Editing Laparoscopic cholecystectomy (section)

== '''Standard lap cholecystectomy:''' ==

* Positioning:
** Left arm in, right arm out      (can also do with both arms out)
** Strap
** Ensure enough room at top of      bed for c-arm
* Entry
** Enter in a quadrant free of      adhesions, either via open or closed technique
** Normal weight -      infra-umbilical
** Obese with low-lying      umbilicus - supra-umbilical
** Small peri-umbi hernia -      access through hernia
** Large peri-umbi hernia -      access above hernia
** 10mm supra-umbilical, 5mm      epigastric (at level of GB), 5mm RUQ (triangulate between epigastric and      umbilical ports) and right lateral
** 12-13mmHg pressure (can go      higher if not enough space, especially obese patients)
* Head up, right side up
* Expose the fundus of the GB     enough to attach a ratcheted McKernan fundus grasper or bowel grasper
* Assess whether GB     decompression is required (able to grasp fundus easily, or not)
** Veress needle decompression      through separate stab, just superior to RUQ port
** Alternatively, make a      serosal hole with the hook diathermy, then jam the sucker the rest of the      way through the wall
* Divide further adhesions to     expose Hatmann's pouch
** If the view is obstructed by      omentum/stomach/duodenum, consider NGT vs further fan retractor
** Easiest way of pulling      omentum down is to use an endoloop pulled out through the skin using and      endoclose suture passer
* Identify landmarks
** Falciform ligament - should      not be dissecting near this plane - too far medial, risk of CBD injury
** Rouviere's sulcus - can be      seen in most patients, where the right portal pedicle enters the liver      and indicates the A-P plane of the CBD. Stay anterior to this.
** Epicholedochal plexus -      visually distinguishes the CBD from cystic duct
** Duodenum - CBD courses      posterior to duodenum
* Grasp Hartmann's with     non-ratcheted McKernan or Johann and begin working on CVS with hook
* Critical view of safety:
** One-third of gallbladder      taken off cystic plate
** Hepatocystic triangle      cleared of fatty and fibrous tissue
** Two and only two structures      entering the inferior aspect of GB
* If CVS cannot be achieved,     stop and either convert to open, change to subtotal, insert a     cholecystostomy or abandon the procedure
* Clip artery
* Clip CD (milk up from below     and clip as high as possible)
* IOC:
** Indications for selective      IOC:
*** Pain at time of operation
*** Abnormal LFTs
*** Anomalous or confusing       biliary anatomy
*** Inability to perform       post-operative ERCP
*** Dilated biliary tree
*** Any suspicion of       choledocholithiasis
** Rationale
*** Allows identification of       bile duct injuries (77% identification vs 22%) and CBD stones, which can       then be promptly treated
** Process:
*** 4-5Fr catheter on three-way       tap, with 1:1 diluted contrast on the vertical axis of the T. Ensure to       flush the system with saline, and set it up in such a way as to avoid       bubbles in the system.
**** 5Fr (yellow) catheter is        better because more rigid and easier to pass
**** If the duct is smaller,        use a 4Fr (blue)
**** Undiluted contrast could        sometimes be useful if hard to visualise but mostly unnecessary
*** Catheter in through RUQ       port. Use epigastric port on Hartmann's pouch.
*** Dribble saline through       catheter during insertion.
*** Change to contrast, check       it's flowing nicely. If finding it hard to get a good seal, distal       obstruction is likely. Check for cystic duct stones.
*** Take instruments off GB
** Look for:
*** Free flow to duodenum
*** Filling defects
**** If it's a bubble, it will        rise against gravity; may show shape change or split into smaller        filling defects; and may be able to be aspirated through the catheter
*** Dilation of       CBD/intra-hepatic ducts
*** RPSD/RASD/LLSD,       particularly RPSD
*** Cystic duct insertion
**** Angular (75%)
**** Parallel (20%)
**** Spiral (5%)
***
** Blumgart classification of      ductal anatomy:
***
* Drain - concern for bile leak     or when haemostasis is not perfect, very wide cystic duct, oedematous     tissue