LAPAROSCOPIC CHOLECYSTECTOMY

LAPAROSCOPIC CHOLECYSTECTOMY 1987 – Phillipe Mouret, performed the first video-laparoscopic cholecystectomy in Lyons, France.

SURGICAL ANATOMY of GALL BLADDER

VARIATIONS IN CYSTIC ARTERY 75 PERCENT CASES ARISES FROM RT.HEPATIC ARTERY 25 PERCENT CASES VARIATIONS IN COURSE & ORIGIN OCCUR ANTERIOR BRANCH IS THE MAIN BRANCH LOOK FOR POSTERIOR BRANCH AFTER DIVISION OF CYSTIC DUCT

INDICATIONS SYMPTOMATIC GALL STONES CLASSICAL BILIARY COLIC – POSTPRANDIAL FULLNESS NONSPECIFIC SYMPTOMS - FATTY FOOD INTOLERANCE - FLATULENT DYSPEPSIA - NONSPECIFIC ABDOMINAL PAIN OR DYSPEPSIA

2. ACUTE CHOLECYSTITIS CALCULUS / ACALCULOUS 3. ASYMPTOMATIC GALL STONES PATIENTS WITH DIABETES MELLITUS PATIENTS FOR RENAL TRANSPLANTATION

4. BILIARY DYSKINESIA with Classic Biliary Pain 5. GALLSTONE PANCREATITIS 6. POLYPS OF GALL BLADDER

Gall stones

PATIENTS NOT FIT FOR GENERAL ANESTHESIA CONTRAINDICATIONS PATIENTS NOT FIT FOR GENERAL ANESTHESIA SEVERE PORTAL HYPERTENSION BLEEDING DIATHESIS CARCINOMA GALL BLADDER NIH Consensus Conference 1992

RELATIVE CONTRAINDICATIONS PREGNANCY GENERALISED PERITONITIS SEPTIC SHOCK FROM CHOLANGITIS ACUTE PANCREATITIS

INDICATIONS FOR CONVERSION TO OPEN 1. ADHESIONS 2. CIRRHOTIC LIVER 3 INDICATIONS FOR CONVERSION TO OPEN 1. ADHESIONS 2. CIRRHOTIC LIVER 3. THICKENED CONTRACTED GALL BLADDER 4. ABNORMAL ANATOMY 5. SEVERE CHOLECYSTITIS WITH FRIABLE G B 6. NO PROGRESS AFTER 15 MINS

FACTORS PREDICTING DIFFICULTY ACUTE CHOLECYSTITIS EMPYEMA GALL BLADDER PREVIOUS ABDOMINAL SURGERY CIRRHOSIS LIVER AGE MORE THAN 65 YEARS MALE PATIENT OBESE PATIENTS B.M.I > 27.5

ULTRASONOGRAPHIC FACTORS WALL THICKENING > 4 MM CONTRACTED GALL BLADDER PERICHOLECYSTIC COLLECTION CALCULUS > 20 MM, PACKED G.B STONE IMPACTED IN HARTMAN’S C.B.D > 7 MM DIAMETER EVIDENCE OF PANCREATITIS

PRE OPERATIVE EVALUATION ROUTINE SURGICAL PROFILE & L F T E.C.G & 2 D ECHO U.S SCAN – SIZE OF STONES THICKNESS OF G B WALL 4. E R C P - H/O JAUNDICE DILATED C B D & STONES U G I SCOPY- COEXISTING D ULCER ANY OTHER RELEVANT INVESTIGATION

ULTRASOUND EXAMINATION calculus

Consent Form — Laparoscopic Cholecystectomy Patient Name: ________________________________________________ I authorize Dr. ______________________________ to do laparoscopic cholecystectomy I understand the reason(s) for the procedure is(are) _____________________________ Risks The reason(s) for the procedure have been discussed with me. The usual risks, pains, and benefits have been explained, and I know about the following problems which may occur: (i) redness and/or swelling, infection in the tissue or bone around the area of the procedure or other parts of the body; (ii) opening of incision or blood vessels after the procedure; (iii) damage to nerves at or near the procedure area, numbness, pain or paralysis in body organs may result; (iv) loss of blood requiring blood transfusion; (v) the heart may stop or a heart attack may occur; (vi) blood vessels in the area of the procedure or elsewhere may plug; (vii) pneumonia; and (viii) allergic reactions. These risks can be serious, extending hospital stay, and can possibly be fatal. The significant risks of this procedure include: damage to liver, bowel, bile ducts, or bile leak (both higher than open surgery); retained stones; open cholecystectomy Alternatives Other methods of treatment, including not having this procedure done, have been discussed with me and this is the method I have chosen. Additional Procedures I understand that during the procedure problems may arise. These problems may require a procedure different than that listed above. If another procedure is needed, I authorize my doctor to do whatever procedure is considered to be in my best interest. Anesthesia Risks and problems of anesthesia have been discussed including an allergic reaction which may cause death. I consent to the use of such anesthetics as may be considered necessary. Guarantee I understand that no guarantee has been made and that the procedure may not cure my condition. I have been allowed to ask questions about the procedure. In addition, I have read this form and/or it has been explained to me. I understand the risks and intend to have the procedure done. Date: ___________ Time: ___________ Signature: _______________________________ Witness: _________________________________ Relationship: _______________________ Physician’s Statement The patient (guardian) and I have discussed the procedure, the risks, complications and alternatives. To the best of my knowledge, the patient (guardian) understands the procedure and consents to it. Date: ___________ Physician’s Signature: _______________________________ NOTE: Any changes or strike-outs must be initialed by both patient(guardian) and physician.  

EQUIPMENT HIGH DEFINITION CAMERA XENON LIGHT SOURCE HIGH PRESSURE CO2 INSUFFLATOR MEDICAL MONITOR 30 degree TELESCOPE ( HARMONIC SCALPEL ) TROLLEY

TROLLEY

INSTRUMENTATION

Veress Needle

TROCAR TIPS

TYPES OF VALVES Trumpet valve might damage distal tip Flap valve Sealing lip / membrane valve Magnetic Ball valve

OPTIVIEW TROCAR

5mm TOOTHED GRASPER

5mm Toothed Grasper traumatic Grasper

DISSECTOR - GRASPER

ATRAUMATIC GRASPERS

SCISSORS

SCISSORS

ELECTRODES

10-mm CLIP APPLICATOR

10 mm Spoon Forceps

10 mm toothed extractor

BIPOLAR FORCEPS

3 PRONGED TISSUE RETRACTOR

PORT DILATOR

CLOSED VERESS NEEDLE METHOD OPEN HASSANS TECHNIQUE POSITION OF PATIENT SUPINE 20- 30 DEGREE ANTI TRENDELENBERG RIGHT SIDE UP PNEUMOPERITONEUM CLOSED VERESS NEEDLE METHOD OPEN HASSANS TECHNIQUE VISUAL TROCAR

PORTS POSITION 5mm 10mm 5mm 10mm

PORTS POSITION

HOLD THE FUNDUS WITH GRASPER STEPS HOLD THE FUNDUS WITH GRASPER CRANIAL TRACTION IN MID CLAVICULAR LINE

DECOMPRESS THE G B IF GROSSLY DISTENDED

ADHESIOLYSIS OMENTAL COLONIC HEPATIC DUODENAL

OBESE PATIENT WITH INVISIBLE CALOT’S PLACE THE PATIENT IN STEEP REVERSE TRENDELENBERG INSERT AN EXTRA 5 MM TROCAR IN LEFT UPPER ABDOMEN USE A FAN RETRACTOR / SUCTION CANNULA PUSH DOWN THE DUODENUM & GREATER OMENTUM

DISSECT CALOTS TRIANGLE TO EXPOSE DUCT & ARTERY

ALWAYS START DISSECTION POSTERIORLY

LATERAL TRACTION OF HARTMANS

IDENTIFY THE JN OF HARTMANS WITH CYSTIC DUCT ( SAFETY ZONE )

IDENTIFY THE CYSTIC ARTERY- SKELETONISE

MAKE A BIG WINDOW BEHIND THE HARTMANS POUCH QUADRANGULAR SPACE

CLIP / LIGATE THE ARTERY & DUCT

DIVIDE THE ARTERY & DUCT

DETACH THE GALL BLADDER FROM BED

HOW TO USE A HOOK

PRINCIPLES OF BED DISSECTION STAY AWAY FROM PORTA HEPATIS HUG THE GALL BLADDER DO NOT ENTER THE LIVER PARENCHYMA AVOID PERFORATING THE GALL BLADDER MINIMISE THE BILE & /OR CALCULI SPILLAGE

BEFORE FINAL DETACHMENT INSPECT THE BED BEFORE FINAL DETACHMENT

IRRIGATION OF BED & SUCTION WITH SALINE

SPECIMEN EXTRACTION -? PORT UMBELICAL Vs EPIGASTRIC PORT EPIGASTRIC PORT : COSMETIC IN INDIAN WOMEN CAN BE EASILY EXTENDED TRACT CAN BE RINSED THOROUGHLY CAN BE CLOSED EASILY LESS INCIDENCE OF HERNIA

EXTRACT THE SPECIMEN ENLARGE THE INCISION IF REQUIRED

SUCK BILE / REMOVE STONES TO DECOMPRESS EXTRACT THE SPECIMEN SUCK BILE / REMOVE STONES TO DECOMPRESS

INSPECT THE DIVIDED DUCT & ARTERY

DRAIN THRU MID AXILLARY PORT IF REQ

PORT CLOSURE ALL TROCARS REMOVED UNDER VISION 10 MM PORTS CLOSED WITH VICRYL 2826 PORT CLOSURE NEEDLE IN OBESE PATIENTS SKIN CLOSURE WITH CLIPS INJECT TROCAR SITES WITH BUPIVACAINE

COMPLICATIONS during surgery BLEEDING a. ABDOMINAL WALL b. CALOT’S TRIANGLE c. BED OF GALL BLADDER 2. SPILLAGE OF STONES / BILE / INFECTED BILE 3. INJURY TO VISCERA / BILIARY TREE

CONTROL OF ABD WALL BLEEDING PREVENT BLEED BY IDENTIFYING VESSELS ( DIAPHONOSCOPY ) APPLY PRESSURE BY ANGULATING TROCAR COMPRESS ABD WALL OVER TROCAR PRESSURE WITH GUAZE SWAB INJECT ADRENALINE (1:1000) USE BIPOLAR ENERGY TRANSFASCIAL SUTURING IF NECESSARY

DIAPHONOSCOPY

BLEEDING FROM CALOT’S TRIANGLE RETRACT THE TELESCOPE FOR WIDER VIEW COMPRESS THE BLEEDER WITH GUAZE CLEAR THE CLOTS WITH SUCTION & IRRIGATION

BLEEDING FROM CALOT’S TRIANGLE IDENTIFY BLEEDER & CLIP PRECISELY BIPOLAR DIATHERMY CAN BE SAFELY USED AVOID BLIND CLIPPING AND PARTIAL CLIPPING LAPAROTOMY IF CONTROL MEASURES FAIL

CONTROL OF LIVER BED BLEEDING *COMPRESS THE BLEEDING WITH GUAZE

CONTROL OF LIVER BED BLEEDING *REMOVE THE GUAZE AFTER FEW MINUTES *SUCTION IRRIGATION CANNULA ON LEFT HAND *SPATULA IN THE RIGHT HAND *DIATHERMISE WHILE GENTLE SUCTION

CONTROL OF LIVER BED BLEEDING CLIP APPLICATION IS A WASTE OF TIME *MINOR TEAR -APPLY SPONGSTAN- COMPRESS & WAIT *MAJOR TEAR -CONVERT TO MINI LAPAROTOMY

CONTROL OF LIVER BED BLEEDING -APPLY SURGICEL / SPONGSTAN-

POST OP BILIARY LEAK CYSTIC DUCT LEAK C B D INJURY RIGHT HEPATIC DUCT INJURY ACCESSORY BILE DUCT INJURY

SAGES GUIDELINES Principles of the technique for laparoscopic cholecystectomy ·     The cystic duct should be identified at its junction with the gallbladder ·     Traction of the gallbladder infundibulum should be lateral rather than cephalad ·     Meticulous dissection of the cystic duct and cystic artery is essential ·     All energy sources may cause occult injury ·     Perforations of the gallbladder should be controlled to prevent loss of stones ·     Spilled stones should be retrieved if possible and irrigation is useful for small stones and bile ·     Biliary tract imaging should be applied liberally to identify surgically important anomalies, clarify difficult anatomy, and detect common bile duct stones(3) The surgeon should convert to open operation for unresolvable technical difficulties or anatomic uncertainties or anomalies, especially in cases of acute cholecystitis

Principles of the technique for laparoscopic cholecystectomy · SAGES GUIDELINES Principles of the technique for laparoscopic cholecystectomy ·     The cystic duct should be identified at its junction with the gallbladder ·     Traction of the gallbladder infundibulum should be lateral rather than cephalad ·     Meticulous dissection of the cystic duct and cystic artery is essential ·     All energy sources may cause occult injury ·     Perforations of the gallbladder should be controlled to prevent loss of stones ·     Spilled stones should be retrieved if possible and irrigation is useful for small stones and bile ·     Biliary tract imaging should be applied liberally to identify surgically important anomalies, clarify difficult anatomy, and detect common bile duct stones(3) The surgeon should convert to open operation for unresolvable technical difficulties or anatomic uncertainties or anomalies, especially in cases of acute cholecystitis

SAGES GUIDELINES Principles of the technique for laparoscopic cholecystectomy ·     The cystic duct should be identified at its junction with the gallbladder ·     Traction of the gallbladder infundibulum should be lateral rather than cephalad ·     Meticulous dissection of the cystic duct and cystic artery is essential ·     All energy sources may cause occult injury ·     Perforations of the gallbladder should be controlled to prevent loss of stones ·     Spilled stones should be retrieved if possible and irrigation is useful for small stones and bile ·     Biliary tract imaging should be applied liberally to identify surgically important anomalies, clarify difficult anatomy, and detect common bile duct stones(3) The surgeon should convert to open operation for unresolvable technical difficulties or anatomic uncertainties or anomalies, especially in cases of acute cholecystitis

SAGES GUIDELINES Principles of the technique for laparoscopic cholecystectomy ·     The cystic duct should be identified at its junction with the gallbladder ·     Traction of the gallbladder infundibulum should be lateral rather than cephalad ·     Meticulous dissection of the cystic duct and cystic artery is essential ·     All energy sources may cause occult injury ·     Perforations of the gallbladder should be controlled to prevent loss of stones ·     Spilled stones should be retrieved if possible and irrigation is useful for small stones and bile ·     Biliary tract imaging should be applied liberally to identify surgically important anomalies, clarify difficult anatomy, and detect common bile duct stones(3) The surgeon should convert to open operation for unresolvable technical difficulties or anatomic uncertainties or anomalies, especially in cases of acute cholecystitis

SAGES GUIDELINES Principles of the technique for laparoscopic cholecystectomy ·     The cystic duct should be identified at its junction with the gallbladder ·     Traction of the gallbladder infundibulum should be lateral rather than cephalad ·     Meticulous dissection of the cystic duct and cystic artery is essential ·     All energy sources may cause occult injury ·     Perforations of the gallbladder should be controlled to prevent loss of stones ·     Spilled stones should be retrieved if possible and irrigation is useful for small stones and bile ·     Biliary tract imaging should be applied liberally to identify surgically important anomalies, clarify difficult anatomy, and detect common bile duct stones(3) The surgeon should convert to open operation for unresolvable technical difficulties or anatomic uncertainties or anomalies, especially in cases of acute cholecystitis

SAGES GUIDELINES Principles of the technique for laparoscopic cholecystectomy ·     The cystic duct should be identified at its junction with the gallbladder ·     Traction of the gallbladder infundibulum should be lateral rather than cephalad ·     Meticulous dissection of the cystic duct and cystic artery is essential ·     All energy sources may cause occult injury ·     Perforations of the gallbladder should be controlled to prevent loss of stones ·     Spilled stones should be retrieved if possible and irrigation is useful for small stones and bile ·     Biliary tract imaging should be applied liberally to identify surgically important anomalies, clarify difficult anatomy, and detect common bile duct stones(3) The surgeon should convert to open operation for unresolvable technical difficulties or anatomic uncertainties or anomalies, especially in cases of acute cholecystitis

SAGES GUIDELINES Principles of the technique for laparoscopic cholecystectomy ·     The cystic duct should be identified at its junction with the gallbladder ·     Traction of the gallbladder infundibulum should be lateral rather than cephalad ·     Meticulous dissection of the cystic duct and cystic artery is essential ·     All energy sources may cause occult injury ·     Perforations of the gallbladder should be controlled to prevent loss of stones ·     Spilled stones should be retrieved if possible and irrigation is useful for small stones and bile ·     Biliary tract imaging should be applied liberally to identify surgically important anomalies, clarify difficult anatomy, and detect common bile duct stones The surgeon should convert to open operation for unresolvable technical difficulties or anatomic uncertainties or anomalies, especially in cases of acute cholecystitis

Principles of the technique for laparoscopic cholecystectomy · SAGES GUIDELINES Principles of the technique for laparoscopic cholecystectomy ·     The cystic duct should be identified at its junction with the gallbladder ·     Traction of the gallbladder infundibulum should be lateral rather than cephalad ·     Meticulous dissection of the cystic duct and cystic artery is essential ·     All energy sources may cause occult injury ·     Perforations of the gallbladder should be controlled to prevent loss of stones ·     Spilled stones should be retrieved if possible and irrigation is useful for small stones and bile ·     Biliary tract imaging should be applied liberally to identify surgically important anomalies, clarify difficult anatomy, and detect common bile duct stones The surgeon should convert to open operation for unresolvable technical difficulties or anatomic uncertainties or anomalies, especially in cases of acute cholecystitis

THANK YOU THANK YOU THANK YOU