Basic laparoscopy: Cholecystectomy 07.37.00 Gallbladder removal

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This is part of a multimedia training program for a typical basic laparoscopic operation.

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Under construction 18 02 2008


Basic laparoscopy: Cholecystectomy 07.37.00 Gallbladder removal

Introduction.

Use the epigastric port.

This is a convenient route to remove the gallbladder as long as the epigastric port lies to the right hand side of the falciform
ligament (described in this program).
The technique of inserting the epigastric port through the falciform ligament makes removal of the gallbladder difficult by
this route.
An alternative route for removing the gallbladder through the umbilical port involves placing the telescope in the epigastric port.
A telescope in the epigastric port reverses the image on the monitor, which also reverses the direction of movement of the
instruments. This is quite difficult to handle.

Using a retrieval bag.


This program does not routinely use a retrieval bag for removal of the gallbladder from the abdomen.


The retrieval bag is inserted into the abdomen down the epigastric port.


The bag should be placed below the liver, lying with the mouth of the bag facing the freed gallbladder.


The bag should be opened up wide, so that the gallbladder will fit easily inside the bag.


The beak forceps holds the upper lip of the bag so that it stays open.


The gallbladder is grasped by its neck by the Rotweiler forceps.


The neck of the gallbladder is pushed right down into the bottom of the bag so that the fundus also lies completely inside the bag.


The Rotweiler forceps are removed from the bag very smoothly, so that the gallbladder remains entirely inside the bag.


The Rotweiler forceps are used to withdraw the bag up the epigastric port.


Then, the procedure to remove the bag with the gallbladder through the abdominal wall and skin is the same as for the gallbladder


alone.


Remove the diathermy hook from the epigastric port

07.37.00 remove the hook electrode.jpg


Remove the epigastric down sizer

07.37.00 remove the down sizer.jpg


Insert the large grasping forcep (Rotweiler)

07.37.00 insert the Rotweiler forceps.jpg


Identify the Rotweiler forceps on the screen.

07.37.00 locate the Rotweiler forceps.jpg


Grasp the neck of the gallbladder with the Rotweiler forcep.

07.37.00 grasp the neck of the gallbladder.jpg


Flip the gallbladder round using the beak forceps on the fundus, so that the neck of the gallbladder faces the Rotweiler forceps.


Grasp the neck of the gallbladder at the site of the clip.


Release the beak forcep from the fundus of the gallbladder.

07.37.00 release the fundus of the gallbladder.jpg


Close the jaws of the beak forceps under direct vision on the screen to prevent visceral damage.


Pull the gallbladder towards the epigastric port.

07.37.00 pull the gallbladder neck to the epigastric port.jpg


Have the cameraman show the way up to the epigastric port opening on the anterior abdominal wall (the ceiling).


Pull the epigastric port out of the abdomen with the Rotweiler forcep inside it.

07.37.00 pull the gallbladder neck through the epigastric port.jpg


Pull the gallbladder up into the epigastric wound.


Rarely, the gallbladder will pull easily out through the wound at this stage using a cholecystectomy forcep.


07.37.00 pull out the gallbladder.jpg

Go to next article


Usually, however, the gallbladder is too distended to pass through the wound.


Read on.


Grasp the neck of the gallbladder outside the wound.

07.37.00 grasp Hartmann's pouch with cholecystectomy forceps.jpg


Use 2 Roberts' cholecystectomy forceps to hold the corners of the gallbladder.


Remove the Rotweiler forcep.


Use the Roberts' forceps to prevent the gallbladder dropping back into the peritoneal cavity.


If the gallbladder drops back into the peritoneal cavity:


Replace the port and instruments to find the gallbladder again.


Plug the epigastric wound temporarily with a finger to allow the pneumoperitoneum to build up.


If the gallbladder will not go through the epigastric wound:


Keep hold with the Rotweiler forcep.


Enlarge the opening as described below.


If the patient is too fat for the gallbladder to reach the skin:


Enlarge the epigastric opening using a scalpel to make, in effect, a mini-mini-open laparotomy.


Remove the gallbladder using a retrieval bag as described above.


RETURNING TO THE STANDARD OPERATION: Open the galbladder.

07.37.00 open the gallbladder with scissors.jpg


Use the 2 Robert's cholecystectomy forceps to hold the gallbladder wall above the skin.


Open the intervening gallbladder wall with scissors.


Make an 8mm. opening, which will easily allow the 5mm. diameter sucker to pass into the gallbladder.


Swab the bile.

07.37.00 swab the gallbladder bile.jpg

Send the specimen for culture.


Aspirate the gallbladder.

07.37.00 insert the sucker into the gallbladder.jpg


Pass the suction/irrigator down to the fundus of the gallbladder.


Check on the monitor that the gallbladder is emptying.


Try to avoid contaminating the epigastric wound with potentially infected bile.


Try pulling the gallbladder out.

07.37.00 pull out the gallbladder.jpg


The gallbladder will come out if aspiration has emptied it enough to pass through the epigastric port.

07.37.00 pull out the gallbladder from the abdomen.jpg


If the gallbladder comes out:


Go to next article


If the gallbladder is too thick, or contains too large a mass of stones:


Read on.


Try crushing the stones from outside the gallbladder.

07.37.00 crush large gall stones.jpg


Use a Roberts' cholecystectomy forcep.


Pass the forcep down the epigastric opening, outside the gallbladder.


Crush the stones through the gallbladder wall.


Stretch the epigastric opening with the forcep as you pull the forcep out.


Try pulling out the gallbladder again.


If the gallbladder is still too thick, or the stones are too large:

Read on.


Enlarge the epigastric opening.

07.37.00 enlarge the epigastric port.jpg


Push a slightly angled grooved director into the epigastric opening alongside the gallbladder.


Face the grooves away from the gallbladder.


Cut the epigastric opening 1-2mm. caudally.


Use a scalpel with a no.15 Swann-Morton blade to run down the grooves, sharp side facing outward.


This will enlarge the opening to allow the gallbladder to pull out.


If the blade breaks:


Retrieve it using the racquet forcep passed down the epigastric port.


Repeat this cutting until the opening is wide enough for the gallbladder to pull out.


Pull out the gallbladder.


It is difficult to make this move look elegant.


Repeat the cutting of the abdominal wall as needed.


Cut the skin in the same way if the skin opening is too small. You can easily underestimate the size of the gallstones on the


monitor.


Avoid bursting the gallbladder by trying to pull it through too small a hole.


If the gallbladder leaks:


Use a retrieval bag as described above.


If gallstones spill back into the peritoneal cavity:


Ignore them.


Take great care to remove all stones inadvertently spilling into the anterior abdominal wall fat.


They may need secondary removal if left.


Place the gallbladder in a preservative solution such as Formaldehyde

07.37.00place the gallbladder in formaldehyde.jpg


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