Laparoscopic Management of Biliary Stone Disease

All patients are given Toradol (Roche Pharmaceuticals) and Cefizox (Fujisawa USA) during induction.

A standard laparoscopic cholecystectomy has been initiated by the surgeon, at which time he assesses an anterior laparoscopic cholecystectomy should be performed.

Using the stationary or lateral 5 mm grasper, the tip of the fundus of the gallbladder is grasped and retracted cephalad. An ENDO SHEARS* Instrument is inserted via the sub-xyphoid trocar (with electrocautery connection). Using the other lateral grasper, the anterior aspect of the gallbladder is dissected meticulously. The dissection should be extended as low as possible toward the cystic duct without compromising the safety of the procedure. 

Using the ENDO SHEARS* Instrument, the gallbladder is entered and the anterior wall of the gallbladder should be resected. Hemostasis should be controlled with the ENDO SHEARS* Instrument connected to an electrocautery source. Spilled gallstones should be retrieved and removed with a morcilator-type grasper (10 mm). The specimen should be removed via the sub-xyphoid trocar. The gallbladder fossa should be flushed thoroughly with normal saline.

Two Blake™ drains are inserted into the intra-abdominal cavity. The best method for the insertion of these drains is to insert a 5 mm grasper via one of the lateral trocars into the intra-abdominal cavity and out through the sub-xyphoid trocar. The sub-xyphoid trocar is removed. The end of the Blake drain is grasped by the grasper outside the abdominal cavity and pulled back into the intra-abdominal cavity. The lateral grasper pulls it via the 5 mm trocar site. One drain is inserted into the open gallbladder fossa and the other into the sub-hepatic fossa.

The procedure is completed as usual.

Postoperative Management: Postoperatively, the clinical behavior of these patients is the same as for all patients undergoing a minimally invasive procedure. The next day they usually are on a regular diet and ambulatory. Unless they have associated medical problems, most patients can be discharged within 48 hours. They are discharged with Blake drains in place. Interestingly, some patients will have a bile leak-drainage noticeable on postoperative day one, and others will not. This is most likely secondary to a blocked cystic duct secondary to an impacted gallstone. Nonetheless, these drains are to remain in place for two weeks or until they cease to drain.

Bile Leak-Drainage: Most patients will have significant bile drainage, as this procedure effectively creates a controlled bilio-cutaneous fistula. The average or mean bilious drainage is two days. The longest recorded drainage has been 21 days. As a rule, in the absence of a distal common bile duct obstruction, all bilious drainage or leaks will cease within three weeks.

Associated Complications: This procedure does not allow the performance of an intra-operative cholangiogram or the placement of a cystic duct cannula. One patient was found postoperatively to have a retained common bile duct stone  requiring an Endoscopic Retrograde Cholangiography and Papillotomy. Another patient developed a sub-phrenic abscess and eventually required a laparotomy.

Impact of Anterior-subtotal Laparoscopic Cholecystectomy On the Conversion Rate: Prior to introducing this procedure, most conversions occurred in patients with acute, severe, and gangrenous cholecystitis. This procedure effectively decreased our conversion rate as soon as it was introduced. Actually, since its introduction, 896 LapCholes were done with only one conversion. This reduction in the conversion rate is probably the most significant advantage of this technique.