Basic laparoscopy: Cholecystectomy 07.30.00 Cystic duct dissection

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Under construction 18 02 2008



Basic laparoscopy: Cholecystectomy 07.30.00 Cystic duct dissection

Introduction.


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Check you are holding the fundus of the gallbladder upwards.


Check you are holding Hartmann's pouch to the patient's right.


You will not be certain of the anatomy at this point.


Expect the anatomy to emerge as you dissect.


You will probably find the cystic duct first, but a prominent artery (a hepatic artery perhaps)


may come into view first.


Aim to identify a segment of the cystic duct only.


Do not aim to display the whole extra-hepatic biliary tree.


Perhaps 20% of conversions occur in this section.


Open the peritoneum.


Start where Hartmann's pouch has been dissected.


1 Dissect TOWARDS the cystic duct\artery area.

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Do not start the dissection IN the cystic duct/artery area.


You may be dissecting the common bile duct by mistake.


The dissection may only need a sweeping action of the heel of the hook electrode.


Cut tougher tissue with the toe of the electrode if necessary.


2 Cut the peritoneum towards the liver on the left of Hartmann's pouch.

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3 Cut the peritoneum towards the liver behind Hartmann's pouch.

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4 Extend the dissection along the posterior and anterior sides of the gallbladder


2mm. from the liver to get better access.


5 Dissect slowly into the deeper tissues


The cystic duct will probably emerge first out of the adventitia and fat.


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This will be in the lower margin of the tissues being dissected.


It will look at first like a thickening in the fatty adventitia.


As you pick off strands of tissue, its duct shape and whitish colour will emerge.


The cystic duct will be 2 - 10mm. in diameter.


Traction on Hartmann's pouch will make the cystic duct run from the west.


Be suspicious of a "cystic duct" more than 8mm. diameter:


It may be a tented common bile duct.

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It may be the common bile duct itself, or the right hepatic duct.

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It may be the right hepatic artery.

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Remember that dissection using the hook electrode can damage a duct.


A cystic duct will be largely removed from the body, so such damage is less relevant.


The common bile duct and hepatic ducts remain in the body and may fibrose as a result of such damage


Continue the dissection of the "cystic duct" towards the gallbladder.


This is safer than dissecting towards the common bile duct.


In fact, it is better to mobilise an adequate section of the cystic duct without positively


identifying the common bile duct.


A retained length of cystic duct between the site of clipping and the common bile duct is of no clinical importance.


Indeed, the cystic duct sometimes extends alongside the common bile duct for 30mm. or more,


in addition to its normal route from the gallbladder.


It is safer not to dissect this section out, for fear of damaging the common bile duct


Aim for a 20mm. length of freed cystic duct (skeletalised).


This will enable secure application of 3 clips later in the operation.


Less than 20mm. of freed cystic duct may lead to the clips slipping off when the cystic duct is cut.


Stop dissecting:


When you have skeletalised 20mm. of duct.


And there is enough space behind the duct for the jaws of the clip applier. (10mm.)


Run the hook electrode up and down behind the cystic duct to make sure that it is completely free from any other tissue.


If the junction of the cystic duct with the common bile duct appears before a 20mm.section is freed:


Increase the length of the freed section by dissecting the cystic duct in the direction of the gallbladder.


If the length of freed cystic duct is still not adequate:


10mm. can be adequate if the clips are applied with great care.


Consider placing 2 clips on the common bile duct end of the distal cystic duct as usual, but use an endoloop on the neck of the


gallbladder instead a clip.


Consider converting to an open operation.


If the cystic duct is too short for freeing a 20mm. length.


As above, 10mm. can be adequate if the clips are applied with great care.


Consider placing 2 clips on the common bile duct end of the cystic duct as usual, but use an endoloop on the neck of the


gallbladder instead of a clip.


For a cystic duct less than 10mm. long:


Convert to an open operation.


When there is too much fibrosis and oedema for safe dissection.


Convert to an open operation.


If you do not know where you are.


Convert to an open operation.


If you meet bleeding.


Blood on the telescope.

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Identify the cause of the bleeding and respond as described below.


The camera magnifies the bleeding alarmingly.


Don't panic.

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Try local pressure with the hook electrode for 2 minutes.


Use pressure with a pledget held in a racquet diathermy forcep for 2 minutes.


Connect the diathermy forcep to the diathermy machine.


Put the suction/irrigator in the subcostal port.


Put the diathermy forcep in the epigastric port.


Grasp a 1-2mm. vessel precisely with forcep and coagulate it.


Grasp a larger vessel with the forcep and wait for 3 minutes to allow spontaneous coagulation.


Dissect out a vessel held in the forcep to allow clipping.


Wait 10 minutes before deciding on an open operation.


For uncontrollable bleeding, do a laparotomy.





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