Mini-Laparoscopic Cholecystectomy with Intraoperative Cholangiogram for Symptomatic Cholelithiasis (Gallstones) 2 Brunt LM1 Singh R1, Yee A2 September 26, 2017Disclosure: No authors have a financial interest in any of the products, devices, or drugs mentioned in this production or publication.Minimal invasive laparoscopic cholecystectomy is the typical surgical treatment for cholelithiasis (gallstones), where patients present with a history of upper abdominal pain and episodes of biliary colic. The classic technique for minimal invasive laparoscopic cholecystectomy involves four ports: one umbilical port, two subcostal ports, and a single epigastric port. The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) has instituted a six-step strategy to foster a universal culture of safety for cholecystectomy and minimize risk of bile duct injury. The technical steps are documented within the context of the surgical video for (1) achieving a critical view of safety for identification of the cystic duct and artery, (2) intraoperative time-out prior to management of the ductal structures, (3) recognizing the zone of significant risk of injury, and (4) routine intraoperative cholangiography for imaging of the biliary tree. In this case, the patient presented with symptomatic biliary colic due to a gallstone seen on the ultrasound in the gallbladder. The patient was managed with mini-laparoscopic cholecystectomy using 3mm ports for the epigastric and subcostal port sites with intraoperative fluoroscopic cholangiogram. Specifically, the senior author encountered a tight cystic duct preventing the insertion of the cholangiocatheter and the surgical video describes how the author managed the cystic duct for achieving a cholangiogram, in addition to the entire technical details of laparoscopic cholecystectomy.Keywords: intraoperative cholangiogramgallstonescystic duct and arterypatient safetycholelithiasislaparoscopic cholecystectomy Standard Edition Table of Contents- Slow down- Frustration00:00:00 - Introduction00:00:20 - Umbilical Port Incision and Exposure for Abdominal Access00:01:19 - Placement of 2-0 Vicryl Stay Sutures into Umbilical Fascia for Hasson Cannula00:02:13 - Insertion of Hasson Cannula into Abdominal Cavity00:02:35 - Insertion of Laparoscopic Camera and 360Â° Inspection of Abdominal Cavity00:02:44 - Surgical Finding of Indirect Inguinal Hernia00:02:49 - Placement of Lateral Subcostal Port and Insertion of 3mm Trocar00:03:13 - Grasping of Fundus of Gallbladder for Initial Inspection and Superior Elevation00:03:19 - Placement of Medial Subcostal Port and Insertion of 3mm Trocar00:03:39 - Placement of Epigastric Port and Insertion of 3mm Trocar00:03:58 - Inspection of Indirect Inguinal Hernia00:04:12 - Take Down of the Fatty Adhesions from Gallbladder00:04:45 - Take Down of the Duodenal Adhesion from Gallbladder00:05:52 - Identification of the Hepatocystic Triangle and the Cystic Duct and Artery00:05:56 - Clearing the Cystic Bundle of Fat and Fibrous Tissue00:06:06 - Identification of the Cystic Artery00:06:21 - Identification of the Cystic Duct00:06:45 - Developing the Interval between the Cystic Artery and Duct00:07:25 - Elevating the Lower 1/3 of Gallbladder from Cystic Plate for Critical View of Safety00:08:23 - Further Clearance of Fat and Fibrous Tissue from Cystic Duct and Artery00:10:10 - TIMEOUT – Confirm Attaining the Critical View of Safety with the 3-Point Strategy00:10:22 - Insertion of Camera into Epigastric Port for Clipping of the Cystic Duct and Artery00:10:35 - Clipping the Cystic Artery at the Neck of Gallbladder00:11:04 - Insertion of Camera into Umbilical Port for Incision over/into Cystic Duct00:11:10 - Incision over the Cystic Duct for Insertion of Cholangiocatheter for Cholangiogram00:11:29 - Insertion Attempt of Cholangiocather into a Tight Cystic Duct00:12:08 - Upsize of Medial Subcostal Port to 5mm Trocar for Cystic Duct Cholangiography00:12:47 - Division of the Cystic Artery00:12:54 - Further Clearance of Fat and Fibrous Tissue from the Proximal Cystic Duct00:13:49 - Successful Insertion of Cholangiocather for Cholangiogram00:14:03 - Fluoroscopic Cholangiogram and Imaging of the Biliary Tree00:14:29 - Insertion of Camera into Epigastric Port for Proximal Clipping of Cystic Duct00:14:37 - Clipping of Proximal Cystic Duct00:14:49 - Insertion of Camera into Umbilical Port for Division of Cystic Duct00:14:55 - Division of Cystic Duct00:15:04 - Elevating the Gallbladder from the Liver Bed00:16:03 - Irrigation of the Liver Bed and Inspection for Hemostasis00:16:26 - Insertion of Camera into Medial Subcostal Port for Extraction of Gallbladder00:16:40 - Extraction of Gallbladder with Entrapment Bag00:17:17 - Closure of Umbilical Fascia with Interrupted 2-0 Vicryl Sutures00:18:10 - Demonstration of Gallstone within Gallbladder and Taken to Histopathology00:18:25 - Credits Extended Edition Table of Contents- Slow down- Frustration00:00:00 - Introduction00:00:20 - Umbilical Port Incision and Exposure for Abdominal Access00:01:58 - Placement of 2-0 Vicryl Stay Sutures into Umbilical Fascia for Hasson Cannula00:03:30 - Insertion of Hasson Cannula into Abdominal Cavity00:04:09 - Insertion of Laparoscopic Camera and 360Â° Inspection of Abdominal Cavity00:04:21 - Surgical Finding of Indirect Inguinal Hernia00:04:34 - Placement of Lateral Subcostal Port and Insertion of 3mm Trocar00:05:12 - Grasping of Fundus of Gallbladder for Initial Inspection and Superior Elevation00:05:25 - Placement of Medial Subcostal Port and Insertion of 3mm Trocar00:05:55 - Placement of Epigastric Port and Insertion of 3mm Trocar00:06:30 - Inspection of Indirect Inguinal Hernia00:07:14 - Take Down of the Fatty Adhesions from Gallbladder00:08:06 - Take Down of the Duodenal Adhesion from Gallbladder00:10:02 - Identification of the Hepatocystic Triangle and the Cystic Duct and Artery00:10:07 - Clearing the Cystic Bundle of Fat and Fibrous Tissue00:10:23 - Identification of the Cystic Artery00:10:56 - Identification of the Cystic Duct00:11:37 - Developing the Interval between the Cystic Artery and Duct00:12:40 - Elevating the Lower 1/3 of Gallbladder from Cystic Plate for Critical View of Safety00:14:32 - Further Clearance of Fat and Fibrous Tissue from Cystic Duct and Artery00:17:20 - TIMEOUT – Confirm Attaining the Critical View of Safety with the 3-Point Strategy00:17:56 - Insertion of Camera into Epigastric Port for Clipping of the Cystic Duct and Artery00:18:23 - Clipping the Cystic Artery at the Neck of Gallbladder00:19:10 - Insertion of Camera into Umbilical Port for Incision over/into Cystic Duc00:19:22 - Incision over the Cystic Duct for Insertion of Cholangiocatheter for Cholangiogram00:19:48 - Insertion Attempt of Cholangiocather into a Tight Cystic Duct00:20:49 - Upsize of Medial Subcostal Port to 5mm Trocar for Cystic Duct Cholangiography00:22:18 - Division of the Cystic Artery00:22:39 - Further Clearance of Fat and Fibrous Tissue from the Proximal Cystic Duct00:23:43 - Successful Insertion of Cholangiocather for Cholangiogram00:24:35 - Fluoroscopic Cholangiogram and Imaging of Biliary Tree00:25:14 - Insertion of Camera into Epigastric Port for Proximal Clipping of Cystic Duct00:25:25 - Clipping of Proximal Cystic Duct00:25:47 - Insertion of Camera into Umbilical Port for Division of Cystic Duct00:25:56 - Division of Cystic Duct00:26:10 - Elevating the Gallbladder from the Liver Bed00:28:19 - Irrigation of the Liver Bed and Inspection for Hemostasis00:29:11 - Insertion of Camera into Medial Subcostal Port for Extraction of Gallbladder00:29:37 - Extraction of Gallbladder with Entrapment Bag00:30:49 - Closure of Umbilical Fascia with Interrupted 2-0 Vicryl Sutures00:32:49 - Demonstration of Gallstone within Gallbladder and Taken to Histopathology00:33:15 - Credits POSITION The patient is positioned supine on the operating table. The primary operating surgeon stands on the patient’s left and operates using the medial subcostal and epigastric ports. The surgical assistant stands on the patient’s right and operates using the lateral subcostal port and directs laparoscopic camera view through the umbilical port or with a third assistant as the camera operator. At training institutions, the senior surgeon can direct the procedure and provide retraction through the lateral and medial subcostal ports. Laparoscopic monitors are placed, on the patient’s left and right, at eye level directly across the surgical field from the surgeon and assistant. INCISIONS FOR ABDOMINAL ACCESS Umbilical Port The first incision is made at the umbilicus with the initial entry into the abdominal cavity using an open (Hasson) technique. The laparoscope is introduced through the umbilical trocar for initial abdominal inspection. The umbilical port is also used for introduction of clip applicator. Lateral Subcostal Port The second incision is made to introduce a 3mm trocar to serve as the lateral subcostal port. This incision is placed 1-2 cm inferior to the right subcostal margin, at the mid-axillary line halfway between the subcostal margin and anterior superior iliac spine. This port utilizes grasping forceps to grasp the fundus of the gallbladder for manipulation with the liver superiorly to expose the posterior aspect of the gallbladder and its trunk. This port is performed under direct vision. Medial Subcostal Port The third incision is made to introduce a 3mm trocar to serve as the medial subcostal port. This incision is placed 1-2 cm inferior to the right subcostal margin, at the right midclavicular line just below the inferior border of the liver. This port utilizes grasping forceps to provide counter-traction by the primary surgeon, scissors, and introduction of the cholangiocatheter for intraoperative fluoroscopic cholangiogram. In this case, this port was upsized to a 5mm trocar to handle large sharp dissecting scissors to manage a tight cystic duct. Epigastric Port The fourth incision is made to introduce a 3mm trocar to serve as the epigastric port. This incision is placed 1-2 cm inferior to the mid-subcostal margin, in the high epigastric/subxiphoid region, just left to the falicform ligament. Instrumentation includes L-Hook Bovie, dissecting scissors, Maryland forceps, and secondary camera placement for clipping and gallbladder extraction. SPECIFIC CASE SURGICAL JUDGEMENT In this case, there was difficulty during the insertion of the cholangiocather into the cystic duct for the intraoperative cholangiogram. This was due to a tight cystic duct that involved careful dissection and cholangiogram of the cystic duct. This required an upsizing of medial subcostal port to accommodate larger instrumentation for careful cholangiography within the duct, division of cystic artery, and further clearance of the fat and fibrous tissue from the cystic duct. In this order, the cystic duct was proximally mobilized to allow for the opening of the cystic duct and successful insertion of the cholangiocather. This surgical video demonstrates the careful handling of the cystic duct for this operative finding of a restrictive and a tight cystic duct. SIX-STEP STRATEGY FOR SAFETY IN CHOLECYSTECTOMY (LINK) The six-step strategy for creating a universal culture of safety in cholecystectomy was established by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). This strategy was developed to minimize bile duct injuries due to the increased injury rates since the introduction of laparoscopic cholecystectomy, occurring in about 3 per 1,000 procedures of over 750,000 cholecystectomies performed per year (1-3). Bile duct injuries can be life-altering complication which leads to significant morbidity and costs. (4,5). Due to the infrequences of bile duct injuries, definitive studies comparing methods to minimize these complications will likely never be performed. Thus, SAGES recommend the following strategy for minimizing risk of bile duct injury. Critical View of Safety (CVS) method of identification of cystic duct and artery. Intraoperative time-out prior to clipping, cutting, or transecting any ductal structures. Awareness of aberrant ductal and arterial anatomy. Use of intraoperative cholangiography or other imaging methods. Recognition of approach to zone of significant risk and alteration of surgical approach depending on CVS findings. Help from another surgeon when dissection or conditions are difficult. CRITICAL VIEW OF SAFETY METHOD OF IDENTIFICATION IN CHOLECYSTECTOMY The term “critical view of safety” CVS was introduced by an analytical review in response to the increase rate of biliary injury associated with laparoscopic cholecystectomy (6). CVS is a method for the safe identification of the cystic duct and artery, after which the lower one-third of the gallbladder has been mobilized from the cystic plate (7). This mobilization of the gallbladder allows for the clear identification of these two structures for assessment of aberrant anatomy, however more importantly for the safe clipping, cutting, and transection of the cystic duct and artery. The CVS method has been assessed as part of a compressive six-step strategy for safety in cholecystectomy for reducing biliary injuries (8). Clearing the hepatocystic triangle of fat and fibrous tissue. Mobilization of the lower one-third of the gallbladder from the cystic plate. Identification of two anatomical structures: cystic duct and cystic artery. POST-OPERATIVE MANAGEMENT For uncomplicated and elective laparoscopic cholecystectomy, patients can drink clear liquids once awake after anesthesia with their diet being advanced as tolerated. In most healthy and reliable patients with good home support, they can leave the hospital within six hours after surgery. The patients have no activity restrictions unless the umbilical incision was particularly large, therefore limited heavy lifting is recommended for the first few weeks. Most patients return to work within one week and follow-up occurs 2-4 weeks after surgery. REFERENCES Hurley V, Brownlee S. Cholecystectomy in California: A Close-Up of Geographic Variation. California Healthcare Foundation 2011. MacFadyen BV, Jr., Vecchio R, Ricardo AE, Mathis CR. Bile duct injury after laparoscopic cholecystectomy. 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