CHAPTER 8 Cholecystectomy
Step 1. Surgical anatomy
♦ The triangle of Calot is the most important anatomic boundary that needs to be defined when performing cholecystectomy. It is formed by the boundaries of the cystic duct, common hepatic duct, and cystic artery.
♦ Roughly parallel to this triangle is the hepatocystic triangle in which the cystic artery boundary is replaced with the liver edge. The only structure that should be found within this triangle is the cystic artery.
Step 2. Preoperative considerations
Patient preparation
♦ Straightforward symptoms of biliary colic along with objective evidence of gallstones by any imaging modality (ultrasound most sensitive) constitute adequate information to recommend cholecystectomy.
♦ In the absence of stones or sludge, studies of biliary function may help to diagnose pathology and need for surgery.
♦ Asymptomatic patients with stones do not generally require surgery unless immunocompromised. Obviously, the risks and benefits need to be weighed for each patient in making a recommendation for surgery.
♦ In cases of acute cholecystitis, inflammation of the gallbladder and bile ducts makes both open and laparoscopic cholecystectomy more difficult. In early or mild cases, the procedure can usually be managed laparoscopically. However, in severe cases it is often best to manage conservatively with intravenous antibiotics and delay surgery until the inflammation has subsided. Occasionally, in very sick patients, a cholecystostomy tube for drainage is also needed.
Equipment and instrumentation
♦ A 30-degree scope is helpful for providing additional views, especially of the hepatocystic triangle and surrounding structures. Frequently the common bile duct can be seen without any dissection using this type of endoscope.
♦ Standard laparoscopic equipment is used, including the following:
♦ A clip applier is necessary to control the cystic duct. If the cystic duct is too large for a clip, then a pretied loop can be used to occlude the cystic duct stump.
♦ A specimen retrieval bag is recommended to prevent spillage of bile and stones into the abdomen during extraction of the gallbladder from the abdomen.
Anesthesia
♦ Prophylaxis for DVT is important in all patients undergoing laparoscopic procedures. We use sequential compression devices and subcutaneous heparin is started before induction with anesthesia.
♦ An orogastric tube is placed to decompress the stomach and duodenum to facilitate exposure during the procedure.
♦ Patients are asked to void before being brought to the operating room for their comfort after surgery. A Foley catheter is not usually necessary because ports are not placed in the lower abdomen. If a longer procedure is anticipated, then a catheter is placed at the beginning of the procedure.
Room setup and patient positioning
♦ The patient is placed in the supine position. The surgeon operates from patient’s left side. The arms may remain out on armboards unless a cholangiogram is anticipated, in which case the right arm should be tucked to make room for the C-arm.
♦ Although not usually an issue with thin patients, footplates are used to secure the patient on the table and prevent sliding, as most of the procedure is performed with the patient in the reverse Trendelenburg position.
♦ The table is rolled toward the left so that the abdominal contents fall into the left lower quadrant by gravity. This position is also more comfortable because the patient is brought closer to the surgeon and the left-handed instrument can reach the working port more easily.
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