Dr V Gandhi DNB GI Surgery DNB Gen Surgery MNAMS Consultant GI amp HPB Surgeon Pune surgical Society What is safe cholecystectomy What is difficult cholecystectomy Predict difficult gall bladder ID: 777498
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Difficult Cholecystectomy
Dr. V GandhiDNB (GI Surgery), DNB (Gen Surgery), MNAMSConsultant GI & HPB SurgeonPune surgical Society
Slide2Slide3What is safe cholecystectomy ?
What is difficult cholecystectomy ?Predict difficult gall bladderManagement options
Preview
Slide4Safe Cholecystectomy
Critical View of Safety
Slide5Difficult Cholecystectomy
Procedure with an increased surgical risk compared with standard CholecystectomyOne taking longer that 90 minutes, tearing the gallbladder, spending more that 20 minutes dissecting the gallbladder adhesions, or more than 20 minutes dissecting Calot’s triangle
Lal P ; JSLS 2002
Slide6Surgeon
Surgical carrierFour port Three port Single port SILS NOTES
Slide7Patient factors
MaleobesityMirrizi syndromeAscitisPortal hypertensionAcute cholecystitis & sequelae
Anatomical anomaliesIntrahepatic GBPrevious surgery
Slide8Slide9Grade 1 MILD
Grade 2 MODERATE
Grade 3 SEVERE
Severity assessment of acute cholecystitis TOKYO Guidelines
Slide10Slide11Slide12Damage Control
CholecystostomyFundus first approachSubtotal Cholecystectomy – lap/open
Endoscopic sphincterotomy
Slide13Ideal Procedure – Safe cholecystectomy not possible
Does not leave a remnant gallbladder that will become symptomatic and require a later operation.Has low morbidity due to bile fistula. If a fistula occurs it should resolve spontaneously over a short period
Can be done laparoscopicallyCan be done by a surgeon without additional training in HPB surgery
Slide14Removal vs Non removal of posterior wall of gall bladder
Haemorrhage
– no difference in both groups
Subhepatic
collections , bile leak , retained stones – more in group with non removal of posterior wall
Slide15Closure vs non closure of GB stump for subtotal cholecystectomy
Non closure of GB stump – more collections & bile leak
Closure of stump – more retained stones
No significant difference in weighted analysis
Slide16Open vs lap subtotal cholecystectomy
Lap SC associated with less risk of sub hepatic collections, retained stones ,
wound infections and re operations
Lap SC associated with more bile leaks
Slide17Subtotal Fenestrating Cholecystectomy
Slide18Subtotal Reconstituting Cholecystectomy
Slide19Prevention of bile leak using omental plug technique after subtotal cholecystectomy
for difficult gall bladders
Slide20Problems
Adhesions and neovascularity – harmonic, ligasure
Difficult traction of the liver – additional ports Inadequate exposure of the cholecystohepatic triangle –
retraction on the GB body Fundus first approach
High risk gallbladder bed
High risk Hilum
Slide21High risk GB bed – Type 1 Lap SC High risk Hilum – Type 2 Lap SC
Slide22High risk GB bed + High risk Hilum – Type 3 Lap SC
Slide23Advantages of Lap in Cirrhotic
Wound infection, dehiscence & postoperative hernia are lessInadvertent bacterial seeding & contamination of ascitis is significantly reduced
Magnification inherent in lap surgery makes identification of the presence of dilated vascular channelsNeedle stick injuries are reduced
Less post op adhesions – benefit for future transplantation
Slide24Lap
chole in cirrhotic patients is associated with a higher complication rate than in non cirrhotic patients, due to several inherent risk factors.
Improvements in operating skills, equipment and accumulating experience in performing LC in difficult conditions over the years has made LC in cirrhotic patients a safe proposition when used judiciously.
The postoperative complications are related primarily to Child-Pugh class, being maximum in patients of Child-Pugh class C . Proper selection of the patients, adequate preoperative optimization, and appropriate instrument use have led to lower morbidity and significantly
less mortality
Slide25Acalculous cholecystitis
AAC Percutaneous Transhepatic cholecystostomy Tube cholangiography
No gall stones Gall stones +
Tube removal
No cholecystectomy
Elective cholecystectomy
Slide26Mirrizi syndrome
Type 1 – Lap / open cholecystectomy
Type 2 - subtotal cholecystectomy / choledochoplasty / T tube
Type 3/ 4 – biliary bypass
Slide27Gall Bladder Perforation - Type I
Generalized biliary peritonitis
Slide28Type II GBP
Stones eroding into the liver with abscess
Patient had jaundice on presentation
Cholecystectomy & T tube drainage of CBD was done
Perforated GB with abscess in
the liver
Gall Bladder Perforation - Type 2
Slide29Anatomical variants
Vascular anomaliesBiliary tract variantsLeft sided gall bladder
Bilobed gall bladderDouble cystic duct
Slide30Nagral S : JMIS 2005
Slide31Difficult cystic duct
Metal clipsHemolockEndoloopTieIntracorporeal suturingEndo GIA staplers
Bipolar sealantHarmonic ultrasonic shears
Slide32Methods of safe laparoscopic cholecystectomy for left-sided (sinistroposition) gallbladder: A report of two cases and a review of safe techniques
LEFT SIDED GALL BLADDER
Int J
Surg Case Rep. 2014; 5(10): 769–773
Slide33When to convert …..
Unable to proceed Ongoing BleedingSuspected biliary injuryAnatomical variationsPoor instrumentationOperating in periphery – low threshold
When in doubt !
Slide34Conclusion
Anticipate trouble • Open subtotal/total cholecystectomy is safe and effective • Be Wary of: – Difficult anatomy
– Difficult pathology
Slide35Choose well, Cut well, Get well
drgandhivv@gmail.com
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