Difficult Cholecystectomy Dr V Gandhi DNB GI Surgery

Difficult Cholecystectomy Dr. V Gandhi DNB (GI Surgery), DNB (Gen Surgery), MNAMS Consultant GI & HPB Surgeon Pune surgical Society

Preview • What is safe cholecystectomy ? • What is difficult cholecystectomy ? • Predict difficult gall bladder • Management options

Safe Cholecystectomy Critical View of Safety

Difficult Cholecystectomy • Procedure with an increased surgical risk compared with standard Cholecystectomy • One 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

Surgeon • Surgical carrier • • • Four port Three port Single port SILS NOTES

Patient factors • • • Male obesity Mirrizi syndrome Ascitis Portal hypertension Acute cholecystitis & sequelae Anatomical anomalies Intrahepatic GB Previous surgery

Severity assessment of acute cholecystitis TOKYO Guidelines Grade 2 MODERATE Grade 1 MILD Grade 3 SEVERE

Damage Control • Cholecystostomy • Fundus first approach • Subtotal Cholecystectomy – lap/open • Endoscopic sphincterotomy

Ideal 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 laparoscopically • Can be done by a surgeon without additional training in HPB surgery

Removal 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

Closure 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

Open 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

Subtotal Fenestrating Cholecystectomy

Subtotal Reconstituting Cholecystectomy

Prevention of bile leak using omental plug technique after subtotal cholecystectomy for difficult gall bladders

Problems 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

High risk GB bed – Type 1 Lap SC High risk Hilum – Type 2 Lap SC

High risk GB bed + High risk Hilum – Type 3 Lap SC

Advantages of Lap in Cirrhotic • Wound infection, dehiscence & postoperative hernia are less • Inadvertent bacterial seeding & contamination of ascitis is significantly reduced • Magnification inherent in lap surgery makes identification of the presence of dilated vascular channels • Needle stick injuries are reduced • Less post op adhesions – benefit for future transplantation

Lap 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

Acalculous cholecystitis AAC Percutaneous Transhepatic cholecystostomy Tube cholangiography No gall stones Tube removal No cholecystectomy Gall stones + Elective cholecystectomy

Mirrizi syndrome Type 1 – Lap / open cholecystectomy Type 2 - subtotal cholecystectomy / choledochoplasty / T tube Type 3/ 4 – biliary bypass

Gall Bladder Perforation - Type I Generalized biliary peritonitis

Gall Bladder Perforation - Type 2 Type II GBP Stones eroding into the liver with abscess Perforated GB with abscess in the liver Patient had jaundice on presentation Cholecystectomy & T tube drainage of CBD was done

Anatomical variants Vascular anomalies Biliary tract variants Left sided gall bladder Bilobed gall bladder Double cystic duct

Nagral S : JMIS 2005

Difficult cystic duct • • Metal clips Hemolock Endoloop Tie Intracorporeal suturing Endo GIA staplers Bipolar sealant Harmonic ultrasonic shears

LEFT SIDED GALL BLADDER Methods of safe laparoscopic cholecystectomy for left-sided Int J Surg Case Rep. 2014; 5(10): 769– 773 (sinistroposition) gallbladder: A report of two cases and a review of safe techniques

When to convert …. . • • • Unable to proceed Ongoing Bleeding Suspected biliary injury Anatomical variations Poor instrumentation Operating in periphery – low threshold When in doubt !