The fear of transgastric cholecystectomy: misinterpretation of the biliary anatomy

Misinterpretation of normal anatomy and anatomical variations contribute to the occurrence of major complications like biliary injury during cholecystectomy. Performing a NOTES transgastric cholecystectomy under endoscopic view, whenever the anatomy of the biliary tract is confusing as happened in the case here presented, a temporary conversion to a laparoscopic view more familiar to the surgeon’s eye and therefore clearer, will provide a better understanding of the anatomy. The contribution of a preventive strategy in avoiding injury during NOTES procedure needs to be investigated.

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The   fear   of   transgastric   cholecystectomy:   misinterpretation   of   the   biliary   anatomy

Authors
S Perretta, Gf Donatelli, B Dallemagne, J Marescaux
Abstract
Misinterpretation of normal anatomy and anatomical variations contribute to the occurrence of major complications like biliary injury during cholecystectomy. Performing a NOTES transgastric cholecystectomy under endoscopic view, whenever the anatomy of the biliary tract is confusing as happened in the case here presented, a temporary conversion to a laparoscopic view more familiar to the surgeon’s eye and therefore clearer, will provide a better understanding of the anatomy. The contribution of a preventive strategy in avoiding injury during NOTES procedure needs to be investigated.
Keywords
Transgastric cholecystectomy, misinterpretation, biliary anatomy
Media type
Duration
06'00''
Publication
2009-09
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Audio
en
Subtitles
en
E-publication
WeBSurg.com, Sept 2009;9(09).
URL: http://www.websurg.com/doi-vd01en2613.htm

The   fear   of   transgastric   cholecystectomy:   misinterpretation   of   the   biliary   anatomy

1. Script 00'07''
The prevention of major biliary duct injury at cholecystectomy relies on the accurate dissection of the cystic duct and artery and avoidance of major adjacent biliary and vascular structures. The advent in popularity of NOTES cholecystectomy has led to a new look and insight into biliary anatomy, especially of the Calot’s triangle area. Here we show the case of a NOTES cholecystectomy performed via a transgastric approach in which a misinterpretation of the biliary anatomy occurred. After induction of pneumoperitoneum using a Veress needle, a single 5mm transparietal port was introduced at the umbilicus to allow the peritoneoscopy and ascertain the feasibility of the transgastric cholecystectomy. Once the feasibility was clarified, transgastric access was obtained using a double-channel endoscope under laparoscopic visual control. An endoscopic monopolar needle knife was used to create a minute full-thickness cut on the anterior wall of the mid-body of the stomach. Then an 18mm balloon dilator expanded the gastrotomy and allowed the passage of the 12mm gastroscope. Once the endoscope has entered the peritoneal cavity, the laparoscopic optic can be switched to a 5mm standard laparoscopic grasper, which was used to expose the gallbladder. In this patient, while retraction was provided by the laparoscopic grasper, the dissection started by using the endoscopic flexible tools. An endoscopic blunt-tipped electrode was used to begin the dissection at the junction between the infundibulum and what was thought to be the cystic duct. Assistance during this dissection was provided by grasping instruments inserted via the second working channel of the flexible endoscope. During the dissection, the size and the orientation of the cystic duct appeared in clear. Following the same precepts of safe dissection that has been developed for any operation, namely “no clear view, no step further”, the decision was made to switch to a laparoscopic view to re-orientate the dissection and define the correct planes. At this point, we realize that the dissection of the triangle of Calot, although started in close proximity to the gallbladder, was far too low and that we had mistaken the common bile duct with the cystic duct. Fortunately, the dissection maneuvers had been performed with extreme care and an injury to the CBD occurred. Once the biliary anatomy was clarified, the vision was switched back to the endoscope, but a 2mm grasper was introduced to improve retraction. A laparoscopic hook was used to skeletonize the cystic duct and artery that were clipped using a 5mm laparoscopic clip applicator inserted via the umbilical port. Misinterpretation of normal anatomy and anatomical variations contribute to the occurrence of major postoperative complications like biliary injury following a cholecystectomy. At this stage, whenever the anatomy of the biliary tract is confusing as happened in this case, a temporary conversion to a laparoscopic view more familiar to the surgeon’s eye and therefore clearer, will provide a better understanding of the location of the common bile duct in respect to the cystic duct. Specific anatomical distortions due to the NOTES technique along with a lack of exposure with the present methods of retraction tend to distort the Calot’s triangle by actually flattening it rather than opening it out. The contribution of a preventive strategy in avoiding injury needs to be investigated. After division of these elements, the cholecystectomy was performed in a standard fashion. At the end of the dissection, the operative site was checked to ensure hemostasis and biliostasis and to exclude any inadvertent injury to the adjacent organs, especially the common bile duct. The gallbladder was extracted through the gastrotomy under laparoscopic view. This case stresses once again the importance of a hybrid approach at this stage of NOTES and that represents the safest format for patients.