Laparoscopic cholecystectomy for gallstones: vascular anatomical variation (anterior right hepatic artery)

This video demonstrates a standard laparoscopic cholecystectomy, which demonstrates some vascular variation with presence of an anterior and a posterior branch of the cystic artery. The surgeon demonstrates how a careful dissection of the Calot's triangle ensures that any anatomic anomaly is identified.

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Laparoscopic cholecystectomy for gallstones: vascular anatomical variation (anterior right hepatic artery)

Authors

D Mutter, J Marescaux

Abstract

This video demonstrates a standard laparoscopic cholecystectomy, which demonstrates some vascular variation with presence of an anterior and a posterior branch of the cystic artery. The surgeon demonstrates how a careful dissection of the Calot's triangle ensures that any anatomic anomaly is identified.

Classification

basic techniques

Keywords

anatomical vascular variation, laparoscopy,cholecystectomy,common bile duct

Media type

Surgical video

Duration

14'00''

Publication

2004-12

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E-publication

WeBSurg.com, Dec 2004;4(12).
URL: http://www.websurg.com/doi-vd01en1596.htm

Laparoscopic cholecystectomy for gallstones: vascular anatomical variation (anterior right hepatic artery)

1. Patient and trocar placement 00'27''

We are used to performing our cholecystectomy using 4 ports. The 1st port is placed just over the umbilicus in order to provide direct access to the gallbladder. We use a second 5mm port placed just at the epigastric level in order to retract the gallbladder, and then we use 2 operating ports, one placed through the rectal muscle on the left side over the umbilicus and the second one at mid-distance between the umbilicus and the iliac crest. We always place our first port performing an open laparoscopy after insertion of the first 10mm port. Under direct control, we place the three 5mm ports. We see that the gallbladder is located exactly at the place where we have drawn it so we will have a good triangulation by respecting the standard positioning of our instrumentation. The ports are placed under direct vision in order to avoid any injury. After port placement, the patient is put in an operative position, with the legs down. This patient is presenting with a thin wall of the gallbladder. Grasping must be done cautiously.

2. Exposure 02'02''

Sometimes we may have some problems with a very big left lobe. Here you see the Hartmann’s pouch. Here we can identify very easily the way of the common bile duct in a standard fashion. We try to retract a bit the stomach to the left side and we can identify the cystic duct, which is very clear here as well as the common bile duct in its lateral position.

3. Dissection of Calot\'s triangle 02'43''

We can begin with mobilization of the Hartmann’s pouch. We perform this dissection using a hook. The beginning of this procedure is to open the peritoneum anteriorly and posteriorly to the Hartmann’s pouch in order to lengthen the cystic pedicle. We use monopolar cautery at a very low voltage in order to avoid any diffusion of the electric current and any remote bleeding. We have a hook completely protected on its posterior aspect in order to avoid any contact between the tissues and the hook. This mobilization of the gallbladder is done on its posterior aspect. We always try to avoid any injury of the liver. Here you see that after freeing the posterior attachment of the peritoneum between the gallbladder and the liver, it allows a much better mobilization of the gallbladder and it offers an increased operative field. Here we have lengthened the cystic pedicle. Here I will open the peritoneum anteriorly in order to leave the node on the neck of the gallbladder and to have access to the cystic duct and artery after opening the peritoneum, leaving the node on the side of the gallbladder. Here you see that we open only the peritoneum and we perform on the upper part exactly the same dissection that we have performed downwards, which means that we grasp only the peritoneal sheet. For the moment, we don’t try to have access to any other tissues. Here you see that we have completely freed the triangle of Calot. For the moment, we have not identified the cystic artery or the cystic duct, but the length of our pedicle allows us to perform a high quality dissection. We never cut an element blindly because we don’t perform routine cholangiography. Here you see that step by step, we identify all the little attachments along this pedicle in order to have a totally free access to the cystic duct and cystic artery. Here we begin to identify the cystic duct and the cystic artery separately. We rotate the end of the hook, which is a very useful device for this type of dissection. The hook allows a very precise dissection of the hepatic pedicle. Here we have a little vessel, it is the vascularization of the node, and we have to complete this dissection in order to completely free the cystic duct. This patient seems to present with an early division of the cystic artery with an anterior branch joining the cystic duct very rapidly. Here you see the anatomy of the Calot’s triangle. Here we have some more fibrous attachments along the node and we know that we can also lengthen very easily the cystic duct. Here we identify posteriorly the right hepatic artery, the origin of the cystic artery with its anterior branch and a small posterior branch.

4. Clipping and division of cystic duct and artery 07'36''

So we’ll first control this branch with a clip, which will allow us to mobilize and lengthen a little more the cystic duct and we control this branch with double clip application. Here we have this cystic branch coming immediately from the right hepatic artery, which is very well identified. Here we have to finish the dissection of the cystic duct anteriorly and afterwards the cystic artery posteriorly. We can apply simultaneously the clip on the branch of the cystic artery, again with double application in order to avoid any leakage, and we also apply immediately clips in order to control the cystic duct. This clip application is performed with anterior and posterior control in order first to be sure to have a global control of the cystic duct to avoid any injury of the common bile duct, which is again identified here. Here again as we don’t perform routine cholangiography, we have to have this complete identification. Here we have cut the artery; then we cut the cystic duct, first half of it. We have no bleeding in the operative field, a clear image identification of accessory artery, main artery, both double clipped, and of the cystic duct, and we can complete the dissection using the monopolar hook.

5. Gallbladder bed dissection 09'39''

We must have a progressive control of the gallbladder bed in order to avoid bleeding and any hepatic injury. Here we cauterize regularly and closely the peritoneal sheet and all the small vessels joining the liver directly. Precise coagulation is performed to avoid postoperative bleeding. We try to avoid opening the hepatic capsule, and here we have a small pedicle coming from the liver. We have to control the possibility to have a Luschka accessory biliary tract coming from the liver; so if we have such a significant small pedicle coming from the liver as we have here, if necessary we can put a single clip on this to control it. Whenever this is the case, a single clip application can be made on the side of the liver. This can be controlled using bipolar cautery. Anyway, we can safely apply a clip at this level, and then the dissection is continued with the hook. We make sure to avoid any contact between the hook and the clip in order to avoid diffusion of electric current from the gallbladder to the liver. Here you see that a very gentle spark allows dissection of the gallbladder. The assistant places his retractor along the liver and here again, using a small movement from upwards to downwards, we control all the small attachments between the gallbladder and the liver bed. We always try to complete hemostasis in order to avoid any bleeding into the operative field, so we just modify the positioning of the gallbladder in order to have access to the peritoneum again, and the opening of the peritoneal sheet allows us to identify the avascular plane. There is no longer any tension on the tissues. When the dissection is complete, we check the hemostasis, and especially hemostasis of the liver.

6. Extraction 13'06''

The gallbladder is always removed using a bag. Then we catch the gallbladder that was placed over the liver. The gallbladder is placed into the bag, then we close this bag using 2 graspers. To be removed, the bag is taken by one grasper, which is the one placed at the most distance from the entry port, and using this grasper, the closed bag is pushed into the 12mm port. The 5mm grasper is removed and the bag is pushed and exteriorized. We try to avoid any contamination of the parietal wall, and if the gallbladder doesn’t come out very easily, the bag is opened. It is controlled with 3 Kelly forceps and the gallbladder will be removed along with the bag. The gallbladder is emptied from its bile and stones will be gradually retracted until the entire gallbladder can be removed. We have absolutely no contamination of the parietal wall.