Laparoscopic cholecystectomy for gallstones with intraoperative cholangiography

This video demonstrates a routine laparoscopic cholecystectomy with intraoperative cholangiogram through the cystic duct. The cholangiocatheter is inserted through a small opening in the cystic duct after mobilization and application of a proximal clip. After completion of the cholangiogram the catheter is removed and the cystic duct is clipped distally and divided. The gallbladder is excised and removed.

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Laparoscopic cholecystectomy for gallstones with intraoperative cholangiography

Authors

D Mutter, J Marescaux

Abstract

This video demonstrates a routine laparoscopic cholecystectomy with intraoperative cholangiogram through the cystic duct. The cholangiocatheter is inserted through a small opening in the cystic duct after mobilization and application of a proximal clip. After completion of the cholangiogram the catheter is removed and the cystic duct is clipped distally and divided. The gallbladder is excised and removed.

Classification

routine cases

Keywords

cholecystectomy,intraoperative cholangiogram, laparoscopic

Media type

Surgical video

Duration

06'00''

Publication

2003-01

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E-publication

WeBSurg.com, Jan 2003;3(01).
URL: http://www.websurg.com/doi-vd01en1372e.htm

Laparoscopic cholecystectomy for gallstones with intraoperative cholangiography

1. Positioning and trocars 00'22''

The patient is placed in a lithotomy position with the left arm tucked along the body. The optical trocar in A is a 10 to 12mm trocar and the 3 others are 5mm trocars. The trocar D is used to insert a retracting instrument. This instrument grasps the gallbladder and retracts it cephalad. Adhesions between the omentum and the gallbladder are gently dissected free using the hook and monopolar coagulation. Trocar B and C are used as operating trocars.

2. Dissection of Calot\'s triangle 01'55''

The left hand grasper is used to retract to the left and to the right Hartmann’s pouch. The lower third of the gallbladder is dissected off the gallbladder bed. This is performed interiorly and posteriorly. This dissection helps to open up the space of Calot’s triangle. Then using careful dissection with the hook, the cystic artery and duct are isolated. To expose the triangle of Calot, the retraction of Hartmann’s pouch is performed in a caudad and lateral fashion. The lower third of the gallbladder is now almost completely freed from the gallbladder bed. The cystic artery and duct are well individualised. The cystic artery is clipped doubly, and the cystic duct is clipped only proximally to allow for the introduction of a cholangiography catheter. It is introduced on the right subcostal margin and the cystic duct is partially divided. There is a slight outflow of bile and the cholangiography catheter is introduced into the cystic duct and inflated. The instruments are taken out to allow for the performance of the intraoperative cholangiography. Cholangiography is normal, catheter is deflated and brought out and the cystic duct is clipped away from the common bile duct. The cystic artery is divided as well as the cystic duct.

3. Dissection of the gallblader 04'56''

The gallbladder is now retracted interiorly and this allows for the division of the attachments between the gallbladder and the gallbladder bed. This is performed using monopolar coagulation with the hook. Care is taken to divide precisely the fibrous attachments between the two structures to avoid liver injuries or entering into the gallbladder. A caudad and lateral traction is exerted on the gallbladder to allow for sufficient traction between the gallbladder and the liver bed. The same plane is kept throughout the whole dissection of the gallbladder bed. The quality of the hemostasis on the gallbladder bed should be checked. The gallbladder is inserted into a retrieval sac which is closed and the sac is extracted through the optical trocar. This concludes the procedure.