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10 Tips for Laparoscopic Cholecystectomy in Acute Cholecystitis

Early surgery

  • In cases of hot GB, plan for surgery within 48 hours. Or else we need do wait at least 6 weeks prior to surgery. Surgery during day 7-14 can be hazardous with adhesions and bleeding.
  • Inflammatory edema makes early cholecystectomy relatively straight forward and risk of bile duct injury is not any higher.

Decompression of GB

  • Mucocele of GB or Empyema of GB or thick walled acute acalculous cholecystitis would require decompression by means of either aspiration needle or suction cannula without undue spillage.
  • This would enable us to hold the GB and proceed with Calot’s triangle dissection

Push technique

  • In cases of very thick walled GB, it is often frustrating not able to hold the Hartmann’s pouch or Fundus with forceps. In such situation suturing through fundus of GB or retracting the GB with open jaws of crocodile forceps would help us to concentrate on Calot’s triangle
  • Also never hesitate to put 5th port in the left midclavicular line and push the omentum and duodenum downwards with the help of liver retractor.

Suction tip Dissection

Blunt dissection of Calot’s triangle is primarily done with suction tip as it sucks all the edema fluid and oozing blood and helps us to find the cleavage between bile duct and cystic duct. It is akin to our index finger in open Chole.

Gauze

Do not hesitate to take one or two gauze pieces up front to control the oozing

Contents evacuation

If Calot’s triangle is frozen due to stone impaction of Hartmann’s pouch or cystic duct, do not hesitate to make an incision in the Hartmann’s pouch to empty all its contents in to a retrival bag. This will enable us to see the cystic duct opening from inside and dissection can proceed accordingly. After subtotal cholecystectomy, cystic duct can be suture ligated or we can use Roeder knot loops. Always keep a drain. We should not regret later for not keeping a drain!

Fundus first

If still we are not sure of anatomy at Calot’s triangle, one may proceed from fundus downwards with the help of Harmonic scalpel or diathermy spatula. Gauze packs over the dissected liver bed will prevent blood dribbling towards calot’s.

Be sure of anatomy

  • Rouvier’s Sulcus is the fissure between quadrate lobe and caudate lobe. Cystic duct is always anterior to this sulcus. So never clip anything that lies behind or below Rouvier’s sulcus.
  • Strasburg’s critical view of safety of clearly visualizing cystic duct and artery is not possible every time, so take all the cues for safe cholecystectomy. Dissect between cystic lymphnode and GB and look for junction of cystic duct GB and not Cystic duct to bile duct. Be satisfied with 99% cholecystectomy than 101% cholecystectomy!

Subtotal cholecystectomy

If the posterior wall is very adherent with no proper plane especially in cases of Cirrhotic liver, don’t hesitate to leave the posterior wall intact and do subtotal cholecystomy. Posterior wall mucosa can be destroyed with diathermy spatula.

Retrieval bag

Keep the GB, all stones and gauze packs in the bag and remove them through the enlarged epigastric port or Hasson’s port at the umbilicus. Avoid any spillage. Give thorough lavage with 1-2 litre of saline and look for haemostasis. If any Golden yellow coloured bile is seen in the region of Porta, it usually means bile duct injury or bile leak, so be vigilant. Always put a drain in acute GB and this ensures that you sleep well!