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Laparoscopic subtotal cholecystectomy
Laparoscopic cholecystectomy is a hazardous operation when the anatomy of Calot’s triangle is distorted by acute inflammation or any other factor (in our case, adhesions due to the recent surgery, and especially due to radiotherapy). In these difficult situations, the intraoperative decision to use a protective surgical technique as subtotal cholecystectomy is made with the purpose to prevent any injury to the biliary tree.
This video demonstrates the case of a 69-year-old woman with morbid obesity (BMI of 55) and diagnosed with acute cholecystitis. Her past medical history is relevant for right nephrectomy for renal carcinoma using a right subcostal laparotomy followed by radiochemotherapy completed 3 months earlier.
Subtotal cholecystectomy is a procedure which aims to remove portions of the gallbladder when structures of Calot’s triangle cannot be safely identified in "difficult gallbladders". The conversion rate to open surgery was higher among this category of patients. We describe our experience with a technical change, namely, a tactical laparoscopic subtotal cholecystectomy which almost always prevents conversion at the end of the procedures, and prevents both the risk of injury to the common bile duct and the risk of hemorrhage. In such cases, there is a need for rigor and prudence in order to return to the traditional technique in real time, if necessary.
Laparoscopic subtotal cholecystectomy can be considered a safe and feasible alternative to conversion to open surgery. Subtotal cholecystectomy is an essential technique to be used in difficult gallbladders. It achieves morbidity rates comparable to those reported for total cholecystectomy in simple cases.
A Cotirlet, M Nedelcu
Surgical intervention
2 years ago
4833 views
286 likes
0 comments
20:31
Laparoscopic subtotal cholecystectomy
Laparoscopic cholecystectomy is a hazardous operation when the anatomy of Calot’s triangle is distorted by acute inflammation or any other factor (in our case, adhesions due to the recent surgery, and especially due to radiotherapy). In these difficult situations, the intraoperative decision to use a protective surgical technique as subtotal cholecystectomy is made with the purpose to prevent any injury to the biliary tree.
This video demonstrates the case of a 69-year-old woman with morbid obesity (BMI of 55) and diagnosed with acute cholecystitis. Her past medical history is relevant for right nephrectomy for renal carcinoma using a right subcostal laparotomy followed by radiochemotherapy completed 3 months earlier.
Subtotal cholecystectomy is a procedure which aims to remove portions of the gallbladder when structures of Calot’s triangle cannot be safely identified in "difficult gallbladders". The conversion rate to open surgery was higher among this category of patients. We describe our experience with a technical change, namely, a tactical laparoscopic subtotal cholecystectomy which almost always prevents conversion at the end of the procedures, and prevents both the risk of injury to the common bile duct and the risk of hemorrhage. In such cases, there is a need for rigor and prudence in order to return to the traditional technique in real time, if necessary.
Laparoscopic subtotal cholecystectomy can be considered a safe and feasible alternative to conversion to open surgery. Subtotal cholecystectomy is an essential technique to be used in difficult gallbladders. It achieves morbidity rates comparable to those reported for total cholecystectomy in simple cases.
Diagnosis and treatment of symptomatic common bile duct stones following cholecystectomy by means of EUS and ERCP
A post-cholecystectomy syndrome is a well-known condition, which includes dyspepsia and biliary-like abdominal pain coupled with deterioration of liver enzymes. Biliary factors responsible for a post-cholecystectomy syndrome could be the following: biliary iatrogenic duct strictures, retained stones in the common bile duct (CBD), cystic stump, or even a gallbladder remnant.
The diagnosis of stones is difficult to establish considering that even trans-abdominal ultrasonography has a diagnostic sensitivity of only 27%. Conversely, endoscopic ultrasound (EUS) is a very useful tool to diagnose stones in such situations, allowing to perform subsequent ERCP and stone extraction during the same anesthetic session. Here, we report the case of a 69-year-old man who underwent laparoscopic cholecystectomy and who was referred to us after 24 hours of abdominal colic pain and cholestasis. He underwent EUS, which diagnosed residual common bile duct stones. As a result, treatment was performed by means of ERCP during the same session.
Gf Donatelli, F Cereatti, B Meduri
Surgical intervention
4 years ago
1464 views
62 likes
0 comments
03:26
Diagnosis and treatment of symptomatic common bile duct stones following cholecystectomy by means of EUS and ERCP
A post-cholecystectomy syndrome is a well-known condition, which includes dyspepsia and biliary-like abdominal pain coupled with deterioration of liver enzymes. Biliary factors responsible for a post-cholecystectomy syndrome could be the following: biliary iatrogenic duct strictures, retained stones in the common bile duct (CBD), cystic stump, or even a gallbladder remnant.
The diagnosis of stones is difficult to establish considering that even trans-abdominal ultrasonography has a diagnostic sensitivity of only 27%. Conversely, endoscopic ultrasound (EUS) is a very useful tool to diagnose stones in such situations, allowing to perform subsequent ERCP and stone extraction during the same anesthetic session. Here, we report the case of a 69-year-old man who underwent laparoscopic cholecystectomy and who was referred to us after 24 hours of abdominal colic pain and cholestasis. He underwent EUS, which diagnosed residual common bile duct stones. As a result, treatment was performed by means of ERCP during the same session.
Acute gangrenous cholecystitis with biliary peritonitis in a diabetic patient: laparoscopic cholecystectomy
This video demonstrates an early laparoscopic cholecystectomy in a diabetic 49-year-old female patient with acute gangrenous cholecystitis and biliary peritonitis. She was admitted to the emergency department with retrosternal pain radiating towards the epigastrium associated with vomiting and fever for the past 3 days. During clinical examination, she had signs of acute cholecystitis without jaundice. Her blood tests showed an important systemic inflammatory reaction without alteration of liver function tests (LFT). Finally, imaging studies (ultrasound and CT-scan) confirmed an acute calculous cholecystitis with signs of gallbladder wall ischemia and peritoneal-free fluid.
A technically challenging early laparoscopic cholecystectomy with preoperative cholangiogram was performed. The disease was controlled and the postoperative course was uneventful with patient discharge 4 days after the operation.
Early laparoscopic cholecystectomy is the standard of care for patients with mild acute cholecystitis and an onset of symptoms of less than 72 hours (Tokyo Guidelines 2013, Recommendation 1, Level A) [1]. Patients with severe local inflammation of the gallbladder presenting factors such as >72 hours from the onset, a white blood cell count >18,000, and a palpable tender mass in the right upper abdominal quadrant have grade II (moderate) cholecystitis. For these patients, a conservative treatment with gallbladder drainage can be proposed followed by delayed cholecystectomy, as early cholecystectomy can be technically challenging. Early cholecystectomy for moderate (grade II) acute cholecystitis is recommended in experienced centers [2].
A recent Cochrane meta-analysis of 5 RCTs demonstrated that there was no significant difference in the proportion of people who developed bile duct injury, nor in the proportion of people who required conversion to open cholecystectomy in patients with acute cholecystitis. Total hospital stay was 4 days shorter in the early cholecystectomy group as compared to the delayed cholecystectomy group. About 20% of the people belonging to the delayed cholecystectomy group had either non-resolution of symptoms or recurrence of symptoms before their planned operation and had to undergo emergency laparoscopic cholecystectomy. However, since the incidence of major complications is rare (about 0.2%) in cholecystectomy, a trial would have to include 50,000 patients to have sufficient power for this endpoint [3].
References:
1. Yamashita Y, Takada T, Strasberg SM, Pitt HA, Gouma DJ, Garden OJ, Büchler MW, Gomi H, Dervenis C, Windsor JA, Kim SW, de Santibanes E, Padbury R, Chen XP, Chan AC, Fan ST, Jagannath P, Mayumi T, Yoshida M, Miura F, Tsuyuguchi T, Itoi T, Supe AN; Tokyo Guideline Revision Committee. TG13 surgical management of acute cholecystitis. J Hepatobiliary Pancreat Sci 2013;20:89-96.
2. Yokoe M, Takada T, Strasberg SM, Solomkin JS, Mayumi T, Gomi H, Pitt HA, Garden OJ, Kiriyama S, Hata J, Gabata T, Yoshida M, Miura F, Okamoto K, Tsuyuguchi T, Itoi T, Yamashita Y, Dervenis C, Chan AC, Lau WY, Supe AN, Belli G, Hilvano SC, Liau KH, Kim MH, Kim SW, Ker CG; Tokyo Guidelines Revision Committee. TG13 diagnostic criteria and severity grading of acute cholecystitis (with videos). J Hepatobiliary Pancreat Sci 2013;20:35-46.
3. Gurusamy KS, Nagendran M, Davidson BR. Early versus delayed laparoscopic cholecystectomy for acute gallstone pancreatitis. Cochrane Database Syst Rev 2013;9:CD010326.
D Ntourakis, D Mutter, J Marescaux
Surgical intervention
4 years ago
3170 views
123 likes
0 comments
20:03
Acute gangrenous cholecystitis with biliary peritonitis in a diabetic patient: laparoscopic cholecystectomy
This video demonstrates an early laparoscopic cholecystectomy in a diabetic 49-year-old female patient with acute gangrenous cholecystitis and biliary peritonitis. She was admitted to the emergency department with retrosternal pain radiating towards the epigastrium associated with vomiting and fever for the past 3 days. During clinical examination, she had signs of acute cholecystitis without jaundice. Her blood tests showed an important systemic inflammatory reaction without alteration of liver function tests (LFT). Finally, imaging studies (ultrasound and CT-scan) confirmed an acute calculous cholecystitis with signs of gallbladder wall ischemia and peritoneal-free fluid.
A technically challenging early laparoscopic cholecystectomy with preoperative cholangiogram was performed. The disease was controlled and the postoperative course was uneventful with patient discharge 4 days after the operation.
Early laparoscopic cholecystectomy is the standard of care for patients with mild acute cholecystitis and an onset of symptoms of less than 72 hours (Tokyo Guidelines 2013, Recommendation 1, Level A) [1]. Patients with severe local inflammation of the gallbladder presenting factors such as >72 hours from the onset, a white blood cell count >18,000, and a palpable tender mass in the right upper abdominal quadrant have grade II (moderate) cholecystitis. For these patients, a conservative treatment with gallbladder drainage can be proposed followed by delayed cholecystectomy, as early cholecystectomy can be technically challenging. Early cholecystectomy for moderate (grade II) acute cholecystitis is recommended in experienced centers [2].
A recent Cochrane meta-analysis of 5 RCTs demonstrated that there was no significant difference in the proportion of people who developed bile duct injury, nor in the proportion of people who required conversion to open cholecystectomy in patients with acute cholecystitis. Total hospital stay was 4 days shorter in the early cholecystectomy group as compared to the delayed cholecystectomy group. About 20% of the people belonging to the delayed cholecystectomy group had either non-resolution of symptoms or recurrence of symptoms before their planned operation and had to undergo emergency laparoscopic cholecystectomy. However, since the incidence of major complications is rare (about 0.2%) in cholecystectomy, a trial would have to include 50,000 patients to have sufficient power for this endpoint [3].
References:
1. Yamashita Y, Takada T, Strasberg SM, Pitt HA, Gouma DJ, Garden OJ, Büchler MW, Gomi H, Dervenis C, Windsor JA, Kim SW, de Santibanes E, Padbury R, Chen XP, Chan AC, Fan ST, Jagannath P, Mayumi T, Yoshida M, Miura F, Tsuyuguchi T, Itoi T, Supe AN; Tokyo Guideline Revision Committee. TG13 surgical management of acute cholecystitis. J Hepatobiliary Pancreat Sci 2013;20:89-96.
2. Yokoe M, Takada T, Strasberg SM, Solomkin JS, Mayumi T, Gomi H, Pitt HA, Garden OJ, Kiriyama S, Hata J, Gabata T, Yoshida M, Miura F, Okamoto K, Tsuyuguchi T, Itoi T, Yamashita Y, Dervenis C, Chan AC, Lau WY, Supe AN, Belli G, Hilvano SC, Liau KH, Kim MH, Kim SW, Ker CG; Tokyo Guidelines Revision Committee. TG13 diagnostic criteria and severity grading of acute cholecystitis (with videos). J Hepatobiliary Pancreat Sci 2013;20:35-46.
3. Gurusamy KS, Nagendran M, Davidson BR. Early versus delayed laparoscopic cholecystectomy for acute gallstone pancreatitis. Cochrane Database Syst Rev 2013;9:CD010326.
Laparoscopic cholecystectomy 2 months after acute cholecystitis with intra-abdominal abscess
Cholecystectomy for symptomatic gallstones is mainly performed as soon as an acute cholecystitis episode settles. The main reason is the fear of higher morbidity and conversion from laparoscopic cholecystectomy to open cholecystectomy during acute cholecystitis.
Acute cholecystitis is generally caused by gallstones. Gallstones affect about 10% of the population in the Western world but over 80% of people with gallstones are asymptomatic. Acute cholecystitis develops in 1 to 3% of patients with symptomatic gallstones. Cholecystectomy can be performed by laparotomy or by laparoscopy, either at the time of the initial attack (early treatment) or 2 to 3 months after the initial attack has subsided (delayed treatment). A factor complicating the assessment of outcomes of early treatment is that “early” has been variably defined as anywhere from 24 hours to 5 days after either the onset of symptoms or the time of diagnosis. If a delayed or conservative treatment is selected, patients are treated during the acute phase with antibiotics, very occasionally patients undergo percutaneous cholecystostomy (placement of a tube in the gallbladder). Fifteen to 20% of patients who underwent delayed procedures had persistent or recurrent symptoms requiring intervention before the planned operation. Today early laparoscopic cholecystectomy is considered to be the treatment of choice for most patients.
L Marx, A D'Urso, D Mutter, J Marescaux
Surgical intervention
6 years ago
8219 views
117 likes
1 comment
07:53
Laparoscopic cholecystectomy 2 months after acute cholecystitis with intra-abdominal abscess
Cholecystectomy for symptomatic gallstones is mainly performed as soon as an acute cholecystitis episode settles. The main reason is the fear of higher morbidity and conversion from laparoscopic cholecystectomy to open cholecystectomy during acute cholecystitis.
Acute cholecystitis is generally caused by gallstones. Gallstones affect about 10% of the population in the Western world but over 80% of people with gallstones are asymptomatic. Acute cholecystitis develops in 1 to 3% of patients with symptomatic gallstones. Cholecystectomy can be performed by laparotomy or by laparoscopy, either at the time of the initial attack (early treatment) or 2 to 3 months after the initial attack has subsided (delayed treatment). A factor complicating the assessment of outcomes of early treatment is that “early” has been variably defined as anywhere from 24 hours to 5 days after either the onset of symptoms or the time of diagnosis. If a delayed or conservative treatment is selected, patients are treated during the acute phase with antibiotics, very occasionally patients undergo percutaneous cholecystostomy (placement of a tube in the gallbladder). Fifteen to 20% of patients who underwent delayed procedures had persistent or recurrent symptoms requiring intervention before the planned operation. Today early laparoscopic cholecystectomy is considered to be the treatment of choice for most patients.
Totally laparoscopic single port hepatic left lobectomy and cholecystectomy for cholangiocarcinoma
Background: Single port (SP) hepatic resection presents a few examples in the recent literature which suggest a clear possibility for better cosmetic results and shorter hospital stay. This video presents a patient who has undergone totally laparoscopic SP left hepatic lobectomy for cholangiocarcinoma and cholecystectomy for cholelitiasis.

The present case shows a 70-year-old woman with a BMI of 26 kg/m2 with documented 45mm hepatic mass and irregular margins involving segment III suggesting intrahepatic cholangiocarcinoma. A 40mm peri-umbilical incision was performed. SP hepatic left lobectomy was performed using a 4-access OCTO™ port (High-Tech Center, Seoul, Korea), with a 30-degree scope, a curved grasping forceps, and Atlas Ligasure™ (Covidien, USA) and Vascular Endo GIA™ (Covidien, USA); specimen retrieval was performed through the right periumbilical incision.

Results: No conversion to open surgery was necessary, neither were additional trocars. Total operative time was 120 minutes and laparoscopic time 80 minutes; liver transection time was 24 minutes. Final umbilical incision length was 40mm. Blood loss was lower than 40cc, no transfusion or abdominal drainage was required. The postoperative course was uneventful and the patient was discharged on postoperative day 2.

Conclusions: Left hepatic lobectomy for localized intrahepatic cholangiocarcinoma and associated cholecystectomy can be safely performed with a periumbilical SP procedure, with macro- and microscopically neoplasia-free margins.
U Cillo, E Gringeri, R Boetto, G Zanus
Surgical intervention
7 years ago
3935 views
30 likes
0 comments
05:20
Totally laparoscopic single port hepatic left lobectomy and cholecystectomy for cholangiocarcinoma
Background: Single port (SP) hepatic resection presents a few examples in the recent literature which suggest a clear possibility for better cosmetic results and shorter hospital stay. This video presents a patient who has undergone totally laparoscopic SP left hepatic lobectomy for cholangiocarcinoma and cholecystectomy for cholelitiasis.

The present case shows a 70-year-old woman with a BMI of 26 kg/m2 with documented 45mm hepatic mass and irregular margins involving segment III suggesting intrahepatic cholangiocarcinoma. A 40mm peri-umbilical incision was performed. SP hepatic left lobectomy was performed using a 4-access OCTO™ port (High-Tech Center, Seoul, Korea), with a 30-degree scope, a curved grasping forceps, and Atlas Ligasure™ (Covidien, USA) and Vascular Endo GIA™ (Covidien, USA); specimen retrieval was performed through the right periumbilical incision.

Results: No conversion to open surgery was necessary, neither were additional trocars. Total operative time was 120 minutes and laparoscopic time 80 minutes; liver transection time was 24 minutes. Final umbilical incision length was 40mm. Blood loss was lower than 40cc, no transfusion or abdominal drainage was required. The postoperative course was uneventful and the patient was discharged on postoperative day 2.

Conclusions: Left hepatic lobectomy for localized intrahepatic cholangiocarcinoma and associated cholecystectomy can be safely performed with a periumbilical SP procedure, with macro- and microscopically neoplasia-free margins.
Dealing with vascular variation: laparoscopic cholecystectomy
This video describes the technique of laparoscopic cholecystectomy for symptomatic cholelithiasis with intraoperative cholangiography.
The key steps are presented: exploration, exposure, dissection of Calot’s triangle, intraoperative cholangiography, clipping and division, gallbladder bed dissection.
This technique is well standardized for the management of this condition.
The authors use intraoperative cholangiography for symptomatic cholelithiasis. To dissect Calot’s triangle, the authors first place grasping forceps through the epigastric trocar to grasp the gallbladder’s fundus and retract it cephalad and toward the patient’s right shoulder. They use a second grasping forceps on the infundibulum and retract the gallbladder laterally and caudally, thus opening Calot’s triangle. They start the dissection close at the junction of the infundibulum with the cystic duct, then incise the anterior and posterior peritoneal leaflets to access the vascular and biliary elements of Calot’s triangle. They then skeletonize the cystic duct and cystic artery.
D Mutter, J Marescaux, C Solano
Surgical intervention
11 years ago
3369 views
127 likes
0 comments
09:14
Dealing with vascular variation: laparoscopic cholecystectomy
This video describes the technique of laparoscopic cholecystectomy for symptomatic cholelithiasis with intraoperative cholangiography.
The key steps are presented: exploration, exposure, dissection of Calot’s triangle, intraoperative cholangiography, clipping and division, gallbladder bed dissection.
This technique is well standardized for the management of this condition.
The authors use intraoperative cholangiography for symptomatic cholelithiasis. To dissect Calot’s triangle, the authors first place grasping forceps through the epigastric trocar to grasp the gallbladder’s fundus and retract it cephalad and toward the patient’s right shoulder. They use a second grasping forceps on the infundibulum and retract the gallbladder laterally and caudally, thus opening Calot’s triangle. They start the dissection close at the junction of the infundibulum with the cystic duct, then incise the anterior and posterior peritoneal leaflets to access the vascular and biliary elements of Calot’s triangle. They then skeletonize the cystic duct and cystic artery.
Laparoscopic management of CBD stones in acute cholecystitis
This video demonstrates a complex case of a patient with obstructive jaundice and acute cholecystitis. The surgeon performs a transcystic cholangiogram, which demonstrates three large stones in the CBD. The choledochotomy is then made and a choledochoscope is used to visualize the stones. Under direct vision a Dormia basket is used to retrieve the three stones. After the choledochoscopy confirms the absence of any further stones in proximal and distal biliary tree, the choledochotomy is closed with interrupted absorbable sutures over a T-tube. A completion cholangiogram is performed. A Penrose drain is left in place after the cholecystectomy is completed.
M Simone, J Marescaux
Surgical intervention
13 years ago
3235 views
26 likes
0 comments
05:50
Laparoscopic management of CBD stones in acute cholecystitis
This video demonstrates a complex case of a patient with obstructive jaundice and acute cholecystitis. The surgeon performs a transcystic cholangiogram, which demonstrates three large stones in the CBD. The choledochotomy is then made and a choledochoscope is used to visualize the stones. Under direct vision a Dormia basket is used to retrieve the three stones. After the choledochoscopy confirms the absence of any further stones in proximal and distal biliary tree, the choledochotomy is closed with interrupted absorbable sutures over a T-tube. A completion cholangiogram is performed. A Penrose drain is left in place after the cholecystectomy is completed.