1. SURGICAL TECHNIQUES FOR CHOLECYSTECTOMYBy
Brig. Abrar Hussain Zaidi

2. Prologue
Cholecystectomy is one the commonest general surgical procedures
Gall stone disease, acalculus cholecystitis ,ca-gall bladder and hepatobiliary trauma –are the common indications for cholecystectomy.
Different clinical situations demand different methods and techniques to perform the procedure.
In any one situation one may need to change one surgical technique to another one if the difficulties arise.
Availability of surgical expertise and armamentarium.

4. Surgical planning Terminology Elective cholecystectomy Emergency =
Early =
Delayed /interval =
Prophylactic cholecystectomy
Extended cholecystectomy
Partial cholecystectomy

5. Clinical situations Asypmtomatic Biliary colics / dyspesia
Acute Infection /complications-Acute cholecystitis-empyema- perforation
Chronic cholecystitis,adhesions,fistulae,
Assoiciated CBD calcli
Malignancy

6. What we need to know General principles of operative procedures
Common techniques
Techniques in Difficult operations

7. General principles of operative procedures
Basic principles are same for all techniques
Care full selections of cases
Complete evaluations and assessment
Written consent
Proper preparation
Methodology
Asepsis
Exposure
Inspection
Care dissection at callot’s triangle
Dealing with the cystic duct and artery
Dissection of gallbladder bed
Extraction
Re-examination

8. Contemporary methods of Cholecystectomy
Open
Laparoscopic
-conventional
-SILS
-Needle-scopic

9. OPEN CHOLECYSTECTOMY

10. Open Cholecystostomy Conventional open Oblique sub-costal incision
Transverse incision
Midline
Rt. para-median
Mini-lap open

11. Planning the incision

12. Planning the incision

13. Planning the incision

14. Planning the incision

15. Cutting through the abdominal wall layers
Muscle cutting
Muscle splitting
Scissors
Diathermy
Protection of nerves vessels

16. Examination, planning, packing
Visualize the primary area
Release adhesions
Examine the cavity/adjacent structures

17. Dissection in callot’s triangle
Dissect out the Cystic artery and the duct
Ligate and cut the artery and the duct
Dissect out slowly
Prevent damage to CBD

18. Exposing the Cystic Duct and Artery

19. Dissection at gall bladder bed
Neck side first
Fundus first method

20. Re-examination Remove old gauze packs
New Dry White gauze pack wait
Bile stainig
- callot’s triangle
- Liver bed
Bleeding /Oozing
-from liver bed
-Callot’s triagle
Instument and gauze count

21. Difficult gall bladder
Wall thickness
Anatomy not clear
Thick adhesions
Abdominal girth
Other factors
Concerns : Bleeding at porta
Bile duct injuries
Injury - duodenum,colon,stomach etc

22. Anterior partial Cholecystectomy
Removal of fundus and part of anterior wall and the harman’s area
Leaving the upper wall near porta-hepatis
Method in difficult situations

23. Cholecystostomy Opening the gall bladder lume Removal of calculi
Drainage of pus
Insertion of drain inside and adjacent to gall bladder

24. Drains or no drains--?

25. Choledochotomy, operative cholangiogram

26. Do’s and Don'ts Plann well,cut well [to get well] Good Exposure
Retraction
Visualization of anatomy at callot’s
Dissect lateral to medial
Carefully use the instruments and diathermy
Keep eye on assistants
Packing and re-examination
Drain if in dought

27. Do’s and Don'ts Never be in hurry - [don’t be a turtle either].
Never cut without proper visualization.
Don’t apply forceps blindly –prefer packing.
Never use diathermy close to the CBD.
Don’t pull from medial to lateral.

28. Audit - the out come

29. Difficult situations Empyema Thick wall Extensive adhesions Cancer
Fistulae
Per-operative injuries
CBD
Hepatic artery/portal vein tributary
Duodenal
Gastric
Colonic

30. Difficult situations Re-orientate yourself Never be in panic
Pack relax and think
Manage the difficulty at its merit

31. Difficult situations Options Difficult dissection
Cholecystostomy
Anterior partial Cholecystectomy
Biopsy
Drain
Ask for help
Treat the injuries as per
T_Tube drain
By pass

32. Laparoscopic Cholecystectomy

33. Innate Human Desire =
To Be Minimally Harmed / Surgically
The foundation of what is now referred to as minimally invasive surgery.

34. First solid state camera in 1982
Phillipe Mouret performed the first
laparoscopic cholecystectomy.
An ignition for the laparoscopic surgery.

35. Conceptual debates - ISSUES
Post-operative pain
Recovery / Hospital stay
Visual field for surgeons
Operation time
Cost
Cosmetic outcome
Patient acceptance
The complications

36. Advantages/ benefits Reduced operative trauma Reduced bleeding
Reduced post operative pain and analgesic requirement
Reduced operative trauma
Reduced bleeding
Faster recovery, discharge and return to work
Reduced wound infection, seroma and haematoma
Reduced chronic wound pain
Less cardiorespiratory complications

37. Advantages/ benefits Less ileus from reduced handling
Improved cosmesis
Reduced contamination of theatre staff (Hepatitis and HIV)
Interesting for surgeons
Reduced outpatient/social costs

38. Advantages/ benefits Reduced risk of DVT/PE
Reduced incisional hernia rate
Fewer adhesions and less likely to develop obstruction
Immunological benefits
Better visualisation for the surgeon

39. Disadvantages/ Risks
High risk of co-lateral injury eg Common bile duct in lap cholecystectomy
Bowel/bladder/vascular injury in hernia surgery
Verres needle injury
Diathermy may lead to organ damage eg late cbd stricture
Increased operating time

40. Disadvantages/ Risks Increased costs due to theatre time and equipment
Tumour seeding
Poor quality surgery eg cancer resection
Loss of tactile sensation
Long learning curve
Loss of training opportunity eg appendicitis and inguinal hernia
Some surgeons not able to develop skills

41. THE ART AND THE CRAFT

42. THE EQUIPMENT
THE TECHNIQUE
THE TRAINING

43. THE EQUIPMENT

44. The Equipment Laparoscope/video system Light source Insufflator
Diathermy /coagulation:cutting system [+Harmonic ace]
Suction irrigation system
Specialized hand instruments

45. Trolley

46. The Equipment Laparoscope/video system There are two types:
Telescopic rod lens system, that is connected to a video camera (single chip or three chip) or
A digital laparoscope where the charge-coupled device[CCD] is placed at the end of the laparoscope, eliminateing the rod lens system.

47. Telescopic rod lens system
There are three important structural differences in telescope available in the market.
6 to18 rod lens system telescopes
0 to 120 degree telescopes
1.5 mm to 15 mm of telescopes

48. Telescopic rod lens system

49. Three primary colours (Red,Blue, Green).
Video camera
Single chip VS three chip
Three primary colours (Red,Blue, Green).
In single chip camera all these 3 primary colours are sensed by single chip.
In three chip camera there are 3 CCD- Chips for separate capture and processing of 3 primary colours—High resolution

50. Video camera

52. Monitor No different from the T.V.
Basic principle of image reproduction is horizontal beam scanning on the face of the picture tube.

53. The existing television systems in use differ according to the country.
The U.S.A uses the NTSC (National Television System Committee) system.
In European countries the PAL (Phase Alternation by Line) system is in use.
French system called SECAM (Sequential color and memory).

54. Light source
A fiber optic cable system connected to a 'cold' light source (halogen or xenon), to illuminate the operative field,

55. Light source

56. Fiber optic cable

57. Insufflator
The abdomen is insufflated with carbon dioxide gas [pneumoperitomeum] to create a working and viewing space.
Elevates the abdominal wall above the internal organs like a dome.
Gasless surgery –with mechanical wall elevators

58. Insufflator

59. Coagulation & cutting System
Diathermy monopolar / bipolar Harmonic

60. Harmonic dissector

61. Harmonic dissector

62. Specialized hand instruments
A-ACCESS INSTRUMENTS
B-DISSECTING/OPERATING
INSTRUMENTS
C-RETRIEVAL INSTRUMENTS

63. Specialized hand instruments
5-10mm diameter instruments
Trocars & Ports---access devices
Graspers
Scissors
Dissectors
Clip applier,Knotting devices,Staplers
Cutting /coagulation –
hooks,spatulas,balls,forceps
Irrigation suction tubes
Retrieval instruments

64. Disposable vs Reusable instruments Conventional vs.
Needle scopic /miniaturized
instruments—2mm size

65. Veress Needles

67. Trocars

69. Scissors

70. Dissectors

71. Graspers

72. Hook & spatula

73. Diathermy/harmonic dissector

74. Clip applicator

75. Staplers
Knotting devices
Suturing devices

76. Irrigation suction instruments

77. Irrigation suction instruments

78. Irrigation suction instruments

79. Retrieval instruments

80. Retrieval instruments

81. Retrieval instruments
Extractor

82. The technique
and the training

83. Learning the art parallels the steps followed in actual performance
of a Laparoscopic procedure

84. The learning curve
Step by step learning

85. SIMULATOR TRAINING-Endotrainers

86. SIMULATOR TRAINING-manikins

87. SILS

91. LAPAROSCOPIC CHOLECYSTECTOMY
Indications
patient selection
Consent/special features
Preparation
Procedure
Post-operative care
Record and audit

92. Operation Room Set up

93. Approach

94. Positioning and setting the instruments
Check the diathermy
Focusing & White balancing of camera
Pressures

95. Approach

96. Pneumoperitoneum

98. Insertion of access ports
Camera
Grasping and holding instruments
Dissecting instruments
Additional

99. Basic principles of surgical procedure are
the same as for open surgery
Only the technique differs

100. Inspection-diagnostic laparoscopy
Primary area of concern
Rest of the cavity
Resectability
Adhesions

101. Mobilizing the Gall bladder

102. Aspiration

103. Dissecting in Callot’s triangle
Grasp the fundus of the gallbladder and elevate it over the anterior edge of the liver by progressive traction.
The infundibulum, or Hartmann’s pouch, is pulled upward using a second grasper placed through the remaining accessory port. This exposes the cystic duct and artery as well as the common bile duct.
Constant retraction and good exposure .
The patient is then positioned in reverse Trendelenburg and tilted to his/her left.

104. Dissecting the Cystic Duct and Artery
Fundus grasped with the lateral most grasper and pulled laterally, further exposing the cystic artery and cystic duct.
Defined by the cystic artery above, the cystic duct below and the common bile duct medially.
Dissecting instrument through the subxiphoid cannula
Identifies the cystic duct by teasing away the peritoneal covering of the cystic duct-gallbladder junction.
In acute cholecystitis, edematous layers of tissue will have to be stripped downward to expose the cystic duct.
Dissection should continue in a lateral to medial direction, beginning at the infundibulum and continuing medially toward the entrance of the cystic duct into the gallbladder neck.
Avoid damage to key structures such as CBD, right hepatic artery, and duodenum.
Identify junction between the cystic duct and gallbladder neck
the cystic duct is dissected circumferentially near the junction.
In most cases, the cystic duct is anterior to the artery.

105. The cystic artery is then dissected circumferentially in a similar fashion. The artery is usually found just posterior to the cystic duct, toward the liver bed. The operator must be meticulous at this stage, as the right hepatic artery can be immediately adjacent to the cystic artery, and can be damaged with overzealous dissection. The cystic artery is then clipped twice proximally, once distally (toward the gallbladder) and divided with scissors. Again, the clip on the specimen side should be placed as close as possible to the gallbladder neck to allow for maximal clearance of the clips adjacent to the porta hepatis.  

107. Displaying the Cystic duct

108. Clipping the cystic duct

109. Cutting the cystic duct

110. Dealing with cystic artery

111. Summary of callot’s dissection

112. Dissecting out Gallbladder from liver bed

113. Dissecting out Gallbladder from liver bed

117. Preparing for Retrieval

118. Retrieval

119. Post-operative cholangiogram

120. Complition Re-inspection Irrigation suction Drain Deflation
Check the ports
Close the incisions
Carefully collect the instruments/equipment

121. Post op follow up

122. Thanks you