Laparoscopic Cholecystectomy with Intraoperative Cholangiogram
DESCRIPTION OF OPERATION: The patient was brought to the operating room and placed in the supine position. After adequate general endotracheal anesthesia, the abdomen was shaved, prepped and draped in sterile fashion. The patient was already on preoperative antibiotics. Next, two towel clamps were placed on either side of the umbilicus.
An incision was made and the Veress needle was introduced without any difficulty. The water-drop test was positive. The needle was then attached to the CO2 insufflator and insufflated to a pressure of 15 mm. Next, the needle was removed and a 10 mm trocar was slowly and carefully introduced without any difficulty. The camera was placed in the introducer and the abdomen was scanned. Three accessory ports were placed under direct visualization; one was placed in the subxiphoid region, one in the midclavicular line, and one in the midaxillary line.
Next, we were able to elevate the liver. The gallbladder was near gangrenous, and once we manipulated the fundus of the gallbladder, there was a large stone which actually came out and we placed this in the right upper quadrant while we were doing the procedure. This was all considerably difficult just to maneuver and the gallbladder was tearing throughout the procedure. We were able to dissect down on the gallbladder down to the cystic duct, which was easily identified at its junction of the common bile duct. We also identified the cystic artery. The clip was placed distally on the cystic duct.
A small enterotomy was made in the cystic duct. There was good bile flow back. We placed the Cholangiocath without any difficulty and there was good flow without any leak. We then placed the patient back in supine position, shot a series of cholangiograms with the possibility of distal common bile duct stones noted, but good flow into the duodenum. The rest of the ductal system was intact without any defects.
At this point, we placed the patient back into position. After I discussed this with the radiologist, the clip was removed and the catheter was removed. Two clips were placed proximally on the cystic duct. The duct was divided from the tube. The cystic artery had two clips placed proximally, one distally and was divided. The gallbladder, which was near gangrenous and intrahepatic was then taken off of liver bed using blunt dissection and cautery.
When we had it removed, there was no active bleeding or bile leak noted. The gallbladder and the stone, which were separate, were then placed in the Ethicon pouch and brought out the umbilicus after opening the fascia further. We then irrigated the right upper quadrant and suctioned it dry.
There was no purulent material, bleeding or bile leak noted. We then removed each of the ports under direct visualization and de-insufflated the abdomen. The fascia at the umbilicus was closed with 0-Vicryl sutures. Each skin incision was closed with 4-0 Vicryl subcuticular sutures and each of the sites was locally anesthetized with 0.5% Marcaine with epinephrine for a total of 24 mL.
The patient tolerated the procedure well and was sent to the recovery room in a satisfactory condition.
