122

How to do itTHE NATIONAL MEDICAL JOURNAL OF INDIA VOL.6, NO.3

Laparoscopic cholecystectomy

D. S. BURKITI, G.IMVRIOS, P. McMASTER

INTRODucnONThe technique of cholecystectomy had not changed for100 years until the first laparoscopic procedure was per-formed in 1987. Rarely has such a change been so rapidlyand widely accepted by the surgical community. Themajority of procedures can be performed by thistechnique and although it may take longer to performthan open cholecystectomy, there are major benefits tothe patient as a result of the shorter duration of stay, lesspostoperative discomfort, better cosmetic result! andan earlier return to work.?

This article aims to guide the reader through the opera-tion. We emphasize that it is not a substitute for learningthe technique under the supervision of an experiencedsurgeon nor do we wish to imply that this is the only wayto perform a laparoscopic cholecystectomy.

CASE SELECTIONEach patient is assessed clinically in the same way asfor an open cholecystectomy. Particular note is taken of ahistory suggesting recent pancreatitis, cholangitis,obstructive jaundice or of previous upper abdominalsurgery. The patient has to be fit for an open cholecystec-tomy as it may be necessary to change to the open operationfrom the laparoscopic procedure.

It is not our practice to perform routine peroperativecholangiography (POC) but in order to minimize thechance of retained common bile duct (CBD) stones wecheck preoperatively that the liver function tests arenormal and that the CBD is not dilated on ultrasono-graphic examination. Any patient considered to have abile duct stone has a preoperative endoscopic retrogradecholangiogram and stone extraction. Some centresadvocate a preoperative intravenous cholangiogram withtomography to exclude CBD stones but we have noexperience of this technique.

The list of contraindications (Table I) is getting shorteras more experience is being gained but early in thelearning curve it is best not to operate on patients whoare obese or those with acute cholecystitis.

Queen Elizabeth Hospital, Queen Elizabeth Medical Centre,Edgbaston, Birmingham B15 2TH, England

D. S. BURKITI, G. IMVRIOS, P. McMASTER Liver Unit

Correspondence to P. McMASTER

© The National Medical Journal of India 1993

We inform the patient that there are a variety of treat-ment options for cholelithiasis but cholecystectomy is theonly method of ensuring that recurrence does not occur.The laparoscopic method is successful in 95% to 100% ofcases but appropriate consent should be obtained for anopen procedure.

EQUIPMENTHigh quality equipment for visualization is essential. Weuse a 0° (forward viewing) laparoscope but there areadvantages for this particular procedure in using a 30°laparoscope. A 5 mm laparoscope is also useful forinspecting the umbilical and subxyphoid sites if the firstportal of entry has to be in the midclavicular line (MCL).The camera and both monitors should have a high resolu-tion and the xenon light- source should have an automaticiris.

The carbon dioxide (C02) insufflator must be able toproduce a flow rate of at least 4 litres per minute andmaintain a constant intra-abdominal pressure despite thefrequent removal of instruments and the use of suction.An exhaust system enables the gas to be pumped out ofthe abdominal cavity, passed through a smoke filter andrecycled. This keeps the operative field clear whilst thediathermy is in use.

The size of the trocar sleeves is often referred to collo-quially as 10 mm and 5 mm as these are the sizes of theinstruments which can be passed through them; in fact theyare 11 mm and 5.5 mm. These allow room for the passageof gas around the instruments of which two of each sizeare required. A reduction sleeve is necessary as it enablesthe surgeon to use 5 mm instruments through an 11 mmport without losing gas. The disposable 11mm sleeves canbe used with 5 mm instruments by inserting a plastic capwith a hole.

The suction-irrigation device delivers heparinizedsaline (10000 unitslL) under pressure which prevents

TABLE I. Contraindications to performing laparoscopiccholecystectomy

PeritonitisPortal hypertensionEmpyemaPregnancyPrevious extensive upper abdominal surgery

HOWTODOIT

the formation of blood clots as these cannot be aspirated.Suction should be applied only when the tip of the instru-ment is under water to prevent loss of pneumoperitoneum.

A variety of grasping forceps are available with andwithout ratchet mechanisms, heavy 'traumatic' ones forextracting the gall bladder and less traumatic ones forholding viable tissue. Atraumatic forceps with ratchetsare necessary to hold the fundus of the gall bladder andHartmann's pouch. Many of these are, in fact, standardgynaecological instruments.

Two basic types of scissors are available: fine pointedmicro dissectors and a heavier 'hooked' or 'parrot-beaked'design for dividing the cystic duct and artery.

Curved dissectors are more useful than straight onesand we favour the Petelin design which is manufacturedwith two different radii of curvature. These facilitatedissection around the back of the cystic duct and artery.

We use a reusable Ligaclip applicator as the disposableautomatic loading devices, though convenient, are expen-sive. An aspiration needle is very useful to decompress atense gall bladder.

A laser is not necessary to perform this operation andwe do not use one. The diathermy generator should be ofa type which incorporates circuits which minimize inter-ference on the video system. An L-shaped hook is themost useful instrument for division of tissues and a button-ended instrument can be used to coagulate bleedingpoints on the gall bladder bed. Endoloops and suturematerial should be available for ligating a wide cystic duct.

Conversion to an open operation is usually an electivedecision but there may be an occasion when unexpectedbleeding makes this a matter of urgency. A basiclaparotomy set should, therefore, be available in thetheatre during each case.

The success of the procedure depends on the correctuse and proper maintenance of a number of pieces ofequipment with which the surgeon may not be familiar.Failure of anyone of them is likely to result in conversionto an open operation. It is vitally important that the staffare trained to disassemble the instruments, clean andsterilize them appropriately and reassemble them withcare. These items are expensive and some of them aredifficult to replace at short notice. It is wise to have aspare set of the instruments which deteriorate quicklysuch as scissors, and items which are vital such as the clipappliers or the xenon light bulb.

THEATRE LAYOUT.The surgeon stands on the patient's left and the camera-man stands on his left. The assistant stands on the patient'sright and the scrub nurse to his right. The position of theequipment is shown in Fig. 1.

THECAMERAMANHe should assess the picture quality, colour balance andfocusing of the camera before the laparoscope is intro-duced. We use a suture pack as a test card. Once thelaparoscope is introduced the camera should remainoriented so that the anterior edge of the liver remains inthe horizontal plane. Rotating the camera disorientates

123

FIG 1. Positions of the surgeons and equipment.1 Anaesthetic machine 2 Insufflator 3 Second monitor4 Surgeon 5 Cameraman 6 Diathermy7 Instruments 8 Nurse 9 Assistant10 Main monitor, camera equipment and light source

the surgeon and makes identification of the anatomydifficult.

It is helpful to withdraw the laparoscope partially whenthe surgeon introduces an instrument so as to provide awider field of view which should include the appropriateport and the operative field. When the tip of the instru-ment is visible the laparoscope should follow it with itsimage at the centre of the screen. Smooth movement ofthe laparoscope is aided by opening the trumpet valve onthe 11 mm port sleeve.

Haziness frequently occurs when the laparoscope isfirst introduced. This is due to condensation on the coldlens in the warm and humid abdominal cavity and isavoided by prewarming the laparoscope in a water bath.Occasionally condensation can occur between the cameraand the eyepiece of the laparoscope. During the proce-dure haziness may be cleared quickly by gently wiping thetip on the omentum ('dipping'); ifthis is inadequate thenthe laparoscope has to be withdrawn and the lens cleanedwith care, remembering that it may be hot.

PATIENT PREPARATIONA prophylactic antibiotic (cephalosporin) is givenintravenously on induction of general anaesthesia. Anasogastric tube is passed to deflate the stomach, therebyreducing the risk of perforation by the Verres' needle ortrocar and improving the subsequent view of the opera-

124

tive field. Some surgeons advocate catheterization ofthe urinary bladder but we do not consider this to benecessary.

The patient is placed supine on the operating table withthe left arm out on an arm board. Pneumatic leggings helpto minimize venous stasis and a leather strap across thepelvis helps to stabilize the patient's position. A trussshould be fitted on those patients who have an inguinalhernia. The skin is prepared and draped to expose a widearea of the right upper quadrant and the drapes sewn intoplace. The table is then tipped to the left and into a reverseTrendelenburg position but then 'split' so that the legs areelevated slightly above the horizontal line.

THE OPERATIONEstablishing a pneumoperitoneumBefore starting the procedure the surgeon must check thatall the equipment is functioning satisfactorily, especiallythe suction-irrigation device. If the umbilicus is free ofscars then a 1em vertical incision is made through the skinat the inferior margin of the umbilicus in the midline. Theanterior abdominal wall on either side of the umbilicus isgrasped by the surgeon's right hand and by the assistantand elevated. The Verres' needle is then inserted like adart with the left hand holding the barrel and aimed atright angles to the abdominal wall and away from thegreat vessels. A definite click can be heard as the tippenetrates the peritoneum.

If there is doubt that the tip is free in the peritonealcavity then several tests should help to confirm its position(Table II). If the doubt persists then the needle should bewithdrawn and another attempt made.

The Verres' needle is then connected to the CO2insufflator and flow started at a low rate, around 1 litreper minute. The abdomen should start to distendsymmetrically and become resonant to percussionthroughout. This is easiest to detect by the loss of liverdullness. When 1 litre of gas has been insufflated satisfac-torily, the flow rate may be increased to 4 litres perminute. The volume of gas required to reach a workingpressure of 12 to 15mmHg varies according to the size andparity of the patient. The needle is then removed.

If there is a midline scar then the Verres' needle may beplaced at the site of the MCL port. Later, when the port isestablished, the umbilical and the subxyphoid (SX) sitescan be inspected with a 5 mm laparoscope to ensure thatthey are free of adhesions. A Hasson trocar allows thesurgeon to enter the peritoneal cavity under direct visionbefore creating a pneumoperitoneum. In the presence ofmultiple adhesions this technique is safer than blind trocarentry.TABLEII. Tests for correct position ofthe Verres' needle

Free circumferential movement in the horizontal plane (in the absenceof adhesions)

A drop of saline placed on the hub will be sucked in if a negative intra-abdominal pressure is created by lifting the anterior abdominal wall

Aspiration should not return blood or fluidInjected saline should go in freely and not return on aspiration

THE NATIONAL MEDICAL JOURNAL OF INDIA VOL.6, NO.3

~',,,,"

...... ...•.•.....

A B cFIG 2. Sites of the ports required for the procedure.

A 5.5 mm port in the anterior axillary lineB 5.5 mm port in the midclavicular lineC 11 mm port in the midline

Port insertionThe umbilical port is then established using an 11 mmtrocar. This is the only one which is inserted blindly andthere is a case for using a disposable model with a shieldwhich protects the abdominal contents from the sharp tip.The trocar is inserted with the left hand, again supportingthe anterior abdominal wall with the help of the assistant.The trocar is pointed towards the liver. Removal of theobturator should produce a reassuring hiss of gas. A 0°laparoscope is inserted through this port and the insufflatorline attached to the side. The abdominal cavity may thenbe examined to exclude other pathology and whethertrauma has occurred as a result of the procedure.

Three other ports are required and can be insertedunder direct vision (Fig. 2). The 11 mm SX port is usuallyinserted in the midline about 5 em below the tip of thexyphoid and the trocar is aimed at the right of the falciformligament. This can produce crowding of the instrumentsin patients with narrow costal margins and some authorsrecommend an insertion site on the left of the midline andunder the falciform ligament." A 5.5 mm port is estab-lished in the MCL, a minimum of 3 em below the costalmargin and the last 5.5 mm port is inserted in the anterioraxillary line (AAL) at the level of the umbilicus. Thetrocars should be aimed at the gall bladder during theirinsertion and the exhaust of the insufflator connected tothe SXport.

HOW TO DOll

FIG 3. Position of the two grasping forceps on the gallbladder. Forceps 1: Midclavicular line grasping forceps,pulling' to the right and away from the liver. Forceps2: axillary line graspers, pushing cephalad and to the right

ExposureGrasping forceps with a ratchet are passed through theAAL port and the fundus of the gall bladder is heldcephalad and to the right by the assistant (Fig. 3). Thisexposes the body of the gall bladder and undersurface ofthe liver. A second pair of grasping forceps is introducedthrough the MCL port and grasps the area aroundHartmann's pouch which is pulled to the right and awayfrom the liver. This opens up the area of Calot's triangle(Fig. 4). If the gall bladder is too tense to be graspedsatisfactorily it should be aspirated.

If exposure is poor despite a working intra-abdominalpressure, it may be necessary to aspirate the stomach,tip the patient further to the left or increase the reverseTrendelenburg tilt. Lifting the falciform ligament mayalso help.

Before starting the dissection it is helpful to put a smallvolume of irrigant in the subhepatic space. This will

\\\\, 3

,,,,,

125

FIG 4. Peritoneum between Hartmann's pouch and thecommon bile duct being divided

prevent blood from clotting and obscuring the surgeon'svision.

DissectionDissection is performed with the surgeon's right handthrough the SX port. A variety of instruments anddissection techniques have been described. We use acombination of hook diathermy, Petelin dissectingforceps and 'parrot beak' scissors. Other authorsadvocate microscissor and pledget dissection.

The dissection is commenced at the neck of the gallbladder, working towards the common hepatic duct(Fig. 5). Blunt dissection should always be towards thecommon hepatic duct (CHD) to avoid avulsing the cysticduct. The junction of the cystic duct, CHD and CBDshould be identified with certainty. At least 1 em of cysticduct should be freed around its whole circumference. The

1 '

2

FIG 5. Dissection of Calot's triangle 1 Common hepatic duct 2 Common bile duct 3 Cystic artery and duct4 Gall bladder 5 Direction of dissection

126 THE NATIONAL MEDICAL JOURNAL OF INDIA VOL. 6, NO.3

FIG 6. Dissection of the gall bladder off the liver using the argon beam coagulator 1 To show right side of the gall bladder2 Midclavicular line graspers 3 To show left side of the gall bladder 4 Anterior axillary line graspers

dissection is aided by the use of the two-handed technique.The surgeon's right hand performs the dissection and theleft holds the grasping forceps on the neck of the gallbladder. Lifting the neck cephalad aids dissection belowand behind the cystic duct while displacing the neck of thegall bladder caudally and to the right facilitates dissectionabove the cystic duct. The cystic artery may be identifiedand freed at this stage but it is often easier when the ducthas been divided.

When the duct is freed, a peroperative cholangiogrammay be performed. The cystic duct is then controlled withclips passed through the SX port. Two clips are placedproximal and two distal to the proposed line of division.Every clip must be fully across the duct and all must. beparallel. If the duct is wide then it can be partially clipped,partially divided and then clipped again and fully divided.This does not provide adequate control but minimizes bileleakage until a Roeder knot endoloop is placed over thecystic duct stump. Alternatively and probably more

satisfactorily, the cystic duct can be ligated in continuityand then divided with scissors.'

Division of the duct exposes the area of the cysticartery. This is dissected out close to the gall bladder whereit may already have divided into anterior and posteriorbranches. The artery is freed over a 1 cm length, clippedand divided in a similar manner to the duct.

The gall bladder is then dissected off its bed from theneck towards the fundus using the diathermy hook oncoagulation. Cutting diathermy may perforate the gallbladder. This part of the dissection is easier using thetwo-handed technique as it allows the surgeon to exposeeach side of the gall bladder in turn (Figs. 6 and 7). TheMCL port graspers hold the clipped cystic duct and sometraction should be applied upwards and to the right.Haemostasis of the gall bladder bed must be achieved andthe stumps of the artery and duct checked before thefundus is completely freed from the liver.

FIG 7. Dissection of the gall bladder off the liver using the diathermy hook 1 Diathermy hook through subxyphoid port2 Midclavicular line graspers looping neck of the gall bladder over the anterior axillary line graspers (3)

to expose the gall bladder fossa

HOW TO DO IT

Extraction of the gall bladderThe AAL grasping forceps are removed and a suctiontube fed through the port and positioned in the subhepaticspace before removing the sleeve. The drain should besutured in place and occluded to minimize loss ofpneumoperitoneum. The cystic duct on the gall bladderis grasped with heavy forceps passed through the portalthrough which the gall bladder is to be removed (Fig. 8).We use the SX port although others advocate the umbilicalport and moving the laparoscope to the SX port. This maybe necessary if the SX port is not in the midline. The cysticduct and neck of the gall bladder are withdrawn into thesleeve as far as possible. It may be helpful to aspirate thegall bladder through the MCL port if this has not alreadybeen done. The sleeve and the grasping forceps areremoved together until the grasping forceps can no longerbe withdrawn; the sleeve is withdrawn fully exposingthe gall bladder neck and duct. These should be clippedcircumferentially with three 7-inch long artery forcepsand the neck opened so that the contents can be removedeither by suction or by crushing the stones and extractingthe fragments with Desjardins' forceps. During thismanoeuvre the surgeon must watch the fundus of the gallbladder on the monitor (Fig. 9). The gall bladder isremoved by gentle traction; it is not difficult to perforatethe gall bladder by using excess force.

The puncture site is plugged by the surgeon's rightindex finger to maintain the pneumoperitoneum longenough to remove the MCL port under vision with thelaparoscope and inspect the other sites for bleeding. Thefinger is removed allowing the abdomen to deflate, thelaparoscope is removed and finally the umbilical sleeveis removed with the trumpet valve open to preventomentum being pulled into the puncture site. We do notclose the fascia unless the incision has been extended. Theskin is infiltrated with local anaesthetic and then suturedor clipped.

The nasogastric tube is removed before the patientleaves the theatre.

PEROPERATIVE CHOLANGIOGRAPHY (POC)This may be performed when the cystic duct has beendissected and its gall bladder end clipped. The duct ispartially divided and cannulated with a SF ureteralcatheter (Figs. lOand 11) passed either percutaneously orthrough a reduction sleeve in the MCL port and clippedinto place. Alternatively a number of catheters designedfor this purpose may be used. Prior to exposing the filmsit is necessary to ensure that the ports do not overlie theregion of interest.

The main advantage of performing a POC is identifica-tion of unsuspected common bile duct stones, but what isto be done with them? Small stones are likely to passspontaneously and probably do not warrant an opencholedocholithotomy. Larger stones are likely to havebeen detected preoperatively but if missed there is a highprobability that they could be extracted endoscopically ata later date. Our experience has been that patients preferthis line of management rather than all open operation forcholedocholithiasis.

127

FIG 8. Gall bladder held by the cystic duct with a heavygrasper. Note the suction drain in the subhepatic space

FiG 9. Gall bladder being removed through the subxyphoid port

FIG 10. Cystic duct being divided prior to cannulation forperoperative cholangiography

128 THE NATIONAL MEDICAl! JOURNAL OF INDIA VOL. 6, NO.3

dissection should be extensive enough to allow thesurgeon to be certain of the anatomy, without cholangio-graphy, before any structure is clipped or divided.

POSTOPERATIVE CAREAlthough the procedure can be done on a day care basiswe normally discharge our patients the following day.Most of them can tolerate free fluids when they are awakeand start to take solids after a few hours. Some patientsrequire a dose of narcotic analgesic early in the postopera-tive period. Normal domestic activities are resumedwithin the first postoperative week. '

REFERENCES1 Grace PA, Quereshi A, Coleman J, et al. Reduced postoperative hospitaliza-

tion after laparoscopic cholecystectomy. Br I Surg 1991;78:160-2.2 Spaw AT, Reddick EJ, Olsen DO. Laparoscopic laser cholecystectomy:

Analysis of 500 procedures. Surgical Laparoscopy and Endoscopy 1991;1:2-7.3 Nathanson LK, Shimi S, Cuschieri A. Laparoscopic cholecystectomy: The

Dundee technique. Br J Surg 1991;78:155-9.4 Nathanson LK, Easter OW. Cuschieri A. Ligation' of the structures of the cystic

pedicle during laparoscopic cholecystectomy. Am] Surg 1991;161:350--4.

FIG 11. A SF catheter in place in the cystic duct

The second advantage of performing a POC is that itprovides the surgeon with a 'road map' of the a9atomy ofthe biliary tree. However, it is our contention that the

Brain Death and Organ Transplantation in IndiaCompiled by

c.K. Pande, P. K. Patnaik, S. Gupta, P. Sahni• Would the recognition of brain death add to

the illegal trade in human organs?

• Indeed, should the buying and selling ofhuman organs be permitted?

• What is brain death?

• Why have 47 countries in the world, includingmost developed nations and many Islamicstates, recognized brain death?

• Why is the concept of )rain death notaccepted in India?

This book documents these and related questions which were discussed at a workshop on'Brain Death and Organ Transplantation' held at Calcutta in June 1990.

Published byThe National Medical Journal of IndiaOrder from: The National Medical Journal of India

All India Institute of Medical SciencesNew Delhi 110029Price Rs 25/- + Rs 8/- (postage)