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Mutter D, Marescaux J. Laparoscopic cholecystectomy in a cirrhotic patient. Epublication: WeBSurg.com, Feb 2013;13(2). URL: http://www.websurg.com/ref/doi-vd01en3865.htm

D Mutter (France), J Marescaux (France)

English - 23'26''
February 2013

Laparoscopic cholecystectomy in cirrhotic patients may be associated with several difficulties. These include a more difficult mobilization of the rigid fibrotic liver as well as the increased risk of bleeding due to associated portal hypertension. This video shows that the mere respect of basic rules for the performance of a cholecystectomy allows to safely manage associated problems. Child A cirrhosis is not a contraindication for the laparoscopic approach to the gallbladder.

Keywords: Laparoscopic cholecystectomy, cirrhotic patient

00'19'' Introduction
It is the case of a 55-year-old patient presenting a symptomatic biliary lithiasis. This patient has otherwise hepatitis C, with a cirrhosis that is known. There is no sign of cholestasis. On the other hand, there is a mild perturbation in the hepatic enzymes, which accounts for his hepatitis.
00'45'' Port position
The procedure starts as usual. Here we have subcostal margin, that is the area of the gallbladder, and we will start by performing an incision at the level of the umbilicus. It is an open access as we do usually in this patient. We start with a 10mm incision and we will make an open access. Open access is made as usually. Skin incision, opening of the different layers, control with the retractor until we get the access to the aponeurosis. And after the access of the aponeurosis, opening of the aponeurosis is performed. Control is made to be sure to be inside the abdomen.
After this, we take a port that is inserted bluntly. The port is inserted into the abdomen. Just before insufflation, we start to control the position into the abdomen; we are in the abdomen so we can now insufflate the patient.
01'52'' Exploration
Quick exploration of the abdomen, no abnormality. Bladder is not empty in this patient, see, but it\'s not the problem for this type of surgery. Mild cirrhotic patient, micro-nodular liver. Here, we see the installation of the patient, now we will change the position. You see that the exposure is better now.
02'26'' Trocars insertion
The next step is to insert the three trocars. One trocar will be inserted at the level of the xiphoid appendix. One trocar will be placed laterally 5 to 7cm away on the left side. One trocar will be inserted close to the right iliac fossa, 7cm away from the umbilicus. These are only 5mm trocars. The three trocars are inserted under direct control. This direct control is done in order to avoid any injury and to check immediately if there is any potential bleeding coming from the introduction port. No bleeding. Port number three. Now the epigastric port will be used for a retracting grasper, below the round ligament of the liver, in order to have a good exposure of this area, we confirm this cirrhotic liver, and we will present the gallbladder using this trocar.
03'43'' Exposure: freeing of adhesions to the gallbladder
We use a very low electric current. The objective is first to free the adhesions between the gallbladder and the omentum. No inflammation of this gallbladder. Very light and gentle adhesions, perhaps the sign of previous inflammation but this will allow progressively to free the gallbladder from all its landmarks. There is a little node here, now we see the critical area, some fat here, so we will change the position of the assistant after freeing the gallbladder. Take it in the middle of the gallbladder, put some more tension. We see that the traction of the round ligament is performed almost automatically thanks to the retraction of the round ligament and the liver.
04'38'' Dissection of cystic pedicle
This fatty liver is held here spontaneously. The critical area is here. Now the objective is to dissect close to the gallbladder in order to avoid any injury. Here, we have a node that is certainly around the cystic duct. So the dissection has to preserve this area and to start close to the gallbladder by opening only the peritoneal reflection. The opening is then done upwards, we really avoid the dissection downwards, which could be at risk of injury and we open the peritoneal dissection upwards, up to the liver. Here, we see the posterior attachment-here probably the area of the vessels, here certainly the common bile duct. The dissection is performed very carefully, far away with permanent cautery to avoid bleeding at this step. You see that the hook is also achieving some retraction effect.

No tension of the tissue to avoid any type of bleeding and oozing. That\'s the first step of dissection. We see that even if we have some elements here that for the moment are not completely identified, we can see here some big veins, probably some portal vein hypertension, which can be associated with the cirrhosis. But at this step, everything is done. Here we see probably some part of the hepatic artery on the right side, so using the same trocar and the same hand, we retract the gallbladder on the opposite side, we stay again close to the infundibulum, and we do again the same freeing of the adhesions and opening of the peritoneal layer. We always take only the peritoneum and we try not to take more tissue. Here, the infundibulum is progressively freed and the posterior opening will be continued until the first vessel is dissected. Again at this first step, the objective is to lengthen the distance between the gallbladder and the common bile duct, and to have a critical view of the exposure of Calot\'s triangle. Usually this dissection is performed until this first vessel 2 to 3cm; we see here a little vein that should be controlled with monopolar cautery. It is a millimetric vein but we know that it is a cirrhotic patient, and there is probably some more fat here. I will begin to identify the critical view here. Somewhere here we will identify the cystic duct so the adhesion around it will be freed. Here, we have a good freeing of the first structure, which is certainly the cystic duct. Dissection is continued until we identify the cystic artery. Here, we have an artery, we don\'t know whether it is a hepatic artery or a cystic artery, so the dissection is continued close to Hartmann\'s pouch of the gallbladder. That is a little artery, I will probably better put a clip at least on the side of the vessel, this could be associated with some bleeding here.
You see it is a really small artery. Again we see the very nice view we have here, very safe dissection, so we will open the peritoneal reflection in the same way we have done this posteriorly, we do it anteriorly. Very close to the gallbladder, always a little risk of injury to the gallbladder. All these attachments have to be lowered. You see that it is very quickly a little bit hemorrhagic. Here, we can lower all these little attachments here, and again we are coming in a completely free area. Very gentle blunt dissection. If there are more attachments, we see by transparency the little elements that we can have. Here we have some nodes.
09'53'' Exposure: critical view of safety
Now we have the critical view of safety here, only two elements joining the gallbladder. Here we have one little artery, no other element, no element coming from the posterior part. It is before control of any significant vessel in a cirrhotic patient that is very quickly bleeding, the artery here, cystic duct here, no duct going in another direction, the gallbladder is here, so we can control the artery, and we can control the cystic duct. The common bile duct is lowered, it will not be dissected, but it is in this area here, lower. We stay at distance for safety reasons.
10'45'' Clips to cystic duct and artery
The first clip is always placed on the remaining area, far away from any risky area, we look if there is a complete control of the duct, double the clip for safety reasons. One clip on the side of the gallbladder, complete control of the vessel, the same control will be performed during the same insertion. Two clips will be controlled for the artery and one clip for the remaining side of the gallbladder. This element will be cut and you see that we don\'t change the position of the right hand in order to win time. And this is in fact a little artery.
11'37'' Freeing of gallbladder
The dissection is almost free, now we can go on the neck of the gallbladder, posteriorly. Again, no change in the position of the assistant, no change in the position of the surgeon, and as there is no cholestasis, now we do a control of the common bile duct in this patient in which a quick and operation may be as beneficial as any other complementary procedure. Here we have a dense adhesion. Again dissection has to be performed very close to the gallbladder neck to avoid bleeding of veins as other tissues. Here we can come down, here probably a very little injury of the gallbladder at this level of dissection, and in fact at this level, we have probably made a little injury during the cautery of the vein that we have seen previously. I will change the position of the assistant, now we are allowed to have more space for dissection like that, now I can increase the distance between the gallbladder and the liver, I will change the position and start to do a dissection of the anterior reflection of the peritoneum.

I will successively do a posterior dissection, there is some bleeder that is due to the cirrhosis, so when you are in contact with the liver, there is bleeding and this will be controlled at the end with bipolar cautery. Fibrotic tissue, dense adhesion of the gallbladder, this can be associated with a risk of perforation of the gallbladder, which is the only real risk. Again this allows to identify fibrotic tissue. Here, we can identify the plane of fibrotic tissue. Little bleeder. These little bleeders are ideally controlled with bipolar cautery, certainly more effective than monopolar one here. It is a minor bleeding and on the other hand, it is a cirrhotic patient with still medication that can make him bleed, so I will open the peritoneal reflection more and I will control this bleeding with bipolar cautery at the end of the procedure. You see that the gallbladder is a little bit into the liver, so this nice traction will allow to open the capsule here. It\\'s fibrotic, a bit hyper-vascularized as compared to usual cases, always put tension on the tissue we are dissecting. We will go ahead back. Use only suction to clean this little area here. No possibility from the anterior part, so I will try to change and to do it from the posterior part.
The dissection plane is very close to the liver. There may be some bleeding on the gallbladder, but to avoid bleeding, it is better to identify landmarks, now I go back to the fibrotic tissue posteriorly. The dissection area is not always easy to identify. That is the little opening that we have done. Here it is the fibrotic plane, in which we have done some bleeding, so I will try to open it again. Little perforation due to monopolar cautery when controlling the vessel previously. I will clean again the operative field, we have a permanent oozing from the little vessel here. We will control the bleeding area afterwards. We have to free the gallbladder now. It’s interesting to have a hook completely protected to avoid cautery of the gallbladder with the posterior part of the hook, so I have completely opened the peritoneum up so I will dissect this area, which is not bleeding. We see that the dissection of the liver is really a little bit hemorrhagic, that is due to the cirrhosis, so I can put tension on the side of the liver and complete with an anterograde dissection here. Again, we see all these little veins, which are of bigger diameter than usual at the origin of the bleeding, that is the consequence of cirrhosis and portal hypertension so we will complete the dissection, and afterwards complete the hemostasis with bipolar cautery. We see that the oozing is significant in this patient at this step. The gallbladder is not completely free but almost. Some remaining adhesions in the middle. Here we see the dissection area.
18'10'' Control of hemostasis
The gallbladder is free, placed over the liver is the first step, now we will take the suction device in one hand, bipolar cautery in the other. Usually when the cholecystectomy is completed, there is a big limitation of the oozing, so we will start the control of the gallbladder bed from the upper part and we will move progressively to the lower part.
We see that there is almost no more bleeding. I clean gently the operative field, as usual all these little bleeders stop at the end of the cholecystectomy. We will complete cautery with bipolar cautery on the reflection line of the peritoneum. Very selective cautery, well localized.

A little bit deeper cautery, but there is still bleeding here in the liver, and the solution will perhaps be only a compression, we don\\'t know for the moment. We have taken a hemostatic agent, which should be used for gentle compression. During the compression time I will take the gallbladder out, take the time to insert a bag, there is no bleeding. This will be kept in place, controlled after five minutes to be sure that there is no more bleeding at this level. It is very superficial bleeding.
19'55'' Extraction of gallbladder
We insert a bag that will be inserted through the 10mm port. The bag will be held by two hands, one by the operator, one by the assistant, to be kept open. We will then take the gallbladder, which is placed over the liver here, and so the gallbladder can be very quickly and safely inserted in this bag. The bag will be closed. It is ready for extraction. I will leave this area like that, it\'s dry. We keep this little swab in. The area of resection is free. No active bleeding. There is a spontaneous compression at this level, and then we will use the epigastric trocar to take the gallbladder out, and the trocar is extracted; the bag is here. The bag is extracted here. This is open. The gallbladder is put into the bag; the suction goes into the gallbladder to empty the gallbladder, which can then easily come out, and only the stones block it, and everything is out, very clean, without any tension.
21'33'' Final control and trocars removal
A trocar is re-inserted. We can re-insufflate the patient. The gallbladder is out, no contact, no contamination. The last check will be used to control if there is no bleeding in the gallbladder bed, first control. No active bleeding. That was the first check. The second check is to take out the trocar under direct control. We extract the trocar with the bipolar inserted, so we can complete hemostasis. If there is any slight bleeding in the trocar, it can be controlled with the bipolar. Second trocar here, no bleeding at extraction; trocar number three, no bleeding in the trocar’s pathway, and the trocar number four was placed under open approach so there is no risk of bleeding. Exsufflation is always performed through the trocar and never directly to avoid anything going in. The patient is completely exsufflated. The 10mm opening will be closed with a suture and a subcutaneous suture will be performed in the other hole.
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