Laparoscopic cholecystectomy

https://www.sages.org/safe-cholecystectomy-program/

Anatomy

Use Coineaud classification of intra-hepatic bile ducts
Classify cystic artery entering into CHD (angular, parallel, spiral)
Variations in RHA anatomy
Also be aware of Strasberg classification of CBD injuries

Principles

Critical view of safety
- Do not divide any structures until this has been achieved
IOC
- Detect CBD stones - many of these would have passed spontaneously
- Identify CBD injuries
- The only time it is mandatory is when you are worries about CBD injury

Risk factors for difficult cholecystectomy:

Older age
Male gender
Cirrhosis and portal hypertension (safe in CP-A with HPB surgeon, mostly safe in CP-B, not safe in CP-C)
Blood dyscrasias/anticoagulation
Longstanding disease with more frequent attacks
Gangrenous/severe cholecystitis risk factors: (consider non-op)
- >72 hours of symptoms
- WCC > 18
- Palpable GB
- Increased age
- Comorbidities
Obesity (fatty liver limits cephalad retraction and can make the GB intra-hepatic; duodenum may be closer to fatty liver; fatty omentum can get in the way). Consider VLCD.
Mirizzi's syndrome
Suspected malignancy
- Unexplained pancreaticobiliary obstruction, fistula, weight loss or mass
- Suspected malignant GB polyps

Preparation

Wear lead
IOC request and radiographer notified
Pathology form
Beta hcg for women of child-bearing age

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

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

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

Post-op:

Precautionary drains can come out 48 hours post-op if no bile
Post-op Abx are probably unnecessary if no systemic sepsis

Complications

Bile duct injury (BDI)

Occurs around 0.15-0.3% (major bile duct injury around 1-4 per 1000)
Strasberg classification (previously used Bismuth, but this is more applicable to open cholecystectomy)
Note that vascular injury, especially right hepatic injury, is common when bile duct injury occurs

Type A:

Leakage of bile not related to injury of the main bile ducts - either cystic duct remnant or ducts of Luschka
Cystic duct leakage can occur from laceration of a small cystic duct, dislodgement of one of the clips or ligatures on the cystic duct, ductal necrosis from cholecystitis, or distal obstruction in CBD causing blowout of cystic duct remnant
Clinically significant leakage from ducts of Luschka is rare
Can be managed by ERCP and stenting, or sphincterotomy. Then remove drain in 3-5 days once output settles. Remove stent in two weeks if the patient is asymptomatic, LFTs are normal, and no ongoing leak at follow-up ERCP.

Type B:

Occlusion of aberrant right hepatic duct
Can occur when cystic duct drains into right hepatic duct
Commonly associated with injury to right hepatic artery
Can remain asymptomatic for years, then present with recurrent cholangitis and fibrosis of segment
Diagnosis usually made by ERCP/MRCP
Treatment is surgical - hepaticojejunostomy +/- resection of affected lobes

Type C:

Transection of aberrant right hepatic duct
Can occur when cystic duct drains into right hepatic duct
Commonly associated with injury to right hepatic artery
Can be managed by ERCP and stenting, or sphincterotomy. Then remove drain in 3-5 days once output settles. Then repeat ERCP or do a HIDA scan to assess for ongoing leak. If minor leak, may need sphincterotomy or replace stent for another month.
Total endoscopic management of bad type C injuries is difficult because a segment is disconnected

Type D:

Lateral damage to CBD
If identified intra-operatively, repair over a T-tube
Can often be managed with ERCP, but need to monitor closely to avoid progression to type E injury
If a larger circumference is involved, usually require operation
If recognised <48 hours, can be managed by ERCP and stenting, or sphincterotomy. Then remove drain in 3-5 days once output settles. Then repeat ERCP or do a HIDA scan to assess for ongoing leak. If minor leak, may need sphincterotomy or replace stent for another month, or hepaticojejunostomy.
If recognised >48 hours, often do PTC to drain proximal system, then plan for hepaticojejunostomy after a few weeks

Type E:

Types:
- E1 (Bismuth 1): Transection >2cm from confluence
- E2 (Bismuth 2): Transection <2cm from the confluence
- E3 (Bismuth 3): transection in the hilum
- E4 (Bismuth 4): separation of major ducts in the hilum
- E5 (Bismuth 5): type C injury plus injury in the hilum
Intra-operative transections can sometimes be repaired end-to-end over a T-tube
But MOST type E injuries require repair with hepaticojejunostomy
Usually present with jaundice weeks to years after cholecystectomy
If identified after operation, PTC is useful to delineate intrahepatic ducts and the length of the stricture. The liver can also be decompressed at the time.
Some strictures or partially occlusive clips will be amenable to dilation and stent insertion
ERCP can be effective, but high-grade strictures >1cm in length are difficult
Strictures not amenable to other methods will likely need an hepaticojejunostomy
If unstable patient, associated major vascular injury, delayed recognition or complex injury, often would delay repair for several weeks.
'Classical' bile duct injury shown below - misidentification of CBD as cystic duct, clipped and divided, further dissection on left side of CBD, then second transection of CBD/CHD to get back onto GB. Often occurs in association with RHA injury.

Bile duct injuries - intra-operative considerations:

Strategies to reduce:

Use critical view of safety (CVS) to identify cystic duct and artery (should be able to get this 90% of the time)
- Fundus retracted superiorly, infundibulum laterally
- Only two structures connected to lower end of GB - cystic duct and artery
Be aware - if short or non-existent cystic duct, easy to mistake CBD for cystic duct, especially if over-zealous retraction
If CVS can't be achieved, subtotal cholecystectomy may be considered, which avoids dissecting in the hepatocystic triangle.
Use IOC in patients with acute cholecystitis or a history of the same
Use IOC if suspicion of BDI or uncertain anatomy
Pre-op risk stratify
- Male
- Older
- Chronic cholecystitis
- Obesity
- Cirrhosis
- Adhesions
- Emergency cholecystectomy
- Cystic duct stones
- Hepatomegaly
- Gallbladder/biliary cancer
- Anatomic variations
- Fistulae
- Limited surgical experience
- More severe acute cholecystitis (as per TG)
Mild acute cholecystitis (TG) - perform lap chole within 72 hours

Warning signs

Given that only 40% of bile duct injuries are noted at time of operation, stay vigilant that things are 'off normal'
Common warning signs to look out for:
- Standard clip is insufficient to completely occlude the distal structure
- Persistent leakage of bile from liver
- Identification of a 'second' ductal structure
- 'extra' soft tissue adjacent to porta hepatis
- Large artery coursing behind the presumed cystic duct
- Sustained bleeding from area medial to GB
- Excessive number of required clips
- Inability to adequately identify regional anatomic structures

Management:

General principles
- Thermal injuries or those complicated by ischaemia are harder to repair and a simple intra-operative repair is less likely to work
Intra-op diagnosis - immediate repair is possible by HPB surgeon
- Convert to open?
- Assess extent of injury - further characterise via IOC
- Discuss with HPB surgeon
  - If no capable HPB surgeon is available to help, terminate the procedure, place drains in the GB bed and the transected proximal duct if possible, wake up the patient and ship them to an HPB unit
- Accessory duct leak - ligate if <3mm diameter with segmental or subsegmental drainage. If >=4mm, it is likely to drain multiple hepatic segments, and thus requires operative repair.
- Partial BDI (Type E) - repair over T-tube
- Divided/almost divided CBD - end to end anastomosis, also with a t-tube (some sources suggest anastamose over T-tube, some say put t-tube distally through separate choledochotomy
  - Can't reoppose without tension - Kocher's maneuvre will give extra length
- Gray's surgical anatomy says if >50% circumferential damage, needs hepaticojejunostomy
- High injury - Roux-en-y biliary enteric anastomosis (low threshold for referral to a tertiary centre)
Post-op diagnosis
- Discuss with HPB surgeon
- Aim to transfer to HPB centre
- Arterial CT to exclude hepatic artery injury
- If there is local inflammation from a delayed recognition of bile duct injury with biloma, staged reconstruction after drainage of the biloma and creation of a controlled bile fistula

Post-op bile leak

Presentation
- Suspect with malaise, ileus, mild jaundice, abdominal distension, RUQ tenderness
Source
- Cystic duct
  - Caused by insecure closure or high-pressure system
  - Can present 0-10 days post-op
  - Tends to cease spontaneously
- Major bile duct injury
- Injured liver parenchyma
  - Minor and self-limiting
- Accessory bile duct (of Luschka)
  - Originating in the right hepatic lobe, and entering the GB directly
  - Rare, unpredictable and easy to manage
- Anomalous bile duct
  - From right lobe to confluence of main RHD and LHD
  - Rare, unpredictable and difficult to manage
Investigation
- USS - define extent of leak (localised collection vs surrounding liver vs diffuse biliary peritonitis). Also assess intra-hepatic ducts.
- CT can be used if necessary
- HIDA scan can delineate leakage of radiotracer into peritoneum to confirm diagnosis
- ERCP can then be used to determine the site of leak
Treatment
- Drain in situ, draining bile
  - Assess the patient for SIRS/sepsis
  - If abdomen is soft, the patient is well, LFTs are normal, and no sign of sepsis - the leak is well-controlled
  - Try to determine the source of leak - reconsider the operation
  - Consider investigations - HIDA can demonstrate flow of bile to abdomen, USS can exclude undrained collections, and MRCP can exclude major bile duct injury
  - Most will dry up eventually - consider discharging the patient with drain in situ and close follow-up, even if initially high-volume output
  - ERCP and stenting can be done for larger leaks that are not resolving, or become complicated
- No drain and you suspect a bile leak, or undrained collection
  - Ultrasound or CT to find the biloma - CT is generally easier and allows you to see anatomy, and maybe exclude PE
  - Consider HIDA to prove the leak
  - Leaks <24 hours - consider re-laparoscopy and cystic duct closure
  - USS/CT-guided drain if necessary (bile peritonitis, sepsis, ileus, etc). Drain can likely come out in 3-5 days - as above.
  - ERCP and stenting in most cases - usually resolves the leak immediately without the need to drain the biloma. Should also be on broad-spectrum antibiotics.

Bleeding

Liver
- Often due to close proximity of middle hepatic vein and tributaries to GB fossa (seen in 10-15%)
- Usually occurs while removing GB from liver
Arterial sources
- Cystic artery - careful with clips if actively bleeding - easy to clip right hepatic artery
- Can become evident post-operatively as an acute haemodynamic decline requiring resuscitation, transfusions, re-operation. Culprit is usually a dislodged clip in that scenario.
Port site bleeding
- If suspicion of haematoma - USS.
- Rarely requires relook laparoscopy

Bowel injury - 1-4/1000

Post-cholecystectomy syndrome

Persistent abdominal pain and dyspepsia that persist after cholecystectomy
Syndrome, not a single pathological process
Differential diagnosis:
- GIT: IBS, pancreatitis, pancreatic tumours, pancreas divisum, hepatitis, PUD, mesenteric ischaemia, diverticulitis, oesophageal disease, diarrhoea from continuous bile flow (usually settles within a few weeks)
- Extraintestinal: intercostal neuritis, wound neuroma, CAD, psychosomatic
- Biliary:
  - Early - biliary injury, retained cystic duct, CBD stone, pancreatitis
  - Late - recurrent CBD stones, bile duct stricutres, inflamed cystic duct/GB remnant, papillary stenosis, biliary dyskinesia
  - Sphincter of Oddi dysfunction
    - Type I - a/w visible sphincter stricture - 95% have resolution after sphincterotomy
    - Type II - non-dilated duct and variable LFTs, less certain response to sphincterotomy
Exclude retained stone and refer to gastro

Jaundice post lap chole

Hopefully retained stone, hopefully not a bile duct injury
If bilirubin continues to climb along with elevated liver enzymes, need to exclude BDI
MRCP or ERCP depending on facilities and expertise

Retained CBD stones

The clear investigation of choice is MRCP. It is sometimes wise to wait and follow the bilirubin trend, to avoid exposing the patient to unnecessary investigations for a stone that was going to pass anyway.
ERCP and sphincterotomy for impacted stone (non-resolution of symptoms, LFTs, or persistent stone on imaging)