Safe Laparoscopic CholecystectomyModern Advancements in HepatoPancreatoBiliary Surgery

Iswanto Sucandy, M.DFlorida Hospital, Tampa, FLMinimally Invasive and Robotic Surgery

HepatoPancreatoBiliary and Advanced Gastrointestinal Surgery

Disclosures

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I fix bile duct injuries (many are very painful operations)

Introduction Introduced in late 1980’s Most commonly performed operation Over 700,000 cases annually in USA Bile duct injury after Lap Cholecystectomy :

0.5-0.8% Bile duct injury after Open Cholecystectomy :

0.1-0.2% Litigation claims - average settlements of up to

$500,000 USD Morbidity and Mortality SAGES Safe Cholecystectomy Task Force

Causes of Lap chole bile duct injury/leak- Misidentification of anatomical structures- Failure to occlude cystic duct stump

securely- Plane of GB dissection into the liver bed - Excessive traction on cystic duct off the

common hepatic duct - “tenting injury”- Improper technique of ductal exploration- Injudicious use of electrocautery for

dissection/hemostasis- Injudicious use of clips for hemostasis

Biliary Anatomy – Type of Union Cystic duct - CHD

a. Angular Unionb. Paralell Unionc. Spiral Union

Biliary Anatomy – Hepatic duct confluence

Biliary Anatomy – Low insertion Right Posterior Hepatic Duct

Cystic duct stump

Right posterior hepatic duct

Laparoscopic cholecystectomy

Excessive traction on cystic duct “tenting injury”

Bile Duct Injury – Laparoscopic Cholecystectomy 1st most common cause : misidentification of

CBD to be cystic duct 2nd most common cause : injury to the

aberrant right posterior hepatic duct

Identification techniques :

Infundibular Technique

Critical View of Safety

Bile Duct Injury – Laparoscopic Cholecystectomy 1st most common cause : misidentification of

CBD to be cystic duct 2nd most common cause : injury to the aberrant

right posterior hepatic duct

Identification techniques :

Infundibular Technique NO !!

Critical View of Safety YES

** Bile duct injury usually associated with Right Hepatic Artery injury – 20% **

Critical View of Safety

1. Triangle of Calot must be cleared of fat & fibrous tissues

2. Lowest part of GB must be separated from cystic plate

3. Two structures & only two are seen entering the GB

Laparoscopic cholecystectomy

Laparoscopic cholecystectomy

Gallbladder

Common Bile Duct (do not dissect/expose)

Cystic duct Cysti

c artery

Critical View of Safety

Critical View of Safety – front view

Critical View of Safety – posterior view

“ 2 windows “ dissection

Critical View of Safety

CVS is difficult to obtain ? Options :

Intraoperative cholangiography Help from a colleague Conversion to an open cholecystectomy When CVS unobtainable – laparoscopic subtotal

cholecytectomy , fenestrating cholecytectomy

Infundibular Technique

Infundibular Technique

Easier but why this technique should not be used

CHD

Very short cystic duct

What you do not want to see during laparoscopic cholecystectomy

What you do not want to see

What you do not want to see postoperatively

Type of Bile Duct Injury

Summary - how to avoid bile duct injury ? Proper identification of anatomy Careful dissection to achieve critical view of

safety Avoid excessive traction during dissection of

Calot triangle Plane of dissection should be close to GB wall Avoid excessive use of electrocautery Avoid blind clipping for hemostasis Gentle tissue manipulation during CBDE

When bile duct injury occurs, what to do ?.. Recognized intraoperatively – refer to an HPB expert

/center for immediate repair/reconstruction

Recognized in immediate postoperative period – delayed repair in 2-3 weeks. Focus : control of biliary leakage/infection/sepsis,

Delayed presentation –biliary tract reconstruction in delayed fashion.

Presenting signs of biliary injury/leak : - Abdominal pain (bile peritonitis), distension, and fever- Jaundice / elevated LFTs- Bile leakage from incision

Minimally Invasive HPB Minimally Invasive HPB

Laparoscopic Approach Robotic Approach

Minimally Invasive HPB MIS Whipple Procedure MIS Biliary Tract Surgery MIS Liver Resection

Advanced procedures, significant learning curve ++

Robotic Whipple Procedure

Robotic Whipple Procedure

Robotic Whipple Procedure

Robotic Biliary Tract Surgery

Laparoscopic Liver Resection

Laparoscopic Liver Resection

Robotic Liver Resection

Robotic Liver Resection

Robotic Liver Resection

Laparoscopic left lateral sectionectomy

References 1. Strasberg SM, Brunt LM. Rationale and use of the critical view

of safety in laparoscopic cholecystectomy. J Am Coll Surg. 2010 Jul;211(1):132-8.

2. Blumgart’s Surgery of the Liver, Biliary Tract, and Pancreas. 5 th Edition Elsevier 2012.

3. Bonrath EM, Dedy NJ, Zevin B, Grantcharov TP. International consensus on safe techniques and error definitions in laparoscopic surgery. Surg Endosc. 2014 May;28(5):1535-44.

4. Callery MP. Avoiding biliary injury during laparoscopic cholecystectomy: technical considerations. Surg Endosc. 2006 Nov;20(11):1654-8

Pucher PH, Brunt LM, Fanelli RD, et al. SAGES expert Delphi consensus: critical factors for safe surgical practice in laparoscopic cholecystectomy. Surg Endosc. 2015 Nov;29(11):3074-85.