Laparoscopic Technique for gallbladder removal
Chronic or acute disease of the gallbladder due to gallstones, biliary sludge, or dysmotility (poor physiological function)
Contraindications for Gallbladder Removal
Definite – coagulopathy (bleeding tendency), peritonitis (inflammation or purulence in abdominal cavity), small bowel obstruction, and significant hernia of diaphragm.
Relative – previous intra-abdominal surgery with likelihood of adhesions (scar tissue), cirrhosis, and acute gangrenous cholecystitis (acutely dead and diseased gallbladder).
Symptoms – pain in the right upper quadrant (under the right rib cage), epigastrium (solar plexus), right shoulder blade or back; pain may occur 30-60 minutes after eating a fatty meal or particularly if pain causes wakening from sleep. Also, nausea and vomiting. There can be no symptoms in patients with diabetes mellitus or in chronic immunosuppression (e.g., patients on steroids or transplant patients).
Imaging Studies – perhaps the most common imaging study obtained to work up gallbladder disease and possible gallbladder removal is the right upper quadrant ultrasound. This test uses a sound probe placed on the anterior abdominal wall just below the right costal margin (under the rib cage) and images the gallbladder, liver, and cystic duct (drains bile from the gallbladder into the common duct), hepatic duct (drains bile from the liver into the common bile duct), and common bile duct (collects bile from the gallbladder and liver and drains it into the duodenum).
“Positive” findings include the presence of gallstones and biliary sludge, although these findings alone are not always enough to prompt a surgery. Other conditions that indicate surgery include pericholecystic fluid (fluid around the gallbladder), gallbladder wall thickening, gallstones wedged in the neck of the gallbladder or cystic duct, dilated common bile duct, gallstones in the common bile duct, and dilated intrahepatic ducts.
Superficial wound infection – this is a risk with all surgical incisions and is increased if the gallbladder is frankly prurulent (there is pus).
Other – as with all surgeries there is always a risk of blood clots, pulmonary embolism, stroke, heart attack, and death.
Surgical Details of the Procedure
1. The Hasson cannula technique is used to enter the abdomen in gallbladder removal.
2. A transverse 10 mm incision is made in the epigastric area just right of the midline (some surgeons infuse local anesthetic such as lidocaine into the skin and subcutaneous tissue at the area of the port placements).
3. A 10 mm port is then placed through the epigastric wall and into the peritoneal cavity under direct visualization with the laparoscopic camera. The port should come out just to the right of the falciform ligament.
4. Two 10 mm ports are then placed in the right abdominal area under direct visualization.
5. A non-crushing grasping forceps is placed through each 10 mm port and the gallbladder is retracted up and away from the liver bed.
6. A Maryland dissector is placed through the 15 mm port and dissection is started on the lateral edge of the gallbladder (away from the area of the common bile duct)
7. Gentle blunt dissection and electrocautery is used until the cystic duct is appreciated and dissected free from the overlying tissue and the posterior cystic artery.
8. Dissection of the cystic duct is performed until the junction of the cystic duct and gallbladder wall is seen.
9. Two surgical clips are placed on the proximal cystic duct (the side that “stays in”) and one surgical clip is placed on the side toward the gallbladder.
10. Endoshears are inserted through the 15 mm port and used to incise the cystic duct. Care must be taken to visualize the tip of the shears both anteriorly and posteriorly to the cystic duct.
11. The Maryland dissector is then used to dissect the cystic artery free.
12. If the cystic artery appears attenuated, care must be taken to search for a posterior branch of the cystic artery.
13. The cystic artery is controlled with two clips on the side toward the hepatic artery and one clip toward the gallbladder.
14. The Endoshears is used to sever the cystic artery.
15. The grasping forceps are then repositioned to allow the gallbladder to be moved from side to side to facilitate dissection off the liver bed.
16. Bovie cautery is attached to the endospatula or J-hook and the gallbladder is separated from the liver bed
17. Care is taken to not enter the gallbladder to prevent spillage of infected bile or gallstones.
18. Any bleeding points seen on the liver bed are cauterized.
19. When approximately 1 cm of gallbladder remains on the liver bed at the dome of the liver, the gallbladder is retracted towards the abdominal wall to allow for visualization of the liver bed and area of placement of surgical clips.
20. The gallbladder is then completely removed from the liver bed.
21. Most surgeons in gallbladder removal then move the camera from the 10 mm umbilical port to the 10 mm epigastric port
22. The endobag is then placed through the 10 mm umbilical port and directed to the dome of the liver where the now resected gallbladder is being held by a grasper.
23. Under direct visualization, the gallbladder is placed in the endobag and the bag is cinched closed.
24. The endobag containing the gallbladder and the Hasson cannula are then removed from the 10 mm umbilical port.
25. The Hasson cannula is then replaced through the 10 mm umbilical incision, the pneumoperitoneum is reintroduced and irrigation is placed into the abdomen.
26. This fluid is then aspirated with care taken to place the tip of the suction device away from the area of the surgical clips. Irrigation and suction is performed (including “up and over” the dome of the liver until the fluid being returned is clear.
27. The ports are then removed under direct visualization
28. The pneumoperitoneum is released with most surgeons placing gentle pressure on the outside of the abdominal wall to express as much of the pneumoperitoneum as possible.
29. The umbilical port is then closed by using the previously placed stay stitches for the Hasson cannula (and perhaps adding additional stitches in the fascia if needed).
30. To complete the gallbladder removal procedure, the skin is then closed most typically usually 4-0 monocryl suture.