Laparoscopic cholecystectomy

Alfred Cuschieri
Department of Surgery, Ninewells Hospital and Medical School, University of Dundee, Dundee, Scotland, U.K.
J.R.Coll.Surg.Edinb., 44, June 1999, 187-92

Laparoscopic cholecystecomy is now the gold standard for the treatment of gallstones. When it was first introduced there were some concerns about its safety owing to its rapid adoption by untrained surgeons. However, when a careful, correct technique is employed, the operation is extremely safe. This article describes a well established technique for laparoscopic cholecystectomy, which has been evolved over several years in a centre that has concentrated on the development of laparoscopic surgery.

Laparoscopic cholecystectomy (LC) is now the gold standard treatment of symptomatic gallstones and is the commonest operation performed laparoscopically worldwide. The indications for its use in the treatment of gallstone are the same as open operation although the cholecystectomy rate has increased by an average of 20%, including in Scotland, since the introduction of LC. (1,2) The exact reasons for this are not known but the rise is somehow linked to perceptions on the part of patients, general practitioners and surgeons that the magnitude of the intervention is reduced by the laparoscopic approach. To a large extent, this is true but the potential for overall morbidity associated with the surgical treatment of gallstone disease is increased by the higher cholecystectomy rate which also impacts on the overall health care costs. In contrast, large retrospective series of LCs from several countries indicate that the overall mortality of cholecystectomy has decreased since the advent of the laparoscopic approach.

LC is indicated in patients who develop symptoms (usually attacks of biliary colic) or complications of the disease (acute cholecystitis and obstructive jaundice). In patients with 'gallstone dyspepsia' careful assessment is needed to establish that the gallstones are indeed the cause of the symptoms (3) since in some of these patients, the symptoms may be of functional origin, for example irritable bowel syndrome; or the result of other organic pathology such as colonic diverticular disease, gastro-oesophageal reflux etc. In the elderly, hilar cholangio-carcinoma and cancer of the gallbladder may present with vague dyspeptic symptoms attributable to gallstones.

Obesity, previous surgery and acute cholecystitis are not contraindications but may necessitate elective conversion if the anatomy of Calot's triangle is obscured, and in the case of acute cholecystitis, if the gallbladder has gangrenous patches or there is gross inflammatory oedema of the porta hepatis. Patients with lower abdominal incisions do not usually pose any problem, but the dissection may prove hazardous in patients with previous surgery in the supracolic compartment, especially partial gastrectomy. Patients with cirrhosis and portal hypertension are at risk for two reasons: low peripheral resistance and the risk of bleeding that is difficult to control during the procedure. Cholecystectomy in these patients should not be attempted laparoscopically.

With good anaesthesia, the adverse haemodynamic effects of a positive pressure pneumoperitoneum are well tolerated but this may not be the case in patients with moderate and high risk for cardiac complications. (4-6) These patients should either undergo open cholecystectomy or the procedure performed with the gas-less or low pressure laparoscopic technique.

In patients with co-existing ductal calculi, the orthodox management consists of endoscopic stone extraction followed by laparoscopic cholecystectomy during the same hospital admission, if possible. The alternative, if local expertise is available, is single stage laparoscopic management with extraction of the ductal calculi through the transcystic approach, if small (< 0.6mm), or by direct supraduodenal common bile duct exploration for large or occluding stones. These two management options, single versus two-stage management, when compared in a randomised clinical trial have been shown to be equally efficacious in achieving ductal stone clearance with similar morbidity and mortality but the laparoscopic approach was accompanied by a significant reduction of the hospital stay. (7)

In fit patients, the only investigations needed are ultrasound examination, haemoglobin estimation, liver function tests and blood for group and save. Endoscopic retrograde cholangiopancreatography (ERCP) is performed when ductal stones are suspected on the basis of clinical, biochemical and ultra-sound criteria. Even so, this investigation proves normal in 25 -50% of such cases. (8) For this reason, in centres with the necessary facilities, magnetic resonance cholangiopancreatography is used in preference to ERCP in these cases. (9) Although practised in some centres, intravenous cholangiography may not be confirmative and is attended with the risk of anaphylactic reactions.

The patient is operated in the supine position with a steep head-up tilt once the pneumoperitoneum has been established. A nasogastric tube is inserted and the stomach aspirated. The tube is kept in the stomach during the operation but removed at the end of the procedure. The surgeon operates from the left side of the patient with the camera person by his side and the assistant and scrub nurse on the other side of the operating table.

The closed technique is produced by the insertion of a Veress needle through the immediate subumbilical area in a previously unoperated abdomen. The propensity for visceral and major vascular damage (aorta, iliac vessels, and vena cava) is well documented unless the technique is flawless. It must be remembered that the distance between the anterior abdominal wall and the aorta and its bifurcation into the iliac vessels averages only 2.0 cm. Some surgeons have abandoned completely the creation of a closed pneumoperitoneum and use the open technique routinely whether or not the patient has had previous surgery. The need for a meticulous technique, even in this situation, is highlighted by the reported incidence of injuries sustained during the creation of an open pneumoperitoneum, although the incidence is undoubtedly lower with this approach.

Some incisions carry a greater risk than others when the closed technique is used, e.g., central transverse and midline incisions as opposed to peripheral ones, e.g., appendicectomy scar, Pfannenstiel, subcostal. With the correct technique, the closed method is safe for patients with peripheral scars, but the open technique is preferred for central incisions. If a closed peritoneum is created in a previously operated abdomen, the Veress needle insertion should be far removed from the scar. The most popular measure used to ensure that the Veress needle is lying in free intraperitoneal space is the saline drop test.

The problem of access is not resolved once a closed pneumoperitoneum is created successfully in a patient with a scarred abdomen since the blind insertion of the optical port may impale adherent structures missed by the Veress needle. An optically guided cannula insertion, for example Visiport (see Figure 1) is highly recommended in these cases.

The open technique dispenses completely with the Veress needle and was originally introduced by Hasson for gynaecological laparoscopy. The technique entails a small subumbilical incision that is taken down behind the umbilical skin to the raphe and linea alba, which is then divided and the peritoneum opened. A sealing optical cannula of the Hasson type is then inserted and held in place by sutures. Insufflation of the peritoneal cavity is then commenced through the side port of the Hasson cannula. A modification of this technique that is favoured by the author is the transumbilical open technique. This entails grasping the edges of the umbilical ring with division of the skin of the umbilical pit. This exposes the linea alba which is divided. A Kelly clamp or equivalent is then used to penetrate the peritoneum. This technique is simpler and easier to perform. It carries two advantages, i.e., an ordinary reusable or disposable 11.0mm cannula can be used (inserted over a plastic rod) and the residual scar is invisible (situated in the umbilical pit).

Insertion of Ports, Initial Inspection and Exposure of the Triangle of Calot

Four ports are used: optical (11mm), one 5mm and one 11mm operating, and one 5.0mm assisting port. The optical port is at or near the umbilicus and routinely a 30° laparoscope is used. An initial 360° scan of the entire abdomen is made primarily to exclude injury/ bleeding during the creation of the pneumoperitoneum, and secondly to identify any gross macroscopic additional disease. The disposition of the other ports introduced under vision are shown in Figure 2.

Most commonly, the American gallbladder lift is used to expose the triangle of Calot. The fundus of the gallbladder is grasped by the assistant and flipped upwards and over the superior edge of the right lobe (see Figure 3).

This manoeuvre/exposure is not possible in patients with contacted gallbladder or fibrotic/ cirrhotic liver. In these cases, the French exposure of the triangle of Calot is used, i.e., elevation of the gallbladder and segment IV by an atraumatic laparoscopic retractor (see Figure 4).

The cystic pedicle is a triangular fold of peritoneum containing the cystic duct and artery, the cystic node and a variable amount of fat. It has a superior and an inferior leaf which are continuous over the anterior edge formed by the cystic duct. An important consideration is the frequent anomalies of the structures contained between the two leaves (15 -20%). The normal configuration is for an anterior cystic duct with the cystic artery situated postero-superiorly and arising from the right hepatic artery usually behind the common bile duct. The most important anomalies are shown in Table 1. The entry of the cystic duct into right side of the common bile duct described in most anatomical textbooks is rarely found and the various cystic duct terminations encountered are shown in Table 2.

Cystic artery

Short cystic artery arising from looped right hepatic artery - latter liable to be mistaken for cystic artery or damaged with bleeding during dissection of cystic duct
Early division of the cystic artery - risk of bleeding usually from the posterior branch if this is overlooked
Anomalous origin of the hepatic or right hepatic artery from the superior mesenteric artery

Cystic duct

Short cystic duct with entry into the common hepatic duct - risk of damage to common hepatic duct
Short cystic duct with entry into right hepatic duct - risk of damage to right hepatic duct
Accessory cystic duct - postoperative bile leakage if unrecognised

Table 2: Termination of the cystic duct into common bile duct

Type	Incidence
Entry on the right side	17%
Spiral duct with entry into posterior wall	41%
Spiral duct with entry on the left	35%
Parallel run with low insertion	7%

The dissection of the cystic pedicle can be carried out with a variety of instruments: scissors, electrosurgical hook knife, Maryland's grasper etc. This does not matter provided a two-handed technique is used, the dissection is careful and proceeds in an orderly fashion. The technique used in Dundee has changed little since it was first described. (10) With downward traction by duckbill grasper placed on the anterior edge of Hartmann's pouch, the peritoneum of the superior leaf of the cystic pedicle is divided superficially as far back as the liver. The incision is taken round the anterior edge of the cystic pedicle when the direction of traction on Hartmann's pouch is altered in an upward and medial direction for exposure of the inferior peritoneal leaf which is divided as far back as the liver. A pledget mounted securely in a pledget holder (see Figure 5) is then used to blunt dissect (front and back) the structures of the cystic pedicle. In thin patients with little fat, this quickly exposes the cystic duct and the cystic artery.

	Figure 5 Pledget holder for laparoscopic blunt dissection. Disposable alternatives can be used but they are less effective and more traumatic

The separation of the cystic duct anteriorly from the cystic artery behind it can be performed by a Maryland’s grasper or electrosurgical hook knife. Sufficient length of the cystic duct and artery on the gallbladder side, i.e. away from the bile duct must be mobilised. The cystic artery is clipped (double proximal, single distal clips) and then divided by hook scissors. This technique is altered when the cystic artery is short, i.e., when it arises from a looped right hepatic artery and when the cystic artery divides early into anterior and posterior branches. Two clips are placed proximally on the cystic artery when this arises from a looped right hepatic artery. The artery is then grasped with a duckbill grasper on the gallbladder wall and then divided distal to the clips when electrocoagulation is applied to the grasper before it is released. The two branches of an early dividing cystic artery have to be clipped and divided separately. The dissection of the cystic pedicle is completed by placement of a clip to occlude the cystic duct at its junction with the gallbladder.

There is still considerable controversy regarding operative cholangiography during LC. There are some who perform it routinely (Dundee technique), others have dispensed with it altogether during LC, or advocate its use selectively, i.e., when needed to identify the anatomy during difficult dissections. The argument against selective use is lack of experience in cystic duct cannulation. When needed, the surgeon is unable to carry it out expeditiously, and what is more important, interpret it accurately. The benefits of routine intraoperative fluorocholangiography during LC are:

There are various techniques and instruments used for operative fluorocholagiography. Our preference is for a ureteric catheter (see Figures 3 and 4) inside a cholangiograsper (see Figure 6).

The opening in the cystic duct in made on the anterosuperior aspect. Correct alignment of the cystic duct and infusion of saline by the scrub nurse facilitates insertion. Insertion is difficult if the opening in the cystic duct is made too close to the gallbladder. The contrast medium should be injected slowly during screening and the patient should be in a slight Trendelenberg position with the table rotated slightly to the right. It is essential that the entire biliary tract (intra and extrahepatic) is outlined (see Figure 7). With routine usage, an intraoperative fluorocholangiogram should take an extra 5 - 10 minutes at most.

The separation of the gallbladder from the liver should be through the areolar tissue plane binding the gallbladder to the Glisson's capsule lining the liver bed. If this is achieved there is virtually no bleeding during the separation and the risk of bile leakage postoperatively from the liver parenchyma is abolished. The actual separation can be performed with scissors or electrosurgical hook knife. The secret for efficient separation is traction on the gallbladder in the right direction. Sometimes, when the gallbladder inflammation is minimal, separation of the gallbladder from the liver bed, after division of the peritoneal reflections on either side, is effected very quickly and atraumatically by pledget blunt dissection.

Perforation of the gallbladder during its separation is a common complication which is encountered in 15% of reported cases. Its importance lies in the escape of stones which must all be retrieved, if at all possible. Fundal perforation is easily remedied by the application of an endoloop. Perforation of the under surface can only be controlled by suturing. If the surgeon has not yet acquired the necessary skills for Intracorporeal suturing, the best option available is to empty the gallbladder of stones into a bag introduced through one of the ports. Once this is achieved, the detachment of the gallbladder from the liver is completed. There is a definite risk of intra-abdominal abscess formation in patients in whom gallstones are missed. This risk is small and does not warrant conversion. However, these patients should be put on an antibiotic course for 5 - 7 days (cephalosporin) and followed up by ultrasound examination at six months after the procedure.

The gallbladder is extracted through the 11.0mm operating port inside a rip-proof bag. Extraction inside a bag is recommended as a safeguard against stone loss and contamination of the exit wound. The latter concerns both bacterial and tumour cell implantation by gallbladders that contain an unsuspected cancer (0.5 - 1% of patients undergoing cholecystectomy for gallstones).

The final step consists of inspection of the stumps of the cystic artery and duct, the gallbladder bed, duodenal bulb and hepatic flexure of the transverse colon. The subhepatic pouch and right parahepatic space are irrigated with saline until returning fluid is clean. Fascial closure of the large port wounds with absorbable (polydioxanone) sutures is recommended to prevent herniation. All port wounds are infiltrated with long-acting local anaesthetic.

Figures 2, 3, 4, 5 and 6 are printed with the permission of Blackwell Science Ltd, Oxford, from Laparoscopic Biliary Surgery 2nd ed. 1992, by Alfred Cuschieri and George Berci.

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	Figure 2 Port sites for laparoscopic cholecystectomy: French approach;
	North American approach

	Figure 6 Cholangiograsper with ureteric catheter used for laparoscopic transcystic fluorocholangiography