Cholecystectomy and Cholangiography

Cholecystectomy and Cholangiography

Surgery for Dummies – Cholecystectomy and Cholangiography

A paramedian or midline incision is used for the operative approach (inset). In order to obtain optimal exposure the gallbladder is elevated with a Mayo forceps. The left hand exposes the hepatoduodenal ligament, and a laparotomy tape is placed over the hand as shown. Once the tape has been placed, the hand is removed and either is held on top of the tape or a Crile blade is used to maintain the exposure of the fossa ovalis, the hepatoduodenal ligament, and the area of the juncture of the gallbladder with the common duct.

The general exposure of the hepato­duodenal ligament and juncture of the gallbladder with the common duct, achieved as in Figure 1, is improved by placing a second Mayo clamp on the ampulla of the gallbladder. Exposure is completed by placing a Deaver retractor against the right lobe of the liver to elevate it cephalad so that a good length of the hepatoduodenal ligament is visible. The dotted line illustrates the incision in the anterior peritoneum over the juncture of the cystic duct with the common duct.

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The anterior surface of the peritoneum over the gallbladder is being incised and the cystic artery is coming into view. This in­cision in the anterior peritoneum is carried up along the anterior surface of the gall­bladder, exposing the cystic artery and cystic duct. The duodenum is barely visible in the lower left-hand portion of the illustra­tion, and the inferior vena cava edge is seen behind the fossa ovalis and hepatoduodenal ligament. The exposure is held constant.

The cystic duct is isolated below the cystic artery, and a tie is being placed around the cystic duct.

With the cystic duct still intact, the cystic artery is isolated where it runs into the gallbladder so that excessive tension will not be placed upon the artery. The cystic artery is doubly ligated and divided. Note that the exposure again is held constant and that the dissection thus far involves only opening the anterior peritoneum around the cystic artery and cystic duct. The field is avascular.

One must be able to see clearly the cystic artery, cystic duct, and entrance of the cystic duct into the common duct before any structure is irreparably ligated and divided. Ordinarily one can achieve this visualization in a completely avascular field; if not, dissection should be discontinued at this point. In this case the ligature should be placed around the cystic duct and the dissection of the gallbladder reversed: the gallbladder should be taken out from the top down until these structures are clearly visualized and isolated. In the majority of cases, however, the dissection can be done at the cystic duct-common duct area with safety, and this gives a much less vascular field for subsequent removal of the gallbladder.

The cystic artery is divided between two ties if possible. If there is sufficient length, one could put a double ligature on the proximal end; however, this is not necessary. All one needs is an adequate cuff distal to one tie for the cystic artery to be ligated adequately. A particular maneuver that is helpful if the cystic artery is very short is to put one tie on it proximally and then clamp the distal end where it enters the gallbladder. One can then cut, leaving the clamp in position, with an adequate cuff on the proximal, ligated end of the cystic artery. The distal end can then be ful­gurated or suture-ligated. These maneuvers in handling the cystic artery are quite helpful when the artery is short.

The cystic artery is divided between two ties. Note the tie placed on the cystic duct so that stones will not drop down into the common duct during these manipulative procedures.

The divided cystic artery and site of entry of the cystic duct into the common duct are clearly seen.

A right-angle clamp is placed behind the cystic duct proximal ‘to the ligature of the cystic duct where it enters the gallbladder. Sufficient length is obtained between the tie and the common duct so that an opening can easily be made in the cystic duct several millimeters from the common duct. The cystic duct is held stationary with the right-angle clamp. A small opening is made in the cystic duct and dilated with a mosquito forceps, breaking the valves of Heister. The cystic duct is then steady and ready for insertion of a Taut cholangio – catheter.

The arrowhead {inset) of the Taut catheter is introduced into the cystic duct. One need insert this only far enough to ligate the cystic duct, holding the arrowhead in place; it is not necessary to insert the catheter all the way into the common duct. In order for the catheter to be inserted, however, the valves of Heister must be divided by dilating the cystic duct with the mosquito forceps if the cystic duct is very small.

The Taut catheter is tied in place once it has been inserted beyond the arrowhead. Ordinarily the catheter has been filled with fluid and attached to the syringe containing the Diodrast so that no air will enter during insertion of the cholangiocatheter. Once the catheter has been inserted and tied in place, the pressure within the common duct is positive and fills the cystic duct. Then, while the gallbladder is removed, the catheter will remain filled with bile because of the positive pressure within the common duct and cystic duct.

One should take care during this maneuver not to lose bile needlessly; using the right – angle forceps behind the duct prevents spillage of bile during manipulation and insertion of the cholangiocatheter.

Once the catheter has been inserted adequately into the cystic duct, the right – angle forceps is used to hold it in position and prevent air from entering.

The cystic duct is divided between the clamp holding the cholangiocatheter in the cystic duct and the tie on the juncture of the cystic duct with the gallbladder. This permits easy access for securing the cholangiocatheter in the proximal end of the cystic duct. The cystic duct is divided so that one can tie around the tip of the right-angle forceps thereby holding the cholangiocatheter in the cystic duct in good position for subsequent cholangiography.

The clear and open field permits the tie to go down around th§ right-angle forceps, ligating the cholangiocatheter within the cystic duct.

The operative field is now ready for cholangiography. One can clearly see the divided cystic duct with the cholangio­catheter coming out the small opening made in the cystic duct and securely ligated in the proximal cystic duct. The arrowhead on the cholangiocatheter prevents the catheter from slipping out of the cystic duct during operative cholangiography. It also permits the cholangiogram to be re­peated if necessary.

Subsequent illustrations demonstrate that once the cholangiogram is taken at this point in the operation, one can place the cholangiocatheter completely out of the operative field and proceed with removal of the gallbladder while the cholangiogram is being developed. By doing the operation in this sequence and using these technical maneuvers, the additional time required for obtaining a cholangiogram during chole­cystectomy is less than five minutes.

The cholangiocatheter is now completely out of the operative field and is helpful in holding the exposure. The peritoneum on the back surface of the gallbladder is being divided. It is mobilized with the right-angle clamp and divided with a cautery, thereby keeping the field avascular. Some of the branches of the cystic artery posteriorly may still be entering the gallbladder as collateral circulation in this area, and it is good to visualize them and divide them with a Bovie diathermy.

The peritoneum on the anterior surface of the gallbladder is now divided with scissors about 0.5 to 1 cm from the anterior surface of the liver. The gallbladder is being readied to enucleate it from the liver bed.

Hemostasis within the bed of the gall­bladder is maintained by using a cautery to divide the small accessory vessels that run directly into the gallbladder. The peri­toneum on the back side of the gallbladder has been divided, thereby permitting the gallbladder to be turned inside out as it is removed from the liver bed while at the same time preserving visibility and an avascular field. A 0.5- to 1 – cm cuff of peritoneum is incised on the posterior aspect of the gallbladder so that two peritoneal edges will be available for reperitonization of the raw surface.

In this fashion a completely dry field is maintained while the gallbladder is being removed, and an adequate peritoneal cuff is achieved for reperitonization of the raw surface of the liver bed.

The two cut peritoneal edges in the liver bed are sutured. The gallbladder has not been completely removed at this point, but traction pressing it against the abdominal wound maintains the exposure of the liver bed so that reperitonization of the raw surface is very simple, direct, and easy.

As soon as the peritoneum of the liver bed has been ligated and closed, the strand of peritoneum holding the gallbladder is divided, as illustrated by the scissors cutting through the final peritoneal attachments to the gallbladder. One can still see the cholangiocatheter in the common duct, and the operative field remains open with all the important structures clearly visible. The field is entirely avascular.

The steps in removal of the catheter are shown. The distal portion of the cystic duct beyond the catheter is grasped with the forceps. The tie is divided. The catheter is removed, and the cystic duct is clamped and ligated.

One can use the stump of the cystic duct to explore the common duct if there is any question about the patency of the common duct. The cystic duct stump is held steady with a small clamp. The opening of the cystic duct is dilated with a mosquito for­ceps, and a Bakes dilator is inserted through the cystic duct into the common duct.

The dilator is passed down the common duct, following the course of the common duct and permitting the dilator to advance easily. With the left hand behind the second portion of the duodenum, the tip of the Bakes dilator can be felt readily passing through into the duodenum. Once in the duodenum, it can be rotated against the lateral duodenal wall, and if proper entry has been made into the second portion of the duodenum one can clearly see the silvery tip of the Bakes dilator shining through the very thin duodenal wall.

Victor Richards, M. D.

Clinical Professor of Surgery, University of California School of Medicine at San Francisco; Chief of Surgery, Children’s Hospital of San Francisco, San Francisco, California

Illustrated by Frank Robinson

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