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Safe Laparoscopic CholecystectomyModern Advancements in HepatoPancreatoBiliary Surgery
Iswanto Sucandy, M.DFlorida Hospital, Tampa, FLMinimally Invasive and Robotic Surgery
HepatoPancreatoBiliary and Advanced Gastrointestinal Surgery
Disclosures
No disclosures
I fix bile duct injuries (many are very painful operations)
Introduction Introduced in late 1980’s Most commonly performed operation Over 700,000 cases annually in USA Bile duct injury after Lap Cholecystectomy :
0.5-0.8% Bile duct injury after Open Cholecystectomy :
0.1-0.2% Litigation claims - average settlements of up to
$500,000 USD Morbidity and Mortality SAGES Safe Cholecystectomy Task Force
Causes of Lap chole bile duct injury/leak- Misidentification of anatomical structures- Failure to occlude cystic duct stump
securely- Plane of GB dissection into the liver bed - Excessive traction on cystic duct off the
common hepatic duct - “tenting injury”- Improper technique of ductal exploration- Injudicious use of electrocautery for
dissection/hemostasis- Injudicious use of clips for hemostasis
Biliary Anatomy – Type of Union Cystic duct - CHD
a. Angular Unionb. Paralell Unionc. Spiral Union
Biliary Anatomy – Hepatic duct confluence
Biliary Anatomy – Low insertion Right Posterior Hepatic Duct
Cystic duct stump
Right posterior hepatic duct
Laparoscopic cholecystectomy
Excessive traction on cystic duct “tenting injury”
Bile Duct Injury – Laparoscopic Cholecystectomy 1st most common cause : misidentification of
CBD to be cystic duct 2nd most common cause : injury to the
aberrant right posterior hepatic duct
Identification techniques :
Infundibular Technique
Critical View of Safety
Bile Duct Injury – Laparoscopic Cholecystectomy 1st most common cause : misidentification of
CBD to be cystic duct 2nd most common cause : injury to the aberrant
right posterior hepatic duct
Identification techniques :
Infundibular Technique NO !!
Critical View of Safety YES
** Bile duct injury usually associated with Right Hepatic Artery injury – 20% **
Critical View of Safety
1. Triangle of Calot must be cleared of fat & fibrous tissues
2. Lowest part of GB must be separated from cystic plate
3. Two structures & only two are seen entering the GB
Laparoscopic cholecystectomy
Laparoscopic cholecystectomy
Gallbladder
Common Bile Duct (do not dissect/expose)
Cystic duct Cysti
c artery
Critical View of Safety
Critical View of Safety – front view
Critical View of Safety – posterior view
“ 2 windows “ dissection
Critical View of Safety
CVS is difficult to obtain ? Options :
Intraoperative cholangiography Help from a colleague Conversion to an open cholecystectomy When CVS unobtainable – laparoscopic subtotal
cholecytectomy , fenestrating cholecytectomy
Infundibular Technique
Infundibular Technique
Easier but why this technique should not be used
CHD
Very short cystic duct
What you do not want to see during laparoscopic cholecystectomy
What you do not want to see
What you do not want to see postoperatively
Type of Bile Duct Injury
Summary - how to avoid bile duct injury ? Proper identification of anatomy Careful dissection to achieve critical view of
safety Avoid excessive traction during dissection of
Calot triangle Plane of dissection should be close to GB wall Avoid excessive use of electrocautery Avoid blind clipping for hemostasis Gentle tissue manipulation during CBDE
When bile duct injury occurs, what to do ?.. Recognized intraoperatively – refer to an HPB expert
/center for immediate repair/reconstruction
Recognized in immediate postoperative period – delayed repair in 2-3 weeks. Focus : control of biliary leakage/infection/sepsis,
Delayed presentation –biliary tract reconstruction in delayed fashion.
Presenting signs of biliary injury/leak : - Abdominal pain (bile peritonitis), distension, and fever- Jaundice / elevated LFTs- Bile leakage from incision
Minimally Invasive HPB Minimally Invasive HPB
Laparoscopic Approach Robotic Approach
Minimally Invasive HPB MIS Whipple Procedure MIS Biliary Tract Surgery MIS Liver Resection
Advanced procedures, significant learning curve ++
Robotic Whipple Procedure
Robotic Whipple Procedure
Robotic Whipple Procedure
Robotic Biliary Tract Surgery
Laparoscopic Liver Resection
Laparoscopic Liver Resection
Robotic Liver Resection
Robotic Liver Resection
Robotic Liver Resection
Laparoscopic left lateral sectionectomy
References 1. Strasberg SM, Brunt LM. Rationale and use of the critical view
of safety in laparoscopic cholecystectomy. J Am Coll Surg. 2010 Jul;211(1):132-8.
2. Blumgart’s Surgery of the Liver, Biliary Tract, and Pancreas. 5 th Edition Elsevier 2012.
3. Bonrath EM, Dedy NJ, Zevin B, Grantcharov TP. International consensus on safe techniques and error definitions in laparoscopic surgery. Surg Endosc. 2014 May;28(5):1535-44.
4. Callery MP. Avoiding biliary injury during laparoscopic cholecystectomy: technical considerations. Surg Endosc. 2006 Nov;20(11):1654-8
Pucher PH, Brunt LM, Fanelli RD, et al. SAGES expert Delphi consensus: critical factors for safe surgical practice in laparoscopic cholecystectomy. Surg Endosc. 2015 Nov;29(11):3074-85.