Micro-instrumentation for minimally invasive cholecystectomy: surgical technique

This video demonstrates an esthetic cholecystectomy using 2mm micro-instruments. The key steps and difficulties of this procedure are shown in detail by Professor Didier Mutter. This video is recommended to general surgeons. The authors use 2mm micro-instruments in this 25-year-old woman with symptomatic cholelithiasis. They dissect in the avascular plane between Glisson’s capsule and the gallbladder. Dissection with the micro-instruments is more time-consuming than with conventional instruments because the 2mm instruments have two drawbacks: flexibility, and being situated inside the abdomen with little of the instrument on the outside. After the dissection, the authors remove the 2 cameras and introduce the extraction bag through the umbilicus. They then reinsert the 10mm camera to check the operative field and help guide removal of the trocars. This step helps to minimize postoperative hemorrhage. Cosmesis is enhanced with three 2mm incisions and one 10mm incision deep in the umbilicus.

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Micro-instrumentation for minimally invasive cholecystectomy: surgical technique

Authors

D Mutter, J Marescaux

Abstract

This video demonstrates an esthetic cholecystectomy using 2mm micro-instruments. The key steps and difficulties of this procedure are shown in detail by Professor Didier Mutter. This video is recommended to general surgeons.
The authors use 2mm micro-instruments in this 25-year-old woman with symptomatic cholelithiasis. They dissect in the avascular plane between Glisson’s capsule and the gallbladder. Dissection with the micro-instruments is more time-consuming than with conventional instruments because the 2mm instruments have two drawbacks: flexibility, and being situated inside the abdomen with little of the instrument on the outside. After the dissection, the authors remove the 2 cameras and introduce the extraction bag through the umbilicus. They then reinsert the 10mm camera to check the operative field and help guide removal of the trocars. This step helps to minimize postoperative hemorrhage. Cosmesis is enhanced with three 2mm incisions and one 10mm incision deep in the umbilicus.

Keywords

cholecystectomy, micro-instruments, gallbladder dissection

Media type

Surgical video

Duration

05'30''

Publication

2007-10

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E-publication

WeBSurg.com, Oct 2007;7(10).
URL: http://www.websurg.com/doi-vd01en2146.htm

Micro-instrumentation for minimally invasive cholecystectomy: surgical technique

1. Trocar placement 00'09''

The cosmetic benefits of the minimally invasive approach for symptomatic cholelithiasis may be optimized by the use of 2mm micro-instruments. We report the case of a 25-year-old female patient presenting with symptomatic cholelithiasis. The setup for this approach is conventional. The patient is placed supine. The surgeon stands between the patient’s legs. Two optical ports are needed for the use of 2 cameras, one of 2mm and another of 10mm. The 1st 10mm port is placed at the umbilical level. It helps to identify the exact position of the gallbladder depending on the patient’s body habitus. It then allows to guide the introduction of the 3 other trocars. The 2mm ports being shorter than conventional trocars, they have to be orientated strictly along the axis of the gallbladder. Once the abdominal cavity is explored, the 2mm instrumentation is used to expose the Calot’s triangle in a conventional fashion.

2. Dissection of Calot\'s triangle 01'10''

Since the tip of the trocars may be fairly traumatic because of their size, the gallbladder is handled with care. The anatomical structures are identified precisely, and especially the common bile duct since we do not perform an intraoperative cholangiography routinely. Calot’s triangle is exposed conventionally and the anterior and posterior aspects of the peritoneum are opened. Because of their small size, the instruments may cause more bleedings in the event of excessive cautery. During this dissection, electrocautery currents must be brought down to 16-18 Watts. Calot’s triangle is totally isolated while the cystic artery and the cystic duct are successively identified. Since no intraoperative cholangiography is being performed, the anatomical structures must be very precisely identified while performing a thorough dissection anteriorly in order to make sure that there is no accessory bile duct around. Once Calot’s triangle has been perfectly identified, clips are applied to control these structures. The clip applier is then introduced through the 10mm umbilical trocar.

3. Division of cystic duct and artery 02'41''

A perfect view of the operative field is provided by the 2mm optical introduced in the midline port. This facilitates safe application of clips even though the whole dissection would be painstaking and time-consuming when performed with the use of this micro-optical. Two clips are placed conventionally on both the cystic artery and the cystic duct, one distal and another proximal to the area of division. Before the clips structures are divided, the position of the cameras is changed. The 10mm camera is then the one again introduced through the umbilical port whereas the 2mm camera is removed. The view of the operative field be enhanced, it helps confirm the good position of clips and allows safe division of anatomical structures. The quality of the cut of the 2mm scissors is poorer than conventional 5mm scissors. Thanks to the wide dissection that has been performed earlier, dissection of the gallbladder may be completed in the avascular plane situated between the Glisson’s capsule and the gallbladder.

4. Gallbladder dissection 04'27''

Dissection of these anatomical structures is slightly more time-consuming than with conventional instruments since 2mm instruments have 2 major drawbacks; their flexibility and their being situated inside the abdomen. Only a very short extremity remains outside of the abdomen. Lastly, at the end of the dissection, the 2 cameras, 2mm and 10mm in order to introduce a bag through the umbilicus that will allow safe extraction of the specimen without any contact with the wall. The 10mm camera may be reintroduced one last time in order to check for the quality of the operative field and remove all trocars under visual guidance, therefore avoiding any postoperative hemorrhage. The cosmetic result is enhanced with three 2mm incisions and one 10mm, which we totally conceal deeper down the umbilicus.