Cholecystectomy Flashcards
What is a Cholecystectomy
A surgical procedure to remove the gallbladder
What is the primary function of the gallbladder
store and concentrate a fluid called bile
What is Bile
A fluid that helps break down fat from food in your intestines
Why is a Cholecystectomy performed?
hardened deposits of digestive fluid can be formed in the gallbladder - removal of gallbladder is a common way to treat that
What must be retracted to gain access to the gallbladder
Liver
What quadrant is the gallbladder in?
RUP - right upper quadrant
What connects the liver and the gallbladder
Biliary tract
What is the role of the pancreas
regulating the level of sugar in the blood
define Cystic Plate
a white fibrous tissue that separates the gallbladder from the liver. Also known as the liver bed.
What two structures need to be clipped and ligated
cystic duct and the cystic artery
What is the Sphincter of Oddi
a muscular valve that opens and closes to allow digestive juices to enter the duodenum
What organ produces Bile
Liver
Where is bile released?
Into the small intestines
What is the pathway of Bile
Bile is released from the liver via the R&L hepatic duct ( which join to form the common hepatic duct)
The common hepatic ducts then joins with the cystic duct - to form the common bile duct
The Common bile duct then merges with the pancreatic duct- which delivers pancreatic secretions to the bile mixture
Bile enters the duodenum through the sphincter of Oddi
- Bile ducts
- Intrahepatic bile ducts,
- Left and right hepatic ducts,
- Common hepatic duct,
- Cystic duct,
- Common bile duct,
- Ampulla of Vater,
- Major duodenal papilla
- Gallbladder.
10–11. Right and left lobes of liver. - Spleen.
- Esophagus.
- Stomach.
- Pancreas: 16. Accessory pancreatic duct, 17. Pancreatic duct.
- Small intestine: 19. Duodenum, 20. Jejunum
21–22. Right and left kidneys.
The front border of the liver has been lifted up (brown arrow).[1]
What does CCK (cholecystokinin) stand for
to move the bag of bile
What are the two effects the CCK has?
- Relaxation of the sphincter of Oddi (to open it)
- stimulation of gallbladder contraction to release stored bile
What happens when the sphincter of Oddi is open
Bile can flow into the duedenum
What happens when the sphincter of oddi is closed
bile is forced back up through the common bile duct and cystic duct into the gallbladder, where it is stored and concentrated for later release
Where is bile stored when the gallbladder has been removed?
The liver makes bile and it drains through the common hepatic ducts down the common bile duct. It’s stored in the liver
Aberrant bile ducts - why is it a problem
- right hepatic junction
- fibrous adhestions
- Cystic duct in front/behind
- no cystic duct
Can make dissection and identification difficult
What can cause fibrous adhesions
Previous surgery
inflammation
What is the problem with fibrous adhesions
can fuse the cystic duct and the common bile duct together
What is the problem with a very sort cystic duct
makes dissection and ligation difficult
What is the problem with a hepatic duct in front or behind?
Can make it very difficult to identify
First steps in a cholecystectomy
Liver needs to be retracted by grabbing the fundus of the gallbladder and retracting anteriorly
After the liver has been retracted, what happens
The peritoneum covering the gallbladder will need to be dissected, in order to expose the critical structures of the gallbladder
What is the fundus
the most distal part of the gallbladder
What is the infundibulum
Funnel - Where the body of the gallbladder narrows into the neck of the GB
Hartmann’s pouch
An area within the infundibulum where gallstones may accumulate
What structures make up Calot’s Triangle
Cystic duct
Common hepatic duct
inferior edge of the liver bed
How do surgeons obtain the critical view of safety
- Visualize the liver bed
- Identify exactly two structures entering the GB
- Cystic duct
- cystic artery
What can firefly do during a cholecystectomy
Assist in identification of critical anatomy
What are the 3 most common signs and symptoms of Biliary disease
- biliary colic: RUQ pain approximately 30 minutes following a meal, typically secondary to gallstones
- fever
- Jaundice: yellowing of skin and the white outer layer of the eyeball
What are the two types of:
Gallstone disease
Cholelithiasis - Formation of gallstones in the gallbladder
Choledocholithiasis - gallstones in the common bile duct
Which requires immediate treatment?
Cholelithiasis or Choledocholithiasis
Choledocholithiasis - gallstones in the common bile duct
Acute Cholecystitis - inflammation of the GB, secondary to gallstones
Bile delivery to the digestive system will be obstructed
What is it, and when is it performed?
Endoscopic Retrograde Cholangiopancreatography (ERCP)
- Used to better visualize the ductal anatomy and diagnose ductal disease
- A flexible tube with an endoscope is inserted throught the mouth and into the duodenum. When access to the biliary tract is gained, a contrast medium is injected into the biliary and pancreatic ducts for radiologic visualization
Benign Billiary Disease
Gallstone disease
- Cholelithiasis
- Choledocholithiasis
Description, Symptoms, Timing of surgery
Description: Presence of gallstones in the gallbladder(cholelithiasis) or in the common bile duct (choledocholithasis)
Symptoms: RUQ Pain, acute nausea and vomiting, pain after fatty meal
surgery: elective/planned
Benign Billiary Disease
Cholecystitis
Description, symptoms, timing of surgery
Description: chronic, low grade inflammation
Symptoms: pain in the right side of the rib cage, vomitting and/or jaundice
Surgery: elective /planned
Benign Biliary disease
Acute Cholecystitis
Description, symptoms, timing of surgery
Description: acute inflammation of the GB, usually secondary to the gallstone blockage of bile duct
Symptoms: severe RUQ pain and vomiting
Timing: Emergent
Benign biliary disease
Gallstone Pancreatitis
Description, symptoms, timing of surgery
D: Stone causing inflammation in pancrease
S: Upper abdominal pain that worsens after eating
T: Elective (patient initially admitted for pancreatitis to reslove, cholecystectomy performed during same admission)
Benign biliary disease
Biliary dyskinesia
Description, symptoms, timing of surgery
D: Dysfunction ofthe gallbladder or sphincter of oddi, causing pain
S: sharp pain, intermitten cramps located under the right ribs
T: elective / planned
Define
Classical Injury / Partial injury
C: an inadvertent injury or ligation of the common bile duct during surgery
P: can sometimes be repaired using suture, but a more severe injury or complete transection will require a hepaticojejuncostomy.
undiagnosed injury can lead to hepatic failure and even death
What is it,
Hepaticojejunostomy
A complex surgery and invasive procedure that is commonly done through open surgery by a hepatobiliary specialist.
During this procedure, the biliary system is reconnected to the small intestine by attaching the common hepatic duct to the jejunum
Critical for Early cases
Ideal Patient selection
6 markers
- Good Performance status - ASA1-11
- Non-obese patients (BMI<30)
- No previous upper abdominal surgery
- Age 18-80
- Symptoms consisten with GB disease (e.g. biliary colic)
- Patient must be a suitable candidates for laparoscopic cholecystectomy
Example - Dr. Canfield.
Operating Room Configuration
Patient cart, anesthesiologist, patient-side ast, surgeon, vision cart
Patient cart on the patients lefts
Anesthesiologist with direct access to patient
Patient-side assist on patient’s right side, with clear view of a monitor
surgeon with direct line of sight to patient
Vision cart touchscreen accessible to circulating nurse
Clinical Application
Firefly for Biliary duct identification
What is it used for? Benefits?
After ICG is taken up by the blood plasma, it is secreted into the bile by the liver. Use Firefly to identify extrahepatic biliary ducts. Identification of aberrant ducts, w/o the use of cholangiogram. This may decrease the concern of misidentification of the biliary anatomy
Technique
Firefly for biliary duct identification
What is ICG, When should you administer?
Reconstitute 25mg of Indocyanine Green (ICG) with 10ml sterile water to obtain a 2.5 mg/ml solution.
Inject 1.5-2.0 ml ICG in peripheral IV
Administer at lease 45 minutes prior to start of case
Length of time from injection to flourensense.
Firefly for Cystic Artery Identification
Flourescense is seen approx. 30-60 seconds after injection
1.5mL ICG peripheral IV, immediately followed by a 10mL saline flush
Patient Positioning and Preparation
Supine, secure the patient to the table using a strap across the things
Place patient in reverse trendelemburg ~ 10 degrees and lower the table all the way down
Tilt the bed 10 degrees to elevate the patients right side to aid in visualization
sterile prep the abdomen
Port Placement
Place initial endoscope port (Arm 3) approximately 2cm superior to the umbilicus. The other ports will be placed on a horizontal line with port 3
- 4, left lateral, 10cm away from 3
- 2, Right lateral, 10cm away from 3
- 1, right lateral, 10 cm away from 3
System Deployment & Docking
Select “Upper Abdomincal” under anatomy on the helm touchpad.
Dock Arm 3 to the initial endoscope port
Insert the Endoscope (30 degree down) and target the approx. position of the cycstic duct
Align the endoschope arm with the endoscope port and target anatomy
Adjust arms to ensure patient clearance
Broad overview
Steps for a Cholecystectomy
by Dr. Canfield
- Once docked, the assist and surgeon will grasp the GB to create exposure
- Calot’s triangle will then be dissected to gain the CVS(critical view of safety)
- This is when the surgeon could utilize firefly or elect to complete a cholangiogram
- Once anatomy has been identified, the cystic duct and artery will be ligated and divided.
- The GB is then dissected off the liver bed and removed from patient
Core instruments
Instrument Guide
- Hot shears (monopolar curved scissors)
- Force bipolar
- 2x Medium-large clip applier
- ProGraps Forceps
Optional Instruments
Instrument Guide
- ProGrasp Forceps
- Cadiere Forceps
- Fenestrated Bipolar Forceps
- Permanent cautery Hook
- Endowrist Suction Irrigator
3rd Party Ancillary Supplies
Instrument Guide
Laparoscopic Graspers
Laparoscopic Scissors
EndoBag for specimen removal (if required)
What the instruments are used for
Hot shears, force bipolar, ProGrasp, Large Clip Appliers x2
Hot shears: dissection and cold cut
Force bipolar: used when moving dense tissue or grasping on tissue that has tension by switching to “strong mode” for more grasping and retracting strength
ProGrasp: retracting GB toward the patient right shoulder
Clip Appliers: Ligate the cystic duct and cystic artery - use two for efficiency
Step 1
Initial exposure
- Take down adhesions (adhesiolysis)
- Grasp and retract the GB anteriorly to expose the cystic pedicle - Using arm 2 may improve triangulation with working arm 1&4
Define
Adhesiolysis
The dissection of adhesions or scar tissue
Step 2
Dissection of Calot’s triangle and the Critical View of Safety
What are the landmarks of Calots triangle, Structures entering the GB
- Retract the infundibulum to expose the landmarks of Calot’s triangle: Inferior surface of the liver, cystic duct, common hepatic duct
- Incise the peritoneum close to the GB neck
- Carefully dissect the structures within Calot’s triangle
- After completing dissection of Calots triangle, obtain CVS by dissecting the infundibulum of the cystic plate
- Confirm that the only structures entering the GB are: Cystic duct, cystic artery
- Avoid ligating the common bile duct!
Step 3
Confirmation with Firefly Flourescense Imaging
Ductal: identify extrahepatic biliary ducts and to examine the GB for potential accessory ducts
Arterial: confirm cystic artery identification and to reveal aberrant vessels
- This step requires and additional administration of 1.5mL ICG via a peripheral IV followed by a saline flush
- This can be observed approx. 1 min after ICG administered
Define, what is it used for
Cholangiography
indications
- Part of a routine practice
- unclear ductal anatomy
- possibility of stone in common bile duct
Overview
- Introduce angiocatheter percutaneously
- Catheter is instrted into the cystic duct
- C-Arm is positioned over patient
- Images are captured to hightlight biliary anatomy
- Not in real time
Firefly is not able to see gallstones w/in the anatomy
Step 4
Ligation and Division of the cystic Duct and Artery
- Using large clip appliers, ligate the cystic duct and cystic artery
- Place 2 clips proximally and one clip distally on the cystic duct
- Place one clip proximally and one clip distally is typically sufficient for the cystic artery
- Divide the cystic duct and cystic artery using cold cutting with the monopolar curved scissors
place 2 because there is minimal/no clotting to stop blood flow
Can you use energy around the clips
Not recommended, as it could shrink the tissue and cause the clip to be less effective
Proximally
towards the patient side
Step 5
Cystic Plate Dissection
- Dissect the GB off the cystic plate using catuery
- Start the dissection att he GB neck, work toward the fundus
- Dissect until the GB is released
Difference
Leakage vs Spillage
leakage - the clip is not on correctly and the bile is leaking into
Spillage - bile that flows out, not much of a issue.
Step 6
Specimen Removal
- Inspect the cystic plate for evidence of bleeding or bile leakage
- Prepare for removal of the specimen through the umbilicus
- Introduce a specimen bag into abdomen
- If necessary, irrigate the surgical field using the suction irrigator
- Undock, and remove all ports
- Remove the specimen bag
