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Laparoscopic cholecystectomy: a gold standard case for the dissection of Calot’s triangle

Authors

Abstract

This authoritative demonstration clearly shows all the key steps of laparoscopic cholecystectomy for symptomatic cholelithiasis.

Keywords

laparoscopy, cholecystectomy, Calot\'s triangle, cholecystitis, gallbladder

Media type

Duration

15'00''

Publication

2008-04

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E-publication

WeBSurg.com, Apr 2008;8(04).
URL: http://www.websurg.com/doi-vd01en2317.htm

Laparoscopic cholecystectomy: a gold standard case for the dissection of Calot’s triangle

1. Case history 00'15''

This is the case of a 35-year-old patient presenting with symptomatic gallbladder. He presented 2 months ago with pain and diagnosis made by ultrasonography demonstrated the presence of biliary lithiasis, the patient has no abnormality of the common bile duct shown at the imaging, no abnormalities at the biology, so we perform as usual a standard cholecystectomy without intraoperative cholangiography.

2. Trocar placement 00'50''

We use 4 ports to perform this procedure; we insert a 12mm port in the umbilicus in a standard way. We then control the position of the gallbladder, it is located in this place, we then put 2 operative ports in order to respect the triangulation. We respect the following rules: first of all, the distance between the camera and the operating port, a minimum distance of 7 to 8cm in order to avoid crossing instruments. The same distance is respected between these 2 ports to respect the triangulation. Out of this exposure area, we have a fourth port located on the upper part of the abdomen, this is a 5mm port that is inserted in order to be able to retract the gallbladder. This port comes this way and will be able to retract the gallbladder upwards. This is a common standard installation. We use a straight 10mm endoscope, it is prepared to be very clean, we put some soap on the end of it to avoid smoke during the procedure and then it is inserted into the abdomen.

3. Operative anatomy 02'25''

We identify the upper port located here, this port retracts the gallbladder upwards to the left hypochondrium. Here you see the gallbladder, you see the fundus, here we identify Calot’s triangle that will be dissected first. Here we can identify very clearly the common bile duct, here is the beating hepatic artery and here is the hilum, in a standard way, we will not need to go there. The procedure starts by using a hook, the cautery is set at 18 Watts.

4. Full skeletonization of Calot\'s triangle 03'10''

The principle of the operation is always the same, first grasp gently the fundus, small monopolar cautery is used while always grasping gently the peritoneum to perform simultaneously cautery and division. The objective is to open the peritoneum and avoid diffusion of current or heat to the common bile duct. That is the position of my hook, always looking in the direction of the gallbladder, never in the direction of the common bile duct. I go below the peritoneum, grasp it and always make a short cut with cautery and I will do the same type of procedure to open the lower part of the peritoneum, to go behind the gallbladder in order to lengthen again Calot’s triangle and to have a better access to the cystic duct and cystic artery. The dissection goes posteriorly on a long distance, it has to start opening the junction between the gallbladder and the liver. Here you see that we preserve 1 to 2mm of the peritoneum and by gentle traction, I can open it very high, up until the origin of this first little vessel. The Calot’s triangle is lengthening as you see here, I try to avoid blunt or blind dissection in order to avoid any bleeding, and all the little tissue here can be very gently coagulated. The only risk of doing the dissection posteriorly is to go here in contact with the right hepatic artery. When we pull the gallbladder upwards like that, we have a good exposure of this field. Posteriorly, there is little risk of being in contact with the common bile duct, but we know that posteriorly here we have the right hepatic artery. We can open posteriorly but very close to the gallbladder neck and with a very clear control of all the elements that are taken in the hook. That is why we only take half a millimetre of tissue with the hook each time. Posteriorly I have completely opened the neck of my Calot’s triangle and so I know that in this patient I will have together the cystic artery and the cystic duct in this area. Here you see again the common bile duct, the gallbladder neck, so the opening of the Calot’s triangle and the separation of artery and cystic duct should be done between these elements. Here I have an opening so I gently go in between and I try to have traction on the structures that are not cystic artery or cystic duct in order to complete this dissection. I have an almost complete dissection. Here you can see the cystic duct very well; when we perform a cholecystectomy without intraoperative cholangiography, we must be absolutely sure about the anatomy. So gentle traction, here we see that the cystic duct is coming laterally to the common bile duct, so I will lengthen the length of the cystic duct very gently in order to be able to have a very safe application of the clips. Here we see that the cystic duct is normal, the right duct could be in this area. It is very dangerous to dissect the hilar plate here in this type of patient, this must be preserved and you see that my dissection is going very far inside, close to the gallbladder. When this is presented, I will apply my clips;

5. Clipping and division of cystic duct and artery 08'15''

for the moment, we use non-absorbable clips. We always place the first clip almost at the lowest position, they must absolutely not cross each other in order to avoid displacing; we put two clips as usual and then one clip on the remaining side. In order to avoid over-manipulation, we will do the same for the artery that is completely dissected. Dissection is always done partially first to be sure of the type of duct we have, here we see some bile so it is the cystic duct. We then do the same for the artery.

6. Dissection of gallbladder from liver bed 09'30''

Thanks to the very low current that we have, 18 Watts no more, we can very clearly identify the plane between the gallbladder and the liver in order to avoid any bleeding. I change the type of grasping on the gallbladder and apply a gentle but very limited tension. If there is too much tension on the gallbladder, it will disrupt the tissue and bleed. I am always changing the place of dissection by going from right to left, which means that I am always looking on the tissue that has some tension. I will free the gallbladder here and ask my assistant to keep his grasper open like that and just keep the liver. I lift the gallbladder, you see that thanks to the open trocar, I have no injury of the liver, the gallbladder is almost dissected and only its upper part is open. I will open the peritoneal reflection, I change the aspect, here I was tearing the peritoneal reflection, which was at the origin of some bleeding. We can complete the dissection, the gallbladder holds itself, just a small part of peritoneal reflection. The gallbladder bed is free, there is some smoke because I work with cautery but I have only 18 Watts, which is a small amount of electricity.

7. Hemostasis of liver bed 11'43''

Here we control the positioning of the clips, the anatomy is normal. I take the camera away.

8. Extraction of gallbladder 12'00''

And I take a bag, which will be completely inserted into the abdomen. The little trick is that we have only three 5mm ports, so first I unroll the bag and place it at the upper part of the liver. Secondly, my assistant will grasp the inferior part of the bag, he holds it open down on the lower part and with my external grasper, I hold it on its upper part. I just have to take the gallbladder and put it directly into the bag, I then close it. Then I put this part of the suture in the epigastric port, I close it and it holds the bag very strongly, I put the grasper in the 10mm tube, the only risk is to touch the optic. I close the CO2 injection, remove the 10mm port, and this grasper with the bag is ready. The bag comes out through the umbilicus. We will try to avoid any contamination of the parietal wall and will use the bag as a protective shield. From this shield, I will grasp the gallbladder and if it does not come out easily, I have another solution: I put suction on, make an incision of the gallbladder, and empty the gallbladder. As it is empty of its bile, there is no contamination of the operative field and the gallbladder is out. The camera is placed back in.

9. Final check and removal of trocars 14'10''

We do a final control of the operative field. There is no bile or blood so we leave it like that, we never put a suction drain in this ideal case. The trick to remove the trocar is first to remove the trocar, keeping the grasper; if there is no bleeding, we remove the grasper and we ask the assistant to put one finger to keep the pneumoperitoneum. To finish, I exsufflate my patient and I have closed the grasper, I exsufflate before removing the trocar, it’s very important to prevent the gas from coming through the port and avoid incarcerated hernias of small bowel, which can be the case if you exsufflate under control.

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