Laparascopic Cholecystectomy

(Lap Chole)

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Definition

-  Laparascopic removal of gallbladder

 

Features

-  May be D/C same day (6-8hrs post op) if voiding, tolerating diet, mobilising, abdo soft, wounds intact

-  Usually stay overnight

-  Port sites

 

Indications

-  Gall stones asymptomatic --> prophylactic

-  Cholecystitis

-  Gall stone pancreatitis

 

Contraindications

-  Perforation, abscess, peritonitis, fistula

-  Suspected Ca

-  Severe coagulopathy

 

Procedure

-  Pre-op

-  Abdo Ultrasound

-  Fasting

-  FBE, LFTs, U&Es

-  Anaesthetic: GA + muscle paralysis

-  DVT prophylaxis: Enoxaparin 20-40mg S/C

-  Operation

-  Prep patient

-  Betadine prep up to lower chest, down to pubis and lateral to edges of abdomen

-  Abdominal Drapes

-   Plastic drape over inferior portion up to pubic symphysis

-   Sterile cloth drapes

-  1: superior with edges clipped & raised

-  2: inferior with edge to op site folded

-  3 & 4: lateral edges to op site folded

-  5: second drape over superior aspect

-   Surgical clips to edges of drapes locking corners & clips folded under drapes to secure out of way

-   Ensure right lower abdominal edge sufficiently low to allow for lower lateral port +/- for conversion to open

-  Scalpel incision superior to umbilicus to subcutaneous tissue

-  Hassan method for first port (umbilical)

-  Blunt dissection down to linea alba by following umbilical cickatrix deeply

-  Stitch bilaterally to incision walls with artery clamps on ends to secure

-  Split open/sharp dissection through linea alba into peritoneal cavity

-  Performed w elevation of wound edges to avoid bowel perforation

-  Insert finger to confirm entry into peritoneal cavity and continue blunt dissection

-  Insert port into umbilical opening

-  Wrap stitch ends around port to secure in place, leave artery clamps on

-  Insuflate abdomen with CO2

-  Insert scope into umbilical port

-  White balance

-  Allows insertion on remaining ports via direct internal visualisation

-  Press planned site of port entry with finer & confirm location via scope

-  Insert LA needle into site & confirm site +/- via jet of LA

-  Inject small volume LA into port site

-  Scalpel incision down to subcutaneous tissue

-  Insert port via trochar under scope guidance

-  Ensure no perforation of viscera (esp bowel perforation & bladder perforation)

-  Insert remaining ports as above (see port sites)

-  Visualise gallbladder & grasp anterior aspect & retract superiorly over anterior edge of liver

-  Blunt dissection of peritoneum surrounding gallbladder & remove adhesions as necessary including stomach & duodenum

-  Free the posterior edge of gallbladder

-  Identify cystic duct & CBD

-  Clip distal portion of cystic duct x1 proximal to Hartmans Pouch

-  If unsure/to confirm --> intra-operative cholangiogram (IOC)

-   Nick wall of duct

-   Insert catheter & inject radiocontrast

-   Image Intensifier (II) to confirm identity of duct

-  Identify cystic artery +/- right hepatic artery

-  Cystic artery passes through Calots Triangle

-  Clip proximal portion of cystic duct x2

-  Resect duct between distal & 2nd proximal clips

-  Reconfirm location of cystic artery

-  Clip proximal portion x2 & distal x1

-  Resect duct between clips

-  Ensure no accessory arteries

-  Dissect gall bladder from cystic plate w diathermy or blunt dissection

-  Gall bladder in to Endocatch

-  Wash & suck abdomen esp if bile leak intra-op

-  +/- drain

-  Ports out

-  Remove gallbladder from abdomen

-  Stitch port sites + tegaderm

-  Post-op

-  F/U w surgeon 3-4/52

 

Complications

-  Clipping or sectioning of CBD --> obstructive jaundice over hours

-  Bile leak

-  Clipping & sectioning of right hepatic artery --> due to alternate supply of liver from portal vein usually nil complications

-  Infection

-  Haemorrhage

-  5% conversion to open

 

Laparascoic Port Sites