168 Section 2: Diagnostic and therapeutic approaches for the biliary tree and gallbladder carefully reviewed by an experienced pathologist to evaluate the degree of tumor infiltration. The surgical approach de- pends on the depth of tumor invasion in the gallbladder wall and major liver resection might be necessary. If the tumor is limited to the mucosa (carcinoma in situ) a simple cholecystectomy is sufficient, offering excellent long- term survival (see Chapter 15). If the tumor infiltrates the muscularis propria without reaching the gallbladder serosa, an extended cholecystectomy (gallbladder resection plus wedge resection of the liver) with dissection of the lymphatic tissue of the hepatoduodenal ligament is the therapy of choice. Therefore, the gallbladder plus a 1- to 3-cm wedge re- section of the gallbladder bed are resected with a frozen sec- tion of the resection margin of cystic duct. If the intraoperative cystic duct biopsy is positive for tumor, a complete resection of the choledochal duct and common hepatic duct up to the bifurcation with the surrounding lymphatic tissue has to be added to the procedure. For gallbladder carcinoma found during or after a laparo- scopic cholecystectomy, we recommend excising the port sites. The incidence of port sites metastases was found to be between 14 and 16% independent from the extend of the gallbladder cancer [29,30]. In addition, in cases with gall- bladder perforation during laparoscopic cholecystectomy the incidence of port site metastases has been as high as 40%. More extensive resections are indicated if the tumor ex- tends beyond the gallbladder serosa. Extended right hemi- hepatectomy or central hepatectomy, including segments IVb and V together with a resection of the cystic duct, com- mon bile duct, and the lymphatic tissue, are often used to achieve tumor clearance. The prognosis and results of the different approaches are discussed in detail in Chapter 15. If a curative resection is not possible due to a large tumor load or extensive involvement of the liver hilum, then sur- gery is not a therapeutic option. The prognosis of patients with unresectable gallbladder cancer is poor and the therapy should focus on minimal invasive approach (percutaneous or endoscopic; see Chapters 5 and 6) and supportive care. The results of each therapeutic approach mentioned above will be discussed in detail in Chapter 15. Reconstruction of the biliary outflow Reconstruction of the biliary outfl ow is necessary after resec- tion of cholangiocarcinoma and sometimes after resection of a gallbladder cancer. More rarely, bypass procedures are re- quired for malignant or benign strictures. Endoscopic and percutaneous drainage procedures are described in Chapters 5 and 6. In this section we will focus on surgical procedures for biliary reconstruction. The goal of biliary reconstruction is to relieve jaundice, prevent cholangitis, and to avoid recurrent biliary stricture. A Roux-en-Y anastomosis is performed in most cases to en- sure good blood supply of a wide mucosa-to-mucosa anasto- mosis between all transected bile ducts and a Roux-en-Y jejunum limb. Although drainage of one side of the biliary tree is theoreti- cally sufficient to relieve jaundice, the jejunal limb should drain all parts of the liver to prevent cholangitis. The princi- ples of reconstruction are: (1) identifi cation of healthy bile duct mucosa proximal to the stenosis/transection; (2) prepa- ration of a Roux-en-Y loop of usually 40 to 60 cm in length; and (3) direct mucosa-to-mucosa anastomosis. Whether a biliodigestive anastomosis should be stented by a drain re- mains controversial. There is no proven benefit for stenting, and we do not insert anastomotic stents. The most common biliodigestive drainage is the end-to- side hepaticojejunostomy. The Roux-en-Y jejunal limb is di- rectly anastomosed to the hepatic bifurcation draining both lobes of the liver. If a major hilum resection has been per- formed, the Roux-en-Y limb can also be anastomosed Figure 8.4 After transection the bile duct is elevated and separated from the hepatic artery and the portal vein. Chapter 8: Surgery of the biliary system 169 directly to segmental ducts (Fig. 8.5). Biliodigestive anasto- moses are performed with absorbal monofilament sutures (e.g. PDS 5.0). The sutures of the anterior layer are performed first, prior to any attempt to place the posterior row. If more than one orifice is present then all anterior row sutures have to be placed before any posterior row can be placed. Each an- terior suture is placed full thickness from the inside to the outside, from left to right. When the entire row is placed, the anterior sutures are elevated and the corner sutures are held tight (Fig. 8.6). Then the sutures of the posterior row are sub- sequently tied with the nodes outside or inside the lumen. Fi- nally, the anterior row is completed by suturing the anterior jejunal side from the inside to the outside. If the hepatic hilum is not accessible for the biliodigestive anastomosis then the left common hepatic duct is the second choice [31,32]. The left main hepatic duct has a long horizon- tal extrahepatic course, which can easily be reached in most cases. Division of the ligamentum teres from the abdominal wall to the diaphragm is necessary. A solid tie has to be placed on the ligament to allow elevation and traction. Then the pa- renchymal bridge connecting the left and the quadrate lobe is transected by diathermy. The Glisson’s capsule at the base of segment IV of the liver is dissected and the main left bile duct is exposed (Fig. 8.7). From this point the dissection can be extended to the right side in order to include the confluence or the right hepatic duct into the anastomosis. A side-to-side anastomosis to a Roux-en-Y loop is performed as described above. Most biliodigestive anastomosis can be performed by a hilum or left duct approach. If neither option is possible, then Common segmental hepatic duct stomata Detail Portal vein Proper hepatic artery Intrahepatic cholangiojejunostomy Figure 8.5 The biliodigestive anastomosis is facilitated if small segmental ducts are sutured together and connected in one anastomosis. 170 Section 2: Diagnostic and therapeutic approaches for the biliary tree and gallbladder (A) (B) Figure 8.6 (A) At first, the sutures of the anterior row are placed in full thickness and the sutures are elevated. (B) Then the posterior row is performed from the right side to the left side. Finally, the anterior row is completed. Figure 8.7 The left hepatic duct is exposed after transection of the Glisson capsule at the base of S IV of the liver. The horizontal extrahepatic course allows a wide Roux-en-Y anastomosis. the round ligament approach is the next option [33]. The lig- amentum teres is divided and the parenchymal bridge be- tween segment IV and the left lobe is transected. Then the liver is lifted up and the ligamentum teres stump is pulled downwards. The left base of the ligamentum teres is transect- ed and the duct for segment III is exposed above and behind the portal vein and a side-to-side anastomosis with a Roux- en-Y loop can be performed (Fig. 8.8). In 1949, Longmire described [34] an approach to the seg- ment I I duct i n pres enc e of ex ten sive s tr ic ture s of the le f t a nd right hepatic duct. The Longmire procedure is often less ef- fective than the other methods, and involves liver resection with an increased risk of bleeding. The left lateral sector of the liver is mobilized. A clamp is placed across the left lateral segment next to the ligamentum teres. A wedge resection of the left lateral sector is performed exposing the ducts of seg- ment II. Careful release of the clamp allows identifi cation of the vessels, which are selectively ligated. The branches of the portal vein run in close proximity to the bile ducts and bleed- ing has to be controlled carefully without compromising the lumen of the ducts. Then, an end-to-side anastomosis with a Roux-en-Y loop can be performed. Occasionally, the right side of the liver has to be approached for drainage. A wedge resection of segments V or VI can be performed, exposing the underlying ducts. Similarly, a cho- lecystectomy and incision of the gallbladder fossa has been described to expose the duct of segment V [35]. However, with the advances of percutaneous transhepatic biliary drainage during the last decade, surgical drainage proce- dures using the segmental bile ducts are only rarely indicated today. Chapter 8: Surgery of the biliary system 171 Questions 1. Which of the following is not a major goal of biliodigestive bypass in patients with malignant biliary obstruction? a. improvement of quality of life b. improvement of nutritional status c. relief of jaundice d. avoidance of cholangitis e. prevention of recurrent bile duct obstruction 2. Which of the following surgical procedures is never acceptable as oncologic resection of a common bile duct tumor? a. resection of the common bile duct with end-to-end anastomosis b. resection of the common bile duct with bilioenteric reconstruction c. Whipple procedure d. open cholecystectomy with resection of the cystic lymph node e. extended partial hepatectomy + e xtrah ep at ic bile duct resection in bloc with gallbladder and lymphatic tissue 3. Which is not a risk factor for surgical intervention of the biliary system? a. advanced vascular disease b. chronic liver disease c. cardiac disease d. pulmonary disease e. being overweight 4. Which is not a potential advantage of preoperative biliary drainage in jaundice patients before hepatectomy? a. decrease in the risk for postoperative liver failure b. improvement of long-term survival c. facilitates an intraoperative cholangiogram d. intraoperative palpation of the catheter in the liver hilum e. restores intestinal barrier function in patients with internal bile duct drainage 5. Which is the gold standard to asses hepatic artery involvement in a patient with Klastkin tumor? a. abdominal computed tomogram b. abdominal magnetic resonance imaging c. endoscopic retrograde choledochopanceaticography (ERCP) d. abdominal ultrasound e. liver angiography 6. Which of the following should not be considered as a contraindication for major liver surgery? a. ongoing infection b. coagulopathy c. child C cirrhosis d. acute hepatitis e. advanced age (>80 years old) 7. A nasoenteral feeding tube should be placed before major liver resection in the following situation: a. in all cases b. only in selected cases with malnutrition status c. never d. only in patients with acute cholangitis e. only associated with percutaneous or endoscopic biliary drainage 8. All of the following are absolute contraindications for surgery in patients with Klatskin tumor except a. encasement of the main portal vein b. encasement of the hepatic artery c. vascular involvement of the left and right branches of the hepatic artery d. vascular involvement of hepatic artery major branch with simultaneously major bile duct involvement of the contra lateral side e. vascular involvement of more than four segments of the liver Figure 8.8 The liver is pulled up and the ligamentum teres downwards. The duct of S III can be approached by dissecting the left part of the base of the ligamentum teres. A side-to-side Roux-en-Y anastomosis can be performed. 172 Section 2: Diagnostic and therapeutic approaches for the biliary tree and gallbladder 9. In a patient with tumor progression beyond the second bifurcation on the left or right side (Bismuth III) the adequate surgical strategy is a. bile duct resection + hemihepatectomy or extended hemihepatectomy including segment 1 b. hemihepatectomy or extended hemihepatectomy including segment 1 c. bile duct resection + resection of liver segment 1 d. bile duct resection with Whipple procedure e. central hepatectomy 10. Which of the following radiological evaluations should not be included in the preoperative work up of a patient with distal obstruction of the bile duct a. computed tomogram b. magnetic resonance imaging c. endoscopic retrograde choledocho-pancreaticography (ERCP) d. abdominal ultrasound e. percutaneous transhepatic cholangiogram 11. In a patient with a gallbladder carcinoma infiltrating the muscularis propria without reaching the gallbladder serosa and negative margin in the cystic duct, the adequate strategy to achieve tumor clearance is a. only cholecystectomy b. extended cholecystectomy (gallbladder resection plus wedge resection of the liver) c. extended cholecystectomy + dissection of the lymphatic tissue of the hepatoduodenal ligament d. extended cholecystectomy + complete resection of the choledochal duct and common hepatic duct up to the bifurcation with the surrounding lymphatic tissue e. complete resection of the choledochal duct and common hepatic duct up to the bifurcation with the surrounding lymphatic tissue 12. Regarding biliodigestive bypass in patients with malignant obstruction, which of the following is incorrect? a. jejunum derivations should be preferred rather than duodenal derivations b. a Roux-en-Y jejunal limb should be always preferred c. anastomosis should be done mucosa-to-mucosa d. transanastomotic biliary stent should always be placed e. the most common procedure is the end-to-side hepatojejunostomy References 1. Bobbs J. Case of lithotomy of the gallbladder. Trans Med Soc Indiana 1868;18:68–73. 2. Traverso W. Carl Langenbuch and the first cholecystectomy. Am J Surg 1976;132:81–2. 3. Dahl R. Eine neue operation der Gallenwege. Zentralbl Chir 1909;36:266–7. 4. Mizumoto R, Suzuki H. Surgical anatomy of the hepatic hilum with special reference to the caudate lobe. World J Surg 1988;12:2–10. 5. Cherqui D, Benoist S, Malassagne B, et al. Major liver resection for carcinoma in jaundiced patients without preoperative bili- ary drainage. Arch Surg 2000;135:302–8. 6. Hatfield ARW, Terblanche J, Fataar S, et al. Preoperative exter- nal biliary drainage in obstructed jaundice. Lancet 1982;23: 896–9. 7. McPherson GAD, Benjamin IS, Hodgson HJF, et al. Pre- operative percutaneous transhepatic biliary drainage: the results of a controlled trial. Br J Surg 1984;71:371–5. 8 . K awa rada Y, H igashi guchi T, Yokoi H , e t a l. Preo pe rati ve b ili ary drainage in obstructive jaundice. Hepatogastroenterology 1995; 42:300–7. 9. Takahashi K, Ogura Y, Kawarada Y. Pathohysiological changes caused by occlusion of blood flow into the liver during hepatec- tomy in dogs with obstructive jaundice. J Gastroenterol Heatol 1996;11:963–70. 10. Kamiya S, Nagino M, Kanazawa H, et al. The value of bile replacement during external biliary drainage: an analysis of intestinal permeability, integrity, and microflora. Ann Surg 2004;239:510–7. 11. Dobay K, Freier D, Albaer P. The absent role of prophylactic anti- biotics in low-risk patients undergoing laparoscopic cholecytec- tomy. Am Surg 1999;65:226–8. 12. Higgins A, London J, Charland S, et al. Prophylactic antibiotics for elective laparoscopic cholecystectomy. Arch Surg 1999;134: 611–4. 13. Larraz-Mora E, Mayol J, Martinez-Sarmiento J, et al. Open biliary tract surgery: multivariate analysis of factors affecting mortality. Dig Surg 1999;16:204–8. 14. Selzner M, Clavien PA. Resection of liver tumors: Special emphasis on neoadjuvant and adjuvant therapy. In: Clavien PA, ed. Malignant liver tumors: Current and emerging therapies. Malden, MA: Blackwell Science, 1999: 137–49. 15. Nakayama F, Miyazaki K, Naggafuchi K. Radical surgery for middle and distal thirds bile duct cancer. World J Surg 1988; 12:60–3. 16. Sugiura Y, Nakamura S, Iida S, et al. Extensive resection of the bile ducts combined with liver resection for cancer of the main hepatic duct junction: a cooperative study of the Keio Bile Duct Cancer Study Group. Surgery 1994;115:445–51. 17. Stain S, Parekh D, Selby R. Tumors of the gallbladder and the biliary tract. In: Kaplowitz N, ed. Biliary disease. Los Angeles: Williams & Wilkins, 1996:725–38. 1 8 . B l u m g a r t L , B e n j a m i n I , H a d j i s N , B e a z l e y R . S u r g i c a l a p p r o a c h - es to cholangiocarcinoma at confluence of hepatic ducts. Lancet 1984;14: 66 –9. 19. Blumgart L. Cancer of the bile ducts. In: Blumgart L, ed. Surgery of the liver and biliary tract. New York: Churchill Livingston; 1994:829–53. Chapter 8: Surgery of the biliary system 173 20. Nimura Y, Hayakawa N, KamiyaJ, et al. Hepatic segmentectomy with caudate lobe resection for bile duct carcinoma of the hepat- ic hilus. World J Surg 1990;14:535–44. 21. Launois B, Terblanche J, Lakehal M, et al. Proximal bile duct cancer: high resectability rate and 5-tear survival. Ann Surg 1999;230:266–75. 22. Klempnauer J, Ridder G, Wasielewski R, et al. Resectional sur- gery of hilar cholangiocarcinoma: A multivariate analysis of prognostic factors. J Clin Oncol 1997;15:947–54. 23. Tashiro S, Tsuji T, Kanemitsu K, et al. Prolongation of survival for carcinoma at the hepatic duct confluence. Surgery 1993;113: 270–8. 24. Tsuzuki T, Ueda M, Kuramochi S, et al. Carcinoma of the main hepatic junction: Indications, operative morbidity and mortali- ty, and long-term survival. Surgery 1990;108:495–501. 25. Bismuth H, Caistaing D, Traynor O. Resection or palliation: Priority of surgery in the treatment of hilar cancer. World J Surg 1988;12:39 –47. 26. Mizumoto R, Kawarada Y, Suzuki H. Surgical treatment of hilar carcinoma of the bile duct. Surg Gynecol Obstet 1986;162: 153–8. 27. Pinson W, Rossi R. Extended right hepatic lobectomy, left hepat- ic lobectomy, and skeletonization resection for proximal bile duct cancer. World J Surg 1988;12:52–9. 28. Selzner M, Clavien P-A. Resection of liver tumors: special em- phasis on neoadjuvant and adjuvant therapy. In: Clavien P-A, ed. Malignant liver tumors-Current and emerging therapies. Malden, MA: Blackwell Science, 1999:137–49. 29. Z ’g ragger K, Birrer S, Mau rer C, Weh rl H, K la ib er C , Baer H. I n- cidence of port site recurrence after laparoscopic cholecystecto- my for preoperatively unsuspected gallbladder carcinoma. Surgery 1998;124:831–8. 30. Lundberg O, Kristoffersson A. Port site metastases from gall- bladder cancer after laparoscopic cholecystectomy. Results of a Swedish survey and review of published reports. Eur J Surg 1999;165:215–22. 31. Hepp J. Hepaticojejunostomy using the left biliary trunk for iat- rogenic biliary lesions: the French connection. World J Surg 1985;9:507–11. 32. Hepp J, Moreaux J, Lechaux JP. [Intrahepatic bilio-digestive anastomosis in biliary tract cancers. Results of 62 operations]. Nouv Presse Med 1973;2:1829–32. 33. Hepp J, Pernod R, Hautefeuille P. [Anastomoses using the left hepatic duct in reparative biliary surgery.]. Mem Acad Chir (Paris) 1962;88:295–9. 34. Longmire W, Sandford M. Intrahepatic cholangiojejunostomy with partial resection of the liver. Surgery 1949;128:330–47. 35. Lygidakis N, Heyde M. Surgical management of malignancies of the biliary tree. In: Lygidakis N, Tytgat G, eds. Hepatobiliary and pancreatic malignancies. New York: Thieme; 1989:341–63. CHAPTER 9 Laparoscopic treatment for diseases of the gallbladder and biliary tree Stefan Wildi, Sarah K. Thompson, John G. Hunter and Markus Weber 9 OBJECTIVES • Name the different clinical presentations for cholecystolithiasis, acute cholecystitis, cholangitis, and choledocholithiasis • List the different diagnostic investigations • Know the correct technique of laparoscopic cholecystectomy and its pitfalls • Describe additional investigations and procedures in special cases • Know how to deal with special anatomical findings Introduction In the year 1985, the German surgeon Erich Mühe was the first to perform a laparoscopic cholecystectomy [1]. This was only possible after several technical developments in the past, starting with the firstlaparoscopy in humans by Kelling in 1902 and Jacobaeus in 1910 [2,3]. In 1988, laparoscopic cholecystectomy was introduced in the USA by Reddick et al. [4]. Unlike other technical developments in surgery, laparo- scopic cholecystectomy rapidly spread throughout the world and gained wide acceptance by surgeons. Today,laparoscopic cholecystectomy has become the gold standard in the treat- ment of gallbladder disease. Symptomatic cholecystolithiasis The incidence of cholelithiasis is approximately 10% in the United States, of which 10 to 15% of patients will become symptomatic [5]. The patients usually present with acute, colicky pain in the upper abdomen, typically after fatty meals. In addition, nausea and vomiting can occur. However, some patients only report vague complaints of the upper right abdomen. Diagnostic work-up consists of laboratory investi- gations with special emphasis on bilirubin and alkaline phosphatase and an ultrasound of the abdomen (Table 9.1). These investigations lead to the correct diagnosis in almost all cases. Additional examinations, such as computed tomogra- phy (CT scan) or gastroscopy, might be needed in order to rule out other diseases (e.g. acute gastritis, tumor formation). Uncomplicated cholelithiasis can be treated conservatively 174 with painkillers, and an elective laparoscopic cholecystecto- my is performed later. When no operation is done in the follow-up of patients with mild symptoms, the rate of devel- oping complicated cholelithiasis is slightly higher with up to 3% per year compared to 1 to 2% of patients with asymp- tomatic stones [5]. If the patient’s history (jaundice, acute pancreatitis) and/or the laboratory investigations suggest choledocholithiasis (increased bilirubin or alkaline phospha- tase), a preoperative endoscopic retrograde cholangiopan- creatography (ERCP) is indicated to clear any stones from the bile ducts and to confirm the diagnosis. If no strong evidence for common bile duct stones is present, such as elevated bili- rubin and alkaline phosphatase or dilated intrahepatic bile ducts in the ultrasound, preoperative ERCP is not necessary and can be performed postoperatively, if there is a suspicion of stones remaining in the bile duct [6]. Intravenous cholan- giography before surgery to detect choledocholithiasis or ab- normal bile duct anatomy has not shown a benefit and is no longer justified [7–9]. As an alternative to the invasive ERCP, a magnetic resonance cholangiopancreatography (MRCP) can be performed to investigate the biliary tree. Especially in patients after previous upper abdominal surgery, such as Roux-en-Y reconstruction, it might be very difficult or even impossible to get an ERCP. In these special cases, MRCP can be ve r y helpf ul. However, M RC P ha s no t herapeutic opt io ns. Acute cholecystitis In contrast to symptomatic cholecystolithiasis, patients suf- fering from acute cholecystitis present with a permanent Diseases of the Gallbladder and Bile Ducts: Diagnosis and Treatment, Second Edition Edited By Pierre-Alain Clavien, John Baillie Copyright © 2006 by Blackwell Publishing Ltd Chapter 9: Laparoscopic treatment for diseases of the gallbladder and biliary tree 175 pain and tenderness in the right upper abdomen, also known as Murphy sign. In addition, fever can occur. Laboratory re- sults reveal a leukocytosis and an elevation of C-reactive pro- tein (CRP). Bilirubin usually remains normal and therefore allows differentiation from an acute cholangitis that presents with the classical Charcot triad (i.e. fever, pain, elevated bili- rubin). The ultrasound of the abdomen shows a thickened wall of the gallbladder, but this finding also might be absent. Only in case of a Mirizzi’s syndrome, with external compres- sion of the common bile duct by a stone located in the cystic duct, might acute cholecystitis be accompanied by jaundice. Choledocholithiasis Choledocholithiasis is present in 5% of all patients undergo- ing laparoscopic cholecystectomy [10,11]. In an interesting prospective study, Collins et al. demonstrated that more than one-third of these stones pass spontaneously within 6 weeks after operation and do not need any further treatment [11]. In these patients, intraoperative cholangiography might eas- ily lead to an invasive overtreatment with ERCP or even open common bile duct (CBD) exploration. With the low incidence of CBD stones and the excellent treatment possibilities for symptomatic CBD stones by ERCP, the routine use of intraop- erative cholangiography can no longer be recommended (see also below) [12–15]. Indications for laparoscopic cholecystectomy The indications for laparoscopic cholecystectomy do not dif- fer from those for the open technique. Symptomatic choleli- thiasis remains the most frequent reason to perform a cholecystectomy. In acute cholecystitis, the optimal time point of surgery is still under debate. Most surgeons pre- fer an operation within 48 to 72 hours after the onset of symptoms in order to minimize the conversion to an open procedure [16–19]. Because the conversion rate in acute cho- lecystitis is considerably higher compared to elective proce- dures [20–22], others advocate a two-step procedure with symptomatic treatment (i.e. antibiotics and pain medication) initially, and 4 to 6 weeks later performing the laparoscopic cholecystectomy [23–26]. This strategy is disadvantaged by the fact that the patient has to be hospitalized twice with the consequent social and economic cost. In patients undergoing surgery for morbid obesity, chole- cystectomy might be indicated if gallstones are present at the time of surgery, even if symptoms are lacking [27]. It is known that women with a body mass index greater than 45 kg/m 2 have a seven-fold increased risk of developing gall- stones compared to women with a BMI lower than 24 kg/m 2 [28]. In addition, rapid weight loss is associated with gall- stone formation, thus between 10 and 25% of obese men and women developgallstones within a few months of beginning a very low calorie diet [29]. However, less than 50% of the morbidly obese patients with cholecystolithiasis become symptomatic, and not all of the symptomatic patients require an operation [30,31]. In cases with a normal gallbladder, only a few centers advocate simultaneous cholecystectomy with a laparoscopic bypass procedure since laparoscopic cholecys- tectomy in morbidly obese patients might be technically difficult, and a lesion of the common bile duct would be catastrophic in these patients, especially when the gallblad- der is normal. Contraindications for laparoscopic cholecystectomy In patients who suffer from cardiac and pulmonary diseases, and therefore are at an increased risk for general anesthesia, laparoscopic procedures are sometimes not feasible because intra-abdominal pressure might further deteriorate the pa- tient’s condition [32–34]. In patients with portal hyperten- sion, the laparoscopic cholecystectomy has to be performed with extreme caution, because any bleeding can turn into a surgical catastrophe, enhanced by concomitant diseases such as liver dysfunction and coagulopathy. Previous open sur- gery in the upper abdomen might also be a contraindication for laparoscopic cholecystectomy, because intra-abdominal adhesions do not allow safe establishment of a pneumoperi- toneum and the dissection of the Calot’s triangle and the gall- bladder might not be possible. However, we prefer to start the procedure laparoscopically in all patients with a low thresh- old to convert into an open technique. Only if there is a suspi- cion of gallbladder cancer (e.g. porcelain gallbladder), we also prefer the primary open procedure. Technique General anesthesia is preferred for patients undergoing lapa- roscopic cholecystectomy. If general anesthesia is contrain- dicated (e.g. chronic obstructive pulmonary disease), the procedure also can be performed under epidural anesthesia [35,36]. There are two different ways to position the patient in the operating room: the supine position with the surgeon standing on the left and the assisting surgeon holding the camera on the right side of the patient. Alternatively, the pa- Table 9.1 Investigations prior to laparoscopic cholecystectomy. Blood exams (leucocytes, CRP, bilirubin, alkaline phospatase) Ultrasound of the abdomen Only in selected cases ERCP MRCP CT scan Gastroscopy 176 Section 2: Diagnostic and therapeutic approaches for the biliary tree and gallbladder tient is placed in the lithotomy position, where the operating surgeon stands between the patient’s legs, and the assistant surgeon is on the left side (Fig. 9.1). The supine position is mainly used in the US, whereas the lithotomy position is very popular in Europe. This led to the expression “American po- sition” for the first, and “French position” for the second. In general, an orogastric tube and an indwelling urinary cathe- ter are not necessary because the operating time of the proce- dure is usually less than 60 minutes. However, in cases with a distended stomach, an orogastric tube might be useful in order to get a better exposure of the Calot’s triangle. Pneumoperitoneum can be achieved by two different techniques. A 1-cm incision is made above, below, or in the umbilical scar to allow the insertion of a Verres needle. The intra-abdominal location is verified by aspiration and then inserting normal saline solution through the needle. Finally, a drop of saline solution is placed on the top of needle, and when it is flowing down easily, the needle is in the correct position. Next, a connection to a carbon dioxide insufflator is established to achieve an intra-abdominal pressure of 15 mmHg. This is followed by the insertion of a 10-mm trocar (optic trocar). Alternatively, an open or Hasson technique is performed. Using an identical incision, a blunt dissection through the subcutaneous tissue is carried out in order to reach the mid- line fascia. Next, the fascia and the peritoneum are opened under direct vision, and a 10-mm Hasson trocar is placed in the abdominal cavity. Pneumoperitoneum is then estab- lished as described above. There is no evidence in the litera- ture that the open approach is superior compared to the Verres needle technique in establishing the pneumoperito- neum [37,38]. However, in a teaching setting, we prefer the open (Hasson) approach, because we believe that this tech- nique can be better controlled. We also recommend the open approach in cases of reinterventions with the danger of intra-abdominal adhesions. In contrast, in morbidly obese patients, the open technique may not be easily feasible due to the enormous subcutaneous fat layer, and therefore the Verres needle is preferred. After insertion of a 30° laparoscope, the abdomen is exam- ined for additional pathologies. Then, two 5-mm and one 10- mm trocar are installed under direct vision. A grasper is inserted in the most lateral port to elevate the gallbladder fundus above the liver edge while another grasper is passed through the right mid-clavicular port to retract the infundib- ulum in an inferior and lateral direction. The dissection be- gins laterally at the infundibulum by opening the serosal layer of the gallbladder. Next, the cystic duct is identified and freed from adhesions. Then, the cystic artery, that is usually located cranially to the cystic duct, is exposed. It is of great importance to keep the Calot’s triangle opened using lateral retraction of the gallbladder infundibulum (Fig. 9.2). In gen- eral, it is not necessary to dissect Calot’s triangle out com- pletely, thus it should be avoided to dissect free the CBD, Figure 9.1 Room setup for laparoscopic cholecystectomy. (Adapted from Chirurgische Operationslehre. Spezielle Anatomie, Indikationen, Technik, Komplikationen in 10 Bänden. Herausgegeben von K. Kremer, W. Lierse, W. Platzer, H.W. Schreiber, S. Weller. Band 7 Teil 2; Minimal-invasive Chirurgie. Stuttgart: Georg Thieme Verlag, 1995:115.) Chapter 9: Laparoscopic treatment for diseases of the gallbladder and biliary tree 177 which forms one side of Calot’s triangle. After safe identifi ca- tion of the cystic duct and cystic artery, two clips are placed proximally, and one clip distally. One of the most difficult challenges in laparoscopic chole- cystectomy is a short, wide cystic duct. In this situation, clips usually do not reach across this duct, and even if they do, they may risk narrowing the CBD (Fig. 9.3A). Four acceptable techniques for closing the wide cystic duct are available. If the duct is long and wide, it can be transected and a pretied ligature (an Endoloop) can be applied to the cystic duct stump. Alternatively, two ties can be passed around the cystic duct in continuity and secured with extracorporeal knotting techniques. When the cystic duct is short and wide, there is concern that this technique might narrow the CBD. Under these circumstances, the cystic duct is transected with an en- doscopic stapling device, or it is simply divided and oversewn with an intracorporeal suturing technique (Figs. 9.3B and 9.3C). All of these methods have been applied successfully. After the cystic duct, the cystic artery is clipped and divid- ed. Finally, the gallbladder is dissected from its attachments to the liver, using a hook electrocautery. After complete dis- section, the gallbladder is retrieved in a bag via the umbilical port. At the end of the procedure, the right upper quadrant is rinsed with saline solution and hemostasis is completed. The trocars are retrieved under vision to control bleeding from the trocar sites. The fascia at the 10-mm incision is closed with absorbable sutures to prevent port-site hernias. Occasionally, the identifi cation of cystic duct and artery can be very difficult, especially in cases of cholecystitis. In these cases, it is helpful to start the dissection of the gallblad- der in an anterograde fashion (i.e. from the fundus) in order to mobilize the whole gallbladder until it is only attached to the cystic duct and artery. This technique is called the “dome down” cholecystectomy [39,40]. Complications of laparoscopic cholecystectomy Complications can occur intra- and postoperatively. Bile duct injuries and their management are discussed in depth in a separate chapter. Intraoperative Bleeding can occur at any time during the procedure. It ob- scures anatomical structures and absorbs the light from the Figure 9.2 The triangle of Calot. Dissection of the tissue until the base of the liver bed is exposed. When the triangle of Calot is dissected free, the two structures entering the gallbladder can only be the cystic duct and artery. It is not necessary to see the common bile duct. (Adapted from Strasberg SM, et al. An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg 1995;180 :101–25.) Figure 9.3 Techniques for managing a short, wide cystic duct. When clips are too short or risk common bile duct (CBD) narrowing (A), the cystic duct can be closed by endoscopic stapler (B) or a suture (C). (Adapted from Baker RJ and Fischer JE, Mastery of surgery, 4th ed. Philadelphia: Lippincott Williams & Wilkins, 2001.) [...]... is that the gallbladder plate attaches in its most posterior extent to the anterior surface of the sheath of the main right portal pedicle Therefore, to find the bile duct within the sheath of the right portal pedicle, the cystic plate must be detached from the anterior surface of the sheath of the right portal pedicle The rationale of the dissection is to first identify the left hepatic duct and use... analysis of the problem of biliary injury during laparoscopic cholecystectomy J Am Coll Surg 19 95; 180:101– 25 with permission from the Journal of the American College of Surgeons.) pulls the hepatic ducts down during transection of the biliary tree Hepatic ducts may either be clipped or divided, resulting in either obstruction or bile leak Injury of the bile duct is often associated with an injury to the. .. that leads to conversion and diagnosis of biliary injury or simply to occlusion of the right hepatic duct [36,44–48] (see below) At the time of reconstruction there is often evidence of dissection on the left side of the common duct, even to the point of exposure of the portal vein [12] Sometimes one clip is placed on the cystic duct (Fig 10.9B) and the point of division is either the common duct (Fig... been incised and cannulated when only the lower part of the biliary tree is seen Also an incisional injury of the common bile duct made to perform RIOC may not itself be innocu- (A) (B) Figure 10.12 Effect of the direction of traction on the appearance of the bile ducts at surgery (A) Both graspers pulling superiorly bring the common and cystic ducts into alignment, giving the appearance of a single... grasping and holding of the gallbladder, but has the risk of bile spillage In some patients, the inflammation of the gallbladder wall leads to dense adhesions to the liver bed Because the dissection in these cases may lead to severe bleeding from the liver, it is sometimes advisable to open the gallbladder and just to remove the “frontwall.” The wall adjacent to the liver is left in place and extensively... and C) there is an isolated portion of the right bile duct system and the affected right bile ducts will be separated from the left bile duct by scar or inflammation In these cases the right ducts are not identifiable merely by opening the left duct to the confluence by the standard Hepp–Couinaud approach Recently we described a method of approach to such bile ducts which in most cases provides the ability... Hepp-Couinaud technique Gallbladder plate 2 Carry dissection to right Divide gallbladder plate and find right portal pedicle Figure 10. 15 Schematic diagram of the operative technique for display of isolated right ductal injuries The injured, amputated left and right ducts are shown, as well as the portal vein and the sheath of the right portal pedicle Note that the gallbladder plate is a part of the. .. 1993;14:346 55 gallbladder c that the triangle of Calot be cleared so only two structures enter 15 Wright TB, Bertino RB, Bishop AF, et al Complications of laparoscopic cholecystectomy and their interventional radiologic management Radiographics 1993;13:119–28 the gallbladder and that the base of the gallbladder be raised off the liver bed d that after tracing the cystic duct to the common duct a picture of. .. end of the gallbladder, and the lowest part of the gallbladder attachment to the liver bed has been exposed The latter is an important step, which is equivalent to taking the gallbladder off the liver bed in the open technique It is not necessary to see the common duct Once the critical view is attained cystic structures may be occluded, as they have been positively identified Failure to achieve the. .. therapeutic approaches for the biliary tree and gallbladder Figure 10.10 The “critical view of safety.” The triangle of Calot is dissected free of all tissue except for cystic duct and artery and the base of the liver bed is exposed When this view is achieved, the two structures entering the gallbladder can only be the cystic duct and artery It is not necessary to see the common bile duct (Reproduced from . resection of the liver) with dissection of the lymphatic tissue of the hepatoduodenal ligament is the therapy of choice. Therefore, the gallbladder plus a 1- to 3-cm wedge re- section of the gallbladder. blood supply of a wide mucosa-to-mucosa anasto- mosis between all transected bile ducts and a Roux-en-Y jejunum limb. Although drainage of one side of the biliary tree is theoreti- cally sufficient. grasping and holding of the gallbladder, but has the risk of bile spillage. In some pa- tients, the inflammation of the gallbladder wall leads to dense adhesions to the liver bed. Because the dissection