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Laparoscopic cholecystectomy in a patient with macroscopic liver cirrhosis: use of LigaSure

Authors

Abstract

This video demonstrates a safe approach to carrying a laparoscopic cholecystectomy in a patient with macroscopic liver cirrhosis and portal hypertension. The surgeon uses a 5 mm bipolar cautery to ensure adequate hemostasis during the dissection.

Classification

complex cases

Keywords

gallbladder,liver,cirrhosis,laparoscopy,lithiasis

Media type

Duration

05'00''

Publication

2004-11

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E-publication

WeBSurg.com, Nov 2004;4(11).
URL: http://www.websurg.com/doi-vd01en1601.htm

Laparoscopic cholecystectomy in a patient with macroscopic liver cirrhosis: use of LigaSure

1. Patient and trocar position 00'06''

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.

2. Dissection of Calot\'s triangle 00'44''

The patient has symptomatic cholelithiasis. The cirrhosis is macronodular with Child-Pugh’s score B and the patient suffers from portal hypertension. We can see here on the laparoscopic view the macroscopic changes on the liver. The dissection is commenced in the region of Calot’s triangle using the 5mm Ligasure device. A peritoneal flap is raised to expose the structures within Calot’s triangle. The dissection is continued very gently due to the risk of hemorrhage from portal hypertension and risk of injury to the common bile duct. The monopolar hook is particularly useful for this part of the dissection, now deeper in order to isolate the structures within this area. The dissection continues in order to create a window. A window has now been created with the cystic duct and artery to the left of the screen. Once the anatomical structures have been isolated, clips are applied to control both the cystic duct and the artery.

3. Cystic duct and artery dissection 02'36''

They are then divided to free the end of the gallbladder.

4. Gallbladder bed dissection 02'54''

The dissection is now continued retrograde to separate the gallbladder from the gallbladder bed. The plane is identified by gentle traction and diathermy ensuring that any bleeding is adequately controlled. It is always safer to stay close to the gallbladder especially in this type of case. The final attachment is now divided ensuring adequate hemostasis.

5. Specimen extraction 04'03''

Once free, the gallbladder is placed in a bag ready for retrieval. The empty gallbladder bed is clearly visible here. A final check is made for hemostasis and this is the end of the operation.

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