colecistectomia laparoscopica

Los TERRYbles BooK TeaM


INDICATIONS

Cholecystectomy is indicated in symptomatic patients with proven disease of the gallbladder,

and the indications for laparoscopic cholecystectomy are essentially those for open

cholecystectomy. There are certain definitive contraindications, which at present include

peritonitis, small bowel obstruction, coagulopathy, and large diaphragmatic hernia. Relative

contraindications are becoming fewer as the surgical experience of the individual surgeon

increases. This list includes cirrhosis, previous intra-abdominal surgery with adhesions, and

acute gangrenous cholecystitis.

PREOPERATIVE PREPARATION Following a history and physical examination, the diagnosis of biliary disease is documented

with ultrasound examination of the abdomen. The remainder of the gastrointestinal tract may

require additional studies. A chest x-ray and electrocardiogram are usually performed and

may indicate the need for further evaluation of the cardiopulmonary systems. Routine

laboratory blood tests are obtained and should include a liver function panel as well as

coagulation studies. The risks of laparoscopy, including trocar injuries to viscera or blood

vessels and the increased risk of bile duct injuries during laparoscopic cholecystectomy, are

discussed with the patient as well as the possibility of conversion to an open procedure. The

management of patients with gallstones and common duct stones remains to be defined. An

endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy are commonly

tried first. If the common duct is successfully cleared of stones, then a staged laparoscopic

cholecystectomy is performed. If the ERCP procedure is not successful, the patient should be

prepared for an open cholecystectomy with common duct exploration.

ANESTHESIA

General anesthesia with endotracheal intubation is recommended. Preoperative prophylactic

antibiotics for anticipated bile pathogens are administered such that adequate tissue levels

exist.

POSITION As laparoscopic cholecystectomy makes extensive use of supporting equipment, it is

important to position this equipment such that it is easily visualized by all members of the

surgical team (Figure 1).

The surgeon must have a clear line of sight to both the video monitor and the high flow CO2

insufflator such that he or she can monitor both the intra-abdominal pressure and gas flow

rates. In general, all members of the team are looking across the operating table at video

monitors and therefore the positions of the video monitors may require adjustment once all

members step to their final positions at operation. The patient is placed supine with the arms

either secured at the sides or out at right angles so as to allow the maximum access to

monitoring devices by the anesthesiologist at the head of the table. An orogastric tube is

passed after the patient is asleep. Foley catheter placement is optional. As increased intra-

abdominal pressure from the pneumoperitoneum impedes venous return and may raise the


risk of deep venous thrombosis, both legs are either wrapped or placed in elastic stockings

over which sequential pneumatic compression stockings may be placed. The electrocautery

grounding pad is placed near the hip avoiding any region where internal metal orthopedic

parts or electronic devices may have been implanted. The position of the patient on the table

relative to placement of the x-ray cassette for a cholangiogram or the C arm for fluoroscopy is

rechecked. The legs, arms, and upper chest are covered with blankets to minimize heat loss.

OPERATIVE PREPARATION

The skin of the entire abdomen and lower anterior chest is prepared in the routine manner.

INCISION AND EXPOSURE

The abdomen is palpated to find the liver edge or unsuspected intraabdominal masses. The

patient is placed in a mild Trendelenburg position and an appropriate site for the creation of

the pneumoperitoneum is chosen. In the unoperated abdomen this is usually at the level of

the umbilicus (Figure 2); however, previous laparotomy incisions with presumed adhesions

may suggest a more lateral approach site which avoids the epigastric vessels (Figure 2 at X).

A 1-cm vertical or horizontal skin incision is made and the abdominal wall on either side of the

umbilicus is grasped by the surgeon and first assistant either by thumb and forefinger or by

towel clips so as to elevate the abdominal wall (Figure 3). A Veress needle is held like a

pencil by the surgeon who inserts it through the linea alba and peritoneum where a

characteristic popping sensation is felt (Figure 4). An unobstructed free intraperitoneal

position for the Veress needle is verified by easy irrigation of clear saline in and out of the

peritoneal space (Figure 5) and by the hanging drop method where the saline in the

translucent hub of the Veress needle is drawn into the peritoneal space when the abdominal

wall is lifted.

If one does not obtain a free flow or an unobstructed saline irrigation, then the Veress needle

may be removed and reinserted. In general it is safer to convert the umbilical site into the

Hasson open approach (see Cholecystectomy, Hasson Open Technique, Laparoscopic) if

any difficulty is experienced with the placement, irrigation, or insufflation of the Veress needle.

The appropriate tubing and cables for the CO2 insufflation, the fiberoptic light source, and the

laparoscopic videoscope with its sterile sheath are positioned as are the lines for the cautery

or laser, suction, and saline irrigation. The pneumoperitoneum begins with a low flow of about

1 or 2 L/min with a low-pressure limit of approximately 5 to 7 cmH2O. Once 1 to 2 L of CO2

are in, the abdomen should be hyperresonant to percussion. The flow rate may be increased;

however, the pressure should be limited to 15 cmH2O. Three to four liters of CO2 are required

to fully inflate the abdomen and the Veress needle is removed. After grasping either side of

the umbilicus, a 10-mm trocar port is inserted with a twisting motion, aiming towards the

pelvis (Figure 6). If a disposable trocar port is used, it is important to be certain that the safety

sheath is cocked. A characteristic popping sensation is felt as the trocar enters the peritoneal

space. The trocar is removed and the escape of free CO2 gas is verified.


Although the Veress needle technique has a long history and is preferred by some, most

general surgeons use the Hasson technique, as shown in Cholecystectomy, Hasson Open

Technique, Laparoscopic.

The CO2 source is attached to this port and the videoscope with its sterile light source cord

inserted after white-balancing and focusing the system. Topical antifog solution is applied to

the optical end of the telescope, which may be either angled (30 degrees) or flat (zero

degrees) (Figure 7). A general examination of the intra-abdominal organs is performed taking

special note of any organ pathology or adhesions. The finding of any trocar-related injuries to

intra-abdominal viscera or blood vessels requires an immediate repair using advanced

laparoscopic techniques or more commonly open laparotomy.

Three additional trocar ports are placed, using direct visualization of their sites of intra-

abdominal penetration. The second 10-mm trocar port is placed in the epigastrium about 5

cm below the xiphoid, with its intra-abdominal entrance site being just to the right of the

falciform ligament (Figure 8). Two smaller 5-mm trocar ports for instruments are then placed:

one in the right upper quadrant near the midclavicular line several centimeters below the

costal margin and another quite laterally at almost the level of the umbilicus. These sites may

be varied according to the anatomy of the patient and the experience of the surgeon. The skin

of each selected site is infiltrated with a long-acting local anesthetic. This needle can then be

advanced into the peritoneal cavity under direct vision of the videoscope to verify proper

positioning for the planned port. The skin is opened with a scalpel, hemostasis is obtained,

and the subcutaneous fat is dilated with a small hemostat. The patient is placed in a mild (10

to 15 degrees) reversed Trendelenburg position, although some surgeons prefer to rotate the

patient slightly to the left (right side up) for better visualization of the gallbladder region.

The apex of the gallbladder fundus is grasped with a racheted forceps (A) through the lateral

port. The gallbladder and liver are then lifted superiorly (Figure 9) and the handle of the lateral

forceps (A) is secured to the drapes with a towel clip. This maneuver provides good exposure

of the undersurface of the liver and gallbladder. Omental or other loose adhesions to the

gallbladder are gently teased away by the surgeon (Figure 9).

The infundibulum of the gallbladder is grasped with forceps (B) through the middle port.

Lateral traction with the middle forceps exposes the region of the cystic duct and artery.

Dissecting forceps (C) are used by the surgeon through the epigastric port to open the

peritoneum over the presumed junction of the gallbladder and cystic duct (Figure 10). With

gentle teasing and spreading motions, the cystic duct and artery are exposed (Figure 11).

Each structure is exposed circumferentially.

The clear zone may be verified and elongated by sweeping back and forth (Figure 12). The

importance of the second assistant manning the videoscope now becomes apparent. He or

she must pull back and visualize the entrance of each new delicate instrument through the

ports and then follow the instrument down to the area of dissection, which is maintained in the

center of the field. Suitable magnification is controlled by the closeness of the videoscope to


the dissection site. At this point, if the dissection is difficult because of inflammatory swelling

and scarring, the surgeon should consider conversion to an open procedure.

The cystic artery is cleared for a 1-cm zone and its path followed onto the surface of the

gallbladder. The clear zone is then doubly secured with metal clips both proximally and

distally (Figure 13). The cystic artery may be divided with endoscopic heavy scissors.

However, many prefer to wait until after the cystic duct cholangiogram as the intact cystic

artery may serve as a helpful tether should the cystic duct be transacted during its opening for

the cholangiogram catheter.

The cystic duct is also cleared for about 2 cm or so such that the surgeon can clearly identify

its continuity with the gallbladder and its junction with the common duct. A metal clip is

applied as high as possible on the cystic duct where it begins to dilate and form the

gallbladder. Using the endoscopic delicate scissors through the middle port (Figure 14), the

cystic duct is opened and bile is noted. If necessary, the opening may be dilated with the

scissor tips. The cholangiogram catheter of choice is passed through the middle port and the

duct cannulated (Figure 15). Some catheters are secured within a winged clamp whereas

others rely on an inflated intraluminal Fogarty-like balloon. A simple straight plastic catheter

may be secured with a gently applied metal clip over the lower cystic duct containing the

catheter. It should be snug enough to prevent leakage but loose enough to avoid crimping the

catheter and thus preventing dye injection.

In preparation for the cholangiogram the videoscope and metal instruments are removed. The

radiolucent ports are aligned in a vertical axis so as to minimize their appearance on the x-

ray. The field is covered with a sterile towel and the x-ray equipment positioned. Simple dye

injections with individual films or a sustained injection under fluoroscopy are performed. The

principal ducts are visualized thus assuring anatomic integrity, the absence of ductal stones,

and flow into the duodenum. Upon completion of a satisfactory cholangiogram, the lower

cystic duct is doubly clipped and the cystic duct divided with endoscopic heavy scissors

(Figure 16). However, should an abnormal or confusing cholangiogram be obtained, then the

surgeon should convert to an open procedure with full anatomic verification.

The cystic duct junction with the gallbladder is grasped with forceps through the middle port

and the gallbladder is removed from its bed in a retrograde manner. Most surgeons score the

lateral peritoneum for a centimeter or so with electrocautery (Figure 17) and then elevate the

gallbladder from the liver bed. Appropriate traction, often to the sides, is required to provide

exposure of the zone of dissection with an electrocautery instrument between the gallbladder

and its bed (Figure 18). Vigorous traction with the forceps or dissection into the gallbladder

wall may produce an opening with spillage of bile and stones. Such openings should be

secured if possible using forceps, metal clips, or a suture loop, which is first placed over the

forceps and then closed like a lasso over the hole and the adjacent gallbladder wall that is

tented up by the forceps.

As the dissection proceeds well up the gallbladder bed, it may be necessary for the first

assistant to actively position and reposition the two forceps on the gallbladder so as to


provide good exposure for the surgeon. When the dissection is almost complete and traction

on the gallbladder still allows superior displacement of the liver with a clear view of the

gallbladder bed and operative site, the surgeon should reinspect the clips on the cystic duct

and artery for their security and the liver bed for any bleeding sites. The region is irrigated

with saline (Figure 19) and the diluted bile and blood are aspirated from the lateral gutter just

over the edge of the liver. The final peritoneal attachments of the gallbladder are divided from

the liver and the gallbladder is positioned above the liver, which has now fallen back inferiorly

to its normal position.

The videoscope is removed from the umbilical port and inserted in the epigastric one. A

grasping forceps is passed through the umbilical port so as to pick up the specimen in the

region of the cystic duct (Figure 20). This exchange may be somewhat disorienting to the

surgeon and first assistant as left and right are now reversed in a mirror-image manner on the

monitor screens. If the gallbladder stones are small, one is usually able to withdraw the

gallbladder, forceps, and umbilical port back out to the level of the skin where the gallbladder

is grasped with a Kelly clamp (Figure 21). Bile and small stones may be easily aspirated

whereupon the gallbladder will exit easily through the umbilical site under direct vision of the

videoscope in the epigastric port. Extraction of large stones or many medium-sized stones

may require crushing prior to extraction (Figure 22) or require that the linea alba opening be

enlarged. After extraction, the umbilical site is temporarily occluded with the assistant's gloved

finger so as to maintain the pneumoperitoneum. The middle and lateral ports are removed as

the videoscope inspects for any bleeding at these sites. The videoscope is removed and the

pneumoperitoneum is evacuated so as to lessen postoperative discomfort.

CLOSURE

The operative sites are infiltrated with a long acting local anesthetic (bupivacaine) (Figure 23),

and the fascia at the 10-mm port sites is resutured with one or two absorbable sutures (Figure

24). The skin is approximated with absorbable subcutaneous sutures. Adhesive skin strips

and a dry sterile dressing are applied.

POSTOPERATIVE CARE

The orogastric tube is removed in the operating room prior to emergence from general

anesthesia. Pain at the operative site is usually well controlled with oral medications.

Although patients have some transient nausea, most are able to take oral liquids within 6 to 8

hours and may be discharged home within one day. Follow-up by the surgeon is important, as

biliary injuries are often occult and delayed in presentation. Prolonged or new, unexpected

pain should be evaluated with physical examination, laboratory tests, and a HIDA

radionuclide scan.

colecistectomia laparoscopica

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