Acute cholecystitis management and technical tips

This video demonstrates the laparoscopic approach to cholecystectomy for acute cholecystitis. Key points such as gallbladder decompression, adhesiolysis and exposure of the operative field and dissection of Calot’s triangle during acute inflammation are described in detail.

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Acute cholecystitis management and technical tips

Authors

D Mutter, J Marescaux

Abstract

This video demonstrates the laparoscopic approach to cholecystectomy for acute cholecystitis. Key points such as gallbladder decompression, adhesiolysis and exposure of the operative field and dissection of Calot’s triangle during acute inflammation are described in detail.

Classification

tips and tricks

Keywords

cholecystectomy, gallbladder, cholecystitis, liver bed, Calot’s triangle

Media type

Surgical video

Duration

07'22''

Publication

2007-02

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E-publication

WeBSurg.com, Feb 2007;7(02).
URL: http://www.websurg.com/doi-vd01en2064.htm

Acute cholecystitis management and technical tips

1. Aspiration of gallbladder 00'14''

This is a 50-year-old male patient presenting with a 3-day history of acute cholecystitis confirmed by ultrasound. This operation was undertaken on the 3rd day and the first step is to aspirate the gallbladder. Our preference is to use a Veress needle. This achieves 2 things: Bile obtained is sent for bacterial culture and decompression allows the previously turgid gallbladder to be handled more easily. After this is done, the inflammatory adhesions around the gallbladder are carefully lysed. This can be performed in a blunt fashion using the tip of a grasper or suction catheter, or sharply as in this case using scissors or cautery.

2. Dissection of Calot’s triangle 01'15''

Once the gallbladder is identified clearly,the anterior and posterior peritoneal reflections overlying Calot’s triangle are incised. The incision is made high up on the neck of the gallbladder or it can even be made on the lower half of the gallbladder itself, in order to avoid any inadvertent injury to the cystic duct, artery or common bile duct. This is an important step as inflammation causes thickening of this membranous layer, preventing access to the structures within. Once this is done, dissection of the cystic duct and artery begins. This can be performed in 3 ways. Firstly, sharp dissection is carried out with scissors or a hook if the structures can be visualised easily. If there is a lot of fat in the Calot’s triangle, a grasper can be used in a blunt fashion to open up the space. Finally, another useful technique is dissection with the suction-irrigation catheter, using alternating irrigation and suction. This technique is known as ‘hydro-dissection’. The cystic duct which defines the inferior margin of the Calot’s triangle is usually not difficult to identify. Within Calot’s triangle, the cystic lymph node is often enlarged during acute inflammation. Identification of this lymph node provides 2 significant advantages. Firstly, in approximately 80% of cases, the cystic artery is located just behind or adjacent to this lymph node. Secondly, if one maintains the dissection lateral to this lymph node as you can observe here, the risk of injury to the common bile duct can be reduced. Once the cystic duct is identified, it is dissected along its length for 1 to 2 cm in order to free it up for subsequent ligation.

3. Cystic duct isolation 03'39''

Then, the peritoneal reflection is opened further towards the liver to facilitate the dissection of the cystic artery. With suitable exposure, the cystic artery can then be identified. It is important to bear in mind some of the common anomalies of the cystic artery including double cystic artery. Dissection of this region must proceed with care because bleeding can obscure the vital structures present here and lead to inadvertent injury of the common bile duct, or even of the right hepatic duct.

4. Cystic artery isolation 04'20''

Once the cystic duct and artery are clearly identified, they may be clipped and divided.

5. Clipping and division of cystic duct and artery 04'45''

If there is any doubt as to the identity of the cystic duct, cystic artery and common bile duct, an intra-operative cholangiogram should be performed prior to division of any structures. We do not routinely perform operative cholangiograms in our unit and as in this case the anatomy is well visualised, we proceed with ligation and division of the cystic duct and artery.

6. Gallbladder dissection 05'40''

Once the cystic duct and artery are divided the gallbladder is dissected off the liver bed. This is not always easy to do in the acute setting as the thickened gallbladder can be difficult to manipulate, and bleeding can be a problem. However, once the correct plane is identified, the gallbladder can be gently separated from the liver. Excessive use of cautery here can produce a lot of smoke, obscuring the view and necessitating repeated venting of gas from the peritoneal cavity.

7. Hemostasis of liver bed 06'40''

After the gallbladder is dissected free from the liver, attention is focused on achieving final haemostasis of the liver bed. Monopolar cautery with a spatula, or, as in this case, the bipolar cautery can be used to control liver bed oozing. If necessary, haemostatic material such as Surgicel, or other agents may be applied to the raw surface. Finally, the gallbladder is extracted in a bag to avoid contamination of the port site and also the peritoneal cavity by accidental rupture during removal.