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5 Gastrointestinal Tract and Abdomen

ACS Surgery: Principles and Practice


21 Cholecystetomy and Common Bile Duct Exploration 1

21 CHOLECYSTECTOMY AND
COMMON BILE DUCT EXPLORATION
Gerald M. Fried, M.D., F.A.C.S., Liane S. Feldman, M.D., F.A.C.S., and Dennis R. Klassen, M.D.

Cholecystectomy is the treatment of choice for symptomatic gallstones because it removes the organ that contributes to both the
formation of gallstones and the complications ensuing from them.1
The morbidity associated with cholecystectomy is attributable
to injury to the abdominal wall in the process of gaining access to
the gallbladder (i.e., the incision in the abdominal wall and its closure) or to inadvertent injury to surrounding structures during
dissection of the gallbladder. Efforts to diminish the morbidity of
open cholecystectomy have led to the development of laparoscopic cholecystectomy, made possible by modern optics and video
technology.
Carl Langenbuch performed the first cholecystectomy in
Berlin, Germany, in 1882. Erich Mhe performed the first laparoscopic cholecystectomy in Germany in 1985,2 and by 1992, 90%
of cholecystectomies in the United States were being performed
laparoscopically. Compared with open cholecystectomy, the
laparoscopic approach has dramatically reduced hospital stay,
postoperative pain, and convalescent time. However, rapid adoption of laparoscopic cholecystectomy as the so-called gold standard for treatment of symptomatic gallstone disease was associated with complications, including an increased incidence of major
bile duct injuries.
Since the early 1990s, considerable advances have been made
in instrumentation and equipment, and a great deal of experience
with laparoscopic cholecystectomy has been amassed worldwide.
Of particular significance is the miniaturization and improvement
of optics and instruments, which has reduced the morbidity of the
procedure by making possible ever-smaller incisions. With proper
patient selection and preparation, laparoscopic cholecystectomy is
being safely performed on an outpatient basis in many centers.3
The primary goal of cholecystectomy is removal of the gallbladder with minimal risk of injury to the bile ducts and surrounding structures. Our approach is designed to maximize the
safety of both routine and complicated cholecystectomies. In what
follows, we describe our approach and discuss current indications
and techniques for imaging and exploring the common bile duct
(CBD).
Laparoscopic Cholecystectomy
PREOPERATIVE EVALUATION

To plan the surgical procedure, assess the likelihood of conversion to open cholecystectomy, and determine which patients are at
high risk for CBD stones, the surgeon must obtain certain data
preoperatively. Useful information can be obtained from the
patients history, from imaging studies, and from laboratory tests.
Preoperative Data
History and physical examination A good medical history provides information about associated medical problems that

may affect the patients tolerance of pneumoperitoneum. Patients


with cardiorespiratory disease may have difficulty with the effects
of CO2 pneumoperitoneum on cardiac output, lung inflation pressure, acid-base balance, and the ability of the lungs to eliminate
CO2. Most bleeding disorders can also be identified through the
history. A disease-specific history is important in identifying
patients in whom previous episodes of acute cholecystitis may
make laparoscopic cholecystectomy more difficult, as well as those
at increased risk for choledocholithiasis (e.g., those who have had
jaundice, pancreatitis, or cholangitis).4-9
Physical examination identifies patients whose body habitus is
likely to make laparoscopic cholecystectomy difficult and is helpful for determining optimal trocar placement. Abdominal examination also reveals any scars, stomas, or hernias that are likely to
necessitate the use of special techniques for trocar insertion.
Imaging studies Ultrasonography is highly operator dependent, but in capable hands, it can provide useful information. It is
the best test for diagnosing cholelithiasis, and it can usually determine the size and number of stones.4 Large stones indicate that a
larger incision in the skin and the fascia will be necessary to
retrieve the gallbladder. Multiple small stones suggest that the
patient is more likely to require operative cholangiography (if a
policy of selective cholangiography is practiced) [see Operative
Technique, Step 5, below]. A shrunken gallbladder, a thickened
gallbladder wall, and pericholecystic fluid on ultrasonographic
examination are significant predictors of conversion to open
cholecystectomy. The presence of a dilated CBD or CBD stones
preoperatively is predictive of choledocholithiasis. Other intraabdominal pathologic conditions, either related to or separate
from the hepatic-biliary-pancreatic system, may influence operative planning.
Preoperative imaging studies of the CBD may allow the surgeon to identify patients with CBD stones before operation. Such
imaging may involve endoscopic retrograde cholangiopancreatography (ERCP) [see 5:18 Gastrointestinal Endoscopy],10 magnetic
resonance cholangiopancreatography (MRCP) [see Figure 1],11,12
or endoscopic ultrasonography (EUS). These imaging modalities
also provide an anatomic map of the extrahepatic biliary tree,
identifying unusual anatomy preoperatively and helping the surgeon plan a safe operation. Endoscopic sphincterotomy (ES) is
performed during ERCP if stones are identified in the CBD.
MRCP has an advantage over ERCP and EUS in that it is noninvasive and does not make use of injected iodinated contrast solutions.11 Most surgeons would probably recommend that preoperative cholangiography be performed selectively in patients with
clinical or biochemical features associated with a high risk of
choledocholithiasis. The specific modality used in such a case
varies with the technology and expertise available locally.
Laboratory tests Preoperative blood tests should include

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5 Gastrointestinal Tract and Abdomen

ACS Surgery: Principles and Practice


21 Cholecystetomy and Common Bile Duct Exploration 2

LHD
RHD

RHD

CHD
CBD

LHD

Acc
CBD
PD

GB

PD

Stones
CBD
Stones

Duo

GB

Figure 1 Laparoscopic cholecystectomy. Preoperative MRCP alerts the surgeon to abnormal anatomy
and the presence of stones in the distal CBD. (GBgallbladder, containing stones; RHDright hepatic
duct; LHDleft hepatic duct; CHDcommon hepatic duct; Accaccessory duct entering common hepatic duct near neck of gallbladder; PDpancreatic duct; Duoduodenum)

liver function, renal function, electrolyte, and coagulation studies.


Abnormal liver function test results may reflect choledocholithiasis or primary hepatic dysfunction.
Selection of Patients
Patients eligible for outpatient cholecystectomy Patients
in good general health who have a reasonable amount of support
from family or friends and who do not live too far away from adequate medical facilities are eligible for outpatient cholecystectomy, especially if they are at low risk for conversion to laparotomy
[see Special Problems, Conversion to Laparotomy, below].3 These
patients can generally be discharged home from the recovery
room 6 to 12 hours after surgery, provided that the operation went
smoothly, their vital signs are stable, they are able to void, they can
manage at least a liquid diet without vomiting, and their pain can
be controlled with oral analgesics.
Technically challenging patients Before performing laparoscopic cholecystectomy, the surgeon can predict which patients
are likely to be technically challenging. These include patients
who have a particularly unsuitable body habitus, those who are
highly likely to have multiple and dense peritoneal adhesions, and
those who are likely to have distorted anatomy in the region of the
gallbladder.
Morbidly obese patients present specific difficulties [see Operative Technique, Step 1, Special Considerations in Obese Patients,
below].13 Small, muscular patients have a noncompliant abdominal
wall, resulting in a small working space in the abdomen and necessitating high inflation pressures to obtain reasonable exposure.
Patients with a history of multiple abdominal operations, especially in the upper abdomen, and those who have a history of peritonitis are likely to pose difficulties because of peritoneal adhesions.14 These adhesions make access to the abdomen more risky
and exposure of the gallbladder more difficult. Patients who have
undergone gastroduodenal surgery, those who have any history of
acute cholecystitis, those who have a long history of recurrent gall-

bladder attacks, and those who have recently had severe pancreatitis are particularly difficult candidates for laparoscopic cholecystectomy. These patients may have dense adhesions in the
region of the gallbladder, the anatomy may be distorted, the cystic duct may be foreshortened, and the CBD may be very closely
and densely adherent to the gallbladder. Such patients are a challenge to the most experienced laparoscopic surgeon. When such
problems are encountered, conversion to open cholecystectomy
should be considered early in the operation.14,15
Predictors of choledocholithiasis CBD stones may be
discovered preoperatively, intraoperatively, or postoperatively.The
surgeons goal is to clear the ducts but to use the smallest number
of procedures with the lowest risk of morbidity.Thus, before elective laparoscopic cholecystectomy, it is desirable to classify patients into one of three groups: high risk (those who have clinical
jaundice or cholangitis, visible choledocholithiasis, or a dilated
CBD on ultrasonography), moderate risk (those who have hyperbilirubinemia, elevated alkaline phosphatase levels, pancreatitis, or
multiple small gallstones), and low risk.
In our institution, where MRCP and EUS are available and
reliable and where ERCP achieves stone clearance rates higher
than 90%, we recommend the following approach: (1) preoperative ERCP and sphincterotomy (if required) for high-risk patients
and (2) MRCP, EUS, or intraoperative fluoroscopic cholangiography for moderate-risk patients. Patients at low risk for CBD
stones do not routinely undergo cholangiography [see Figure 2].
Laparoscopic CBD exploration and postoperative ERCP appear
to be equally effective in clearing stones from the CBD.
Ultimately, surgeons and institutions must establish a reasonable approach to choledocholithiasis that takes into account the
expertise and equipment locally available.
Contraindications There are few absolute contraindications to laparoscopic cholecystectomy. Certainly, no patient who
poses an unacceptable risk for open cholecystectomy should be

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ACS Surgery: Principles and Practice

5 Gastrointestinal Tract and Abdomen

21 Cholecystetomy and Common Bile Duct Exploration 3

considered for laparoscopic cholecystectomy, because it is always


possible that conversion will become necessary. Of the relative
contraindications, surgical inexperience is the most important.
Neither ascites nor hernia is a contraindication to laparoscopic
cholecystectomy. Ascites can be drained and the gallbladder visualized. Large hernias may present a problem, however, because
with insufflation, the gas preferentially fills the hernia. Patients
with large inguinal hernias may require an external support to
minimize this problem and the discomfort related to pneumoscrotum. Patients with umbilical hernias can have their hernias
repaired while they are undergoing laparoscopic cholecystectomy.
For such patients, the initial trocar should be placed by open insertion according to the Hasson technique [see Operative Technique,
Step 1, below], with care taken to avoid injury to the contents of
the hernia. The sutures required to close the hernia defect can be
placed before insertion of the initial trocar. A similar technique can
be applied to patients with incisional hernias, although for large
incisional hernias, laparoscopic cholecystectomy may have no
advantages over open cholecystectomy if a large incision and dissection of adhesions are required. Patients with stomas may also
undergo laparoscopic cholecystectomy, provided that the appropriate steps are taken to prevent injury to the bowel during placement of trocars and division of adhesions.
Patients with cirrhosis or portal hypertension are at high risk for
morbidity and mortality with open cholecystectomy.16,17 If
absolutely necessary, laparoscopic cholecystectomy may be
attempted by an experienced surgeon.The risk of bleeding can be
minimized by rigorous preoperative preparation, meticulous dissection with the help of magnification available through the
laparoscope, and use of the electrocautery.
Patients with bleeding diatheses, such as hemophilia, von
Willebrand disease, and thrombocytopenia, may undergo laparoscopic cholecystectomy. They require appropriate preoperative
and postoperative care and monitoring, and a hematologist should
be consulted.
Questions have been raised about whether laparoscopic cholecystectomy should be performed in pregnant patients; it has been

argued that the increased intra-abdominal pressure may pose a


risk to the fetus. Because of the enlarged uterus, open insertion of
the initial trocar is mandatory, and the positioning of other trocars
may have to be modified according to the position of the uterus.
Inflation pressures should be kept as low as possible, and prophylaxis of deep vein thrombosis (DVT) is recommended. Despite
these potential problems, safe performance of laparoscopic cholecystectomy and other laparoscopic procedures in pregnant
patients is increasingly being described in the literature. If cholecystectomy is necessary before delivery, the second trimester is the
best time for it.18-21
Patients in whom preoperative imaging gives rise to a strong
suspicion of gallbladder cancer should probably undergo open
surgical management.
OPERATIVE PLANNING

Antibiotic Prophylaxis
Some surgeons recommend routine preoperative administration of antibiotics to all patients undergoing cholecystectomy, on
the grounds that inadvertent entry into the gallbladder is not
uncommon and can lead to spillage of bile or stones into the peritoneal cavity. Other surgeons do not recommend routine prophylaxis. Resolution of this controversy awaits appropriate prospective
trials. We recommend selective use of antibiotic prophylaxis for
patients at highest risk for bacteria in the bile (including those with
acute cholecystitis or CBD stones, those who have previously
undergone instrumentation of the biliary tree, and those older
than 70 years) and for patients with prosthetic heart valves and
joint prostheses.
Prophylaxis of DVT
The reverse Trendelenburg position used during laparoscopic
cholecystectomy, coupled with the positive intra-abdominal pressure generated by CO2 pneumoperitoneum and the vasodilatation
induced by general anesthesia, leads to venous pooling in the lower
extremities.This consequence may be minimized by using antiem-

Patient is identified preoperatively as being


at moderate or high risk for CBD stones
Perform preoperative cholangiography.

No stones are detected

Stones are detected

Intraoperative CBD exploration


(open or laparoscopic) is planned

Intraoperative CBD exploration


(open or laparoscopic) is not planned
Perform ERCP with ES.

Exploration is successful

Exploration is unsuccessful

Continue with laparoscopic


cholecystectomy.

Perform postoperative
ERCP/ES.

Figure 2 Laparoscopic cholecystectomy. Shown is an


algorithm outlining the use of preoperative cholangiography in patients at moderate or high risk for CBD stones.

ERCP/ES is unsuccessful
Perform cholecystectomy
and intraoperative CBD
exploration (open or
laparoscopic).

ERCP/ES is successful

Proceed to laparoscopic
cholecystectomy.

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ACS Surgery: Principles and Practice

5 Gastrointestinal Tract and Abdomen

21 Cholecystetomy and Common Bile Duct Exploration 4

b
Anesthesia

Video Monitor

Anesthesia

2nd Video Monitor


(Optional)

2nd Video Monitor


(Optional)

Video Monitor

Surgeon

Camera Operator
Assistant

Assistant

Surgeon

Camera Operator
Figure 3 Laparoscopic cholecystectomy. A patient undergoing laparoscopic cholecystectomy
should be positioned so as to allow easy access to the gallbladder and a clear view of the monitors. Shown are the positions of the surgeon, the camera operator, and the assistant in the OR
according to (a) North American positioning and (b) European positioning.

bolic stockings or by wrapping the legs with elastic bandages.


Subcutaneous heparin and pneumatic compression devices may
be employed for patients at increased risk for DVT [see 6:6 Venous
Thromboembolism]. As yet, however, there is no convincing evidence that the incidence of DVT is higher with laparoscopy than
with open surgery.
Patient Positioning
In North American positioning, the patient is lying supine and
the surgeon is positioned on the patients left side [see Figure 3a].
In European positioning, the patient is in low stirrups and the
surgeon is on the patients left or between the patients legs [see
Figure 3b].
With North American positioning, the camera operator usually
stands on the patients left and to the left of the surgeon, while the
assistant stands on the patients right. The video monitor is positioned on the patients right above the level of the costal margin. If
a second monitor is available, it should be positioned on the
patients left to the right of the surgeon, where the assistant can
have an unobstructed and comfortable view. Exposure can be
improved by tilting the patient in the reverse Trendelenburg position and rotating the table with the patients right side up. Gravity
pulls the duodenum, the colon, and the omentum away from the
gallbladder, thereby increasing the working space available in the
upper abdomen.
The OR table should allow easy access for a fluoroscopic C
arm, to facilitate intraoperative cholangiography. The table cover
should be radiolucent.
Equipment
The equipment required for laparoscopic cholecystectomy
includes an optical system, an electronic insufflator, trocars
(cannulas), surgical instruments, and hemostatic devices [see
Table 1].

Optical system The laparoscope can provide either a


straight, end-on (0) view or an angled (30 or 45) view. Scopes
that provide an end-on view are easier to learn to use, but angled
scopes are more versatile. Scopes with a 30 angle cause less disorientation than those with a 45 angle and are ideal for laparoscopic cholecystectomy. Excellent 30 scopes are currently available in diameters of 10 mm, 5 mm, and 3.5 mm.
Fully digital flat-panel displays are now available that yield better resolution than analog video monitors, take up less space, are
less subject to signal interference, and require less power.
The resolution and quality of the final image depend on (1) the
brightness of the light source; (2) the integrity of the fiberoptic
cord used to convey the light; (3) clean and secure connections
between the light source and the scope; (4) the quality of the
laparoscope, the camera, and the monitor; and (5) correct wiring
of the components.The distal end of the scope must be kept clean
and free of condensation: bile, blood, or fat will reduce brightness
and distort the image. Lens fogging can be prevented by immersion in heated water or by antifogging solutions.
Insufflator CO2 is the preferred insufflating gas for laparoscopic procedures because it is highly soluble in water and it does
not support combustion when the electrocautery is used.The CO2
should be insufflated with an electronic pump capable of a flow
rate of at least 6 L/min; most current systems have a maximum
flow rate of 20 L/min or higher.The insufflator is connected to one
of the trocars by means of a flexible tube and a stopcock.
Trocars For cholecystectomy, at least one trocar site must be
large enough to allow passage of the gallbladder and any stones
removed. Most surgeons prefer to use a 10/12 mm trocar at the
umbilicus for this purpose. The other trocars can range from 2 to
12 mm, depending on the size of the instruments to be placed
through them. The conventional approach is to use a 10/12 mm

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ACS Surgery: Principles and Practice

5 Gastrointestinal Tract and Abdomen

21 Cholecystetomy and Common Bile Duct Exploration 5

Table 1Equipment for Laparoscopic Cholecystectomy


Instrument/Device

Number

Size

Comments

3.510 mm

Atraumatic grasping forceps

24

210 mm

Large-tooth grasping forceps

10 mm

Used to extract gallbladder at end of procedure

Curved dissector

25 mm

Should have a rotatable shaft; insulation is required

Scissors

23

25 mm

One curved and one straight scissors with rotating shaft and insulation; additional
microscissors may be helpful for incising cystic duct

Clip appliers

12

510 mm

Either disposable multiple clip applier or 2 manually loaded reusable single clip appliers for
small and medium-to-large clips

Dissecting electrocautery hook or spatula

5 mm

High-frequency electrical cord

Suction-irrigation probe

10to5 mm reducers

Allow use of 5 mm instruments in 10 mm trocar without loss of pneumoperitoneum; these


are often unnecessary with newer disposable trocars and may be built into some reusable
trocars

5to3 mm reducer

Allows use of 23 mm instruments and ligating loops in 5 mm trocars

Laparoscopic cart
High-intensity halogen light source
(150300 watts)
High-flow electronic insufflator (minimum
flow rate of 6 L/min)
Laparoscopic camera box
Videocassette recorder (optional)
Digital still image capture system (optional)
Laparoscope

Available in 0 and angled views; we prefer to use a 30 5 mm diameter laparoscope


Selection of graspers should allow surgeon choice appropriate to thickness and
consistency of gallbladder wall; insulation is unnecessary

Available in various shapes according to surgeons preference; instrument should have


channel for suction and irrigation controlled by trumpet valve(s); insulation required
Cord should be designed with appropriate connectors for electrosurgical unit and instruments
being used

510 mm

Probe should have trumpet valve controls for suction and irrigation; may be used with
pump for hydrodissection

Ligating loops
Endoscopic needle holders

12

5 mm

Cholangiogram clamp with catheter

5 mm

Veress needle

Allis or Babcock forceps

Allows passage of catheter and clamping of catheter in cystic duct


Used if initial trocar is inserted by percutaneous technique

12

5 mm

Long spinal needle

14-gauge

Retrieval bag

Allow atraumatic grasping of bowel or gallbladder


Useful for aspirating gallbladder percutaneously in cases of acute cholecystitis or hydrops
Useful for preventing spillage of bile or stones in removal of inflamed or friable gallbladder;
facilitates retrieval of spilled stones

trocar at the operating port site and 5 mm trocars for the other
instruments; however, if a 5 mm laparoscope and a 5 mm clip
applier are used, the operating port size can be reduced to 5 mm.
Although 2 mm instrumentation is also available, it must be
remembered that as a rule, the smaller the working port, the less
versatile the instruments. In our experience, the combination of a
10 mm umbilical trocar, a 5 mm operating port, and 2 mm ports
for grasping forceps is a good one: optical quality is maintained, little flexibility is lost with respect to selecting operating instruments,
trocar size is minimized, and the cosmetic result is excellent.
Hemostatic devices Hemostasis can be achieved with
monopolar or bipolar electrocauterization. A monopolar electrocautery can be connected to most available instruments; however,
bipolar electrocauterization may eventually prove safer. With a
monopolar electrocautery, depth of burn is less predictable, current can be conducted through noninsulated instruments and tro-

cars, and any area of the instrument that is stripped of insulation


may conduct current and result in a burn. Caution is essential
when the electrocautery is used near metallic hemostatic clips
because delayed sloughing may occur.
Electrocauterization should be avoided near the CBD because
delayed bile duct injuries and leaks may occur as a result of
sloughing from a burned area and devascularization of the duct.
Care must be exercised when a cautery is employed near the
bowel and when intra-abdominal adhesions are being taken down.
The electrocautery can be used with a forceps, scissors, hooks (L
or J shaped), a spatula, and other instruments. Some cautery
probes incorporate nonstick surfaces to prevent buildup of eschar.
The use of hand-activated cautery probes and the presence of a
channel that allows suction and irrigation through the cautery
probes are especially convenient.
More advanced energy sources and instruments are also available. Bipolar devices designed to weld tissues have proved capable

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ACS Surgery: Principles and Practice

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21 Cholecystetomy and Common Bile Duct Exploration 6

Figure 4 Laparoscopic cholecystectomy. With the open insertion technique, the initial trocar is placed under direct
vision. (a) The umbilical skin is elevated with a sharp towel clip. A curvilinear incision is made in the inferior umbilical fold. The skin flap is elevated, and the raphe leading from the dermis to the fascia is thereby exposed. (b) The fascia
is grasped in the midline between forceps and elevated. The fascia and the underlying peritoneum are incised under
direct vision. (c) A blunt instrument is placed into the peritoneum to ensure that the undersurface of the peritoneum is
free of adhesions. The opening can be enlarged sufficiently to allow placement of a blunt 10/11 mm trocar.

of achieving superb hemostasis. Ultrasonic dissecting shears can


also be used to dissect and coagulate tissues effectively and precisely. For laparoscopic cholecystectomy, however, such
advancedand costlydevices are rarely needed.
OPERATIVE TECHNIQUE

Step 1: Placement of Trocars and Accessory Ports


Placement of initial trocar The first step in laparoscopic
cholecystectomy is the creation of pneumoperitoneum and the
insertion of an initial trocar through which the laparoscope can be
passed. This step is critical because complications resulting from
improper placement may cause serious morbidity and death. The
surgeon may use either a percutaneous technique or an open technique. We prefer the open technique, which eliminates the risks
inherent in the blind puncture [see Figure 4].22,23
Scars Patients who have previously undergone abdominal
surgery may have adhesions, both to the undersurface of the
abdominal wall and intra-abdominally. Adhesions to the undersurface of the abdominal wall make access to the abdominal cavity potentially hazardous, particularly when the percutaneous
method is used for placement of the initial trocar. Scars from previous operations may affect insertion of the initial trocar, depending on its orientation and location. If a patient has a scar in the
lower abdomen (e.g., from a Pfannenstiel incision or an incision in
the right lower quadrant for an appendectomy), the position of the
initial trocar need not be changed. If the scar is in the upper
abdomen, the initial trocar may be inserted below the umbilicus in
the midline. If there is a long midline scar that is impossible to
avoid, careful dissection of the peritoneum through a vertical incision that is somewhat longer than usual affords safe access to the
peritoneum in most cases.
An alternative is to insert the initial trocar high in the epigastrium or in the right anterior axillary line, where bowel adhesions are
less common.The laparoscope is inserted through this trocar and

used to examine the undersurface of the old scar for a clear site
near the umbilicus where a 10 mm trocar can be placed. Previous
laparoscopy, which rarely creates significant intra-abdominal
adhesions, rarely necessitates modification of trocar insertion.
The surgeon should also consider the reason for the previous
surgery. For example, a patient who underwent an appendectomy
for perforating appendicitis may have had diffuse peritonitis and
may have adhesions well away from the old scar.
Placement of accessory ports In most cases, four ports are
necessary.The first port is for the laparoscope; the remaining ports
are for grasping forceps, dissectors, and clip appliers. The precise
position of the accessory ports depends on the surgeons preference, the patients body habitus, and the presence or absence of
previous scars or intra-abdominal adhesions. A rigid approach to
port placement is inappropriate: trocar placement determines
operative exposure, and improper placement will haunt the surgeon throughout the procedure. In some cases, a fifth trocar is
required to elevate a floppy liver or to depress or retract the omentum or a bulky hepatic flexure of the colon. In trocar placement,
as in patient positioning, European practice tends to differ from
North American practice [see Figure 5].
Most surgeons elect to place one of the grasping forceps on the
fundus of the gallbladder through an accessory port placed approximately in the anterior axillary line below the level of the gallbladder. Because the level of the gallbladder varies from patient to
patient, the placement of this accessory port should not be decided on until the gallbladder is visualized. If the gallbladder is low
lying and the trocar is placed too high, the surgeon will have difficulty achieving the appropriate angle of retraction. As a general
rule, positioning the trocar in the anterior axillary line approximately halfway between the costal margin and the anterosuperior
iliac spine provides the appropriate exposure. A 2 to 5 mm port
usually suffices at this site because its only likely function is to allow
retraction of the gallbladder. In some cases of acute cholecystitis,
however, a larger port may be preferable, so that a larger grasper

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21 Cholecystetomy and Common Bile Duct Exploration 7

can be inserted and used to hold the gallbladder without tearing it.
A second accessory port (also 2 to 5 mm) allows the surgeon to
grasp the gallbladder in the area of Hartmanns pouch for retraction. This port is usually positioned just beneath the right costal
margin. Some surgeons prefer it to be approximately at the midclavicular line; others prefer it to be higher and more medial, just
to the right of the falciform ligament.
The main operating port should be 5 or 10 mm in diameter, so
that clip appliers can be readily placed through it and the laparoscope can be moved to this port at the end of the procedure. The
positioning of this port is determined by the surgeons preference
and, in particular, by the patients body habitus. The optimum
placement is at about the same horizontal level as the gallbladder
or slightly higher, so that during the operation, the laparoscope
and the operating instrument form an angle of about 90. Some
surgeons prefer to place the operative port in the midline, to the
right of the falciform ligament; others prefer to place it to the left
of the falciform, passing the trocar underneath the ligament and
elevating it with the trocar.
Surgeons should be encouraged to use both hands when performing laparoscopic cholecystectomy. One hand should control
the grasping forceps holding Hartmanns pouch, so that the gallbladder can be moved to provide the best possible exposure. The
other hand should control the dissecting instruments placed
through the operating port.
Special considerations in obese patients Port placement
in obese patients may be complicated by the thick abdominal wall,
the large amount of intra-abdominal fat, or both. A thick abdominal wall makes it more difficult to rotate the trocar around the
normal fulcrum point in the abdominal wall. Consequently, the
trocar must be placed at the angle most likely to be used during
the procedure. When a trocar is tunneled through the abdominal

25 mm
Grasping
Forceps

512 mm
Dissecting Forceps
and Clip Appliers

1012 mm
Laparoscope

wall, more of the cannula is within the abdominal wall than if the
trocar had been placed perpendicularly; accordingly, the trocar is
less mobile. If the trocars are not easily rotated, the instruments
placed through them will be difficult to manipulate smoothly.
Thus, in the patient with a very thick pannus, a standard-length
trocar may be too short. Displacement of trocars can lead to insufflation into the abdominal wall and consequently to subcutaneous
emphysema, which further thickens the abdominal wall and hinders exposure.
To prevent such problems, special extra-length trocars designed
for morbidly obese patients have been developed. It may also be
necessary to place the trocars closer to the area of the gallbladder
to ensure that the operating instruments can reach the gallbladder.
For example, the initial port may have to be placed above the
umbilicus.
In obese patients, the bulky falciform ligament and the large
omentum may adversely affect exposure. A 30 laparoscope may
help the surgeon see over the omentum and the high-lying hepatic flexure of the colon. In some cases, it is useful to place a fifth
port so that the surgeon can retract the hepatic flexure downward.
Fat may envelop the cystic duct and artery and the portal structures, obscuring normal anatomic landmarks. When the electrocautery is used, the heat melts the fat and causes it to sizzle and
spray onto the lens of the laparoscope, resulting in a blurry image.
To prevent this, the camera operator should pull the scope slightly away from the operative field during electrocauterization, then
advance the scope during dissection. This should also be done
when an ultrasonic dissector is being used.
Given that obese patients are more difficult candidates for open
cholecystectomy and have a higher complication rate with laparotomy, the advantages of laparoscopic cholecystectomy in these
individuals justify the effort needed to overcome the technical
problems.

b
25 mm
Grasping Forceps

25 mm
Grasping
Forceps

512 mm
Dissecting
Forceps and Clip
Appliers
1012 mm
Laparoscope

Figure 5 Laparoscopic cholecystectomy. Illustrated are the differences between typical North American
practice (a) and typical European practice (b) with respect to the placement of the trocars and the instruments inserted through each port.

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ACS Surgery: Principles and Practice

5 Gastrointestinal Tract and Abdomen

21 Cholecystetomy and Common Bile Duct Exploration 8

Duodenum

Figure 6 Laparoscopic cholecystectomy. Adhesions of duodenum and omentum to gallbladder wall obscure view of structures
of Calots triangle.

Step 2: Exposure of Gallbladder and Calots Triangle


Dissection of adhesions Adhesions must be dissected to
provide an unimpeded view of the gallbladder through the laparoscope. Not all intra-abdominal adhesions must be taken down,
just enough to allow entry of accessory trocars under direct vision
and thus permit access to the gallbladder.This process is facilitated by pneumoperitoneum, which provides traction on adhesions
to the abdominal wall, and by the magnification provided by the
optical system, which allows identification of the avascular plane
of attachment.
The most difficult problem is positioning the dissecting instruments so that they can reach the undersurface of the anterior
abdominal wall. A rigid trocar inserted through the anterior
abdominal wall cannot be rotated enough to allow scissors passed
through this port to cut adhesions to the anterior abdominal wall.
In such cases, one or two trocars should be placed laterally, near
the anterior axillary or midaxillary line. Instruments passed
through these ports can easily be angled parallel to the anterior
abdominal wall, and the adhesions can then be dissected without
difficulty.
Bowel adhesions should be taken down with endoscopic scissors at their insertion to the abdominal wall, where they are least
vascular. Electrocauterization, generally unnecessary, should be
avoided because of the risk of thermal injury to the bowel.
Interloop adhesions, which rarely interfere with exposure of the
gallbladder, need not be dissected. Frequently, adhesions to the
gallbladder occur as a reaction to inflammatory attacks [see Figure
6].They are usually relatively avascular. Dissection of these adhesions should begin at the fundus of the gallbladder and should
then proceed down toward the neck of the gallbladder. The best
way to take them down is to grasp the gallbladder with one grasping forceps at the site where the adhesions attach and gradually
place traction on the adhesions with the other hand. Usually, the
adhesions peel down in an avascular plane. Dissection should
continue until all adhesions to the inferolateral aspect of the gallbladder have been taken down. It is not necessary to divide adhesions between the superior surface of the liver and the undersurface of the diaphragm unless they impede superior retraction of
the liver.

Exposing Calots triangle Obtaining adequate exposure of


Calots triangle is a key step. First, the patient is placed in a reverse
Trendelenburg position, with the table rotated toward the left side.
Next, the fundus of the gallbladder and the right lobe of the liver
are elevated toward the patients right shoulder. One grasping forceps, inserted through the most lateral right-side port and held by
an assistant, is placed on the fundus of the gallbladder [see Figure
7], and the gallbladder is retracted superiorly and laterally above
the right hepatic lobe. This maneuver straightens out folds in the
body of the gallbladder and permits initial visualization of the area
of Calots triangle. If Calots triangle is still obscured, the patient
can be placed in a steeper reverse Trendelenburg position, the
stomach can be emptied of air via an orogastric tube inserted by
the anesthetist, or, if necessary, a fifth trocar can be inserted on the
patients right side to push down the duodenum.
In some patients, such as those with acute cholecystitis and
hydrops of the gallbladder, the gallbladder is tense and distended,
making it difficult to grasp and easy to tear. In these patients,
retraction of the fundus is difficult, and exposure of Calots triangle is unsatisfactory. This problem is best managed by aspirating
the contents of the gallbladder either percutaneously with a 14- or
16-gauge needle inserted into the fundus of the gallbladder under
laparoscopic vision or by using the 5 mm trocar in the right upper
abdomen to puncture the fundus and then aspirate with the suction irrigator. After the needle is withdrawn, a large atraumatic
grasping forceps can be used to hold the gallbladder and occlude
the hole; a 10 mm forceps may be preferred if the wall is markedly thickened. An alternative is to place a stitch or a ligating loop
around the fundus of the collapsed gallbladder; the tail of the
suture can then be grasped with a forceps to achieve a secure grip
and also prevent further leakage of gallbladder contents from the
needle hole.
Once the fundus of the gallbladder is retracted superiorly by the
assistant, the surgeon places a grasping forceps in the area of
Hartmanns pouch. Using both hands, the surgeon controls the
grasper on Hartmanns pouch as well as the operating instrument.
The surgeon maneuvers Hartmanns pouch to provide various
angles for safe dissection of Calots triangle. Initially, lateral and

CD

CBD

HP

Figure 7 Laparoscopic cholecystectomy. Initial view of gallbladder and related structures is facilitated by appropriate tilting of
the operating table. Hartmanns pouch (HP), the cystic duct
(CD), and the common bile duct (CBD) can be readily identified
before any dissection.

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5 Gastrointestinal Tract and Abdomen

ACS Surgery: Principles and Practice


21 Cholecystetomy and Common Bile Duct Exploration 9

tic duct. A third option is to place a stitch in Hartmanns pouch


and grasp the end of the stitch to provide exposure.
CHD

CD

Step 3: Stripping of Peritoneum


The key to avoiding injury to the major ducts during laparoscopic cholecystectomy is accurate identification of the junction
between the gallbladder and the cystic duct [see Figure 10]. Unless
the gallbladdercystic duct junction is immediately obvious upon
examination of Calots triangle anteriorly, our approach is to begin
dissection of Calots triangle posteriorly [see Figure 11]. From this
approach, the insertion of the gallbladder neck into the cystic duct
is usually more clearly identified, especially with the aid of a 30
laparoscope. Exposure is obtained by retracting Hartmanns

CBD

Figure 8 Laparoscopic cholecystectomy. The area of Hartmanns


pouch is retracted laterally. The cystic duct (CD) is seen at an
angle to the common hepatic duct (CHD) and the common bile
duct (CBD).

CD
GB-CD
Junction

CBD

pouch superomedially and is facilitated by looking from below


with a 30 scope.
Dissection should always start high on the gallbladder and hug

Figure 9 Laparoscopic cholecystectomy. In this case, the gallbladder is retracted cephalad. The cystic duct (CD) can be seen
running in the same direction as the common bile duct (CBD).
The CBD may be misinterpreted as being the cystic duct and
consequently is at risk for injury.

inferior traction are placed on Hartmanns pouch, opening up the


angle between the cystic duct and the common ducts [see Figure
8], avoiding their alignment [see Figure 9].
A large stone impacted in the gallbladder neck may impede the
surgeons ability to place the forceps on Hartmanns pouch. This
problem can usually be managed by dislodging the stone early in
the operation, as follows: the gallbladder is grasped as low as possible with one grasping forceps; a widely opening dissecting instrument, such as a right-angle dissector, a Babcock forceps, or a
curved dissector, is used to dislodge the stone and milk it up
toward the fundus; with the same forceps or another large grasper,
the stone is held up and away from the neck of the gallbladder, and
appropriate retraction is provided.
If the stone cannot be disimpacted, an instrument can be used
to elevate the infundibulum of the gallbladder superiorly, allowing
exposure of Calots triangle. Alternatively, one can attempt to
crush the stone, but small pieces of the stone may fall into the cys-

Figure 11 Laparoscopic cholecystectomy. A view from below


with a 30 laparoscope demonstrates the point for beginning dissection (arrow), where the gallbladder funnels down to its junction with the cystic duct. Just below this point can be seen a cleft
in the liver known as Rouviers sulcus. This cleft, present in 70%
to 80% of livers, reliably indicates the plane of the CBD.

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5 Gastrointestinal Tract and Abdomen

Figure 12 Laparoscopic cholecystectomy. The peritoneum is dissected from the gallbladdercystic duct junction (arrow), as seen
from below through a 30 angled laparoscope.

Figure 13 Laparoscopic cholecystectomy. Arterial bleeding can


be seen (arrow) from a branch of the cystic artery injured during
dissection from the posterior approach.

the gallbladder closely until the anatomy is identified clearly. Using


a curved dissector, the surgeon gently teases away peritoneum
attaching the neck of gallbladder to the liver posterolaterally to
visualize the funneling of the neck of the gallbladder into the cystic duct [see Figure 12]. Only the posterior layer of peritoneum is
dissected; care must be taken not to dissect deeply in this area
because of the risk of injury to the cystic artery [see Figure 13].
In some problem cases, edema, fibrosis, and adhesions make
identification of the gallbladdercystic duct junction very difficult.
An anatomic landmark on the liver known as Rouviers sulcus may
be helpful in such circumstances [see Figure 11].This sulcus, or the
remnant of it, is present in 70% to 80% of livers and usually contains the right portal triad or its branches. Its location is consistently to the right of the hepatic hilum and anterior to the caudate
process (Couinaud segment 1). This landmark reliably indicates
the plane of the CBD.Therefore, dissection dorsal to it should be
done with caution. Once the funneling of the gallbladder into the
cystic duct has been identified, the area of Hartmanns pouch

ACS Surgery: Principles and Practice


21 Cholecystetomy and Common Bile Duct Exploration 10

should be again pulled laterally and inferiorly so that the anterior


peritoneum can be dissected, while the 30 scope is angled to view
the area. The two-handed technique facilitates the surgeons
movement between the posterior and anterior aspects of Calots
triangle, providing complete visualization. Dissection should
always take place at the gallbladdercystic duct junction, staying
close to the gallbladder to avoid inadvertent injury to the CBD. A
curved dissecting forceps is used to strip the fibroareolar tissue just
superior to the cystic duct. The superior border of the cystic duct
can then be identified and the cystic duct gently and gradually dissected [see Figure 14].The cystic duct lymph node is a useful landmark at this location and may facilitate identification of the gallbladdercystic duct junction.
When traction is placed as described, the cystic artery tends to
run parallel and somewhat cephalad to the cystic duct. This artery
can often be identified by noting its close relation to the cystic duct
lymph node. Complete dissection of the area between the cystic
duct and the artery develops a window through which the liver
should be visible.The cystic duct is then encircled with a curved dissecting instrument or an L-shaped hook. Downward traction
should be applied to the cystic duct to open this window and ensure
that there is no ductal structure running through this space in
Calots triangle to join the cystic duct (i.e., the right hepatic duct).
Dissection of Calots triangle should be completed before the
cystic duct is clipped or divided.This is best accomplished by dissecting the neck of the gallbladder from the liver bed. Unequivocal
identification of the gallbladdercystic duct junction is imperative.24,25 The cystic duct should be dissected for a length sufficient
to permit secure placement of two clips; it is not necessary, and
indeed may be hazardous, to attempt to dissect the cystic
ductCBD junction.
The cystic artery is exposed next [see Figure 15]. A small vein
can usually be identified in the space between the cystic duct and
the cystic artery; it can usually be pulled up anteriorly and cauterized. Because dissection is done near the gallbladder, it is not
unusual to encounter more than one branch of the cystic artery.
Each of these branches should be dissected free of the fibroareolar tissue. Care should also be taken to ensure that the right hepatic artery is not inadvertently injured as a result of being mistaken
for the cystic artery.
Step 4: Control and Division of Cystic Duct and Cystic Artery
At this point, the cystic duct is clipped on the gallbladder side,
and a cholangiogram is obtained if desired [see Step 5, below]. If a
cholangiogram is not desired, three or four clips should be placed
on the cystic duct and the cystic duct divided between them.Two
or three hemostatic clips are placed on the cystic artery, and the
vessel is divided. It is prudent to incise the artery partially before
transecting it completely to ensure that the clips are secure and
that there is no pulsatile bleeding. Once the artery is completely
divided, the proximal end will retract medially, making it more difficult to expose and control the artery safely if bleeding occurs.
Electrocauterization should be avoided near the cystic duct and all
metallic clips. Electrical current will be conducted through metallic clips and may result in delayed sloughing of the duct or a clip.
Delayed injuries to the CBD may be caused by a direct burn to
the duct or by sparking from noninsulated instruments or clips
during dissection. An alternative is to use locking polymer clips
that fit through 5 mm ports, clip across a greater width of tissue,
and do not conduct electricity.
Control of short or wide cystic duct Edema and acute
inflammation may lead to thickening and foreshortening of the

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5 Gastrointestinal Tract and Abdomen

ACS Surgery: Principles and Practice


21 Cholecystetomy and Common Bile Duct Exploration 11

cystic duct, with subsequent difficulties in dissection and ligation.


If the duct is edematous, clips may cut through it; if the duct is too
wide, the clip may not occlude it completely. A modified clipping
technique can be employed, with placement of an initial clip to
occlude as much of the duct as possible. The occluded portion of
the duct is then incised, and a second clip is placed flush with the
first so as to occlude the rest of the duct. Alternatively, wider polymer clips may be used.
Because this technique is not always possible, the surgeon
should be familiar with techniques for ligating the duct with either
intracorporeal or extracorporeal ties. It is extremely helpful to

know how to tie extracorporeal ties so that the cystic duct can be
ligated in continuity before it is divided. In some cases, the duct
can be divided, held with a forceps, and controlled with a ligating
loop. If there is concern about secure closure of the cystic duct, a
closed suction drain may be placed. If inflammation, as in cholecystitis, has caused the duct to be shorter than usual, dissection
must be kept close to the gallbladder to avoid inadvertent injury to
the CBD. A short cystic duct is often associated with acute cholecystitis. Patient blunt dissection with the suction-irrigation device
may be the safest technique.
Cystic duct stones Stones in the cystic duct may be visualized or felt during laparoscopic cholecystectomy. Every effort
should be made to milk them into the gallbladder before applying
clips. Placing a clip across a stone may push a fragment of the
stone into the CBD and will increase the risk that the clip will
become displaced, leading to a bile leak. If the stone cannot be
milked into the gallbladder, a small incision can be made in the
cystic duct (as is done for cholangiography), and the stone can
usually be expressed and retrieved. Given that cystic duct stones
are predictive of CBD stones, cholangiography or intraoperative
ultrasonography is indicated.26
Step 5: Intraoperative Cholangiography

Figure 14 Laparoscopic cholecystectomy. The superior border of


the cystic duct has been dissected. Funneling of the gallbladder
into the cystic duct is clearly seen (arrow).

CA

GB

CD

Figure 15 Laparoscopic cholecystectomy. Dissection of Calots


triangle further exposes the cystic duct (CD) and the cystic artery
(CA) near their entry into the gallbladder (GB) in preparation for
clipping and division.

Whether intraoperative cholangiography should be performed


routinely is still controversial. Advocates believe that this technique
enhances understanding of the biliary anatomy, thus reducing the
risk of bile duct injury27,28; at present, however, there are no objective data to confirm this impression. Cholangiography is not a substitute for meticulous dissection, and injuries to the CBD can
occur before cystic duct dissection reaches the point at which
cholangiography can be performed. Catheter-induced injuries and
perforations of the biliary tree have been reported, and cholangiograms have been misinterpreted. On the other hand, one of the
main advantages of cholangiography is that injuries can be recognized during the operation and promptly repaired. Another advantage of routine cholangiography is that it helps develop the skills
required for more complex biliary tract procedures, such as transcystic CBD exploration.
The two methods of laparoscopic cholangiography differ in
their technique for introducing the cholangiogram catheter into
the cystic duct. In both approaches, a clip is placed at the gallbladdercystic duct junction and a small incision made in the
anterior wall of the cystic duct. In the first technique, a specially
designed 5 mm cholangiogram clamp (the Olsen clamp) with a 5
French catheter is inserted via a subcostal trocar. For easy guidance of the catheter into the incision in the cystic duct, the catheter
should be parallel, rather than perpendicular, to the cystic duct.
This angle is facilitated by placing the subcostal port directly
below the costal margin, near the anterior axillary line. A fifth trocar may occasionally be needed if exposure is lost when one of the
grasping forceps is removed to allow passage of the cholangiogram
clamp. The clamp and the catheter are then brought to the cystic
duct under direct vision, and the catheter is steered into the duct
[see Figure 16]. The clamp is then closed, holding the catheter in
position and sealing the duct to avoid extravasation of dye.
In the second method, the cholangiogram catheter is introduced percutaneously through a 12- to 14-gauge catheter, inserted subcostally as described (see above). The surgeon then grasps
the cholangiogram catheter and directs it into the cystic duct. A
hemostatic clip is applied to secure the catheter in place. If passage
of the catheter into the cystic duct is prevented by Heisters valve,
a guide wire can be passed initially.

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5 Gastrointestinal Tract and Abdomen

Catheter

Cystic Duct

Figure 16 Laparoscopic cholecystectomy. The cystic duct has


been clipped, a small incision has been made for placement of the
cholangiogram catheter, and the catheter has been advanced
through the specialized cholangiogram clamp into the cystic duct.

If the cystic duct is tiny and cannulation is expected to be difficult or impossible, the gallbladder can be punctured, bile aspirated, and contrast material injected through the gallbladder until the
biliary tree is filled.
The cannulas and operating instruments should be positioned
so as not to obstruct the view of the biliary tree. If the cannulas cannot be positioned outside the x-ray window, radiolucent cannulas
should be used, or the cannulas should be removed and replaced
after the cholangiogram. A cholangiogram that does not visualize
the biliary tree from the liver to the duodenum is inadequate.
Fluoroscopic cholangiography [see Figure 17] may be performed either with hard-copy film or with digital imaging and
storage. After the C arm is positioned, with the operating staff protected behind a lead screen, full-strength contrast is slowly injected under fluoroscopic control. The goal is to visualize the biliary
tree in its entirety, including the right and left hepatic ductal systems as well as the distal duct. Once the cholangiogram is
obtained, the catheter is removed, and the cystic duct is doubleclipped and transected.
Laparoscopic ultrasonography Evaluation of the biliary
tree with intraoperative laparoscopic ultrasonography appears to
be as accurate as intraoperative fluorocholangiography in identifying biliary stones.28,29 This modality has several advantages over
conventional cholangiography: it does not expose patients and
staff to radiation; contrast agents are unnecessary; there is no need
to cannulate the cystic duct; significantly less time is required; the
capital cost of most ultrasound units is less than that of fluoroscopic equipment; and disposable cholangiogram catheters are
not needed.
Most of the laparoscopic ultrasound devices in use at present
are 7.5 MHz linear-array rigid probes 10 mm in diameter. Flexible
probes capable of multiple frequencies are also available, and it is
likely that future probes will be increasingly versatile.The probe is
inserted through a 10/12 mm port (usually a periumbilical or epigastric port) and placed directly on the porta hepatis, perpendic-

ACS Surgery: Principles and Practice


21 Cholecystetomy and Common Bile Duct Exploration 12

ular to the structures of the hepatoduodenal ligament. The probe


is then moved to the cystic ductCBD junction. The transverse
image obtained should show the three tubular structures of the
hepatoduodenal ligament in the so-called Mickey Mouse head
configuration: the CBD, the portal vein, and the hepatic artery
[see Figure 18]. As the probe is moved distally, it is rotated clockwise to allow identification of the distal CBD and the pancreatic
duct where they unite at the papilla. Instillation of saline into the
right upper quadrant can enhance acoustic coupling and improve
visualization.
Because of its many advantages, intraoperative laparoscopic
ultrasonography may eventually replace fluorocholangiography in
this setting, particularly for surgeons who practice routine intraoperative evaluation of the CBD.30 Although the learning curve for
effective performance of laparoscopic ultrasound examination is
not long, surgeons should receive expert mentoring and formal
instruction in ultrasonography before attempting it. During the
first few attempts, it may be instructive to perform intraoperative
laparoscopic ultrasonography in conjunction with fluorocholangiography. It should be emphasized that intraoperative laparoscopic ultrasonography is not a replacement for intraoperative
cholangiography if the purpose of the examination is to define an
anomalous anatomy or to evaluate a suspected injury or leak.
Step 6: Dissection of Gallbladder from Liver Bed
The gallbladder is grasped near the cystic duct insertion and
pulled down toward the right anterosuperior iliac spine, placing
the areolar tissue between the gallbladder and liver anteriorly

Figure 17 Laparoscopic cholecystectomy. Shown is a normal


intraoperative cholangiogram.

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5 Gastrointestinal Tract and Abdomen

CBD

ACS Surgery: Principles and Practice


21 Cholecystetomy and Common Bile Duct Exploration 13

Common
Hepatic
Artery

Portal Vein

probe or through a 32 French chest tube passed through the 10


mm operating port. Unfortunately, small stones may be lost in the
omentum or between bowel loops. In such cases, it is probably
appropriate to leave the stones within the peritoneum rather than
perform a laparotomy to attempt to retrieve them. However, there
have been reports of serious morbidity, including intra-abdominal
abscess, fistula, empyema, and bowel obstruction, resulting from
lost stones.
If the gallbladder is perforated and it seems likely that multiple
stones will be spilled, the surgeon should introduce a sterile bag
into the peritoneal cavity, placing it close to the perforation.
Spilled stones can then be transferred immediately into the bag.
After the gallbladder is removed from the liver bed, it too is placed
in the bag, affording some protection to the wound when it is
removed from the abdominal cavity.
Step 7: Extraction of Gallbladder

Figure 18 Laparoscopic cholecystectomy. A transverse intraoperative ultrasound scan of the hepatoduodenal ligament reveals a
typical Mickey Mouse head appearance. Visible are the CBD,
the common hepatic artery, and the portal vein.

under tension. The areolar tissue is cauterized with an L-shaped


hook dissector or spatula, and dissection is carried upward as far
as possible for as long as there is sufficient exposure.When exposure begins to diminish, the cystic duct end of the gallbladder
should be pulled up toward or over the left lobe of the liver to
expose the posteroinferior attachments of the gallbladder. A twohanded approach by the surgeon facilitates this dissection. It is
sometimes helpful to apply downward and lateral traction on the
forceps grasping the fundus. Bleeding during this stage generally
indicates that the surgeon has entered the wrong plane and dissection has entered the liver. Bleeding can usually be readily controlled with the electrocautery. In some difficult cases (e.g., an
intrahepatic gallbladder), it may be prudent to leave some of the
posterior wall of the gallbladder in situ and cauterize it rather than
persist with an excessively bloody dissection.16
Dissection continues until the gallbladder is attached only by a
small piece of peritoneum at the fundus. Before the last attachment to the gallbladder is completely divided, the vital clips are
reinspected to ensure that they have not slipped off, and the operative field is checked for hemostasis and the presence of any bile
leakage. The final attachment to the gallbladder is then divided.
The gallbladder is placed over the right lobe of the liver and laterally so that it can be found again to be retrieved.The grasping forceps on the gallbladder should not be removed.
Perforation of gallbladder The gallbladder may be accidentally breached at some point in the operation, with the result
that bile and stones spill into the peritoneal cavity.31,32 Efforts
should be made to suction the spilled bile, which accumulates in
the suprahepatic space, the right subhepatic space, and the lower
abdomen because of the patients position. Each of these areas
should be irrigated and the effluent aspirated until it is clear.
Stones should be located and removed whenever possible. An
effective way of removing small stones is to irrigate the subhepatic space copiously. Cholesterol stones usually float on the irrigation fluid and can then be suctioned through a 10 mm suction

The laparoscope is moved to the epigastric port, and a largetooth grasping forceps is inserted through the umbilical port to
grasp the gallbladder at the area of the cystic duct. Under direct
vision, the gallbladder is then retrieved and pulled out as far as
possible through the umbilical port. If the gallbladder is small
enough, it can be drawn right into the trocar sleeve, and it and the
trocar can then be removed together. It is sometimes necessary to
stretch the fascial opening with a Kelly clamp or to aspirate bile
from the gallbladder. It is far preferable to enlarge the incision
than to have stones or bile spill into the abdominal cavity from a
ripped gallbladder. Enlargement of this incision is easier if initial
access was obtained via the Hasson technique. All of the other
ports are then removed from the abdominal wall under direct
vision to ensure that there is no bleeding. All residual CO2 should
be removed to prevent postoperative shoulder pain. The fascial
opening at the umbilicus should be sutured closed to prevent subsequent herniation, and all skin incisions should be closed.
Need for drainage The decision to place a drain after
laparoscopic cholecystectomy should be governed by the same
principles applied to patients undergoing open cholecystectomy.
There are two main indications for drainage: (1) the cystic duct
was not closed securely, and (2) the CBD was explored by either
a direct or a transcystic approach.
Drain placement is easily accomplished. A closed suction drain
is inserted intra-abdominally through the 10 mm operative port.
A grasping forceps placed through the right lateral port is used to
pull one end of the drain out through the abdominal wall. The
other end is then positioned according to the surgeons preference, usually in the subhepatic space.
COMPLICATIONS

Intraoperative
Veress needle injury A syringe must always be attached to
the Veress needle, and fluid must be aspirated before insufflation
is initiated: failure to do so may lead to insufflation into a vessel
and consequently to massive gas embolism. If the aspirate from
the syringe attached to the Veress needle contains copious
amounts of blood, a major vascular injury may have occurred, and
immediate laparotomy is indicated. Because the problem at this
point is a needle injury, it can usually be repaired easily and without serious sequelae.
Puncture of the bowel by a Veress needle is usually signaled by
aspiration of bowel contents through the needle. If this occurs, the
needle should be withdrawn and the approximate course and

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5 Gastrointestinal Tract and Abdomen

direction of the puncture remembered. The initial trocar should


then be inserted by means of the open technique, under direct
vision, to ensure that the undersurface of the abdominal wall is free
of adherent bowel. Once pneumoperitoneum is created, careful
examination of the abdomen through the laparoscope is undertaken. In most cases, either further leakage of bowel contents, staining of the serosal surface with bowel contents, or an ecchymosis on
the serosal surface of the bowel helps the surgeon locate the site of
the bowel injury. If ecchymosis is present without spillage of bowel
contents, the bowel loop should be marked with a suture and reinspected at the end of the procedure. If ongoing leakage of bowel
contents is noted, the injured loop of bowel can be either repaired
by means of laparoscopic suturing or grasped with an atraumatic
forceps and gently withdrawn through an enlarged umbilical incision for suture repair.The bowel is returned to the peritoneal cavity and the laparoscopic cholecystectomy completed.
Improper placement of the Veress needle into the omentum, the
retroperitoneum, or the preperitoneal space may be signaled by
high inflation pressures, uneven distribution of the gas on percussion, or marked subcutaneous emphysema. If such misplacement
goes unrecognized, creation of a safe intraperitoneal space is
impossible, and subsequent blind insertion of the trocar may result
in injury to an intraperitoneal structure.
Trocar injury Trocar injury to blood vessels or bowel is
much more dangerous than Veress needle injury to the same structures. Major vascular injuries virtually never occur when trocars
are placed under direct vision; however, they remain a potentially
lethalthough rarecomplication of percutaneous trocar insertion. If active bleeding follows removal of the trocar from the cannula, prompt laparotomy is mandatory; if bleeding passes unnoticed and insufflation begins, massive air embolism will result. At
the time of laparotomy, both the anterior and the posterior wall of
the vessel must be examined after proximal and distal control of
the vessel have been obtained.
Bowel injuries can result from either percutaneous or open
insertion of the initial trocar.With open insertion, the bowel injury
should be immediately obvious and can be repaired after the
injured bowel is pulled through an enlarged umbilical incision;
laparoscopic cholecystectomy can then proceed. Bowel injuries
caused by percutaneous insertion may occur even in the absence
of abdominal wall adhesions and can be managed in the same way
as those caused by open insertion. The one caveat is that it is possible to spear the bowel in a through-and-through fashion so that
when the laparoscope is inserted through the trocar, the view is
normal and the injury is not recognized.This type of injury can be
diagnosed only if the laparoscope is repositioned to the operating
port at some time during the procedure and the undersurface of
the umbilical site is carefully examined. This step is mandatory
during the course of the operation, preferably early.
Bleeding Abdominal wall. Bleeding from the abdominal
wall can usually be prevented by careful trocar placement. The
abdominal wall should be transilluminated before percutaneous
trocar insertion and the larger vessels avoided. If a vessel is speared,
the cannula usually tamponades the bleeding reasonably effectively during the procedure.
Once the procedure is completed, each trocar is removed under
direct vision. If bleeding follows the removal of a trocar, the puncture hole can be occluded with digital pressure to maintain pneumoperitoneum and the bleeding controlled by cauterization or
suture repair. Alternatively, the surgeon may place a Foley catheter
through the trocar site with a stylet, inflate the balloon, and place

ACS Surgery: Principles and Practice


21 Cholecystetomy and Common Bile Duct Exploration 14

traction on the catheter for 4 to 6 hours; however, tissue ischemia


can make this technique quite painful.
Omental or mesenteric adhesions. Generally, omental adhesions
can be bluntly teased from their attachments to the gallbladder,
with the plane of dissection kept close to the gallbladder, where the
adhesions are less vascular. Adhesions to the liver should be taken
down with the electrocautery to prevent capsular tears. Persistent
bleeding from omental adhesions is unusual but can be managed
by means of electrocauterization (with care taken to avoid damage
to the duodenum or colon) or the application of hemostatic clips
or a pretied ligating loop.
Cystic artery branch. Arterial bleeding encountered during dissection in Calots triangle is usually from loss of control of the cystic artery or one of its branches. Biliary surgeons must be aware of
the many anatomic variations in the vasculature of the gallbladder
and the liver. Because the main cystic artery frequently branches,
it is common to find more than one artery if dissection is maintained close to the gallbladder. If what seems to be the main cystic
artery is small, a posterior cystic artery may be present and may
have to be clipped during the dissection.
Prevention of arterial bleeding begins by dissecting the artery
carefully and completely before clipping and by inspecting the
clips to ensure that they are placed completely across the artery
without incorporating additional tissue (e.g., a posterior cystic
artery or right hepatic artery). When arterial bleeding is encountered, it is essential to maintain adequate exposure and to avoid
blind application of hemostatic clips or cauterization. The laparoscope should be withdrawn slightly so that the lens is not spattered
with blood. The surgeon should then pass an atraumatic grasping
forceps through a port other than the operating port and attempt
to grasp the bleeding vessel. An additional trocar may have to be
inserted for simultaneous suction-irrigation. Once proximal control is obtained, the operative field should be suctioned and irrigated to improve exposure. Hemostatic clips are then applied
under direct vision; in addition, a sponge may be introduced to
apply pressure to the bleeding vessel. Conversion to open cholecystectomy is indicated whenever bleeding cannot be promptly
controlled laparoscopically.
Liver bed. Bleeding from the liver bed may be encountered when
the wrong plane is developed during dissection of the gallbladder.
Patients who have portal hypertension, cirrhosis, or coagulation
disorders are at particularly high risk. Control of bleeding requires
good exposure, accomplished via lateral and superior retraction of
the gallbladder; hence, all bleeding should be controlled before the
gallbladder is detached from the liver bed. Most liver bed bleeding
can be controlled with the electrocautery, and it should be controlled as it is encountered to allow exposure of the specific bleeding site. Either a hook-shaped or a spatula-shaped coagulation
electrode is effective. If oozing continues, oxidized cellulose can be
placed as a pack through the operative port and pressure applied
on the raw surface of the liver. If needed, fibrin glue can be applied
to the bleeding raw surface.
Postoperative
If a patient (1) complains of a great deal of abdominal pain
necessitating systemic narcotics, (2) has a high or prolonged fever,
(3) experiences ileus, or (4) becomes jaundiced, an intra-abdominal complication may have occurred. Blood should be drawn for
assessment of the white blood cell count, hemoglobin concentration, liver function, and serum amylase level. Abdominal ultra-

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ACS Surgery: Principles and Practice

5 Gastrointestinal Tract and Abdomen

21 Cholecystetomy and Common Bile Duct Exploration 15

Patient has severe abdominal pain, has high or prolonged


fever, experiences ileus, or becomes jaundiced
Perform abdominal ultrasonography.

No fluid collection is seen

Fluid collection is seen

Perform 99mTc-HIDA scan.

Aspirate fluid.

Scan is normal

Scan is abnormal

Fluid is enteric contents

Fluid is bile

Fluid is blood

Observe patient.

Perform cholangiography.

Perform immediate
laparotomy.

Perform percutaneous
drainage.

Observe patient.

Figure 19 Laparoscopic cholecystectomy. Shown


is an algorithm outlining a screening approach that
is often useful when the patient shows signs (e.g.,
pain, fever, or ileus) that are suggestive of a postoperative intra-abdominal complication, such as
fluid collection or bile leakage.

sonography may help diagnose dilated intrahepatic ducts and subhepatic fluid collections [see Figure 19].
Fluid collection or bile leakage When a significant fluid
collection is seen, it should be aspirated percutaneously under
ultrasonographic guidance. If the fluid is blood and the patient is
hemodynamically stable and requires no transfusion, observation
of the patient and culture of the fluid are usually sufficient. If the
fluid is enteric contents, immediate laparotomy is indicated. If the
fluid is bile and the patient is ill, immediate laparotomy should be
considered; if the patient is stable and the appropriate facilities are
available, MRCP or ERCP may be performed to identify the site
of bile leakage, determine whether obstruction is also present, and
assess the integrity of the extrahepatic biliary tree. If the bile ducts
are in continuity and the bile is coming from the cystic duct stump
or a small lateral tear in the bile duct, ES, with or without stenting, usually controls the leak. Percutaneous placement of a drain
under ultrasonographic guidance allows control of the bile leakage
and measurement of the quantity of fluid present.
Fever Postoperative fever is a common complication of
laparoscopic cholecystectomy. As noted, it may be indicative of a
complication such as a bile collection or bile leakage. Other common reasons for postoperative fever (e.g., atelectasis) should also
be considered.
Abnormal liver function When postoperative blood tests
indicate significantly abnormal liver function, possible causes
include injury to the biliary tree and retained CBD stones [see
Figure 20].33 Cholangiography is required, even if it was performed
intraoperatively. If MRCP or ERCP yields normal results, observation is sufficient; the abnormalities may be attributable to a
passed stone or drug-related cholestasis. If stones are present, ES
can usually solve the problem. If ERCP demonstrates extravasation of bile, it is important to establish whether the CBD is in continuity. If the duct is interrupted, early reoperation, ideally at a specialized center, is the best option. If the duct is in continuity, endoscopic and radiologic techniques may successfully resolve the

Patient is ill
Perform immediate laparotomy.

Patient is stable
Perform MRCP or ERCP
to delineate biliary anatomy.

problem without substantial morbidity.34,35 Percutaneous drainage


is instituted to control the fistula, and sphincterotomy or stenting
is useful to overcome any resistance at the sphincter of Oddi. Any
retained stones causing distal obstruction should also be removed.
Major ductal injuries usually call for operative repair. When such
an injury is identified at operation, the surgeon must decide
whether to attempt repair immediately; this decision should be
based on the surgeons experience with reconstructive biliary
surgery and on the local expertise available. At a minimum, adequate drainage must be established. Most major ductal injuries are
not in fact identified intraoperatively.When such an injury is identified postoperatively, adequate drainage must be established and
the anatomy of the injury clarified as well as possible before repair.
MRCP or transhepatic cholangiography may be required to delineate the anatomy of the proximal biliary tree when ERCP does not
opacify the biliary tract above the injury. If surgical repair is indicated, it should be performed by a surgeon experienced in complex biliary tract procedures. Often, referral to a specialized center
is the most appropriate decision, especially in the case of more
proximal biliary injuries.
SPECIAL CONSIDERATIONS

Conversion to Laparotomy
Conversion from laparoscopy to laparotomy may be required in
any laparoscopic cholecystectomy, in accordance with the judgment of the surgeon. The most common reason for such conversion is the inability to identify important anatomic structures in the
region of the gallbladder. Distorted anatomy may be the result of
previous operations, inflammation, or anatomic variations.
Conversion may also be required because of an intraoperative
complication [see Complications, Postoperative, above]. Ideally, the
surgeon would wish to convert before any complication occurs. It
must be emphasized that conversion to open surgery should not
be considered a failure or a complication. Rather, it should be considered a prudent maneuver for achieving the desired objective
namely, safe removal of the gallbladder. Accordingly, every patient
consent obtained for a laparoscopic cholecystectomy must explic-

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ACS Surgery: Principles and Practice

5 Gastrointestinal Tract and Abdomen

21 Cholecystetomy and Common Bile Duct Exploration 16

Postoperative liver function tests yield abnormal results


Perform ERCP to detect biliary tree injury or retained CBD stones.

ERCP yields
normal results
Observe patient.

ERCP reveals
presence of CBD
stones
Perform ES.

Duct is completely
interrupted or lacks
continuity
Reoperate at an early
stage.

ERCP reveals
leakage of bile
Determine whether
CBD is in continuity.

Duct is in continuity
Perform percutaneous drainage
in conjunction with ES or
endoscopic stenting.
Remove any retained stones.

Figure 20 Laparoscopic cholecystectomy. Shown is an algorithm outlining an approach to abnormal liver function test
results after laparoscopic cholecystectomy.

itly allow for the possibility of conversion to an open procedure.


Attempts have been made to predict the probability of conversion
on the basis of preoperative information.36,37 It is clearly useful to
stratify patients according to likelihood of conversion. This information is helpful in selecting patients for laparoscopic cholecystectomy in an outpatient versus hospital setting, in determining the
resources required in the OR, and in assisting patients in planning
their work and family needs around the time of surgery.
Factors found to be predictive of an increased probability of
conversion include acute cholecystitis, either at the time of surgery
or at any point in the past; age greater than 65 years; male sex; and
thickening of the gallbladder wall to more than 3 mm as measured
by ultrasonography. Other factors more variably associated with an
increased likelihood of conversion are obesity, previous upper
abdominal operations (especially gastroduodenal), multiple gallbladder attacks over a long period, and severe pancreatitis. Factors
not associated with an increased likelihood of conversion are jaundice, previous ES, previous lower abdominal procedures, stomas,
mild pancreatitis, and diabetes.
On the basis of our data, a 45-year-old woman with no history
of acute cholecystitis and no gallbladder wall thickening has a
probability of conversion lower than 1%; such a patient is a good
candidate for laparoscopic cholecystectomy in an outpatient setting. Conversely, a 70-year-old man with acute cholecystitis and
ultrasonographic evidence of gallbladder wall thickening has a
probability of conversion of about 30%; such a patient would be
better managed in a traditional hospital environment.
Acute Cholecystitis
Laparoscopic cholecystectomy has been shown to be safe and
effective for treating acute cholecystitis.38,39 There are, however,
several technical problems in this setting that must be addressed if
the procedure is to be performed with minimal risk. It should also
be recognized that the probability of conversion to laparotomy is
greatly increased in these circumstances. There appears to be no
advantage to delaying surgery in patients with acute cholecystitis,
even if rapid improvement is noted with nonoperative management.40,41 Many patients return within a short time with recurrent
attacks, and delaying surgery does not reduce the probability of

conversion.
Technical difficulties associated with cholecystectomy for acute
cholecystitis include dense adhesions, the increased vascularity of
tissues, difficulty in grasping the gallbladder, an impacted stone in
the gallbladder neck or the cystic duct, shortening and thickening
of the cystic duct, and close approximation of the CBD to the gallbladder wall.
The surgeon should not hesitate to insert additional ports (e.g.,
for a suction-irrigation apparatus) if necessary. Because the tense,
distended gallbladder is difficult to grasp reliably, it should be aspirated through the fundus early in the procedure, as previously
described. If the graspers fail to grasp the wall or cause it to tear,
exposure of Calots triangle can be achieved by propping up or levering the neck of the gallbladder and the right liver with a blunt
instrument. A sponge can be used for this purpose, thereby reducing the potential trauma of the retraction. This maneuver is also
useful when an impacted stone in the neck of the gallbladder prevents the surgeon from grasping the gallbladder in the area of
Hartmanns pouch. Dense adhesions that may be present between
the gallbladder and the omentum, duodenum, or colon should be
dissected bluntly (e.g., with a suction tip). Because the tissues are
friable and vascular, oozing may be encountered. Electrocauterization should be only sparingly employed until the vital structures
in Calots triangle are identified. Instead, the surgeon should move
to another area of dissection, allowing most of the oozing to coagulate on its own. Liberal use of suction and irrigation will keep the
operative field free of blood.
In the identification of anatomic structures, it is important to
keep dissection close to the gallbladder wall, working down from
the gallbladder toward Calots triangle. Dissection of the lower part
of the gallbladder from the liver bed early in the operation may aid
in identification of the gallbladder neckcystic duct junction (analogous to an open, retrograde dissection). The surgeon should be
aware that edema and acute inflammation may cause foreshortening of the cystic duct. If the anatomy cannot be identified, preliminary cholangiography through the emptied gallbladder may indicate the position of the cystic duct and the CBD.
Often, the obstructing stone responsible for the acute attack is
in the neck of the gallbladder; thus, the cystic duct will be normal
and easily secured with clips. If the stone is in the cystic duct, it
must be removed before the duct is clipped or ligated. A thickened,
edematous cystic duct is better controlled by ligation with an
extracorporeal tie or a ligating loop than by clipping. If closure of
the cystic duct is tenuous, closed suction drainage is advisable.
Obviously, conversion to open cholecystectomy is indicated if the
anatomy remains obscure. Conversion should also be considered if
no progress is made after a predesignated period (e.g., 15 minutes)
because at this point, the surgeon is unlikely to make any headway.
CBD Stones
Identification of patients at risk About 10% of all patients
undergoing cholecystectomy for gallstones will also have choledocholithiasis. To select from the various diagnostic and therapeutic
options for managing choledocholithiasis, it is helpful to know preoperatively whether the patient is at high, moderate, or low risk for
stones. Patients with obvious clinical jaundice or cholangitis, a
dilated CBD, or stones visualized in the CBD on preoperative
ultrasonography are likely to have choledocholithiasis (risk >
50%). Patients who have a history of jaundice or pancreatitis, elevated preoperative levels of alkaline phosphatase or bilirubin, or
ultrasonographic evidence of multiple small gallstones are somewhat less likely to have choledocholithiasis (risk, 10% to 50%).
Patients with large gallstones, no history of jaundice or pancreati-

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5 Gastrointestinal Tract and Abdomen

ACS Surgery: Principles and Practice


21 Cholecystetomy and Common Bile Duct Exploration 17

Figure 21 Open cholecystectomy. (a) Shown are the resting positions of the cystic duct and the CBD
(with Calots triangle closed). (b) Improper upward retraction of Hartmanns pouch lines up the CBD and
the cystic duct so that one can easily encircle the CBD or clamp the cystic duct and the CBD. (c) Correct
downward and rightward retraction opens Calots triangle; dissection proceeds lateral to the CBD.

tis, and normal liver function are unlikely to have choledocholithiasis (risk < 5%).
Diagnostic and therapeutic options One argument for
routine intraoperative cholangiography is that it is a good way of
identifying unsuspected CBD stones. However, more selective
approaches to diagnosing choledocholithiasis make use of preoperative cholangiography via MRCP, EUS, or, more invasively,
ERCP [see 5:18 Gastrointestinal Endoscopy]. Preoperative identification of choledocholithiasis allows the surgeon to attempt preoperative clearance of the CBD by means of ES or intraoperative clearance during laparoscopy, depending on his or her expertise.
Preoperative cholangiography is suggested when the patients history and the results of laboratory and diagnostic tests suggest that
there is a moderate or high risk of CBD stones. It is our practice to
have patients at high risk for CBD stones undergo ERCP and ES
if warranted. For patients at moderate risk, MRCP or EUS is done
first, followed by therapeutic ERCP if CBD stones are identified.
Intraoperative cholangiography can also be used to identify choledocholithiasis. ERCP with ES may result in pancreatitis, perforation, or bleeding and carries a mortality of approximately 0.2%.
When stones are detected during the operation, the options
include laparoscopic transcystic duct exploration, laparoscopic
choledochotomy and CBD exploration, open CBD exploration,
and postoperative ERCP/ES.10,42 If a single small (~ 2 mm) stone
is visualized, it can probably be flushed into the duodenum by
flushing the CBD via the cholangiogram catheter and administering glucagon, 1 to 2 mg I.V., to relax the sphincter of Oddi. Even
if a stone of this size does not pass intraoperatively, it will usually
pass on its own postoperatively.
Laparoscopic transcystic CBD exploration Access to biliary tree. The cholangiogram is reviewed; the size of the cystic
duct, the site where the cystic duct inserts into the CBD, and the
size and location of the CBD stones all contribute to the success
or failure of transcystic CBD exploration.43-45 For example, transcystic exploration is extremely challenging in a patient who has a
long, spiraling cystic duct with a medial insertion. The size of the
stones to be removed dictates the approach to the CBD: stones
smaller than 4 mm can usually be retrieved in fluoroscopically
directed baskets and generally do not necessitate cystic duct
dilatation; larger stones (4 to 8 mm) are retrieved under direct

vision with the choledochoscope.


A hydrophilic guide wire is inserted through the cholangiogram
catheter into the CBD under fluoroscopic guidance. The cholangiogram catheter is then removed. If the largest stone is larger than
the cystic duct, dilatation of the duct is necessary, not only for passage of the stone but also to allow passage of the choledochoscope,
which may be 3 to 5 mm in diameter.
Dilatation is accomplished with either a balloon dilator or
sequential plastic dilators. Because plastic dilators may cause the
cystic duct to split, balloon dilatation is recommended. A balloon
3 to 5 cm in length is passed over the guide wire and positioned
with its distal end just inside the CBD and its proximal end just
outside the incision in the cystic duct.The balloon is then inflated
to the pressure recommended by the manufacturer and observed
closely for evidence of shearing of the cystic duct.The cystic duct
should not be dilated to a diameter greater than 8 mm. Larger
stones in the CBD may be either fragmented with electrohydraulic or mechanical lithotripsy, if available, or removed via
choledochotomy.
Once dilatation is complete, the guide wire may be removed or
left in place to guide passage of a choledochoscope or baskets.
When the choledochoscope is used, a second incision in the cystic duct, close to the CBD, avoids Heisters valves and allows
removal of the guide wire. If baskets are used, a 6 French plastic
introducer sheath may be inserted through the trocar used for
cholangiography into the cystic duct.This sheath is especially useful if multiple stones must be removed.
Fluoroscopic wire basket transcystic CBD exploration. Stones
smaller than 2 to 4 mm that do not pass with irrigation through the
cholangiocatheter after injection of glucagon can usually be
retrieved by using a 4 French or 5 French helical stone basket
passed into the CBD over a guide wire under fluoroscopic guidance.The baskets can be passed alongside the cholangiocatheter or
inserted via a plastic sheath replacing the cholangiocatheter. The
basket is opened in the ampulla of Vater, pulled back into the
CBD, and rotated clockwise until the stone is entrapped.The stone
and basket are then removed together. A Fogarty catheter should
not be used, because the stones are likely to be pulled up into the
hepatic ducts, where they are much more difficult to remove.
Endoscopic transcystic CBD exploration. When stones are 4 to 8

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5 Gastrointestinal Tract and Abdomen

ACS Surgery: Principles and Practice


21 Cholecystetomy and Common Bile Duct Exploration 18

may be needed. If the cystic duct is long or spiraling or inserts


medially, this measure may not be feasible, in which case access
must be obtained by means of choledochotomy.

Figure 22 Open cholecystectomy. In so-called fundus down dissection, the fundus and infundibulum are retracted up and away
from the liver while dissection is performed with electrocautery.
Sharp dissection with scissors or scalpel or blunt digital dissection all may be used, at the surgeons discretion.

mm in diameter, the helical stone basket wires are generally too


close together to permit retrieval. Hence, choledochoscopic basketing is utilized. A 7 to 10 French choledochoscope with a working channel is either passed over the guide wire or inserted directly into the cystic duct. Because the usual grasping forceps may
damage the choledochoscope, forceps with rubber-covered jaws
should be used. A separate camera should be inserted onto the
choledochoscope, and the image it produces can be displayed on
the monitor by means of an audiovisual mixer (i.e., a picture within a picture) or displayed on a separate monitor.
Once the choledochoscope enters the cystic duct, warm saline
irrigation is begun under low pressure to distend the CBD and
provide a working space. The choledochoscope usually enters the
CBD rather than the common hepatic duct.When a stone is seen,
a 2.4 French straight four-wire basket is inserted through the operating port. The stones closest to the cystic duct are removed first,
by advancing the closed basket beyond each stone, opening the
basket, and pulling the basket back, thereby trapping the stone.
The basket is then closed and pulled up against the choledochoscope so that they can be withdrawn as a unit. Multiple passes may
be required until the duct is clear. A completion cholangiogram is
done to ensure that the duct is clear and to rule out proximal
stones. The dilated, traumatized cystic duct is ligated with a ligating loop rather than a hemostatic clip. If drainage is required, a red
rubber catheter can be inserted into the CBD via the cystic duct.
Because of the angle created by the cephalad and superior
retraction of the gallbladder, it may be difficult to pass the choledochoscope into the proximal ducts. If a common hepatic duct
stone is seen on the cholangiogram, the patient is placed in a steep
reverse Trendelenburg position. In this position, any nonimpacted
stones may fall into the distal duct for retrieval. It may be possible
to pass the choledochoscope into the proximal ducts by applying
caudal traction to the cystic duct so as to align it with the common
hepatic duct. An additional access port in the right upper quadrant

Laparoscopic CBD exploration Large stones (> 1 cm), as


well as most stones in the common hepatic ducts, are not retrievable with the techniques described above. Ductal clearance can be
achieved via choledochotomy if the duct is dilated and the surgeon
is sufficiently experienced.46,47 The anterior wall of the CBD is
bluntly dissected for a distance of 1 to 2 cm. When small vessels
are encountered, it is preferable to apply pressure and wait for
hemostasis rather than use the electrocautery in this area.Two stay
sutures are placed in the CBD. An additional 5 mm trocar is
placed in the right lower quadrant for insertion of an additional
needle driver. A small longitudinal choledochotomy (a few millimeters longer than the circumference of the largest stone) is
made with curved microscissors on the anterior aspect of the duct
while the stay sutures are elevated. A choledochoscope is then
inserted and warm saline irrigation initiated. In most cases, baskets should suffice for stone retrieval; however, lithotriptor probes
and lasers are available for use through the working channel of the
choledochoscope. The choice of approach depends on availability
and individual surgical experience.
Subsequently, a 12 or 14 French latex T tube is fashioned with

Figure 23 Open cholecystectomy. In patients with severe


inflammation and edema, the surgeon must be cautious when
approaching Calots triangle during fundus down dissection. In
such circumstances, digital palpation can be very helpful in safely identifying the cystic duct and artery.

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ACS Surgery: Principles and Practice

5 Gastrointestinal Tract and Abdomen

21 Cholecystetomy and Common Bile Duct Exploration 19

Figure 24 Open common bile duct exploration. (a) The common bile duct is opened vertically between laterally positioned stay sutures. (b) A catheter is then used to irrigate and flush stones from the duct. If stones are
impacted within the duct, they can be retrieved with Fogarty catheters, wire stone retrieval baskets, or stone
retrieval forceps. The choledochoscope can be used if any of these methods fail or as the initial method of
exploration.

short limbs, placed entirely intraperitoneally to prevent CO2 from


escaping, and positioned in the CBD.The choledochotomy is then
closed with fine interrupted absorbable sutures. The first suture is
placed right next to the T tube, securing it distally, and the second
is placed at the most proximal end of the choledochotomy; lifting
these two sutures facilitates placement of additional sutures.
Intracorporeal knots are preferred to avoid sawing of the delicate tissues.The end of the T tube is then pulled out through a trocar, and
cholangiography is performed after completion of the procedure.
Open Cholecystectomy

Open cholecystectomy is usually reserved for patients in whom


the laparoscopic approach is not feasible or is contraindicated. As
such, it is typically performed only in the most difficult situations
or when additional maneuvers such as CBD exploration are anticipated. Conversion from the laparoscopic to the open approach is
not considered a complication and does not represent failure.
Rather, conversion to this time-honored and effective procedure
represents the prudent judgment of a safe surgeon.
OPERATIVE TECHNIQUE

The choice of incision depends on the surgeons experience and


preference, along with patient factors such as previous surgical
procedures and body habitus. Typically, open cholecystectomy is
performed through a right subcostal (Kocher) incision, but it can
also be approached through an upper midline incision or, less
commonly, through a right paramedian or transverse incision. A
mechanical retraction system should be used, if available, so that
the hands of the participating surgeons are free; there is no good

rationale for struggling to perform difficult biliary surgery with


handheld retractors.
The abdomen is opened and then explored; the abdominal viscera are inspected and palpated and a retraction system is put in
place. Long curved or angled clamps, such as Kelly or Mixter, are
placed on the gallbladder fundus and infundibulum for the application of gentle traction. The fundus is elevated and the
infundibulum is pulled laterally and away from the liver [see Figure
21]. If the gallbladder is not too inflamed and edematous, the procedure may be performed similarly to the typical laparoscopic
approach: the surgeon identifies and ligates the cystic duct and
artery, and then removes the gallbladder from the liver bed.
With more difficult open cases, the above technique may not be
possible. In such cases, a retrograde or so-called fundus down
approach is usually employed. Staying as close to the gallbladder
wall as is possible, the surgeon uses electrocautery or sharp and
digital blunt dissection to remove the gallbladder from the liver
bed, continuing downward to the cystic duct and artery [see Figure
22]. Anatomic variations of the duct and artery must always be
anticipated. These structures can be very difficult to identify and
safely dissect in cases of severe inflammation and markedly edematous tissues. In such cases, palpation and gentle digital blunt
dissection of the duct and artery between thumb and index finger
is useful [see Figure 23]. Opening the gallbladder to remove stones
or aspirate bile or pus may be necessary when it is tense and distended or necrotic and gangrenous. As with laparoscopic cholecystectomy, it is critical to identify the cystic duct and artery and
their anatomic relations to the gallbladder and common bile duct
before division and to avoid injury to the common bile duct or
common hepatic duct. The cystic duct and artery may be suture

ACS Surgery: Principles and Practice

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5 Gastrointestinal Tract and Abdomen

21 Cholecystetomy and Common Bile Duct Exploration 20

Figure 25 Open common bile duct exploration. (a) After common bile duct exploration, a T tube is
fashioned and is placed into the duct. (b) Interrupted 4-0 absorbable sutures are used to close the choledochotomy snug around the tube. A completion cholangiogram may then be performed. The tube is
brought out through the right abdominal wall, through a separate stab incision, and secured to the skin.

ligated or divided between clips. Stones found in the cystic duct


should be gently milked back into the gallbladder.
SPECIAL CONSIDERATIONS

Cholangiography
The indications for cholangiography are the same as for laparoscopic cholecystectomy. Several techniques for the performance of
cholangiography can be utilized. Usually the same technique as for
laparoscopic cholecystectomy is employed; the cystic duct is ligated or clipped high near the infundibulum and incised just below
this point for insertion of a cholangiography catheter, which is
secured against leakage by another clip or ligature. Alternatively,
the cystic duct can be divided near the infundibulum and the gallbladder removed; then the cystic duct is cannulated. Needle puncture cholangiography can also be performed via the cystic duct or
the common duct. Once cholangiography is complete, the gallbladder is removed and sent for pathologic examination.The operative field is inspected for hemostasis and irrigated. Any bile leak
is identified. Drains are not routinely placed but can be used at the
surgeons discretion. If drains are used, a closed suction JacksonPratt or similar drain is recommended; the drain should be
brought out through a separate stab incision.
Open CBD Exploration
Open common bile duct exploration has become a rare procedure, but it remains a skill that surgeons require. If ERCP has
failed or is not possible, if the surgeon does not have the experience and necessary tools to perform laparoscopic duct exploration, or if laparoscopic efforts have failed, then open explora-

tion becomes necessary. Ductal stones are identified either preoperatively or intraoperatively by ultrasound, cholangiography, or
palpation.
Appropriate retraction and exposure are crucial. The anterior
aspect of the duct is exposed over a distance of 1 to 2 cm, avoiding electrocautery during dissection. Two stay sutures of a 3-0
monofilament are placed lateral to the midline of the duct. The
common hepatic duct is sharply opened with a No. 11 or No. 15
scalpel and longitudinally incised further with a Potts arteriotomy
or similar scissors.When performing these maneuvers, the surgeon
must respect the arterial blood supply of the duct, which courses
laterally on either side of the duct in the 3 oclock and 9 oclock
positions [see Figure 24]. In some cases, stones are immediately visible and can simply be plucked from the duct once it is opened.
Flushing the duct with saline, proximally and then distally,
through a 12 or 14 French Foley or red rubber catheter may also
clear the duct of stones. The intravenous administration of 1 to 2
mg of glucagon will relax the sphincter of Oddi, which may help
in the flushing of stones from the duct. In some cases, stones will
be impacted within the duct and will require additional maneuvers. Kochers maneuver (liberally mobilizing the lateral duodenum and head of the pancreas) will allow the surgeon to hold and
palpate the duodenum, the head of the pancreas, and stones within the duct, facilitating instrumentation. Stone retrieval forceps,
biliary Fogarty catheters, and wire baskets can all be employed to
retrieve stones. A choledochoscope can also be used, either at the
outset of exploration or for stone retrieval, if simpler maneuvers
are not successful.
Either T tube cholangiography or choledochoscopy may be
employed to confirm clearance of ductal stones. If no stones are

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ACS Surgery: Principles and Practice

5 Gastrointestinal Tract and Abdomen

21 Cholecystetomy and Common Bile Duct Exploration 21

present, primary closure of the choledochotomy has been successfully employed, although most surgeons will leave in place a
12 or 14 French T tube, which is brought out through a separate
stab incision in the right lateral abdominal wall [see Figure 25]. If
stone clearance is not achieved, a T tube is mandatory for
decompression of the biliary tract and to provide a route for
future duct instrumentation. The T tube is connected to a bag
for free drainage. Several days later, cholangiography is repeat-

ed. If it shows good flow into the duodenum without obstruction, the tube may be clamped and removed at the 2-week mark.
If there are retained stones, a more mature tract must be allowed
to develop over 4 to 6 weeks for future instrumentation and
stone retrieval. Retained stones may require ERCP, percutaneous transhepatic instrumentation, T tube tract instrumentation, or combinations of these for removal.
1. McSherry CK: Cholecystectomy: the Gold Standard. Am J Surg 158:174, 1989

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Acknowledgments
Figures 2, 5 Tom Moore.
Figure 18 Courtesy of Nathaniel J. Soper, M.D.,
Northwestern University Feinberg School of Medicine,
Chicago.
Figures 21 through 25 Alice Y. Chen.