Editing Laparoscopic cholecystectomy (section)

== '''Non-standard situations:''' ==

* Acute cholecystitis
** Ratcheted McKernans to grasp      fundus with
** Decompress at start - Veress      needle
** Longitudinal incision,      generous fascial incision (especially when known large stone)
** Incise peritoneum up      posterior wall, then anterior wall, then join the two into a V-shape. Try      and get into the right plane, then start peeling GB out of peritoneum.
** Blunt dissection in Calot's      - right angle useful to get around the artery
* Cirrhosis
** Send to HPB surgeon wherever      possible. CP-A is generally ok, CP-B is mostly ok, but CP-C is not ok.
** General peri-op things - ''see      separate topic under 'cirrhosis'''
** Cholecystectomy-specific      things
*** Be careful with caput       medusae/recanalized umbilical vein - go infra-umbilical carefully, or       enter elsewhere altogether
*** Particularly careful around       cystic plate in portal hypertension and be careful to stay in the right       plane - bleeding from a cirrhotic liver is difficult to control
*** Topical haemostatic agents,       energy device or even APC can be especially useful if there is bleeding
*** May need extra port for       liver retractor for stiff liver
*** Low threshold for subtotal
* Pregnancy
** Lap chole can be performed      safely in any trimester, if indicated
** Need to place trocars higher      in the abdomen
** Keep CO2 at lowest possible      pressure
** Avoid IOC - consider      intra-op USS
** Perioperative fetal      monitoring
* Gangrenous cholecystitis
** Consider subtotal and leave      back wall - harmonic scalpel would be particularly useful to go across      infundibulum
* Intra-hepatic GB
** About 10% of patients don't      have a capsule between the GB and its liver bed, described as      intra-hepatic
** The dissection can be more      difficult and bloody
* '''Difficulties:'''
** Bleeding
*** If landmarks are visible -       clip
*** Otherwise, apply local       pressure to oozing by flipping the GB onto it and working elsewhere
*** More significant bleeding       can be controlled with gauze
*** A specific vessel bleeding       can be grasped and controlled
*** If uncontrollable bleeding,       or unstable patient, convert to open.
*** Cystic artery
**** Control with pressure
**** If landmarks identified -        clip
**** If no landmarks - grasp,        temporise, continue to develop landmarks, and maybe convert to open if        unable to define landmarks
*** RHA
**** Avoid electrosurgery
**** Typically requires        conversion to open, unless an experienced laparoscopic HPB surgeon is        available
*** Middle hepatic vein - a       large branch lies close to liver surface in GB bed in 8%
**** Firm pressure 5 minutes        with gauze
**** Theoretically may need to        get control with Pringle manoeuvre, then clamp on supra-hepatic IVC,        and maybe below liver IVC as well
**** Then suture ligate with        big monofilament
*** Liver parenchyma
**** Direct pressure, then        diathermy (up to 80, spray, short bursts), then maybe a stitch, and        consider haemostatic agents afterwards
*** Significant bleeding during       final stages of removal of GB from cystic plate:
**** Maybe middle hepatic vein        laceration
**** Be careful, as RHA and RHD        lurk nearby
**** Try to control        laparoscopically - increase insufflation pressure to 25mmHg, ask        anaesthetist to temporarily stop ventilation (from Schein's)
**** May need conversion to        open and suture ligation
** Large cystic duct
*** Is it really the cystic       duct, and not the hepatic or CBD?
*** Milk it before clipping it
*** Should put an endoloop on       in addition to clips, or use a Hemolock
*** Intracorporeal suturing
*** Could even theoretically       use a stapler - although risk of late stone formation
** Bile spillage
*** Close hole - using clips is       technically difficult and risks making the hole worse - EndoLoop is       sometimes quite effective
*** Not been shown to increase       infections
*** Remove all spilled       gallstones - nidus for infection
** Filling defect on IOC
*** Flush
*** IV glucagon 1mg OR 10-20mg       buscopan (hyoscine butylbromide)
*** Flush 100mL
*** Repeat cholangiogram
*** If still there, place       endoloop and complete operation (unless going to do LCBDE)
**** LCBDE - see separate topic
** Difficult anatomy:
*** Arterial
**** RHA arising low from SMA        passing through Calot's triangle posteriorly and parallel to the cystic        duct (8%)
**** Multiple cystic artery        branches in 25% - divide each branch individually at the gallbladder        wall
**** 10% of cystic arteries        originate outside the hepatocystic triangle
*** Ductal
**** Cystic duct arising from        RHD or RPSD
**** Parallel cystic duct -        risk of injury to CHD/CBD if dissected too low
**** 'Short' or absent cystic        duct - this is most likely an acquired condition seen in cholecystitis,        with obliteration of planes
**** Subvesical intrahepatic        bile ducts, just under capsule of Glisson, present in up to 30% of        patients, and can be injured if dissection is too deep. NOT ducts of        Lushka, which are rare.
** Dense adhesions to another      structure and possible fistula
*** Better to leave a piece of       GB on the other structure than the other way round
*** GIA stapler can be used to       divide the fistula
** Difficult view due to      omentum/bowel in the way
*** Add another 5mm port for a       retractor
*** Try endoloop to omentum and       retract externally using a trans-fascial suture passer
** Back wall fused to liver -      leave it in place, and cauterise mucosa