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ICG fluorescent cholangiography in difficult laparoscopic cholecystectomy with inflammatory biliary fusion post-cholecystitis and pancreatitis
Laparoscopic cholecystectomy in the presence of inflammatory billiary fusion is a technically challenging procedure associated with a 0.5% risk of injury to major extrahepatic bile ducts.
Preoperative planning and intraoperative visualization of the anatomy of the biliary tree using an intraoperative cholangiogram reduces the risk or the severity of injury to major biliary ducts.
Indocyanine green cholangiography has emerged as a promising non-invasive modality for visualization of extra-hepatic biliary ducts, having the advantage of very easy use repetitively at various stages of critical areas of dissection.
This video demonstrates a laparoscopic cholecystectomy in a patient who had an emergency admission for mild acute cholecystitis (as per Tokyo guidelines, 2018) and concomitant moderately severe acute gallstone pancreatitis (revised Atlanta classification) with a preoperative MRCP predictive of biliary inflammatory fusion between the gallbladder neck and the common hepatic duct.
Consequently, we planned and performed a laparoscopic cholecystectomy with an indocyanine green cholangiogram as a non-invasive method to help identify the intraoperative anatomy of the extra-hepatic biliary ducts.
The main feature of our video is the use of indocyanine green during the difficult dissection of the gallbladder neck and exposure of the critical view of safety in Calot’s triangle as cased with clear features of significant biliary inflammatory fusion between the cystic duct and the common hepatic duct.
ICG fluorescent demonstration of the extra-hepatic biliary tree is used in real time and with ease repeatedly at several stages of this difficult dissection, facilitating a safe completion of a difficult laparoscopic cholecystectomy and may become a standard practice.
G Kumar, S Ramachandran, M Paraoan
Surgical intervention
4 months ago
243 views
5 likes
1 comment
13:21
ICG fluorescent cholangiography in difficult laparoscopic cholecystectomy with inflammatory biliary fusion post-cholecystitis and pancreatitis
Laparoscopic cholecystectomy in the presence of inflammatory billiary fusion is a technically challenging procedure associated with a 0.5% risk of injury to major extrahepatic bile ducts.
Preoperative planning and intraoperative visualization of the anatomy of the biliary tree using an intraoperative cholangiogram reduces the risk or the severity of injury to major biliary ducts.
Indocyanine green cholangiography has emerged as a promising non-invasive modality for visualization of extra-hepatic biliary ducts, having the advantage of very easy use repetitively at various stages of critical areas of dissection.
This video demonstrates a laparoscopic cholecystectomy in a patient who had an emergency admission for mild acute cholecystitis (as per Tokyo guidelines, 2018) and concomitant moderately severe acute gallstone pancreatitis (revised Atlanta classification) with a preoperative MRCP predictive of biliary inflammatory fusion between the gallbladder neck and the common hepatic duct.
Consequently, we planned and performed a laparoscopic cholecystectomy with an indocyanine green cholangiogram as a non-invasive method to help identify the intraoperative anatomy of the extra-hepatic biliary ducts.
The main feature of our video is the use of indocyanine green during the difficult dissection of the gallbladder neck and exposure of the critical view of safety in Calot’s triangle as cased with clear features of significant biliary inflammatory fusion between the cystic duct and the common hepatic duct.
ICG fluorescent demonstration of the extra-hepatic biliary tree is used in real time and with ease repeatedly at several stages of this difficult dissection, facilitating a safe completion of a difficult laparoscopic cholecystectomy and may become a standard practice.
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
3128 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 for phlegmonous acute cholecystitis
This video demonstrates the early surgical management of a 3-day history of acute cholecystitis in an 83-year-old patient. This patient was admitted to the emergency department for epigastric and right hypochondrium pain, without any other symptoms. Clinically, the patient presented with a localized abdominal guarding; Murphy’s sign was positive. Blood chemistries demonstrated the presence of an inflammatory syndrome and liver function tests were normal. The ultrasound exam confirmed the diagnosis of acute cholecystitis. A laparoscopic cholecystectomy was decided upon. The postoperative outcome was uneventful and the patient was discharged on postoperative day 3. Laparoscopic cholecystectomy is the gold standard for the early treatment of acute cholecystitis with an onset of symptoms less than 72 hours (Tokyo Guidelines 2013, recommendation 1, grade A).
O Perotto, H Jeddou, D Mutter, J Marescaux
Surgical intervention
4 years ago
6858 views
269 likes
0 comments
10:57
Laparoscopic cholecystectomy for phlegmonous acute cholecystitis
This video demonstrates the early surgical management of a 3-day history of acute cholecystitis in an 83-year-old patient. This patient was admitted to the emergency department for epigastric and right hypochondrium pain, without any other symptoms. Clinically, the patient presented with a localized abdominal guarding; Murphy’s sign was positive. Blood chemistries demonstrated the presence of an inflammatory syndrome and liver function tests were normal. The ultrasound exam confirmed the diagnosis of acute cholecystitis. A laparoscopic cholecystectomy was decided upon. The postoperative outcome was uneventful and the patient was discharged on postoperative day 3. Laparoscopic cholecystectomy is the gold standard for the early treatment of acute cholecystitis with an onset of symptoms less than 72 hours (Tokyo Guidelines 2013, recommendation 1, grade A).
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
8182 views
117 likes
0 comments
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.
Single stage laparoscopic management of common bile duct stones with acute cholecystitis
Ten to 18% of patients undergoing cholecystectomy for gallstones have common bile duct (CBD) stones. Treatment options for these stones include pre- or post-operative endoscopic retrograde cholangiopancreatography (ERCP), open surgery, or laparoscopic surgery.
The first option depends mainly on the availability of an experienced endocopist who could successfully clear stones in most patients. However no stones are found in 20% to 60% of cases. In such patients, rare and unpredictably severe ERCP morbidity can occur.
Thanks to progress in laparosocopic techniques, associated with technological developments, the single stage laparoscopic management of CBD and gallbladder stones has become one of the main options for the treatement of choledocholithiasis associated with cholelithiasis.
After the analysis of local conditions and the interpretation of intraoperative cholangiography images it is fundamental to decide which type of access to use to get to the main biliary tract, either transcystic access or directly through choledochotomy.
J D'Agostino, J Marescaux
Surgical intervention
7 years ago
6421 views
64 likes
0 comments
06:11
Single stage laparoscopic management of common bile duct stones with acute cholecystitis
Ten to 18% of patients undergoing cholecystectomy for gallstones have common bile duct (CBD) stones. Treatment options for these stones include pre- or post-operative endoscopic retrograde cholangiopancreatography (ERCP), open surgery, or laparoscopic surgery.
The first option depends mainly on the availability of an experienced endocopist who could successfully clear stones in most patients. However no stones are found in 20% to 60% of cases. In such patients, rare and unpredictably severe ERCP morbidity can occur.
Thanks to progress in laparosocopic techniques, associated with technological developments, the single stage laparoscopic management of CBD and gallbladder stones has become one of the main options for the treatement of choledocholithiasis associated with cholelithiasis.
After the analysis of local conditions and the interpretation of intraoperative cholangiography images it is fundamental to decide which type of access to use to get to the main biliary tract, either transcystic access or directly through choledochotomy.
Laparoscopic management of intra-abdominal fish bone mimicking acute cholecystitis
This video shows a female patient of 62 years, presenting with acute upper abdominal pain with fever and vomiting for five days. Clinically, she presented with features of acute cholecystitis.
Blood examination revealed leukocytosis with normal liver function tests. Abdominal ultrasonography showed edema of the gallbladder wall with pericholecystic collection, cholelithiasis and signs of acute cholecystitis.
Under antibiotic cover, the patient was subjected for single-port laparoscopic cholecystectomy using the EK glove port. Due to dense and stubborn adhesions, the procedure was converted to conventional 3-port surgery.
The duodenum was found adherent to the infundibulum of the gallbladder with a fish bone and pus within it. A 3.3cm long fish bone perforated the duodenum, produced abscess and mimicked acute cholecystitis.
The fish bone was extracted, perforation was repaired and cholecystectomy was performed.
E Khiangte, I Newme, P Phukan
Surgical intervention
7 years ago
2854 views
24 likes
0 comments
07:27
Laparoscopic management of intra-abdominal fish bone mimicking acute cholecystitis
This video shows a female patient of 62 years, presenting with acute upper abdominal pain with fever and vomiting for five days. Clinically, she presented with features of acute cholecystitis.
Blood examination revealed leukocytosis with normal liver function tests. Abdominal ultrasonography showed edema of the gallbladder wall with pericholecystic collection, cholelithiasis and signs of acute cholecystitis.
Under antibiotic cover, the patient was subjected for single-port laparoscopic cholecystectomy using the EK glove port. Due to dense and stubborn adhesions, the procedure was converted to conventional 3-port surgery.
The duodenum was found adherent to the infundibulum of the gallbladder with a fish bone and pus within it. A 3.3cm long fish bone perforated the duodenum, produced abscess and mimicked acute cholecystitis.
The fish bone was extracted, perforation was repaired and cholecystectomy was performed.
Single stage laparo-endoscopic management of acute cholecystitis and common bile duct stones
This video demonstrates the case of a 27-year-old woman, admitted to the emergency department for acute right hypochondrium pain.
Clinical examination found a positive Murphy’s sign. Biological findings showed a cholestasis (Gamma Glutamyl Transferase at 576 l/U, Alkaline Phosphatase at 346 l/U), and cytolysis (AST at 460 I/U, ALT at 635 I/U) without jaundice.
Abdominal ultrasonography confirmed the presence of acute cholecystitis with thickening of the gallbladder wall associated with a moderate 8mm dilatation of the common bile duct without any lithiasis.
Antibiotic therapy was started and cholecystectomy with intraoperative cholangiography was decided upon because of the clinical presentation and biological disturbance.
Gf Donatelli, L Marx, C Callari, J Marescaux
Surgical intervention
7 years ago
2007 views
9 likes
0 comments
04:38
Single stage laparo-endoscopic management of acute cholecystitis and common bile duct stones
This video demonstrates the case of a 27-year-old woman, admitted to the emergency department for acute right hypochondrium pain.
Clinical examination found a positive Murphy’s sign. Biological findings showed a cholestasis (Gamma Glutamyl Transferase at 576 l/U, Alkaline Phosphatase at 346 l/U), and cytolysis (AST at 460 I/U, ALT at 635 I/U) without jaundice.
Abdominal ultrasonography confirmed the presence of acute cholecystitis with thickening of the gallbladder wall associated with a moderate 8mm dilatation of the common bile duct without any lithiasis.
Antibiotic therapy was started and cholecystectomy with intraoperative cholangiography was decided upon because of the clinical presentation and biological disturbance.
Laparoscopic management of gangrenous perforated cholecystitis
Laparoscopic cholecystectomy is the gold standard for symptomatic cholecystolithiasis. Technical maturation and advances in instrumentation have enabled the application of this procedure for acute cholecystitis.
This video demonstrates the surgical approach to performing a laparoscopic cholecystectomy in an older male patient with acute cholecystitis and who has had a previous laparotomy for vascular surgery. The surgeon uses a French approach standing between the patient's legs while he optical trocar is placed supraumbilically, 3cm to the right of the midline in order to avoid the adhesions caused by the previous surgery.
An ischemic gallbladder with necrotic area and infundibular perforation was found.
J D'Agostino, J Marescaux
Surgical intervention
10 years ago
4168 views
88 likes
0 comments
05:58
Laparoscopic management of gangrenous perforated cholecystitis
Laparoscopic cholecystectomy is the gold standard for symptomatic cholecystolithiasis. Technical maturation and advances in instrumentation have enabled the application of this procedure for acute cholecystitis.
This video demonstrates the surgical approach to performing a laparoscopic cholecystectomy in an older male patient with acute cholecystitis and who has had a previous laparotomy for vascular surgery. The surgeon uses a French approach standing between the patient's legs while he optical trocar is placed supraumbilically, 3cm to the right of the midline in order to avoid the adhesions caused by the previous surgery.
An ischemic gallbladder with necrotic area and infundibular perforation was found.
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
4739 views
285 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.
Unintentional dissection of the common bile duct
This video demonstrates the case of an 81-year-old woman with chronic cholecystitis. She has had several episodes of right hypochondrium pain with altered liver tests, which spontaneously got back to normal values. Ultrasound and CT-scan demonstrated the presence of uncomplicated gallstones and a slightly hypotonic common bile duct (8mm in diameter). No obstacle was visualized in the common bile duct. A delayed laparoscopic cholecystectomy was scheduled. This video shows how some inaccuracies in the dissection technique and the presence of an altered anatomy have led to a circumferential dissection of the common bile duct. Common bile duct injury was avoided and the importance of an intraoperative cholangiography is emphasized.
M Ignat, N Malibary, D Mutter, J Marescaux
Surgical intervention
4 years ago
3776 views
137 likes
0 comments
06:50
Unintentional dissection of the common bile duct
This video demonstrates the case of an 81-year-old woman with chronic cholecystitis. She has had several episodes of right hypochondrium pain with altered liver tests, which spontaneously got back to normal values. Ultrasound and CT-scan demonstrated the presence of uncomplicated gallstones and a slightly hypotonic common bile duct (8mm in diameter). No obstacle was visualized in the common bile duct. A delayed laparoscopic cholecystectomy was scheduled. This video shows how some inaccuracies in the dissection technique and the presence of an altered anatomy have led to a circumferential dissection of the common bile duct. Common bile duct injury was avoided and the importance of an intraoperative cholangiography is emphasized.
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
3227 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.
Laparoscopic management of Mirizzi syndrome
The surgical management of acute cholecystitis continues to be a matter of personal choice. At our institution, we perform early laparoscopic cholecystectomy electively after treatment with intravenous fluids and antibiotics.
We present the case of a 35-year-old man who was admitted with a history of pain in the right upper abdomen for one day. He was managed with analgesics, intravenous fluids, and antibiotics. Despite relief from pain with aggressive medical therapy, he developed jaundice. An ultrasound examination confirmed a small stone impacted in the neck of the gallbladder and non-dilated biliary radicles. In view of increased serum bilirubin, the patient was scheduled for laparoscopic cholecystectomy.
Laparoscopic cholecystectomy revealed a gangrenous gallbladder with dilated cystic and common bile ducts. Intraoperative cholangiogram showed a suspicious filling defect at the lower end of the common bile duct. The ureteric catheter was therefore left indwelling and removed after one month.
Aa Rai, R Singh, S Rai, Sa Rai
Surgical intervention
6 years ago
6246 views
102 likes
0 comments
16:58
Laparoscopic management of Mirizzi syndrome
The surgical management of acute cholecystitis continues to be a matter of personal choice. At our institution, we perform early laparoscopic cholecystectomy electively after treatment with intravenous fluids and antibiotics.
We present the case of a 35-year-old man who was admitted with a history of pain in the right upper abdomen for one day. He was managed with analgesics, intravenous fluids, and antibiotics. Despite relief from pain with aggressive medical therapy, he developed jaundice. An ultrasound examination confirmed a small stone impacted in the neck of the gallbladder and non-dilated biliary radicles. In view of increased serum bilirubin, the patient was scheduled for laparoscopic cholecystectomy.
Laparoscopic cholecystectomy revealed a gangrenous gallbladder with dilated cystic and common bile ducts. Intraoperative cholangiogram showed a suspicious filling defect at the lower end of the common bile duct. The ureteric catheter was therefore left indwelling and removed after one month.
Laparoscopic cholecystectomy in a patient with nonalcoholic steatohepatitis (NASH) and idiopathic thrombocytopenic purpura
Morbid obesity surgery, which induces a rapid weight loss, is a predisposing factor for the onset of gallstones. There are treatments which help to reduce this risk. However, the observance is poor and lithogenicity brings about risks of complications such as cholecystitis, stone migration, and acute pancreatitis.
This video demonstrates the case of a patient who underwent a sleeve gastrectomy with a substantial weight loss. Stone migration was found along with a less serious pancreatic response. During a blood test analysis, thrombocytopenia was found and investigated by hematologists. Besides a low platelet count, a qualitative anomaly was observed increasing the risk of bleeding. Despite of this, cholecystectomy was necessary to prevent any new stone migration.
The operator was skilled and used a conventional laparoscopic approach. The patient’s liver is the site of a nonalcoholic steatohepatitis (NASH), making the procedure even more complex. Four ports were placed to allow for an adequate gallbladder retraction and for a minute dissection. Calot’s triangle was classically approached first as soon as the adhesions between the omentum and the gallbladder were taken down. Due to a thickened and inflammatory cystic duct, the entire gallbladder was dissected before ligating the cystic duct with two ligatures, one of them being reinforced by means of a surgical loop.
M Vix, B Seeliger, D Mutter, J Marescaux
Surgical intervention
6 months ago
766 views
2 likes
0 comments
13:25
Laparoscopic cholecystectomy in a patient with nonalcoholic steatohepatitis (NASH) and idiopathic thrombocytopenic purpura
Morbid obesity surgery, which induces a rapid weight loss, is a predisposing factor for the onset of gallstones. There are treatments which help to reduce this risk. However, the observance is poor and lithogenicity brings about risks of complications such as cholecystitis, stone migration, and acute pancreatitis.
This video demonstrates the case of a patient who underwent a sleeve gastrectomy with a substantial weight loss. Stone migration was found along with a less serious pancreatic response. During a blood test analysis, thrombocytopenia was found and investigated by hematologists. Besides a low platelet count, a qualitative anomaly was observed increasing the risk of bleeding. Despite of this, cholecystectomy was necessary to prevent any new stone migration.
The operator was skilled and used a conventional laparoscopic approach. The patient’s liver is the site of a nonalcoholic steatohepatitis (NASH), making the procedure even more complex. Four ports were placed to allow for an adequate gallbladder retraction and for a minute dissection. Calot’s triangle was classically approached first as soon as the adhesions between the omentum and the gallbladder were taken down. Due to a thickened and inflammatory cystic duct, the entire gallbladder was dissected before ligating the cystic duct with two ligatures, one of them being reinforced by means of a surgical loop.
Laparoscopic bile duct exploration with bile duct endoscopy and biliary bypass for recurrent biliary pancreatitis after cholecystectomy
This video shows the peculiar case of a 50-year-old male patient who underwent an open cholecystectomy for acute cholecystitis 12 years ago and he has been consulting for pancreatitis symptoms during the last seven years.
The patient reported that he had undergone ERCP twice after cholecystectomy because of bile duct stones and reportedly, complete bile duct clearance was achieved both times.
He presented to our facility with a new episode of mild pancreatitis.
No abnormalities were demonstrated in liver function tests. Amylase, GGT, and alkaline phosphatase values were normal.
Hepatobiliary ultrasound demonstrated a dilated common bile duct. MRCP (cholangio-MRI) showed several filling defects, particularly in the common bile duct and the left hepatic duct. CT-scan of the pancreas did not reveal abnormalities within the pancreatic parenchyma.
We decided to perform a bile duct exploration with endoscopic evaluation of the entire biliary tree and to perform a Roux-en-Y hepaticojejunostomy because of recurrent biliary pancreatitis after cholecystectomy.
JM Cabada Lee
Surgical intervention
2 years ago
1912 views
105 likes
0 comments
10:55
Laparoscopic bile duct exploration with bile duct endoscopy and biliary bypass for recurrent biliary pancreatitis after cholecystectomy
This video shows the peculiar case of a 50-year-old male patient who underwent an open cholecystectomy for acute cholecystitis 12 years ago and he has been consulting for pancreatitis symptoms during the last seven years.
The patient reported that he had undergone ERCP twice after cholecystectomy because of bile duct stones and reportedly, complete bile duct clearance was achieved both times.
He presented to our facility with a new episode of mild pancreatitis.
No abnormalities were demonstrated in liver function tests. Amylase, GGT, and alkaline phosphatase values were normal.
Hepatobiliary ultrasound demonstrated a dilated common bile duct. MRCP (cholangio-MRI) showed several filling defects, particularly in the common bile duct and the left hepatic duct. CT-scan of the pancreas did not reveal abnormalities within the pancreatic parenchyma.
We decided to perform a bile duct exploration with endoscopic evaluation of the entire biliary tree and to perform a Roux-en-Y hepaticojejunostomy because of recurrent biliary pancreatitis after cholecystectomy.
Laparoscopic cholecystectomy: basic rules
In this key lecture, Dr. Dallemagne provides a brief overview of basic rules for a safe laparoscopic cholecystectomy. He demonstrates the incidence, different causes, and impact of biliary injuries in open, laparoscopic, and single port surgery. He describes the main criteria of dissection with the principle of critical view of safety and highlights the Tokyo and SAGES guidelines in relation to the optimal surgical timing. He mentions the recommended surgical techniques, main maneuvers of the technique with modified cholecystectomy, and when the decision to convert is made depending on complications. He also presents alternative methods for the intraoperative imaging of bile ducts, including the role of cholangiography, near-infrared and fluorescence-guided cholecystectomy.
B Dallemagne
Lecture
1 year ago
6510 views
872 likes
0 comments
39:17
Laparoscopic cholecystectomy: basic rules
In this key lecture, Dr. Dallemagne provides a brief overview of basic rules for a safe laparoscopic cholecystectomy. He demonstrates the incidence, different causes, and impact of biliary injuries in open, laparoscopic, and single port surgery. He describes the main criteria of dissection with the principle of critical view of safety and highlights the Tokyo and SAGES guidelines in relation to the optimal surgical timing. He mentions the recommended surgical techniques, main maneuvers of the technique with modified cholecystectomy, and when the decision to convert is made depending on complications. He also presents alternative methods for the intraoperative imaging of bile ducts, including the role of cholangiography, near-infrared and fluorescence-guided cholecystectomy.
Accidental finding of Ascaris lumbricoides in the common bile duct during laparoscopic cholecystectomy transcystic exploration
This is the case of a 37-year-old woman, who had acute cholecystitis for 4 days, accompanied by nausea, vomiting, and abdominal pain in the right upper quadrant.
Physical exam demonstrated a soft abdomen with right upper quadrant pain, positive Murphy’s sign, and a palpable painful mass.
Complete blood count (CBC) reported 7,700/uL WBC, 4.235u/L neutrophils (55%), 1.463u/L lymphocytes (19%), and 1.540/uL eosinophils (20%).
Total bilirubin: 0.7mg/dL, direct bilirubin: 0.4mg/dL, indirect bilirubin: 0.3mg/dL, alkaline phosphatase: 184U/L.
Hepatobiliary ultrasound reports a thin-walled bladder with biliary sludge. The bile duct is not dilated. According to the results, there was no parasite on the bile duct.
Pain does not subside with antispasmodics, and the patient is sent to undergo a laparoscopic cholecystectomy.
In surgery, a hydropic gallbladder was evidenced. It was drained with a Veress needle. It was then found that the cystic duct was dilated and a transcystic exploration was performed with a No. 6 - 8- 10 French gastric tube.
An Ascaris lumbricoides of 25cm in length was extracted.
After exploration was completed with a Fogarty catheter, and no additional parasites were found, conventional cholecystectomy was completed. Antibiotic and anti-parasite treatment was prescribed. The patient was discharged 2 days after the procedure without any complications.
LE Becerra
Surgical intervention
2 years ago
2032 views
126 likes
0 comments
08:19
Accidental finding of Ascaris lumbricoides in the common bile duct during laparoscopic cholecystectomy transcystic exploration
This is the case of a 37-year-old woman, who had acute cholecystitis for 4 days, accompanied by nausea, vomiting, and abdominal pain in the right upper quadrant.
Physical exam demonstrated a soft abdomen with right upper quadrant pain, positive Murphy’s sign, and a palpable painful mass.
Complete blood count (CBC) reported 7,700/uL WBC, 4.235u/L neutrophils (55%), 1.463u/L lymphocytes (19%), and 1.540/uL eosinophils (20%).
Total bilirubin: 0.7mg/dL, direct bilirubin: 0.4mg/dL, indirect bilirubin: 0.3mg/dL, alkaline phosphatase: 184U/L.
Hepatobiliary ultrasound reports a thin-walled bladder with biliary sludge. The bile duct is not dilated. According to the results, there was no parasite on the bile duct.
Pain does not subside with antispasmodics, and the patient is sent to undergo a laparoscopic cholecystectomy.
In surgery, a hydropic gallbladder was evidenced. It was drained with a Veress needle. It was then found that the cystic duct was dilated and a transcystic exploration was performed with a No. 6 - 8- 10 French gastric tube.
An Ascaris lumbricoides of 25cm in length was extracted.
After exploration was completed with a Fogarty catheter, and no additional parasites were found, conventional cholecystectomy was completed. Antibiotic and anti-parasite treatment was prescribed. The patient was discharged 2 days after the procedure without any complications.
Hybrid NOTES transvaginal cholecystectomy using 2 instruments (2.2mm and 3mm)
A 79-year-old patient presented with symptomatic cholecystolithiasis without signs of cholecystitis. Biochemical parameters were normal. Sonography showed large gallstones, which is a good indication for a transvaginal approach.
As we know, NOTES (natural orifice transluminal endoscopic surgery) is under constant evolution. Last year, hybrid procedures gained more importance. In our surgical department, we perform these procedures as a valid alternative for conventional laparoscopy. We observed that out patients have less pain, faster recovery, and at last almost no scar and are not at risk for incisional hernias.
With this video, we describe a comfortable 2 instrument technique using a hybrid transvaginal approach. A pneumoperitoneum of 12mmHg is created using a Veress needle at the umbilicus. A 3mm port is placed. A percutaneous clamp is placed with a diameter of 2.2mm. The patient is placed in a Trendelenburg position, and the transvaginal trocar, 12mm in diameter and 15cm in length, is pushed into the posterior fornix. A conventional cholecystectomy is performed with no loss of triangulation. Transvaginal clipping (by means of a large 45cm clip applier) and extraction are performed. Transabdominal scars are closed with a simple bandage and no suturing. The colpotomy is closed using separate Vicryl 2/0 sutures.
The procedure took 30 minutes. In our group, we have a mean operating time of 30 minutes for hybrid transvaginal cholecystectomies.
S Heyman, B Gypen, F van Sprundel, J Valk, L Hendrickx
Surgical intervention
3 years ago
1165 views
44 likes
0 comments
05:08
Hybrid NOTES transvaginal cholecystectomy using 2 instruments (2.2mm and 3mm)
A 79-year-old patient presented with symptomatic cholecystolithiasis without signs of cholecystitis. Biochemical parameters were normal. Sonography showed large gallstones, which is a good indication for a transvaginal approach.
As we know, NOTES (natural orifice transluminal endoscopic surgery) is under constant evolution. Last year, hybrid procedures gained more importance. In our surgical department, we perform these procedures as a valid alternative for conventional laparoscopy. We observed that out patients have less pain, faster recovery, and at last almost no scar and are not at risk for incisional hernias.
With this video, we describe a comfortable 2 instrument technique using a hybrid transvaginal approach. A pneumoperitoneum of 12mmHg is created using a Veress needle at the umbilicus. A 3mm port is placed. A percutaneous clamp is placed with a diameter of 2.2mm. The patient is placed in a Trendelenburg position, and the transvaginal trocar, 12mm in diameter and 15cm in length, is pushed into the posterior fornix. A conventional cholecystectomy is performed with no loss of triangulation. Transvaginal clipping (by means of a large 45cm clip applier) and extraction are performed. Transabdominal scars are closed with a simple bandage and no suturing. The colpotomy is closed using separate Vicryl 2/0 sutures.
The procedure took 30 minutes. In our group, we have a mean operating time of 30 minutes for hybrid transvaginal cholecystectomies.