StayCurrent Forums - Laparoscopic Cholecystectomy
With Dr. Nathaniel Soper
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Cholelithiasis 5 items
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What the experts said
In patients with BMI under 32-35, Hasson technique is used for initial umbilical port placement
In patients with BMI over 32-35, Veress needle technique is used for initial port placement to avoid large incision required for Hasson
Standard port configuration includes epigastric port (placed last for optimal angle), midclavicular line port, and anterior axillary line port in right upper quadrant
Omental adhesions to chronically inflamed gallbladder can be taken down using low-wattage cautery or harmonic shears at the junction of omentum with underlying tissue
Modified top-down dissection should start approximately one-third of the way up from the infundibulum, not at the fundus
Bilateral dissection technique ("waving the flag") alternating between medial and lateral sides provides better three-dimensional view and more freedom for dissection
Angled laparoscope is superior to 0-degree laparoscope for laparoscopic cholecystectomy
Critical view of safety must be achieved before any irreversible steps such as clipping or cutting structures
Dissecting only on the ventral (left) side of the gallbladder limits freedom of movement and makes dissection more difficult
Intraoperative ultrasound can be performed multiple times during difficult cholecystectomy to identify gallbladder location and bile duct position relative to dissection
Irrigation-suction catheter can be used for blunt (Kittner) dissection in the right hand when there is blood and bile obscuring the field
Indocyanine green (ICG) given too early results in everything appearing bright green, limiting its utility
In cases with significant tissue inflammation, ICG may not adequately visualize ductal structures
Critical view of safety requires complete dissection of fatty material, peritoneal tissue, and scar tissue so the gallbladder infundibulum is separated 1.5 inches from surrounding structures
If critical view of safety cannot be achieved, intraoperative cholangiography is mandatory to clarify ductal anatomy
All residents should learn intraoperative cholangiography technique regardless of selective use in practice
Intraoperative ultrasound should be taught to residents because it allows visualization beyond visible surfaces in the laparoscopic abdomen
Cholangiography adds time and cost, and is not absolutely necessary in the majority of cases
Indications for selective intraoperative cholangiography include uncertain anatomy, cystic duct stones, jaundice, and dilated bile duct on preoperative ultrasound
Before clipping and dividing the cystic duct, place a clip on the gallbladder side, make a small incision, and milk backwards to check for cystic duct stones
Presence of cystic duct stones is a prime indicator that common bile duct stones are also likely present
Chronically inflamed gallbladders are usually intrahepatic with no plane between gallbladder and liver
Controlled avulsion technique for intrahepatic gallbladders involves maximal traction with left hand and minimal contact with low-wattage cautery in right hand at the gallbladder-liver junction
Gallbladder bed hemostasis can be achieved in 99% of cases using cautery with irrigation-suction in left hand and cautery in right hand
For suspected duct of Luschka injury in the gallbladder bed, attempt suture closure but drain placement is usually necessary as sutures are unlikely to hold
Active drain should be placed for deep intrahepatic gallbladder dissection and left in for several hours or overnight to monitor for bile leak
95% of laparoscopic cholecystectomy patients are discharged home the same day
Postoperative pain management includes intraoperative IV acetaminophen, prescription for only 5 hydrocodone tablets, and recommendation for ibuprofen or acetaminophen for first few days
Pain requiring more than 5 hydrocodone tablets postoperatively suggests a problem and warrants patient contact
Dr. Nathaniel Soper is professor and chairman of the Department of Surgery at the University of Arizona College of Medicine at Phoenix