Page 38 - WJOLS - Laparoscopic Journal

Sanjeev Kumar Sareen

Define gallbladder/cystic duct junction—surgical the operative procedure including the decision to operate,
dissection of cystic duct and cystic artery should begin the best intervention, abdominal entry, dealing with common
adjacent to or near the point of origin of cystic duct or near ductstones, proper careful dissection over the
point of entry of the vessel. Identification of cystic lymph cholecystodudenal fistula area for the separation from
node as a landmark to define cystic duct and cystic artery. duodenum, intraoperative cholangiography, exposure of the
Calot’s triangle—Dissection in Calot’s triangle should be biliary anatomy, avoidance of bleeding or common duct
performed after identifying gallbladder/cystic duct junction. injury, spilled stones and postoperative bile collection. One
The tip of the curved dissector should be facing should emphasize on prevention and management of
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anterolaterally towards the gallbladder to avoid the injury to inadvertent injuries. The difficulty of laparoscopic
the liver or the CBD while dissecting the Calot’s triangle. 20 cholecystectomy or the risk of conversion to open
Proper localization of common bile duct should be done cholecystectomy can be predicted by assessing some
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during surgery by retracting the duodenum downwards, preoperative variables. The authors evaluated the efficacy
retracting the right lobe of liver with proper traction to the of the risk score for conversion from laparoscopic to open
Hartmann’s pouch keeping in mind the plane of Rouviere’s cholecystectomy (RSCLO), which was recently developed
sulcus. by Kama et al (Am J Surg 2001;181:520). Safe dissection
Maintain the plane of dissection in the cholecystic plate is the key to complete laparoscopic cholecystectomy
while removing the gallbladder from the liver. Dissection successfully. Minimal use of electrocautery in Calot’s triangle
deeper in this plane may cause injury to the liver and cause should be advocated. Adherence to the basic protocol of
troublesome bleeding while dissection superficial to this surgery and progressing step by step while following the
plane may cause perforation of the gallbladder and spillage landmarks of hepatobiliary anatomy. If the injury is detected
of bile. Cholecystoduodenal fistula can be completely intraoperatively and the necessary facilities with expert
mobilized with a combination of blunt and sharp dissection surgical team are available, then repair should be done in
and divided using the endolinear stapling device for the fistula the same operation or put stent by ERCP in postoperative
closure. These fistulae were repaired laparoscopically using period.
an endo-GIA 35 endoscopic stapling device. The endostapler
can be used in few cases to transect the fistula and in other Risk Factors
cases, the defect in the bowel can be repaired with The review by Strasburg et al in 1995 of approximately
intracorporeal sutures. In the other way, after division of 124000 laparoscopic cholecystectomy reported in literature
the cystic duct and artery, the gallbladder was dissected found the incidence of major bile duct injuries to 0.5%. In
from the liver bed, leaving just the fistulous connection to 1995, Strasberg and Soper modified the Bismuth
the duodenum. Then division of the fistula was completed classification of bile duct injury. Bile duct injury is the most
using the same stapling device. The placement of additional catastrophic event that can happen to a patient undergoing
trocar, frequent irrigation and suction, use of suction canula surgery leaving the patient with high morbidity. In 1991,
for dissection, use of gauze piece in case of minor bleed surgeons of French society of endoscopic and operative
and adequate traction on the infundibulum of gallbladder to radiology reported 101 postoperative complications by
display structures in the Calot’s triangle are useful aids to laparoscopic surgery (morbidity 3.2%) 42 biliary and
dissection. Every effort should be made to avoid the spillage 59 nonbiliary, 18 bile duct injuries and six deaths (0.2%)
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of bile into the peritoneal cavity as this will increase the reported out of 2955 laparoscopic cholecystectomies. The
incidence of postoperative infection, abscess formation and duodenal injuries, gastric injuries, colonic injuries, vascular
also make the incidental stage 1 carcinoma into stage 4. injuries are very common. One should be very careful in
The better outcome has been reported with the use of such cases with complicated gallstone disease to avoid any
harmonic scalpel and fundus first technique in the recent disastrous complication which can result in biliary cripples.
studies.
Complications of the Disease
INTRAOPERATIVE COMPLICATIONS, RISK Peptic duodenal perforation ulceration is the common cause
FACTORS AND PRECAUTIONS TO AVOID for the upper gastrointestinal bleeding, which will affect
THESE COMPLICATIONS
the duodenal bulb. Bouveret´s syndrome is a rare entity
All surgeons will encounter difficult cholecystectomies in consisting in a duodenal obstruction due to the passage of
their lifetime. Many cumbersome situations can be prevented gallstones from the gallbladder (gallstone ileus) to the
or made easier by the cautious surgeon who has a carefully duodenum through a cholecystoduodenal or cholecysto-
thought-out plan for each potential problem. One should gastric fistula. Associated cases of Mirizzi syndrome with
proceed very slowly to counter the challenges that may be cholecystoduodenal fistula will lead to biliary leakage and
faced in beginning with diagnosis and continuing through biliary peritonitis and septicemia.

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