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Laparoscopic Cholecystectomy


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History:

Laparoscopic cholecystectomy was developed and popularized in the United States by Dr. Eddie Joe Reddick in 1989. It was a natural outgrowth of laparoscopic surgery being done by gynecologists and arthroscopic surgery done by orthopaedic surgeons many years prior to 1989. As this minimally invasive surgery was being developed and applied to gall bladder surgery many instruments had to be developed and then modified to accommodate the needs specific to biliary tract surgery. In addition surgical methodology had to be modified as better techniques were developed to accomplish a safe, efficent cholecystectomy.

During this evolving process which continues today the entire general surgical community had to be trained and monitored to use this minimally invasive approach in such a way that assured safety and efficacy in the general population . By late 1990 and early 1991 many surgeons were performing laparoscopic cholecystectomies using the following technique:

The Procedure:

a) After induction of general anesthesia an oral-gastric tube is placed to decompress the stomach and a foley catheter is used to drain the bladder of urine.

b) A small incision is made near the umbilicus and a needle (Veress) is inserted blindly into the peritoneal cavity.

c) Carbon dioxide is introduced in the peritoneal cavity through the Veress needle which is now insufflated to 15mm mercury pressure.

d) A trocar/port is placed into the now insufflated peritoneum and a laparoscope is introduced into the peritoneum which allows the inside of the peritoneum to be projected onto video screens on either side of the operating table.

e) Three additional trocar ports are now placed in the right upper quadrant under direct vision, two are 5mm in diameter and one is 10mm in diameter. It is through these ports that laparoscopic instruments, i.e., graspers, dissectors, scissors, etc. are introduced to separate the gallbladder from the liver bed and the biliary free. This is accomplished in the following fashion:

1) The end of the gallbladder is grasped and pushed up toward the diaphragm. This places the cystic dust and cystic artery on stretch and permits the necessary separation of these structures prior to ligating them. Unfortunately when the end of the gall bladder is placed on stretch it can tent up the common bile duct to which it is attached. To avoid this tenting up of the common bile duct and to gain better exposure of the cystic duct, common duct, cystic artery area (Triangle of Calot), a second grasping instrument is now used to grasp the proximal portion of the gall bladder (Hartmann's pouch) and retract it inferiorolaterally.

This now opens up the cystic duct-common duct junction and allows for safe identification and dissection of this area.

2) Once the cystic duct, common bile duct and cystic artery have been clearly identified and dissected free of each other and other fibrous and fatty tissue, it is now safe to ligate and divide the cystic duct and the cystic artery. This is done by inserting a clipping instrument through the 10mm port and placing two clips proximally and distally then cutting between the clips. With this accomplished the gall bladder is then separated from the liver by dividing the peritoneum between the liver and the gall bladder using electrocautery. The electrocautery can be attached to any number of dissecting instruments designed for this purpose.

Sharp dissection with electrocautery or laser light is very effective in both separating the gall bladder from the liver bed and stopping any bleeding which may be encountered during this part of the operation.

3) Once the gall bladder has been safely separated from the cystic duct, cystic artery and liver bed it is grasped and pulled out through one of the larger 10mm ports.

Complications:

Although there are many advantages of minimally invasive laparoscopic gall bladder surgery including less morbidity and mortality, shorter recovery time and smaller, less visible incisions, there are some disadvantages worth discussing. Early in the national experience with laparoscopic cholecystectomy it became apparent that some surgeons who were in the early phases of their training would misidentify the anatomy and inadvertently clip and divide the common bile duct thinking it to be the cystic duct. In many instances this would result in complete obstruction of the common bile duct which would require a second operation to correct. Often these injuries were not noted at the time of the initial procedure and therefore a delay in the diagnosis of the problem often resulted.

Other problems of much less consequence have also been identified to occur following laparoscopic cholecystecomy. This includes entering the gall bladder and spilling stones and bile into the peritoneal cavity, failure to diagnose stones in the common bile duct, cystic duct clips falling off leading to bile peritonitis, holes being poked in the cystic dust while doing x-rays of the biliary tree (cholangiography), holes poked into the intestine or mesentery by either the needle used to fill the peritoneum with CO2 (Verness needle) or one of the trocars used to introduce the ports.

National Consensus Conference:

Because of these problems a national consensus conference was called by the NIH in 1992 to question the safety and efficacy of laparoscopic cholecystectomy as well as the value and use of cholangiography during laparoscopic cholecystectomy. This was then compared to the results of traditional open cholecystectomy.

The results of this consensus conference were less than definitive except that it was decided that laparoscopic cholecystectomy is a worthwhile procedure that can be done safely given proper training, supervision and experience and:

a) That a learning curve existed and once a particular surgeon performed 25 - 50 laparoscopic cholecystectomies the incidence of common bile duct injuries greatly decreased.

b) That routine x-rays of the bile duct (cholangiography) was not a necessary part of this procedure.

c) That conversion to an open procedure from a laparoscopic procedure should be done whenever there is any question concerning anatomy.

d) That the incidence of common bile duct injuries following laparoscopic procedures should be the same or close to that of open procedures.

Minimally invasive surgery represents a great step forward in the field of general surgery, however, there is no reason to sacrifice safety in it's performance. The standard to which things can be compared is the same as the operation done in the traditional open fashion. Complications which commonly occur during open procedures can also be expected following laparoscopic procedures.

Unfortunately no recommendations were made at the conference concerning credentialling. Although certain observations were made concerning learning curves, individual hospitals were left with the responsibility of monitoring and regulating surgeons at their individual facilities. Hence significant differences exist from institution to institution concerning requirements for credentialling for individual surgeons to do specific laparoscopic procedures. This circumstance continues today and probably will not change in the near future.

* This article is presented and copyrighted by The 'Lectric Law Library
and Dr. Steven E. Lerner & Associates (www.drlerner.com)

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