腹腔镜胆囊切除术治疗急性胆囊炎（图文演示）

LAPAROSCOPIC   CHOLECYSTECTOMY   FOR   ACUTE   CHOLECYSTITIS
Authors
B Navez
Abstract
The description of the laparoscopic cholecystectomy for acute cholecystitis covers all aspects of the surgical procedure used for the management of acute cholecystitis.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: exploration, exposure, dissection, intraoperative cholangiography, ligation and division, extraction.
Consequently, this operating technique is well standardized for the management of this condition.


中文版：腹腔镜胆囊切除术治疗急性胆囊炎（中文图文演示）

1. Introduction
Acute cholecystitis (AC) is one of the most frequent causes of an acute abdomen. The decision to operate must be made promptly.
The use of laparoscopy for acute cholecystitis is less and less controversial. In fact, many publications have demonstrated that laparoscopic cholecystectomy is currently performed more and more frequently for the treatment of acute cholecystitis including a low mortality, a shorter hospital stay and a lower cost as compared to open cholecystectomy (Csikesz NG et al., 2008). Most publications support this approach even for the elderly (Uecker J et al., 2001) as well as for pregnant patients (Chiappetta Porras LT et al., 2009).
At present, in the hands of skilled laparoscopic surgeons, laparoscopic cholecystectomy for AC appears to be safe and feasible with an acceptable operative time.
Several technical key points must be emphasized.

2. Anatomy
• Location

Note: the anatomy section is identical for all chapters on gallbladder diseases.
The gallbladder, situated in the right upper quadrant, is embedded in the liver at the junction of segments IV and V.
The fundus of the gallbladder is generally situated under the right costal margin.
In cases of hydrops or a low-lying liver, the fundus of the gallbladder may drop down as far as the right iliac fossa.

• Topographic 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. Anatomopathology


In AC, there is an acute inflammation of the gallbladder wall due to prolonged obstruction of the cystic duct or neck of the gallbladder. It may also occur as an inflammatory reaction to the passing of a stone.
Inflammatory adhesions can often be found around the gallbladder to neighboring organs such as the duodenum, right colon, and greater omentum.
We distinguish:
- catarrhal acute cholecystitis;
- purulent cholecystitis;
- gangrenous cholecystitis.

4. 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

5. 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)

6. 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


• Variation 1

Anterior crossing, left insertion

• Variation 2

Posterior crossing, left insertion

• Variation 3

Lower insertion

7. 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.

8. Indications
Indications
Clinical symptoms of inflammation at admission:
- hyperthermia over 37.5°C;
- nausea or vomiting;
- severe pain around the right hypochondrium or epigastrium.
Ultrasonic evidence of AC:
- thickened gallbladder wall (>=4 mm);
- distended gallbladder;
- US Murphy's sign when the ultrasound probe is introduced.

Relative contraindications
- patient ASA 4 (moribund) or in Intensive Care Unit with acute calculous cholecystitis (percutaneous cholecystostomy may be a good alternative in these critically ill patients);
- gangrenous cholecystitis (abscesses);
- longstanding AC (over 10 days): this point remains controversial since many recent reviews have found early laparoscopic cholecystectomy safe as it shortens hospital stay, enables a better quality of life, and is not associated with more complications than delayed laparoscopic cholecystectomy (Wilson E et al., 2009).
- surgeon's limited experience in laparoscopy.

Time point for surgery:
For many years, it has been debated that the surgical approach for the treatment of acute cholecystitis, regardless of the surgical approach (open or laparoscopic), should be carried early or should be delayed after the onset of symptoms. Currently, most studies suggest that on average, early laparoscopic cholecystectomy appears less expensive than the delayed approach. The results regarding quality of life do seem improved (Wilson E et al., Br J Surg, 2009). Concerning the surgical results, laparoscopic management of acute cholecystitis is associated with an increased rate of conversion (10-15% versus 1-2%) but is not associated with a higher rate of intraoperative or postoperative complications (Michalowski K et al., Br J Surg, 1998; Csikesz NG et al., Surgery, 2008).

9. 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:
- supine position;
- left arm at 90°;
- right arm alongside the body;
- legs abducted.


• Team

1. The surgeon is positioned between the patient's legs.
2. The first assistant is on the patient's left side.
3. The second assistant is usually to the patient's right, opposite the first assistant.

• 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.