Laparoscopic management of gangrenous perforated cholecystitis

Laparoscopic cholecystectomy is the gold standard for symptomatic cholecystolithiasis. Technical maturation and advances in instrumentation have enabled the application of this procedure for acute cholecystitis. This video demonstrates the surgical approach to performing a laparoscopic cholecystectomy in an older male patient with acute cholecystitis and who has had a previous laparotomy for vascular surgery. The surgeon uses a French approach standing between the patient's legs while he optical trocar is placed supraumbilically, 3cm to the right of the midline in order to avoid the adhesions caused by the previous surgery. An ischemic gallbladder with necrotic area and infundibular perforation was found.

Create account

Browse the WORLD

Virtual University

Google translate

Summary
Chapters
Your comments
Ask the Experts

You need to log in to watch this media!

Click here to log in.

Laparoscopic management of gangrenous perforated cholecystitis

Authors

J D'Agostino, J Marescaux

Abstract

Laparoscopic cholecystectomy is the gold standard for symptomatic cholecystolithiasis. Technical maturation and advances in instrumentation have enabled the application of this procedure for acute cholecystitis.
This video demonstrates the surgical approach to performing a laparoscopic cholecystectomy in an older male patient with acute cholecystitis and who has had a previous laparotomy for vascular surgery. The surgeon uses a French approach standing between the patient's legs while he optical trocar is placed supraumbilically, 3cm to the right of the midline in order to avoid the adhesions caused by the previous surgery.
An ischemic gallbladder with necrotic area and infundibular perforation was found.

Classification

clinical cases

Keywords

Laparoscopic management, gangrenous perforated cholecystitis

Media type

Surgical video

Duration

06'00''

Publication

2009-03

Popular

Favorites

Favorites Media

Audio

Subtitles

E-publication

WeBSurg.com, Mar 2009;9(03).
URL: http://www.websurg.com/doi-vd01en2540.htm

Laparoscopic management of gangrenous perforated cholecystitis

1. Clinical case presentation 00'16''

The patient is an 80-year-old man who has had nausea and vomiting for 3 days, with no abdominal pain or fever. He has a history of diabetes, chronic renal failure and has had vascular surgery through a median laparotomy. The biological findings have shown a leukocytosis with no cholestasis, and the CT-scan has revealed a cholelithiasis with signs of acute cholecystitis. Four trocars are used. The 10 -12mm optical trocar is placed supra-umbilically, 3cm to the right of the midline in order to avoid the adhesions caused by the previous surgery. The other three 5mm trocars are placed in conventional positions following an important adhesiolysis.

2. Freeing of gallbladder adhesions 00'58''

The procedure starts by freeing the body of the gallbladder from the duodenal adhesions. A blunt dissection using forceps is sufficient to isolate the duodenum atraumatically.

3. Identification of gallbladder perforation 01'21''

Once the duodenum has been brought down, we discover a perforation within the infundibulum of the gallbladder. There are no signs of biliary peritonitis. We complete the dissection using the aspiration device in order to free the gallbladder from the omental adhesions. The wall of the gallbladder appears to be thin, as it is found in ischemic cholecystitis. A peanut swab could be useful to control the oozing. This allows to correctly expose the anterior aspect of the Calot’s triangle.

4. Cystic duct and artery dissection and division 02'10''

The cystic duct is identified by using the aspiration device before being isolated using a monopolar cautery hook. We now dissect the cystic artery, and both structures will be ligated using metal clips. The artery is then cut, followed by the cystic duct. A Vicryl loop can be useful to ensure the safe closure of an inflammatory cystic stump.

5. Completion of gallbladder dissection 04'04''

The dissection of the gallbladder bed is completed. The aspect of the gallbladder wall is ischemic with necrotic areas typical of a gangrenous cholecystitis, not rare in diabetic patients.

6. Specimen extraction 05'22''

The specimen and the swab are extracted in a bag and a drain is left in place for 24 hours.