Editing Laparoscopic cholecystectomy (section)

== '''Bail out options''' ==

* '''Options when     critical view of safety cannot be achieved:''' 
** Asking for help
** '''Subtotal      cholecystectomy'''
*** Specific situations
**** Safe option when faced        with a difficult dissection
**** Useful in        cirrhosis/bleeding - leave back wall in situ
*** Rationale
**** Symptomatic gallstones        recur in 2.2% - either biliary colic or choledocholithiasis
**** 10.6% bile leak
**** Can also get remnant        cholecystitis
**** Scarce evidence regarding        safety and feasibility of completion cholecystectomy

* '''Technique'''
** Open the GB just above      Hartmann's pouch
** Suction bile; evacuate      stones into open EndoCatch, including stones in neck
** Attempt cholangiogram      through Hartmann's
** Underrun cystic duct with      2/0 Vicryl (doesn't matter if the tissue is too friable to close - still      unlikely to get a bile leak)
** Dealing with Hartmann's      pouch
*** Reconstituting subtotal:       Close Hartmann's with sutures (V-Lock), stapler or EndoLoop
**** More likely to get a        symptomatic GB remnant (19% vs 9%)
*** Fenestrating subtotal:       leave Hartmann's pouch open
**** More likely to get a bile        leak (18% vs 7%)
** Excise GB wall beyond liver      margin leaving back wall in place; burn mucosa
** Drain
* Post-op
** Drain out 7-10 days      post-procedure (can remove it sooner if cystic duct was successfully      closed)
** Consider cholangiogram prior      to drain removal
** Bile leaks (Type A) usually      settle - spiral valves in cystic duct will scar shut
** Consider ERCP and stent if      not settling

* '''Conversion     to open''' (if     comfortable; seek help from more experienced surgeon)
** Specific situations
*** Patient unable to tolerate       pneumoperitoneum
*** Not able to resolve a       source of bleeding
*** Inability to perform       necessary suturing
*** Inability to complete an       exit strategy laparoscopically
*** Unable to establish view of       GB due to adhesions
** Stand on patient's left
** Kocher incision: parallel to      and 4cm below the costal margin
*** Can use the Kehr       hockey-stick modification in patients with a narrow costal margin
** Body wall retractor for      superior abdo wall (Thomson/OmniTract)
** Place a pack above the liver      to push the GB into field more; can be removed towards end of case to      improve view on Calot's triangle
** Begin with dissection of GB      off liver bed, fundus down, retracting GB away from liver with Rampley's
** Expose CD and ligate with      2/0 Vicryl, after performing cholangiogram if necessary
** Ligate CA with 3/0      PDS/Vicryl
** Close sheath in two layers:      medial to lateral posterior sheath, then lateral to medial anterior      sheath
** Close skin with 3-0 Monocryl      or staples
* '''Surgical     cholecystostomy'''
** Can be done under LA
** Expose the fundus of the GB
** Place a purse-string suture      and incise it
** Suction the contents and      evacuate stones if you can
** Insert a Foley, inflate the      balloon and tie the purse-string
* '''Others''' - not recommended
** Early cholangiography      performed through GB
** Top-down approach/retrograde      cholecystectomy
*** Not recommended due to high       risk for classical CBD injury
*** Easy to misidentify the       GB-CBD funnel as GB-cystic duct, then divided the CBD, before later       encountering the other end of the CBD
*** Especially risky with acute       inflammation, when the cystic duct can become hidden