Page 38 - Journal of Laparoscopic Surgery - WALS Journal

Abhilash Jayachandran
cases to rule out the status of the CBD and cystic duct.
The average time taken for the completion laparoscopic
cholecystectomy was 1 to 1.5 hours.

DISCUSSION

Now, laparoscopic cholecystectomy is the gold standard
treatment for gallbladder stone disease. Around 80 to
85% of patients become asymptomatic postoperatively
but 15 to 20% of patients still persist with their prior
2
symptoms. These symptoms were due to an increase
in the choledochal pressure which results in cystic
stump distension, inflammation and stone obstruction
within the remnants of the cystic duct or gallbladder,
recurrent biliary calculi. Length of the cystic duct more
than 1 cm remaining post cholecystectomy can lead to Fig. 3: Anatomy of calots triangle
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stump cholecystitis with or without stones. The role of
remnant cystic duct length was further studied by Rogy • When any doubt about the anatomy, a fundus first
4
et al in 322 patients undergoing bile duct operation cholecystectomy dissection on gallbladder wall down
after cholecystectomy and found that 35 patients to the cystic duct can be helpful.
(10.8%) were left with a cystic duct length of more than • Bleeding adjacent to the calot’s triangle should

1.5 cm. Out of these, 24 patients were having pathological be controlled by pressure and not by clipping or
findings besides the long stump like pancreatitis. clamping.
Of the remaining, few had stones in the retained • If the cystic duct is densely adherent to the CBD
gallbladder, suture granuloma while other patients and there is possibility of Mirizzis syndrome, the
were having fistula between the remnant cystic duct infundibulum of the gall bladder should be opened,
and duodenum. In the end, only one patient was left the stone should be removed and infundibulum
with long cystic duct as the sole pathological finding. oversewn.
They concluded that cystic duct stump was hardly ever • Always restrict the dissection within rouviere’s sulcus.
a cause of recurrent symptoms in itself and complete But it is present in only 40% of patients.
excision of cystic duct does not eliminate the existence In the field of minimal access surgery (MAS), one
of postcholecystectomy syndrome. Another study should always be aware of the chances of cystic duct
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conducted by Walsh et al revealed that retained calculi stones as the major possibility of postcholecystectomy
in gallbladder and cystic duct (Fig. 4A) can be the source syndrome. So in selected cases, noninvasive investiga-
2
of the postcholecystectomy syndrome. These problems tions, such as magnetic resonance cholangiopancreato-
can be prevented by: graphy (MRCP) can be considered to evaluate the biliary
• When the anatomy of calot`s triangle (Fig. 2) is unclear, tree. Postcholecystectomy, the cystic stump was found
blind dissection should not be proceeded (Fig. 3).
embedded in scar tissue (Fig. 4) and it explored that
laparoscopic technique was of high risk. But now with
the most advanced instruments and with experienced
surgeons even these can be operated laparoscopically.
It has been said that now in these patients laparosco-
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pical management is better. This concept of re-operating
laparoscopically was supported by Chowbey et al,
6,7
Clemente et al recently reported five patients who
underwent reintervention after previous surgery of
cholelithiasis. Their mean operative time was 42 minutes.
They concluded that intervention may be required for
patients with residual gallstones.
In this series of study, completion cholecystectomy
with complementary CBD exploration was needed for
some of the cases. We also conclude that for reintervention,
Fig. 2: Anatomy of biliary tract laparoscopic approach was more beneficial.
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