Townsend Courtney M.Jr., Evers B. Mark. Atlas of General Surgical Techniques: Expert Consult

Подождите немного. Документ загружается.

430 Section V • Gallbladder

OPEN CHOLECYSTECTOMY

1. INCISION

◆ The incision for open cholecystectomy is typically made 2 ﬁ ngerbreadths below the right

costal margin, although an upper midline incision can also be used (Figure 41-8, A).

◆ Retractors are placed to retract the skin, as well as to retract the liver superiorly

(Figure 41-8, B).

Gallbladder

Porta

hepatis

Hepatic

flexure

of colon

FIGURE 41 –8

CHAPTER 41 • Laparoscopic and Open Cholecystectomy 431

2. DISSECTION

◆ A clamp is placed on the gallbladder fundus and used to retract the gallbladder superiorly

(Figure 41-9). A second clamp can be used to retract the infundibulum of the gallbladder

laterally (see Figure 41-9), exposing the triangle of Calot.

◆ Ideally, the cystic artery is identiﬁ ed, circumferentially dissected, and ligated (see Figure 41-9)

before dissection of the gallbladder out of the gallbladder fossa. As in the laparoscopic case,

care should be taken not to injure the right hepatic artery.

◆ The gallbladder is then removed from the gallbladder fossa from the top down using

electrocautery (Figure 41-10).

Serosal

reflection

FIGURE 41 –10

Cystic

duct

Cystic artery

Right hepatic

artery

Cystic

duct

Cystic

artery

FIGURE 41 –9

432 Section V • Gallbladder

◆ Clamps are placed proximally and distally on the cystic duct. The cystic duct is divided

between the clamps (Figure 41-11, A), and the gallbladder is removed from the ﬁ eld.

◆ The cystic duct stump is suture ligated using a 3-0 silk suture (Figures 41-11, B-D).

A B

C D

FIGURE 41 –11

CHAPTER 41 • Laparoscopic and Open Cholecystectomy 433

Common

hepatic duct

Cystic duct and

cystic artery

stumps

Gallbladder

fossa

FIGURE 41 –12

◆ The cystic duct and cystic artery stumps are examined for any signs of bile leakage or

bleeding (Figure 41-12). The abdomen is copiously irrigated with normal saline solution.

3. CLOSING

◆ The placement of closed suction drains is not always required. They are placed only if bile

leakage from the cystic duct stump is expected or observed. If bile leakage is observed, the

surgeon must rule out common bile duct injury.

◆ The fascia is closed in two layers using running or interrupted sutures.

◆ The skin is then closed with absorbable subcuticular sutures or skin staples.

434 Section V • Gallbladder

STEP 4: POSTOPERATIVE CARE (LAPAROSCOPIC AND OPEN CHOLECYSTECTOMY)

◆ Postoperative complications include hematoma, bleeding, or leakage from the cystic duct

stump.

◆ If a drain is placed operatively, the output should be monitored. If no bilious drainage is

observed at 24 to 48 hours, the drain can be removed.

◆ If bilious drainage is noted, this can initially be managed conservatively with continued

observation. Liver function tests should be performed to evaluate for bile duct injury. If

drainage persists, endoscopic retrograde cholangiopancreatography (ERCP) is indicated to

deﬁ nitively rule out injury. In addition, a common bile duct stent placed via ERCP will also

treat persistent cystic duct leaks in the absence of common bile duct injury.

◆ Clear liquids can be started immediately postoperatively for both laparoscopic and open

cholecystectomy and generally advanced as tolerated. Patients undergoing open procedures

may have a longer time to return to regular diet.

◆ Patients are discharged home the same day after laparoscopic cholecystectomy and 2 to 3 days

after open cholecystectomy.

◆ Longer stay may be necessary in the setting of acute cholecystitis.

◆ For uncomplicated gallstone disease, antibiotics are not continued postoperatively.

STEP 5: PEARLS AND PITFALLS

◆ To avoid bile duct injury, it helps to retract the infundibulum of the gallbladder laterally to

open up the triangle of Calot and form a 90-degree angle of the cystic duct with the com-

mon hepatic duct. Pulling the infundibulum superiorly orients the cystic duct similar to the

common bile duct and can lead to injury.

◆ After dividing the cystic duct and cystic artery, it is useful to begin the dissection of the

gallbladder bluntly to make sure there are no ductal structures present.

◆ A 5-mm port and a 5-mm clip applier can be used at the epigastrium. If this is done, a 5-mm

camera will need to be present if a retrieval bag is going to be used to remove the gallbladder,

because this comes in only the larger size.

◆ Cholecystectomy can be performed from the top down in both the laparoscopic and the

open settings, although it is more difﬁ cult in the laparoscopic setting.

◆ The clips placed on the cystic duct and artery need to completely occlude the lumen. If this

is not possible on the cystic duct, an Endoloop can be placed. In this setting, the anatomy

should be reviewed to ensure that the cystic duct is ligated and the anatomy has not been

incorrectly identiﬁ ed, because the clips are usually large enough to occlude the cystic duct.

◆ Cholangiogram can be performed routinely or selectively, based on the preference of the

operating surgeon.

◆ If common bile duct stones are identiﬁ ed, a laparoscopic or open common bile duct

exploration can be performed. Alternatively, ERCP can be performed to clear the duct

postoperatively.

◆ Multiple previous abdominal surgeries, severe cardiac disease, and severe acute cholecystitis

are relative contraindications to laparoscopic cholecystectomy. When a patient has a history

of multiple previous abdominal surgeries, an open technique should be used to place the

initial umbilical port.

◆ When performing laparoscopic procedures, it is best to convert to an open procedure if

(1) there is uncontrolled bleeding; (2) safe laparoscopic access to the abdominal cavity can-

not be obtained; (3) the anatomy of the triangle of Calot cannot be clearly delineated; or

(4) injury to the common bile duct, small bowel, or any other structure is suspected. This

should not be considered a failure.

SELECTED REFERENCES

1. Jones DB, Maithel SK, Schneider BE (eds): Atlas of Minimally Invasive Surgery. Woodbury, Conn, Ciné-Med,

2006, pp 12-39.

2. Cameron JL: Atlas of Surgery, vol 1. Philadelphia, BC Decker, 1990, pp 2-9.

3. Posther KE, Pappas TN: Acute cholecystitis. In Cameron JL (ed): Current Surgical Therapy, 8th ed.

Philadelphia, Mosby, 2002, pp 385-391.

4. Hutter MM, Rattner DW: Open cholecystectomy: When is it indicated? In Cameron JL (ed): Current

Surgical Therapy, 8th ed. Philadelphia, Mosby, 2002, pp 400-401.

CHAPTER 41 • Laparoscopic and Open Cholecystectomy 435

436

STEP 1: SURGICAL ANATOMY

◆ A comprehensive understanding of the biliary, pancreatic, and foregut anatomy is critical

before performing any surgical procedure on the biliary tree, pancreatic duct and pancreas,

distal stomach, and duodenum.

◆ Figure 42-1, A demonstrates the location of the right subcostal incision 2 ﬁ ngerbreadths

below the right costal margin.

◆ Figure 42-1, B shows the surgical anatomy after placement of retractors on the abdominal

wall and liver. In this case the patient had prior cholecystectomy. The common bile duct

travels posterior to the ﬁ rst portion of the duodenum and through the head of the pancreas,

draining into the ampulla of Vater in the second portion of the duodenum. The hepatic ar-

tery lies medial to the common bile duct, and the portal vein is posterior to the common

bile duct.

◆ The diameter of the common bile duct needs to be at least 1.5 to 2.0 cm for a choledocho-

duodenostomy to be performed successfully. This is usually the case if the procedure is

being performed for retained common bile duct stones. Hepaticojejunostomy can be

performed in nondilated ductal systems, but it is more difﬁ cult.

STEP 2: PREOPERATIVE CONSIDERATIONS

1. PREPARATION

◆ The indications for side-to-side choledochoduodenostomy include retained common bile

duct stones after common bile duct exploration, primary common bile duct stones, and

recurrent common bile duct stones. The side-to-side choledochoduodenostomy enables

retained or new stones to pass spontaneously. It is especially useful in the setting of distal

common bile duct stricture.

CHAPTER

Choledochoduodenostomy and

Hepaticojejunostomy

Taylor S. Riall

CHAPTER 42 • Choledochoduodenostomy and Hepaticojejunostomy 437

Common

hepatic duct

Duodenum

Cystic duct

Common

bile duct

FIGURE 42 –1

◆ The indications for hepaticojejunostomy include benign distal biliary stricture, recurrent

cholangitis secondary to a stricture or stone disease, palliation of jaundice in patients with

unresectable periampullary cancer, and bile duct injury (usually iatrogenic). With bile duct

injuries, the duct is often normal caliber, making the operation more difﬁ cult.

◆ The patient is placed supine on the operating room table, with both arms extended.

◆ Subcutaneous heparin is given, and sequential compression devices are used to prevent

venous thromboembolism.

◆ A second-generation cephalosporin is used for antibiotic prophylaxis before skin incision

and redosed for the ﬁ rst 24 hours.

◆ A Foley catheter is placed to monitor urine output.

◆ A nasogastric (NG) tube is placed to decompress the stomach. This is left in postoperatively.

438 Section V • Gallbladder

STEP 3: OPERATIVE STEPS

CHOLEDOCHODUODENOSTOMY

1. INCISION

◆ The operation is performed through a right subcostal incision (see Figure 42-1, A). It can

also be done using an upper midline incision.

2. DISSECTION

◆ Patients have often had previous cholecystectomy, and there may be adhesions between the

liver and the portal structures. The adhesions are dissected sharply using electrocautery or

scissors, or both.

◆ The duodenum and extrahepatic biliary tree are exposed (see Figure 42-1, B).

◆ The duodenum is kocherized out of the retroperitoneum (Figure 42-2). This may require

mobilization of the hepatic ﬂ exure of the colon inferiorly. It is important to completely

mobilize the duodenum to perform the choledochoduodenostomy without tension.

◆ The duodenum is sharply dissected off the anterior surface of the distal common bile duct.

The common bile duct should be clearly exposed in the anterior and lateral surfaces.

◆ Using a no. 15 blade, an anterior choledochotomy is made in the common bile duct where

it courses posterior to the duodenum. The choledochotomy is extended to a length of

approximately 2 cm using Potts scissors (Figure 42-3). Stones are extracted if present.

CHAPTER 42 • Choledochoduodenostomy and Hepaticojejunostomy 439

Common

bile duct

Common

hepatic artery

Duodenum

FIGURE 42 –2

Common

bile duct

Choledochotomy

Kocherized

duodenum

FIGURE 42 –3