Basic laparoscopy: Cholecystectomy 07.31.00 Cystic artery dissection

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Under construction 18 02 2008



Basic laparoscopy: Cholecystectomy 07.31.00 Cystic artery dissection

Introduction


The cystic artery, or its branches, usually runs parallel to the cystic duct.


It lies more deeply, in the fatty adventitia to the left of the duct.


It is pinker and more rounded than the duct.


It does not pulsate as the right hepatic artery does.


It may be absent, thrombosed, or lie deeply behind the cystic duct.


Its function may be taken over by large vessels running directly into the gallbladder from the gallbladder bed.


It is much more fragile than the cystic duct.


It has an unfortunate tendency to bleed during dissection. Minor oozing will stop by itself.


It may arise from a loop of right hepatic artery behind the cystic duct.


It may have the right hepatic duct running parallel and deep to it.


Consider any artery to be one branch of the cystic artery or one of a double cystic artery, until it proves to be solitary.


Dissection


Check again that the gallbladder is elevated and Hartmann's pouch is pulled to the patient's right.
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Use the hook electrode.


Carefully explore the tissues to the patient's left hand side of the cystic duct.


The artery should gradually emerge as the cystic duct did in the last article.
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Once you have identified the artery, dissect it towards the gall bladder.


Dissecting towards the right hepatic artery is more dangerous.


Stop dissecting:


When you have skeletalised a 20mm. section of cystic artery.


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


Run the hook electrode up and down behind the cystic artery to make sure that it is completely free.


If the length of cleared cystic artery is less than 20mm.


Dissect further towards the galbladder to increase the available length of artery.


If 10mm. of artery is available, clipping can proceed normally with extra care.


Consider just applying 2 clips to the proximal cystic artery and using diathermy on the distal cystic artery instead of a


clip.


Consider converting to an open operation.


If you cannot find an artery:


Check you have interpreted the anatomy correctly.


You may have mistaken the common bile duct for the cystic duct.


If you are absolutely certain you have identified the cystic duct correctly:


Cut and clip the cystic duct as in the next article but one.


Look again for the artery.


If the artery is still not found:


The artery is absent.


Be prepared for large arteries in the gallbladder bed when dissecting out the gallbladder later.


If there is too much fibrosis or oedema for safe dissection.


Convert to an open operation.


If you do not know where you are.


Convert to an open operation.


Common variants include:


More than 1 cystic artery.


Branching cystic artery.


Absent cystic artery.


Right hepatic artery mimicking the cystic artery.


Aberrant cystic artery running across the cystic duct from the gastro-duodenal artery.


Dealing with 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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