腹腔镜胆囊切除术有或没有症状的胆石症（图文演示）

10. Major principles
The basic surgical principles of laparoscopic cholecystectomy are:
1. achieving perfect exposure of the right subhepatic region;
2. identification of all anatomical structures;
3. dissection of Calot's triangle;
4. dissection, clipping, and division of the cystic artery and duct;
5. cholecystectomy.

11. Exploration
• Anatomical structures

1. Liver
2. Gallbladder
3. Round ligament
4. Stomach
5. Duodenum
6. Transverse colon
The first operative step consists of the creation of the pneumoperitoneum.
A quick exploration of the abdominal cavity is performed allowing for identification of all the anatomical structures of the right upper quadrant before the start of the dissection.

• Establishing the pneumoperitoneum


We recommend the use of a semi-open or open Hasson technique for creation of the pneumoperitoneum due to the increased risk of injury to vital intra-abdominal structures associated with the use of a blind entry technique of Veress needle placement (Bonjer, 1997).

• Goals of the exploration

- Confirm the absence of adhesions, this allowing for safe introduction under direct vision of the operating trocars;
- confirm the feasibility of the laparoscopic approach;
- confirm the good positioning of the trocars with regard to the patient's anatomy;
- eliminate any unsuspected abdominal pathology (particularly malignant pathologies because of the specific risks involved).

12. Exposure
• Retraction of the liver

Usually, the gallbladder is largely covered by the right lobe of the liver. Exposure of the operative field mandates upward retraction of the liver to give access to the subhepatic region. In cases of adhesions, access to this region may be difficult.
The procedure starts with a 10 mm laparoscope through the umbilical trocar (A).

• Retraction of the gallbladder


A grasping forceps is inserted via the epigastric trocar (D) to grab the fundus of the gallbladder and retract it cephalad and towards the right shoulder of the patient.
A grasping forceps is introduced via trocar C and used to grasp the infundibulum retracting the gallbladder laterally and caudally, thus opening up Calot's triangle.
Exposure can also be facilitated by placing the patient in a reverse Trendelenburg position with a slight leftward tilt.

• Lysis of adhesions


Adhesions, whether spontaneous, inflammatory or postoperative, limit access to the right upper quadrant and the mobility of the instruments.
Any adhesions between the gallbladder and the duodenum or the colon are divided.

13. Dissection/Calot
• Anatomical structures

During this step of the procedure, all the biliary and vascular elements that constitute the triangle of Calot will be dissected. This can be done with the help of two 5 mm graspers introduced via trocar C and D, 5 mm scissors or a hook connected to electrocautery introduced via trocar B, and a 10 mm laparoscope introduced via trocar A.

• Anatomical dissection



The goal of the dissection of Calot's triangle is to clearly identify the cystic duct and the cystic artery. The dissection is started close to the gallbladder at the junction of the infundibulum with the cystic duct. The anterior and posterior peritoneal leaflets are incised, allowing access to the vascular and biliary elements of the triangle of Calot. The cystic duct and the cystic artery are skeletonized.
This dissection can be difficult in cases of inflammation of the Calot triangle lymph node (Mascagni lymph node).

• Identification of the cystic duct


The cystic duct is dissected first. This dissection is started at the level of the infundibulum of the gallbladder. The peritoneal coverage of Calot's triangle is incised. Gradual dissection will lead to the identification of the cystic duct. The cystic duct must be freed over a 5 to 10 mm area starting from the infundibulum of the gallbladder and running towards the CBD in order to allow for safe clip application. The dissection of the cystic duct must not be taken too low, in order to avoid injury to the CBD.

• Identification of the cystic artery



The search for the cystic artery is begun cephalad to the cystic duct and in close proximity to the gallbladder. Taking this dissection further to the left puts the right branch of the hepatic artery at risk. The cystic artery can be either dissected along with the cystic duct or after division of the cystic duct. It should be identified and freed at the level of the gallbladder. In certain cases, a double cystic artery may be identified.

Discrimination: cystic duct and CBD
Excessive traction exerted on the gallbladder can result in distortion of the CBD with its middle portion shifted rightwards. This may cause:
- confusion between the CBD and the cystic duct, leading to the clipping of the CBD;
- a tenting effect of the CBD, leading to placement of lateral clips over this duct.

14. IOC: Technique
• Indications

IOC is indicated when the presence of CBD stones is suspected.
It is used:
- to determine the location, size and number of the calculi,
- to assess the anatomy of the intrahepatic and extrahepatic bile ducts: anatomical variations and size of the CBD.

• Cystic duct incision


Cholangiography is done via a hemicircumferential incision of the cystic duct along its anterior surface. This cysticotomy is performed approximately 1 cm from the junction of the CBD in order to avoid difficulties in inserting the cholangiocatheter due to valvulae or plications of the cystic duct. The right margin of the CBD must be identified.

• Position of the operating table

The operating table is brought back to a flat position (ie, taken out of reverse Trendelenburg and left tilt) and a slight rightward tilt is given to displace the CBD anteriorly.

• Cholangiography
• Catheter introduction





The cholangiocatheter is brought to the cysticotomy site using a rigid introducer, either percutaneously or through the right subcostal trocar. It is inserted 1 to 3 cm inside of the cystic duct and held in place with a clip or a grasper.
When using clips, particular attention should be paid not to injure the cystic duct.
When using a grasper, there is less risk to injure the cystic duct. There is a specific grasper for cholangiography, which eradicates the risk of cystic duct injury observed with the clip fixation technique.

• Controlling leakage

Saline or dilute methylene blue is injected via the cholangiocatheter to make sure there is no leakage.

• The 3 steps

The cholangiography should be done in 3 steps:
1. A few milliliters of diluted contrast are injected into the bile ducts under radiographic guidance. A static cholangiogram is able to detect CBD stones.
2. The dye injection is continued until a complete cholangiogram is obtained. A second radiograph is performed to confirm it. The Trendelenburg position may facilitate the opacification of the intrahepatic bile ducts.
3. The passage of dye into the duodenum under low pressure should be confirmed by a third radiograph.

• Catheter removal

The cholangiocatheter is removed and the cystic duct is closed using a clip.

• Results

The presence of stones in the CBD is suspected when the radiograph demonstrates:
- radiolucent defects;
- a crescent-shaped blockage of the contrast;
- bile duct dilatation;
- the absence of passage of contrast into the duodenum.
The decision to perform a transcystic CBD exploration or a choledochotomy will be based on the analysis of the location of the calculi and morphology of the bile ducts.

15. Clipping and division
• Anatomical structures


All important anatomical structures must be identified prior to clipping or division of the cystic duct in order to prevent injury to other vital structures in the region.

• Clipping and division


Clip application:
A 5 or 10 mm clip applicator is inserted through the lateral trocar on the left side (B) to allow placement of 3 clips on the cystic duct and 3 clips on the cystic artery:
- 2 clips are placed on the CBD side,
- 1 clip is placed on the gallbladder side.
Complete obliteration of the cystic artery and cystic duct by the clips is confirmed before division of these structures.

Division of the cystic duct:
The cystic duct is divided under direct vision.

Division of the cystic artery:
The cystic artery is divided under direct vision.

16. CBD injuries
• Therapeutic options

The intraoperative recognition and identification of a CBD injury (either by direct vision or by cholangiography) normally mandates a conversion to laparotomy.
In rare cases, the treatment of select injuries can be done using the laparoscopic approach. Depending on the type of injury encountered, the therapeutic options are (Gigot, 1997):
- direct suturing without drainage;
- direct suturing over a T-tube;
- Roux-en-Y hepaticojejunal anastomosis.

• Dangers I
• Variation 1

                               
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Lateral clipping of the CBD

• Variation 2

Traumatic desinsertion of the cystic duct junction

• Variation 3

Tenting of the CBD

• Dangers II
• Variation 1

Instrument injury of the CBD during dissection of the triangle of Calot

• Variation 2

Instrument injury of the CBD during cholecystectomy

• Variation 3

Thermal injury of the CBD

• Variation 4

Injury to an anomalous right hepatic duct

• Variation 5

Injury to an anomalous right hepatic duct

• Variations
• Large cystic duct

If the cystic duct is too large to allow for safe clip application, ligation of the cystic duct stump becomes necessary. This can be done either with intracorporeal suturing or by application of a prefabricated loop.

• Difficult dissection


Difficult dissection of Calot's triangle:
In cases of difficulties encountered during simultaneous dissection of the cystic duct and cystic artery, it is possible to dissect, clip, and divide the cystic duct first. This maneuver will create additional operating space that will then allow the dissection, control, and safe division of the cystic artery.

• Clip application






Clip application with 3 mm scope

17. Gallbladder bed dissection
• Downward traction

Dissection of the gallbladder bed is performed by progressive use of electrocautery with a hook or scissors. Constant downward traction over the infundibulum of the gallbladder allows exposure for this operative time.

• Accessory biliary duct



The dissection of the gallbladder bed must be performed carefully to allow for the identification of any accessory biliary ducts draining directly into the gallbladder from the liver. Any such accessory ducts identified during the dissection of the gallbladder bed must be clipped.

18. End of the procedure
• Extraction


The gallbladder is placed into an extraction bag and removed via the umbilical incision.
The use of an extraction bag offers 2 advantages:
- reduced risk of contamination of the umbilical incision by bile or stones in case of a gallbladder rupture during the extraction maneuvers,
- reduced risk of parietal wall seeding in cases of unrecognized gallbladder cancers.
The umbilical incision may enlarged as needed.

• Irrigation and lavage



In cases of bile leakage during the procedure, a lavage of the right upper quadrant can be realized.
Any spilled stones during the procedure should be looked for and extracted. Such stones can be the cause of early as well as late complications (abscess and chronic fistulae).

• Drainage

Under normal conditions in an elective setting, postoperative drainage is not indicated for laparoscopic or open cholecystectomy (Mutter, 1999).
If a drain is used, it must be a suction drain and must be removed relatively quickly. Indeed, prolonged postoperative drainage following open cholecystectomy has resulted in increased morbidity when it lasted more than 48 hours (Hoffmann, 1985; Playforth, 1985; Monson, 1986).

• Closure

At the end of the procedure, the pneumoperitoneum is evacuated after the trocar sites are carefully controlled for bleeding and the trocars are removed. Fascial closure is indicated for incisions >=10 mm in size.
Skin is closed based on the surgeon's preference using:
- clips;
- interrupted sutures;
- steristrips;
- surgical glue;
- or intracuticular sutures (recommended).

19. Reference
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