retrieved patient’s medical records including intra-operative pictures and videos. We also search for any difficulties, complications, any modifications used during the procedure, from available patient records in both digital and manual forms.1,2
Tricks Used during Laparoscopic Cholecystectomy
Patient Position and Perioperative Antibiotics: The Patient was placed in a supine position and a single dose of third-generation IV cephalosporin was used selectively just prior to intubation. Another position like Davis Lloyd was used when this procedure was done with other surgery like sleeve gastrectomy, cystogastrostomy, and splenectomy.
Creation of Pneumoperitoneum
Usually, pneumoperitoneum is created by the open method through a horizontal incision just above the umbilicus. In patients with mid-line scar from previous surgery may lead to bowel injury to avoid this we used optic trocar through the epigastric area which is vergin.
By using this we could place port safely without any bowel and vascular injury.
Vertical Incision on Linea Alba to Retrieve Large Calculus
In the case of large gallbladder calculus (>20 mm) retrieval of calculus is difficult.
Anticipating this difficulty we make a vertical incision at the umbilicus during the placement of the first port. At the time of retrieval, this incision enlarged cranially which facilitates retrieval. This incision is easily closed with Vicryl 2-0 suture material.
Extra Ports Placement in Difficult Cholecystectomy
Globally most of the modifications that have been invented are related to the number of ports placed. A three-port modification is common among these. We have used three port techniques in which the port used for fundus retraction is not placed. In our experience, it is only feasible in selected patients in whom adhesions at port are minimal or not present.
We have put an extra port in three cases where the left lobe of the liver was enlarged obscuring the Calot’s anatomy, precluding the safe dissection and rendering Shuttering effect (Fig. 1). In all these three patients we put a 5 mm extra port in the right hypochondrium to push the enlarged left lobe.
Inspection of Peritoneal Cavity
A thorough inspection of the peritoneal cavity using a 30° telescope is made as the glance of the cavity before commencing may yield some incidental findings (IFs). We have noted hepatic micro/macro nodules, hepatic SOLs, growth from gastric, small bowel wall, and Meckel’s diverticulum (Fig. 2). One patient was finally diagnosed to have hepatic tuberculosis on histopathological examination of the incidentally detected hepatic lesion. Other entities like cirrhosis and adenocarcinoma of GB with hepatic metastasis were also detected. One patient each of gastric/bowel wall lesion was diagnosed to have gastrointestinal stromal tumor (GIST).
Dissection at Calot’s Triangle
In patients with minimal or no adhesions and normal Calot’s anatomy, we do dissection in standard fashion, posterior to anterior with a demonstration of a critical view of safety. Here we dissect part of the infundibulum from the liver bed which is an extra step towards safety to avoid bile duct injury.
Maryland dissecting forceps is traditionally used for dissection however due to its bulky nature of jaws, there is the risk of touching nearby structures which may lead to thermal injury.
A hook dissector is a good alternative for dissection in this area as it allows the dissection of thin fibers and poses minimal risk for transferring energy to neighboring structures (Fig. 3).
The harmonic scalpel is used particularly in patients having thick-walled gallbladders or in patients with portal hypertension where numerous pericholecystic collateral are present (Fig. 4). It also facilitates the division of cystic artery without applying a clip towards the specimen side of the artery.
Dissection of thick and sclerotic tissue by high-pressure water stream (Hydro-Jet) using a laparoscopic irrigation system is also done when initially no lead with other dissecting devices is made (Fig. 5). Tissue planes are opened and become thin which allows identification and further dissection.
Fundus First Approach
This approach is popular in open cholecystectomy (OC) in patients having distorted anatomy at Calot’s triangle due to extensive adhesions. We use this technique during the laparoscopic approach when a frozen Calots is encountered which renders identification and safe dissection. Once GB is dissected from the fossa, we usually divided the cystic duct using an endo GI linear stapler (usually 45 mm blue reload) (Fig. 6).
Dissection of GB from Fossa
We take extra precautions in patients with thick-walled GB where no definitive plane occurs between the GB wall and fossa as exposure and inadvertent injury to segmental branches of the Right portal vein and/or hepatic artery can lead to torrential bleeding at the point of time. A portion of the posterior wall is left in such cases as well as in patients with known cases of cirrhosis or incidentally detected during surgery where high risk of bleeding from GB fossa (Fig. 7).
Both trucut and incisional biopsy are taken in cases of cirrhosis and liver SOL respectively and tissue is submitted for frozen section when suspicion of malignancy is high based upon clinical and radiological background.
We often retrieve the specimen without placing them in the endobag through the epigastric port site and also ensured the single clip placed over the cystic duct toward the specimen side is also present with the specimen. Accidentally leaving this clip behind may lead to infection of the port site and subsequently formation of the sinus as it will act as a foreign body. The port track was also irrigated to clear if there is any calculus stuck during specimen retrieval. Use of endobag is done in cases GB full of calculi, ruptured during dissection, empyema GB, and risk of malignancy.
There used to be a lot of struggle during retrieval in endo bag as GB specimen positioned in horizontal lie to the port site once kept inside. In this grip, extractor holds both leaves of endo bag without holding the part of the specimen (Fig. 8).
We use a different technique in which part of the GB specimen near the clip is held along with both leaves of the endo bag. This manoeuver maintains the lie of the specimen vertically and facilitates smooth passage through the port site (Fig. 9).
As it was mentioned above incise the linea alba vertically as the incision can be further extended in cases of retrieval done through this site. We use this port for retrieval in cases of large stones (Size on preop ultrasound abdomen > 20 mm) and close it with Vicryl 2–0 at the end of the procedure (Fig. 10).
Inspecting port sites we inspect all port sites and ensure hemostasis before terminating pneumoperitoneum.
In our series, there was no single case of CBD injury, major bleeding, or bile leak.
Port site infections were seen in three patients and all patients presented after 6 weeks of the procedure. These patients responded to culture-based oral antibiotics for 6 weeks duration. None of these three patients had an infection caused by non-mycobacterium tubercular (Non-MTB).
About 10–20 % of the population harboring cholelithiasis and the majority (about two-third of them) remain asymptomatic at 20 years follow-up.3 Laparoscopic gallbladder removal First performed, and by Mouret in France in 1987. It was a big leap in the realm of biliary surgery as it reformed the landscape. It gained widespread popularity at a fast pace and replaced conventional OC globally.4 There are myriad modifications that have been made to strive for better cosmetic results and overall outcome. Most of the modifications were related to number and port size. However, the standard technique has to be kept in mind and not to be violated at the cost of patient safety. In this study, we have incorporated tips and tricks which are acquired over decades and seem to be very useful at each and every step during the procedure particularly for surgery residents and budding surgeons to accomplish the procedure with the desired outcome as procedure-related complication rate in young hands continued to be static.
Prophylactic antibiotic is not used and more and more study support this policy. A RC by Anil Mehta et al. concluded that routine prophylactic antibiotics can be omitted safely.5 There are two ways of achieving pneumoperitoneum, the closed technique, and open technique. Although the superiority of one over another is not yet established. However few small study favors the open technique requires less time and has a better safety profile.6 Conventional procedures done using four ports (2 mm × 10 mm, 2 mm × 5 mm) worldwide and yet enjoy the preferred technique despite a maximum number of modifications that have been evaluated. We found 3 port procedure avoiding placement of 5 mm port for fundal retraction only useful in selective patients where thin-walled GB with normal Calot’s ids present. Adding forth port is often required in patients having intraoperative mucocele, pyocele, frozen Calot’s etc. Need of additional 5th port is seldom required to control intraoperative excessive bleeding or excessive adhesion in the case of frozen calots triangle.7 We used an additional 5 mm port in three cases at the right upper abdomen to push the enlarged left hepatic lobe. An additional port in difficult laparoscopic cholecystectomy for surgical safety As soon as we enter the peritoneal cavity we should inspect the abdominal cavity for bleeding or any pathology to abdominal organs. In our study, we found hepatic micro/macro nodules, hepatic SOLs, growth from gastric, small bowel wall, and Meckel’s diverticulum. One patient was finally diagnosed to have hepatic tuberculosis on histopathological examination of the incidentally detected hepatic lesion. Other entities like Cirrhosis, and adenocarcinoma of GB with hepatic metastasis were also detected. One patient each of gastric/bowel wall lesion was diagnosed to have gastrointestinal stromal tumor (GIST). There are few interesting case reports of concurrent appendicectomy for subhepatic inflamed appendix that have been described. We have made this inspection an indispensable part of our surgical practice. In a cross-section study by Baraa Shebli 534 patients underwent laparotomy/laparoscopy while most of the procedures done for cholelithiasis (66%) incidental finding (IF) were present in six patients (1.1%).8
A Maryland forceps connected to diathermy is conventionally used by the majority of surgeons for initial dissection at Calot’s triangle. A major drawback with Maryland forceps is bulky jaws possess a risk of accidentally touching surrounding vital structures and causing thermal injury.
However, we found the hook dissector more feasible for this purpose as less bulky and smoothly negotiable when inflamed thick tissue is encountered. We also started selective use of the hormonic scalpel in patients with thick-walled GB and in patients with cirrhosis having pericholecystic collateral and found it a very useful viable alternative tool in our armamentarium for this procedure which is safe and reduces procedure time.
Current literature also illustrates its usefulness as the study reports it reduces the duration of duration of surgery and overall procedure-related complications.9
Hydro-Jet (High-pressure water stream) is also an effective way for dissection at the calots triangle in grossly thickened tissue which may be amenable to bleeding or injury of neighboring vital structures by using conventional cautery. It is a great savior when no progress of dissection is being made and requires lots of patience.
It is first used by Hodjat Shekarriz et al. for cholecystectomy in the porcine model and reported as an excellent alternative to the conventional technique. This is also replicated by the same study group in a prospective randomized clinical study.10
Fundus first approach is popular in OC, however, remained underutilized in laparoscopic surgery. We found it a good alternative technique in cases where anatomy at the calots triangle is completely obscured. The harmonic scalpel is used to mobilize the fundus from the GB fossa and dissection should be done till the junction of the cystic duct with the common bile duct (CBD). In such cases cystic duct is invariably found dilated therefore endo GI liner stapler is useful for safer division. Beginners and budding surgeons can practice this approach in simple cases also. In such cases, cystic duct and artery can be divided using liga clips or end loop.
In a systemic review by Michael El Boghdady et al., they found a feasible technique resulting in shorter operative time and less post-op pain, nausea and vomiting.11
Retrieval of the specimen at the end of the procedure is the last but not least important step. We use epigastric or umbilical ports for retrieval of specimens depending upon the character of the specimen and the size of the calculus. Thin-walled GB with small calculi can be easily retrieved through an epigastric port without using an endobag.
The umbilical port site is often used with thick-walled GB, i.e., mucocele, pyocele, and stone >20 mm. Improvised polythene bag (locally available bag which is sterilized before use) is usually used for specimen retrieval. Using this type of bag reduces the overall cost.
Once the specimen is retrieved we check for the presence of ligaclips applied to specimens. This clip sometimes dislodged from a specimen and can lead to sinus formation by acting as a foreign body. In most of the study reports endo bag is used selectively when the risk of port site infection and deposition of the malignant cells is high.
Laparoscopic cholecystectomy is one of the most commonly performed elective abdominal procedures globally. Despite a giant leap in experience complication in the form of bile duct injury is still Achilles’s heel. Keeping all the small tricks in mind during surgery may be the great saviour to avoid major ductal injury and other complications.
Balram Goyal https://orcid.org/0000-0001-7037-8445
5. Mehta A, Godara R, Anand A, et al. Evaluation of the role of prophylactic antibiotics in laparoscopic cholecystectomy – A prospective randomized study. Int J Surg Med 2019;5(1):14–17. DOI: 10.5455/ijsm.prophylactic-antibiotics-laparoscopic-cholecystectomy.
6. Zaman M, Singal S, Singal R, et al. Comparison of open and closed entry techniques for creation of pneumoperitoneum in laparoscopic surgery in terms of time consumption, entry-related complications and failure of technique. World J Lap Surg 2015;8(3):69–71. DOI: 10.5005/jp-journals-10033-1250.
10. Shekarriz H, Shekarriz B, Upadhyay J, et al. Hydro-Jet assisted laparoscopic cholecystectomy: Initial experience in a porcine model. JSLS 2002;6(1):53–58. PMID: 12002298.
11. El Boghdady M, Arang H, Ewalds-Kvist BM. Fundus-first laparoscopic cholecystectomy for complex gallbladders: A systematic review. Health science review 2022;2(100014). DOI: https://doi.org/10.1016/j.hsr.2022.100014.
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