Plate 90

Cholecystectomy is indicated in symptomatic patients with proven disease of the gallbladder, and the indications for laparoscopic cholecystectomy are essentially those for open cholecystectomy. There are certain definitive contraindications, which at present include peritonitis, small bowel obstruction secondary to gallstone ileus, coagulopathy, and large diaphragmatic hernia. Relative contraindications are becoming fewer as the surgical experience of the individual surgeon increases. The factors for increased risk include cirrhosis with portal hypertension, previous intra-abdominal surgery with adhesions, and acute gangrenous cholecystitis.

Following a history and physical examination, the diagnosis of biliary disease is documented with ultrasound examination of the abdomen. The remainder of the gastrointestinal tract may require additional studies. A chest x-ray and electrocardiogram are usually performed and may indicate the need for further evaluation of the cardiopulmonary systems. Routine laboratory blood tests are obtained and should include a liver function panel as well as coagulation studies. The risks of laparoscopy, including trocar injuries to viscera or blood vessels and the increased risk of bile duct injuries during laparoscopic cholecystectomy, are discussed with the patient as well as the possibility of conversion to an open procedure. The management of patients with gallstones and common duct stones remains to be defined. An endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy are commonly tried first. If the common duct is successfully cleared of stones, then a staged laparoscopic cholecystectomy is performed. If the ERCP procedure is not successful, the patient should be prepared for an open cholecystectomy with common duct exploration.

General anesthesia with endotracheal intubation is recommended. Preoperative prophylactic antibiotics for anticipated bile pathogens are administered such that adequate tissue levels exist.

As laparoscopic cholecystectomy makes extensive use of supporting equipment, it is important to position this equipment such that it is easily visualized by all members of the surgical team (Figure 1).

The surgeon must have a clear line of sight to both the video monitor and the high flow CO2 insufflator such that he or she can monitor both the intra-abdominal pressure and gas flow rates. In general, all members of the team are looking across the operating table at video monitors and therefore the positions of the video monitors may require adjustment once all members step to their final positions at operation. The patient is placed supine with the arms either secured at the sides or out at right angles so as to allow the maximum access to monitoring devices by the anesthesiologist at the head of the table. An orogastric tube is passed after the patient is asleep. As increased intra-abdominal pressure from the pneumoperitoneum impedes venous return and may raise the risk of deep venous thrombosis, both legs are either wrapped or placed in elastic stockings over which sequential pneumatic compression stockings may be placed. The electrocautery grounding pad is placed near the hip avoiding any region where internal metal orthopedic parts or electronic devices may have been implanted. The position of the patient on the table relative to placement of the x-ray cassette for a cholangiogram or the C arm for fluoroscopy is rechecked. The legs, arms, and upper chest are covered with blankets to minimize heat loss.

The skin of the entire abdomen and lower anterior chest is prepared in the routine manner.

The abdomen is palpated to find the liver edge or unsuspected intra-abdominal masses. The patient is placed in a mild Trendelenburg position and an appropriate site for the creation of the pneumoperitoneum is chosen. The initial port may be placed by an open or Hasson technique which is preferred. Alternatively, a Veress needle technique is used as described below. In the unoperated abdomen this is usually at the level of the umbilicus (Figure 2); however, previous laparotomy incisions with presumed adhesions may suggest a more lateral approach site which avoids the epigastric vessels (Figure 2 at X). A 1-cm vertical or horizontal skin incision is made and the abdominal wall on either side of the umbilicus is grasped by the surgeon and first assistant either by thumb and forefinger or by towel clips so as to elevate the abdominal wall (Figure 3). A Veress needle is held like a pencil by the surgeon who inserts it through the linea alba and peritoneum where a characteristic popping sensation is felt (Figure 4). An unobstructed free intraperitoneal position for the Veress needle is verified by easy irrigation of clear saline in and out of the peritoneal space (Figure 5) and by the hanging drop method where the saline in the translucent hub of the Veress needle is drawn into the peritoneal space when the abdominal wall is lifted.

If one does not obtain a free flow or an unobstructed saline irrigation, then the Veress needle may be removed and reinserted. In general it is safer to convert the umbilical site into the Hasson open approach (Plate 91) if any difficulty is experienced with the placement, irrigation, or insufflation of the Veress needle. The appropriate tubing and cables for the CO2 insufflation, the fiberoptic light source, and the laparoscopic videoscope with its sterile sheath are positioned as are the lines for the cautery or laser, suction, and saline irrigation. The pneumoperitoneum begins with a low flow of about 1 or 2 L/min with a low-pressure limit of approximately 5 to 7 cmH2O. Once 1 to 2 L of CO2 are in, the abdomen should be hyperresonant to percussion. The flow rate may be increased; however, the pressure should be limited to 15 cmH2O. Three to four liters of CO2 are required to fully inflate the abdomen and the Veress needle is removed. After grasping either side of the umbilicus, a 10-mm trocar port is inserted with a twisting motion, aiming towards the pelvis (Figure 6). If a disposable trocar port is used, it is important to be certain that the safety sheath is cocked. A characteristic popping sensation is felt as the trocar enters the peritoneal space. The trocar is removed and the escape of free CO2 gas is verified.

Although the Veress needle technique has a long history and is preferred by some, most general surgeons use the Hasson technique, as shown in the following Plate 91.

Next >