Laparoscopic cholecystectomy in a patient with liver cirrhosis

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Laparoscopic cholecystectomy in a patient with liver cirrhosis

Authors

D Mutter, J Marescaux

Keywords

laparoscopy,cholecystectomy,liver cirrhosis

Media type

Surgical video

Duration

07'00''

Publication

2004-12

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E-publication

WeBSurg.com, Dec 2004;4(12).
URL: http://www.websurg.com/doi-vd01en1602.htm

Laparoscopic cholecystectomy in a patient with liver cirrhosis

1. Patient and trocar placement 00'11''

This video will demonstrate laparoscopic cholecystectomy in a patient with liver cirrhosis. The patient is placed in a supine position with the surgeon between the legs of the patient and 2 assistants on either side. Four trocars are used in the position shown. The optical trocar is placed in a supraumbilical position and the 5mm trocar near the xiphoid is used to grasp the gallbladder for retraction. The 2 operative ports are placed in an arc from the target organ. Now to the operative view. The macronodular cirrhotic changes in the liver can be appreciated.

2. Exposure and dissection of Calot\'s triangle 00'55''

Following exposure of Calot’s triangle, the dissection is commenced in this area using a monopolar hook. Counter-traction combined with gentle coagulation facilitates the division of tissues. The fatty tissue here needs to be separated in order to identify the important structures in Calot’s triangle. Care must be taken not to damage the common bile duct at this point. As the dissection continues, the anatomy becomes clearer, and the position of the common bile duct is well demonstrated here. The dissection is now continued on the other side using the same technique. There seems to be a stone in the neck of the gallbladder making the dissection slightly more challenging. The gallbladder is flagged from on side to another to create a window behind the cystic duct and vessels. Now the separation of the gallbladder from the gallbladder bed. Again the monopolar hook is ideal for these purposes. This is the cystic artery, which is now isolated.The anatomy is now clear, and the cystic artery can be doubly clipped.

3. Clipping and division of cystic duct and artery 03'51''

The cystic duct is then also clipped. These structures are then divided to free this end of the gallbladder. This small vessel here also needs to be controlled. The gallbladder can now safely be separated from the liver.

4. Gallbladder bed dissection 04'52''

The dissection is continued in the gallbladder bed ensuring that adequate hemostasis is achieved. The risk of hemorrhage is higher in this case due to portal hypertension secondary to cirrhosis. It is always safer to stay closer to the gallbladder than the liver, especially in this type of case. Traction and counter-traction is the key to this stage of the dissection. The final attachments of the gallbladder are now separated. The gallbladder is now completely free. A quick check for hemostasis now. The gallbladder is then placed in an Endobag.

5. Extraction 06'45''

The bag is closed, and then this is retrieved from the optical trocar. A final check is made for hemostasis, and this is the end of the operation.