腹腔镜胆囊切除术有或没有症状的胆石症（图文演示）

中文版：腹腔镜胆囊切除术用于有或无胆管造影的症状性胆石症（图文）

Laparoscopic cholecystectomy for symptomatic cholelithiasis with or without cholangiogram

Authors
D Mutter

Abstract
Cholecystectomy, consisting of complete removal of the gallbladder, was one of the first surgical interventions to be performed laparoscopically.
Laparoscopic cholecystectomy is performed using the same operative technique and principles as open cholecystectomy. Nonetheless, the two-dimensional downward to upward view coupled with the use of long instruments for distance manipulation requires specific training. Furthermore, the laparoscopic approach is associated with a risk of specific complications during the learning curve. One should always bear in mind that there is no such thing as a simple cholecystectomy.

Publication 2015-03

1. Introduction

Cholecystectomy, consisting of complete removal of the gallbladder, was one of the first surgical interventions to be performed laparoscopically.
Laparoscopic cholecystectomy is performed using the same operative technique and principles as open cholecystectomy. Nonetheless, the two-dimensional downward to upward view coupled with the use of long instruments for distance manipulation requires specific training. Furthermore, the laparoscopic approach is associated with a risk of specific complications during the learning curve. One should always keep in mind that there is no such thing as a simple cholecystectomy.

2. Anatomy
• Location


Note: the anatomy section is identical for all chapters on gallbladder diseases.
The gallbladder is located in the right upper quadrant. It is attached to the liver at the junction between segments IV and V.
The fundus of the gallbladder is generally situated under the right costal margin.

• Topographical anatomy

1. Liver
2. Stomach
3. Lesser omentum
4. Gallbladder
5. Hepatic flexure
6. Greater omentum

• Local anatomy

1. Fundus
2. Body
3. Infundibulum
4. Cystic duct
5. Common hepatic duct
6. Common bile duct

• Vascular supply

1. Gallbladder
2. Cystic artery
3. Mascagni lymph node
4. Proper hepatic artery
5. Abdominal aorta
6. Portal vein
7. Gastroduodenal artery

3. Anatomical variations I
• Variations in the cystic artery

The anatomy of the biliary tract vasculature is highly variable from one patient to another, especially with the right hepatic artery and the cystic artery.
A sound working knowledge of the various anomalies that may be encountered will facilitate identification of the important structures and protect against intraoperative complications.

• Double cystic artery
• Variation 1

Double cystic artery; both from a normal right hepatic artery in the cystic triangle

• Variation 2

Double cystic artery; one posterior-inferior and one anterior-superior to the cystic duct

• Variation 3

Double cystic artery; both superior to the cystic duct high in the cystic triangle

• Cystic artery origin
• Variation 1

Cystic artery originating from the proper hepatic artery

• Variation 2

Cystic artery originating from a normal left hepatic artery, high in the cystic triangle

• Variation 3

Cystic artery originating from the celiac trunk, anterior-superior to the cystic duct

4. Anatomical variations II
• Intra hepatic duct

1. Common bile duct
2. Gallbladder
3. Cystic duct
4. Right hepatic duct
5. Left hepatic duct

• Right hepatic duct I
• Duplication

- unique right hepatic duct (53% of cases)
- right hepatic duct duplication (47% of cases)
RL: Right Lateral duct
RPM: Right ParaMedian duct
Couinaud C. Controlled hepatectomies and exposure of the intra-hepatic biliary ducts. Paris: C.Couinaud, 1981.

• Trifurcation

- upper biliary trifurcation (10% of cases)
- right paramedian (anterior) duct right lateral (posterior) duct left hepatic duct

• Caudal entrance of RL duct

- caudal entrance of the right lateral (posterior) duct into the main channel (6% of cases)

• Caudal entrance of RPM duct

- caudal entrance of the right paramedian (anterior) duct into the main channel (20% of cases)

• Right hepatic duct II
• Left entrance of RL duct

- entrance of the right lateral (posterior) duct into the left hepatic duct (2% of cases)

• Left entrance of RPM duct

- entrance of the right paramedian (anterior) duct into the left hepatic duct (6% of cases)

• Segmental branching of RL duct

- upper biliary quadrifurcation (1.5% of cases)
- segmental branch (VI and VII) sectorial branch (paramedian) left hepatic duct

• Segmental branching of RPM duct

- quadrifurcation of the upper biliary confluence (1.5% of cases)
- segmental branch (V and VIII) sectorial branch (lateral) left hepatic duct

• Left hepatic duct
• Breakdown

- common stem II and III and a separate branch for segment IV in 80% of cases
- common stem III and IV and a separate branch for segment II with duplication of the left hepatic duct (20% of cases)

• Unique duct: distribution II, (III IV)

- unique duct, distribution (III IV) and II (10% of cases)

• Duplication: distribution (II III), IV

- duplication, distribution (II III) and IV (7% of cases)

• Distribution II, (III IV)

- duplication, distribution (III IV) and II (3% of cases)

5. Anatomical variations III
• Variations in extrahepatic bile ducts

A sound, working knowledge of the anatomical variations will facilitate intraoperative identification of the various ductal structures. In addition, strict accordance with the basic rules of exposure and of dissection, as well as mastery of laparoscopic skills, will provide further protection from potentially serious complications of the surgical procedure.

• Bile and accessory hepatic ducts I

• Anatomy

• Variation 1

Cystic duct insertion of the right lateral (posterior) segment

• Variation 2

Duct of Luschka

• Variation 3

Duct of Luschka

• Variation 4

Direct drainage into the gallbladder of the right lateral (posterior) segments and right paramedian (anterior) segments

• Bile and accessory hepatic ducts II
• Anatomy


• Variation 1

Gallbladder insertion of accessory right hepatic duct

• Variation 2

Congenital absence of a cystic duct

• Variation 3

Low union with common hepatic duct

• Abnormal junctions of the cystic duct
• Anatomy

                               
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• Variation 1

Anterior crossing, left insertion

• Variation 2

Posterior crossing, left insertion

• Variation 3

Lower insertion

6. Anatomical variations IV
• Morphological factors


Morphological characteristics of patients may require an adaptation of the basic technique.
Hypertrophy of the right lobe of the liver or an excessively large gallbladder can present difficulties during the dissection. In these cases, the position of the retracting trocar can be adjusted to allow for improved access to the subhepatic region.

• Unusual localization of gallbladder


The gallbladder may be located inside the hepatic parenchyma, in rare cases.

7. Operating room set-up
• Patient

US Reviewers' note: The operating room set-up has been described by a European author. The standard US set-up has been added under the subtitle American school position.
The patient is prepped and draped in the usual fashion:
- standard skin preparation;
- sterile field;
The patient is placed:
- in a supine position;
- left arm at 90°;
- right arm alongside the body.
- legs abducted;

• Team

1. The surgeon stands between the legs of the patient.
2. The first assistant stands to the left of the patient.
3. If a second assistant is needed, he or she stands to the right of the patient.

• Equipment

1. Radiological equipment (optional)
2. Laparoscopic unit
3. Anesthetic unit
4. Laparoscopic unit (optional)
5. Instrument table
6. Electrocautery
7. Operating table

• American school position
• Patient

The patient is placed:
- in a supine position;
- without abduction of the legs;
- with right arm tucked along the body.

• Team

1. The surgeon stands to the left of the patient.
2. The first assistant stands on the right of the patient.
3. In case a second assistant is needed, he or she stands on the right of the patient.

8. Trocar placement
• Standard technique

The position and size of the trocars used vary from one surgeon/institution to another.
The standard technique utilizes 4 trocars (12 - 10 - 5 - 5 mm).
Most authors use an optical trocar of 10 to 12 mm introduced in the periumbilical region.
One operating trocar is usually situated to the left side of the mid-epigastric region. A second operating trocar is placed in the inferior aspect of the right upper quadrant. The fourth trocar placed in the epigastric region accommodates one or several means of liver and viscera retraction.

• Optical

A - One optical trocar allows introduction of the laparoscope and the camera, usually 12 mm in diameter

• Operating trocars

B - operating trocar introduced left lateral to the umbilicus (10 mm)
C - operating trocar introduced in the right iliac fossa (5 mm)

• Retractor

D - Retracting trocar in the epigastric region (5 mm)

• Variations
• 3 trocar technique

In this technique, the liver can be retracted with the help of a percutaneous suture that suspends the round ligament toward the upper left side of the abdomen. A fourth trocar can be added as needed to help in the exposure of the infundibulum of the gallbladder.

• Using 10/12 - 5 - 5 - 5mm

There is a current tendency to reduce the size of the trocars during laparoscopic procedures. In laparoscopic cholecystectomy, this has been rendered possible by the use of 5 mm clip applicators. The use of 3 trocars plus only a single 10/12 mm trocar does not allow for placement of the gallbladder into an externally controlled extraction bag nor for grasping of the sac through the umbilical trocar under direct vision (unless the 10 mm scope is replaced by a 5 mm scope via the operating/retraction ports for visualization). In these cases, the sac is grasped and guided with the help of an intra-abdominal grasper to the umbilical opening for extraction at the end of the procedure.

• Use of 12 - 2 - 1.6 - 1.6 mm trocars

Attempts to reduce abdominal wall trauma and improve cosmetic results have led to the use of smaller and smaller instruments. The availability of microsurgical instruments (1.6 - 2 - 3 mm in diameter) as well as 2 mm optical scopes allows for a significant reduction in the size of the incisions and trocars used.

• Obese patients I

The position of the trocars needs to be adapted to the morphology of the patients. In obese patients, the distance between the usual trocar introduction site and the operative field is increased by the thickness of the abdominal wall. It is necessary in these cases to move the trocars closer to the operative region.

• Obese patients II

9. Instrumentation
• Overview


• Standard

A standard system providing optimal quality is used.
If intraoperative cholangiography is indicated, a cholangiography catheter will be needed.

• Optical

A
The endoscopic view is provided by a 10 mm endoscope with a 0° angle.
A 3CCD camera with a Halogen or Xenon light source is used.

• Operating


B
- straight and curved scissors
- 5 mm hook
- grasper
- 10 mm clip applicator
- extraction bag

C
- grasper

• Retractor


D
- suction-irrigation device
- 5 mm grasper