Laparoscopic cholecystectomy using micro-instrumentation including monopolar and bipolar 2mm cautery

Authors

Abstract

This video demonstrates the feasibility and the challenges of a laparoscopic cholecystectomy using micro-instrumentation in an uncomplicated cholelithiasis.

Classification

basic techniques

Keywords

laparoscopy, cholecystectomy, micro-instrumentation, monopolar, bipolar cautery, 2mm instruments, cholelithiasis, symptomatic gallbladder lithiasis

Media type

Duration

09'27''

Publication

2008-09

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Audio

Subtitles

E-publication

WeBSurg.com, Sept 2008;8(09).
URL: http://www.websurg.com/doi-vd01en2402.htm

Laparoscopic cholecystectomy using micro-instrumentation including monopolar and bipolar 2mm cautery

1. Clinical case presentation 00'12''

This is the case of a 28-year-old female patient presenting with symptomatic gallbladder lithiasis. There are no clinical, biological or ultrasonographic signs of stone migration to the common bile duct. The patient is slim and has had no lithiasis-related complications. Therefore, a laparoscopic cholecystectomy using micro-instrumentation is proposed.

2. Trocar positioning 00'35''

The procedure begins by the insertion of a 10mm trocar in the umbilicus under direct visual control. Following identification of the gallbladder’s position, three 2mm trocars are introduced successively in the direction of the gallbladder. Because these instruments are short and fragile, the orientation is very important.

3. Gallbladder dissection (Calot’s triangle) 01'05''

The dissection is then performed in a conventional manner, with opening of the peritoneum anteriorly and posteriorly to the Calot’s triangle in order to successively isolate the cystic artery and the cystic duct. Some small bleeding caused by dissection in the hepatic parenchyma is controlled by applying a 2mm bipolar grasper. Monopolar coagulation is difficult because of the small size of the instruments as they only allow for a very restrictive coagulation. Bear in mind that the coagulation is limited at 14 Watts for this dissection.

4. Cystic artery and cystic duct ligation 05'30''

Following complete identification of the structures of Calot’s triangle and after locating the common bile duct, a 2mm optic is introduced in the median trocar and the cystic artery and cystic duct are successively controlled by clip application. The 10mm optic is reintroduced through the umbilicus, the position of the clips is verified and both the cystic duct and cystic artery are divided. The dissection of the gallbladder bed is continued with progressive electrocautery. A vascular pedicle that could potentially contain a small Luschka’s duct is found and controlled using the 2 bipolar electrocautery. The gallbladder is dissected as a whole and freed of its liver attachments.

5. Specimen extraction 08'10''

The 2mm optic is re-introduced and an extraction bag is passed through the 10mm umbilical trocar. The gallbladder is placed in the bag and extracted through the 10mm incision. Following control of the gallbladder bed, the trocars are removed under visual control to verify there is no bleeding. The 10mm incision is closed by a figure of eight stitch and this incision is closed using a running suture. The three 2mm holes are closed using only Steri-strips. The postoperative follow-up is uneventful with the patient being discharged the day after the procedure.

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