Laparoscopic Cholecystectomy - World Laparoscopy … · World Laparoscopy Hospital Essentials of...
Transcript of Laparoscopic Cholecystectomy - World Laparoscopy … · World Laparoscopy Hospital Essentials of...
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World Laparoscopy Hospital Essentials of Laparoscopic Surgery
Laparoscopic
Cholecystectomy
R. K. Mishra
First View
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World Laparoscopy Hospital Essentials of Laparoscopic Surgery
INTRODUCTION :
Laparoscopic cholecystectomy is
now the gold standard for the
treatment of gallstones.
Most commonly performed Minimal
Access Surgery by General
surgeons
Gall stone disease affects 23.3%
population worldwide
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World Laparoscopy Hospital Essentials of Laparoscopic Surgery
INDICATIONS
Cholelithiasis
Mucocele
Empyema gall baldder
Cholesterosis
Typhoid carrier
Porcelain gallbladder
Acute cholecystyitis
Adenomatous gall bladder polyps
As part of Whipple’s procedure
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World Laparoscopy Hospital Essentials of Laparoscopic Surgery
Surgical Anatomy
Portal Vein
Hepatic Artery
Common Bile Duct
Cystic Artery
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World Laparoscopy Hospital Essentials of Laparoscopic Surgery
Topographic Anatomy
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World Laparoscopy Hospital Essentials of Laparoscopic Surgery
Surgical Anatomy of Cholecystectomy Calot’s
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World Laparoscopy Hospital Essentials of Laparoscopic Surgery
American School Position
In American Position Surgeon stand left to patient
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World Laparoscopy Hospital Essentials of Laparoscopic Surgery
American Position
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World Laparoscopy Hospital Essentials of Laparoscopic Surgery
French Position
In French Position Surgeon stand between the leg of the patient
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World Laparoscopy Hospital Essentials of Laparoscopic Surgery
Creation of
Pneumoperitoneum
10-20 degree head down
10 mm trans-umbilical incision
Lift abdominal wall & insert Veress needle at 45 degree elevation angle
Start insufflation at 1litre/minute
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World Laparoscopy Hospital Essentials of Laparoscopic Surgery
Port insertion
Position:
1st 10mm Umbilical for telescope
2nd 10mm Left Epigastric
3rd 5mm right hypochondriac for operating instrument
4th 5mm port in right hypochondrium 5 cm lateral to third port for Fundus traction
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World Laparoscopy Hospital Essentials of Laparoscopic Surgery
Retraction of Gallbladder
Proper exposure of Cystic Pedicle is
required
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World Laparoscopy Hospital Essentials of Laparoscopic Surgery
Traction & Lysis of Adhesion
Hook can be used for adhesiolysis
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World Laparoscopy Hospital Essentials of Laparoscopic Surgery
Traction & Lysis of Adhesion
Dissection starts on the
anterior edge of Hartmann's
pouch
Peritoneum of the superior
leaf of the cystic pedicle is
divided superficially as far
back as the liver by pledget,
Scissors, Hook or Maryland.
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World Laparoscopy Hospital Essentials of Laparoscopic Surgery
Dissection of Cystic Duct
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World Laparoscopy Hospital Essentials of Laparoscopic Surgery
Traction & Lysis of Adhesion
Scissors Dissection with Monopolar current
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World Laparoscopy Hospital Essentials of Laparoscopic Surgery
Dissection of Cystic Pedicle
Separation of the
cystic duct
anteriorly from the
cystic artery
performed by
opening the jaw of
Maryland.
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World Laparoscopy Hospital Essentials of Laparoscopic Surgery
Overshooting is dangerous
During hook dissection principles of electrosurgery
should be kept in mind
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World Laparoscopy Hospital Essentials of Laparoscopic Surgery
Clipping of cystic artery
Two clips are placed proximally on the cystic artery
Cystic artery is clipped and then divided by hook scissors
Artery is then grasped with a grasper on the gallbladder wall and then divided distal to the clips
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World Laparoscopy Hospital Essentials of Laparoscopic Surgery
Operative Cholangiogram
Operative Cholangiogram should be routine
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World Laparoscopy Hospital Essentials of Laparoscopic Surgery
Clipping of cystic duct & artery
Clipping of cystic duct followed by dissection
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World Laparoscopy Hospital Essentials of Laparoscopic Surgery
Operative Cholangiogram
Cholangiography Should Be Routine, Not Selective
(JAMA. 2003;289:1639-1644, 1691-1692 )
Insertion of ureteric catheter by correct alignment of cystic duct and saline infusion
Contrast medium injected & the patient should be in trendelenberg position
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World Laparoscopy Hospital Essentials of Laparoscopic Surgery
Intra-operative Cholangiogram
Obstruction of CBD Normal Cholangiogram
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World Laparoscopy Hospital Essentials of Laparoscopic Surgery
Ligation of Cystic Duct
Roeder or Meltzer extracorporeal slip knot is
used
Clipping though easy but unsafe because of reports of internalization of
clip and formation of Cat eye stones
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World Laparoscopy Hospital Essentials of Laparoscopic Surgery
Dissection of Gallbladder
from Bed
Anterolateral traction helps in proper dissection
of gallbladder from gallbladder bed
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World Laparoscopy Hospital Essentials of Laparoscopic Surgery
Dissection of Gallbladder
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World Laparoscopy Hospital Essentials of Laparoscopic Surgery
Extraction of Gallbladder
The gallbladder is
extracted through the
11.0mm operating
port inside a bag
Extraction inside a
bag is recommended
as a safeguard
against stone loss
and contamination of
the exit wound
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World Laparoscopy Hospital Essentials of Laparoscopic Surgery
Extraction of Gallbladder
Extraction of Gallbladder with
gentle traction
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World Laparoscopy Hospital Essentials of Laparoscopic Surgery
Extraction of Gallbladder
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World Laparoscopy Hospital Essentials of Laparoscopic Surgery
Incision of neck of GB to suck the bile for Extraction of Gallbladder
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World Laparoscopy Hospital Essentials of Laparoscopic Surgery
Extraction of Gallbladder
Suction of Gallbladder to
empty it helps in
extraction of gallbladder
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World Laparoscopy Hospital Essentials of Laparoscopic Surgery
Extraction of Gallbladder
Ovum forceps
should be used
to extract stones
from inside the
gallbladder
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World Laparoscopy Hospital Essentials of Laparoscopic Surgery
Extracted Gallbladder
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World Laparoscopy Hospital Essentials of Laparoscopic Surgery
Extracted gallbladder with stones
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World Laparoscopy Hospital Essentials of Laparoscopic Surgery
Endobag for taking stone out
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World Laparoscopy Hospital Essentials of Laparoscopic Surgery
Ending of the operation
Abdomen should be examined
for any possible bowel injury or
haemorrhage
Remove the Instrument and then
port
Remove telescope leaving gas
valve of umbilical port open
Remove port carefully and close
the port wound
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World Laparoscopy Hospital Essentials of Laparoscopic Surgery
Routine application of
drainage tube is not required
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World Laparoscopy Hospital Essentials of Laparoscopic Surgery
Laparoscopic
Cholecystectomy
Video of laparoscopic cholecystectomy
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World Laparoscopy Hospital Essentials of Laparoscopic Surgery
Two port Cholecystectomy
Two port cholecystectomy is possible
in the hand of experienced surgeon
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World Laparoscopy Hospital Essentials of Laparoscopic Surgery
Two port Cholecystectomy
We have developed new two port technique, First time telecasted on our National News Channel.
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World Laparoscopy Hospital Essentials of Laparoscopic Surgery
Two Port Cholecystectomy
Strategically passed extracorporeal knot helps in two port
laparoscopic cholecystectomy
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World Laparoscopy Hospital Essentials of Laparoscopic Surgery
Two Port Cholecystectomy
The suture can be pulled from outside to give proper exposure
during dissection of gallbladder from bed.
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World Laparoscopy Hospital Essentials of Laparoscopic Surgery
Two Port Cholecystectomy
Gallbladder can be taken out from 10 mm epigastric port
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World Laparoscopy Hospital Essentials of Laparoscopic Surgery
Two Port Cholecystectomy
Video of two port cholecystectomy
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World Laparoscopy Hospital Essentials of Laparoscopic Surgery
R.K. Mishra’s Course in Istanbul, Turkey