Laparoscopic Management of Biliary Stone Disease

The pneumoperitoneum is obtained in the usual fashion. The trocars are inserted as indicated.

The stationary grasper [1: lateral position] is utilized to grasp the tip of the gallbladder and push it over the anterior edge of the liver by progressive traction. Hartmann's pouch is pulled upward. This exposes the cystic duct and artery as well as the common bile duct. It is important to constantly maintain this traction. In most cases, the scrub nurse or assistant hold this retractor. In difficult, longer cases, the handle of the grasper is clamped onto the skin of the abdomen or onto the protective field. The patient is now positioned head down.

CAUTION: It is not always possible to push the tip of the gallbladder (Re: cirrhotic patients) over the anterior hepatic edge. In these cases, gently push its tip against the liver, being very meticulous not to penetrate the parenchyma of the liver.

 

Once the field is exposed, Hartmann's pouch is grasped with the lateral working grasper and pulled laterally, further exposing Calot's triangle. The operator will then pass a dissecting grasper through the subxyphoid trocar and begin to identify the cystic duct. In acute cholecystitis, edematous layers of tissue will have to be stripped downward to expose the cystic duct.

The subxyphoid  Dolphin Nose Grasper instrument is passed behind the cystic duct or actually between the cystic duct and the cystic artery. In most cases, the duct is anterior to the artery.

CAUTION : Hartmann's pouch should always be identified and visualized. The dissection of Calot's triangle can be done safely starting from the pouch and moving toward the cystic duct. This is particularly important in acute cases, when anatomical landmarks are difficult to find. It is essential to visualize Calot's triangle, which includes the cystic artery, cystic duct and the common bile duct. If visualization of this area becomes difficult, always check the tension on the stationary grasper and the intra-abdominal pressure.

 

To view the technique of Routine Intra-operative Cholangiography.

At this juncture, the cystic window is created (i.e., free space behind the cystic duct and the cystic artery). The clip applier is inserted via the subxyphoid trocar. The cystic duct and artery are clipped (three clips) as close as possible to the gallbladder. The ENDO CLIP* Applier is then withdrawn and the EndoShears™ instrument is inserted to cut them.

CAUTION: Be very careful to clearly identify the junction of the gallbladder and cystic duct and plan your transection from this anatomical landmark. In doubt, always check with an IOC.

 

Hartmann's pouch is now retracted upward. Using the EndoShears* instrument, the most lower lateral aspect of Hartmann's pouch should be dissected meticulously.

The ENDO SHEARS*instrument is withdrawn and replaced by the electrocautery hook. The gallbladder is retracted upward and tension is placed on the surgical plane between the gallbladder and its liver bed. The dissection is extended to the top of the gallbladder. Occasionally the grasper holding the cystic duct stump can be used to flip the body of the gallbladder around the stationary grasper which is still holding the fundus of the gallbladder.

In most instances, this dissection will generate smoke which can impair the surgeon's visualization. This smoke can be aspirated by opening the insufflation of the lateral trocar.

A 10 mm, large grasper is introduced via the sub-xyphoid trocar. The two lateral graspers holding the gallbladder present the gallbladder to the newly introduced large grasper. The gallbladder is pulled from the the intra-abdominal cavity through the same trocar site. This trocar site can enlarged bluntly with a peon clamp of a few millimeters. An Endocatch™ Instrument can be used to remove the specimen.

The intra-abdominal cavity is then thoroughly irrigated with normal saline. All stones that have dropped into the intra-abdominal cavity are retrieved with a morcilator or stone retrieving forceps.

The abdomen is deflated; the trocars removed, and the trocar insertion sites are closed in the usual fashion.