Laparoscopic Subtotal Fenestrating Cholecystectomy in a Cirrhotic Patient

CHAPTER 1

Hi there. My name is Dr. Nicole Cherng.I am a general surgeon at UMass Memorial Hospitalin Worcester, Massachusetts.Today the case that I will be presentingis a laparoscopic cholecystectomyin a 60-something-year-old gentleman.He has known alcoholic cirrhosis.He presented many months ago with acute cholecystitis,and at that time,given his cirrhosis and his medical comorbidities,it was deemed that he would be a better candidatefor endoscopic placement of transcystic stents.This was done, and the patient did have good relief;however, he then had clogging of the stentsand he had recurrent cholecystitis,so he underwent an exchange of those stentsas well as the placement of a common bile duct stent.He continued to have multiple admissionswith recurring cholecystitis,and it was deemed that the transcystic stents were failing,so it was decided that we would proceedwith a cholecystectomyfor definitive care with the higher risks,and my plan for the operating roomwould be a laparoscopic cholecystectomyand also removal of the transcystic stents.

CHAPTER 2

Here, we enter the abdomen with a Veress needleto obtain pneumoperitoneum.Once I reach 15 mmHg,I then place a 5-mm supraumbilical port.An angled laparoscope, I use a 5-mm, 30-degree scope.While I am placing the three other trocarsin the right upper quadrant,it is immediately obvious the severely cirrhotic liverthat is visualized.This is not surprising given the patient's history.After placing all of my ports,I then positioned the patient in reverse Trendelenburgwith the left side down.Visualization of the right upper quadrant does show evidenceof the omental adhesions to the gallbladder.Part of these omental adhesions easily come offwith positioning as well as gentle retraction.I am able to visualize the gallbladderand able to retract the fundus towards the right shoulder.

CHAPTER 3

I can tell that there are now some chronic adhesionsof the omentum to the wall of gallbladder.These adhesions are generally evidentin someone who's had multiple episodes of biliary colicor symptomatic cholelithiasis,which this patient clearly had.Given the appearance of the gallbladder,I would deem this a picture more consistentwith chronic cholecystitis.Retracting the fundus of the gallbladdertowards the right shoulder,and then using the retraction of the omentumdown towards the pelvis,I have good tension to take down these omental adhesionswith the hook electrocautery.The duodenum now comes clearly into view.I use short bursts of monopolar cauterysuch that the thermal spread towards the duodenumis minimal.Now, with more of the gallbladder exposed,I'm able to use a locking laparoscopic wavy retractorto grasp the fundus of the gallbladderand retract this towards the right shoulder.

CHAPTER 4

I continue to lyse the band of tissuethat is tethering the duodenumto the infundibulum of the gallbladder.I'm sure to stay closer to the gallbladder sideas the duodenum falls away.I carry my dissection medially towards the liversuch that I can continue to expose the cholecystic triangle.Here, you can tell that the patient's tissueis very pliable and very inflamed.It's very oozy.This is not surprising given the patient's cirrhosisand likely predisposing coagulopathy and thrombocytopenia.I continue my dissection bedtowards the body of the gallbladder.The peritoneum is incredibly thickened,another common finding seen in chronic cholecystitis.I do the same along the lateral aspect of the gallbladder,taking down the peritoneum.Here, I'm clearly staying high along the gallbladder.I'm well above the sulcus.At this point, in a more standard elective cholecystectomy,after taking down the peritoneumof the anterior and posterior portion of the infundibulum,generally for most patients, we would have a senseof where the cystic duct and the cystic artery lie,and we would then proceedto skeletonize those two structures.However, here it's very evidentthat this is incredibly inflamed and fusedand scarred in as well,so I therefore then with good retraction of the infundibulumin my left hand with the laparoscopic grasper,I continue to use the hook electrocautery.I continue to use the hook electrocauteryto take down the second layerof incredibly thickened peritoneumin hopes that it'll show me the critical structures.

CHAPTER 5

I do the similar moveon the lateral backside of the gallbladder.At this point, the interface of the infundibulumto the cystic duct is not fully clear to me.Here on the posterior lateral side of the gallbladder,I take down the second layer of very thickened peritoneumin hopes to better define the edge of the infundibulum.As you can see, it's very thickened in well.It appears to be clear through the hook.It feels thicker tissue than I expect,and so I stopped thereand moved to another part of the gallbladder.I continue on the lateral backside,staying high along the gallbladderto find the gallbladder edge.I carry this dissection straight back towards the liver bed.When I flip the gallbladder back towards the front,it's very evident to me that there's clearly a holewithin the body of the gallbladderjust above the level of the infundibulum.At this point, what is going through my headis now at the hole within the gallbladder,I am committed to having to move forward.I know that at the minimumI will need to do some form of subtotal cholecystectomy.So what is critical for me nowis to find the cystic duct and cystic artery.I go back and forth between the hook electrocauteryas well as the suction irrigator as a blunt dissector.Here along the backside of the gallbladderI have a sense based off of haptic feedbackas well as visualization,that I am coming down to the levelof the edge of the infundibulum of the gallbladder.And I continue to sweep bluntlythis very thickened peritoneum off of itto further expose it.Within the hole of the gallbladder that I made,I visualize the plastic transcystic transpapillary stentsthat were previously placed.

CHAPTER 6

Pigmented gallstones are suctioned out as well.Here I find the edge of the infundibulum of the gallbladder.And at this point, I deemedthat within the cholecystic triangle it will not be feasiblefor me to skeletonize the critical view of safety.I therefore electthat I will do a subtotal fenestrating cholecystectomy.In order to do so, I know that I need to develop the windowbetween the gallbladder and the liver plate.I therefore transition along the body of the gallbladderto stay safe to find this window.Here, I am bluntly dissecting the posterior wallof the gallbladder off of the peritoneal edge.I transitioned to the lateral backside of the gallbladderin hopes to find that same plane and connect the two.With the gallbladder more decompressed,now that the hole in the gallbladder is made,I do think I have better retraction with my left handto find that same plane so that I can meet the two.

CHAPTER 7

However, now the retraction of the gallbladderand the amount of force that has been placedand thinned out the gallbladder wall,I have created a holein the backside of the gallbladder as well.Once again, the transpapillary plastic stent is visualized,as well as multiple pigmented gallstonesare now coming out of the gallbladder.I know that both holesare within the body of the gallbladder,given that I see the stent as well as multiple gallstones.My dissection is - the holes are also well above the area of the dissection,and so I do not think that at this pointthat any danger has been done.As I try to develop a planebetween the posterior wall of the gallbladderfrom the liver plate,I continue to cause a fair amount of shear injuryto the wall of the gallbladder,such that it continues to become - that hole becomes wider.

CHAPTER 8

So at this point, I electthat instead I'll just connect those two holes,which means transecting the anterior wallof the gallbladder.I'm high up, well above the dissection bed,well away from the cystic duct, cystic artery,as well as the common bile duct.

CHAPTER 9

Now you can see that the body of the gallbladderhas been essentially transected, about 80% of it.The two previously placed transpapillary transcystic ductsstents are visualized.I remove both of those,as they're clearly obstructing my view,and we no longer need them.These are plastic stents.They're very small and they're safe to come out.I also clean out and suction outand remove the multiple pigmented black stones seen.My goal at this point is to identify the cystic duct orificeand suture that off with plans for a drain.The patient had a preoperative common bile duct stentplaced as well.I will often have the advanced gastroenterologistplace the common bile duct stentbefore these very difficult gallbladderswho've had multiple interventionssuch as either transpapillary cystic duct stents,or percutaneous cholecystostomy tube placements,because I know that these oftentimescause significant chronic inflammation and scarring,and therefore will pose a fairly difficult gallbladder,and the patients are counseledthat oftentimes the subtotal cholecystectomyis more likely than not to be performed,and so by placing the common bile duct stentbefore the surgery,I know that therefore I can minimizethe amount of bile leakageif anything does occur, postoperatively.Here, I continue to clean out multiple pigmented stones,and just achieving hemostasis herebefore we move on with our subtotal cholecystectomy.Clearly, we can see where the catheter is sittingwithin the cystic duct orifice.This is where I'll plan to stitch the cystic duct orifice.

CHAPTER 10

Here, the cystic duct orifice is visualized.In order for me to place an adequate stitch,I would need adequate exposure, so I actually electto place an additional 5-mm trocaralong the right lateral abdomen.That's where you see the additional blunt grasperholding the cuff of the infundibulum of the gallbladder,such that I could easily visualize the cystic duct orificeand then have two handsto be able to place a stitch laparoscopically.Here, I've chosen to use a 3-0 PDS suture.Oftentimes, I'll use some form of an absorbable suture,either a 3-0 PDS or a 3-0 Vicrylto ligate the cystic duct orifice.Depending on the angle, I either place a figure-of-8 stitchor I'll do interrupteds.While this part is tediousbecause the ports are often not set up for sewing,I do think it's important.With a common bile duct stent in place,any sort of a bile leak will most likely slow with timeas this area scars down.However, I do think that this helpsto prevent the spillage of bileand speed up that process for the patients,and does provide a level of reassurance as well.So here, I've placed a figure-of-8 stitch with a 3-0 Vicryl.No bile is seen exiting the cystic duct orificeafter the stitch is placed.It should be notedthat it was only very minimal bile even before.To complete the subtotal cholecystectomy,the remainder of the fundusin the body of the gallbladder is removed,and any remainder of the back wall of the gallbladderthat stays on is generally fulguratedwith the hook electrocautery to prevent a future mucocele.

CHAPTER 11

I also fulgurate the remaining infundibulum mucosaof the gallbladder.Here, the anterior wall of the gallbladderis being taken down in a top down approach.

CHAPTER 12

That portion of the gallbladderis ultimately sent off to pathology, and for this patientit did show acute-on-chronic cholecystitis.Here, we see some more significant bleedingalong the edge of the posterior peritoneum.This is likely a branch of the cystic artery,and I therefore then use clips to achieve hemostasis.Once again, the overall ooziness of the patientis not surprising given his liver cirrhosisand baseline coagulopathy.And while the bleeding looks fairly impressive on the video,the actual estimated blood loss in this casewas less than 100, and he did not require any transfusions.Here, we use the hook electrocautery to fulgurate the mucosaof the posterior wall of the gallbladder.I reexamined the area of dissectionas well as the placement of the stitch.No bilious output from the cystic duct orificeis really appreciated.Once everything is cleaned up and I remove the specimenas well as any visualized gallstones seen,I planned to place a 19 French JP within the dissection bed.

CHAPTER 13

Postoperatively, the patient did stay overnightin the hospital.From a liver cirrhosis standpoint,he had no hepatic decompensation and actually did very well.His drain was a minimal serosanguineous output,and he was ultimately discharged home on post-op day 1.The drain was removed on post-op day 5,as he had no bilious outputand only minimal serous output thereafter.Final inspection of the gallbladder fossashows good hemostasis.

CHAPTER 14

Here, in the last steps of the case,we see the placement of the 19th French JPthat sits in the gallbladder fossa.This ultimately sits within the gallbladder fossa,as well as under the right lobe of the liver bed.I think this case brings up a few good points:one, that laparoscopic cholecystectomy is safein patients with cirrhosis;secondly, that while we have come farwith our advanced endoscopy techniques,in that transpapillary stents do play a role -they often do lead to a fair amount of scarringand inflammation of the gallbladder,should a surgeon choose to proceedwith a definitive cholecystectomy.And lastly,that for a subtotal fenestrating cholecystectomy,I think technically having an additional porthelps with any suturingand ligating of the cystic duct orifice,and either preoperatively or soon postoperatively,placement of a common bile duct stentcan help with any form of a bile leakand accelerate its healing process.Placement of a few pieces of Surgicelwithin the gallbladder fossa, just given how oozy it was.

CHAPTER 15

[No Dialogue.]

CHAPTER 16

In the case that you just saw,we did a laparoscopic subtotal fenestrating cholecystectomy.In this case, you were able to seethat the gallbladder was severely chronically inflamedand had a very thickened gallbladder wall.Given this, it was unsafe to proceedwith trying to skeletonizethe traditional critical view of safety,and at one point, given how thick the wall was,I did end up entering the gallbladder.So at that point,my plan for the operating room did have to change,and I could see the two transcystic stents,which I did remove.I did at that point then open up the gallbladderto identify the cystic duct orifice.I think it's important to identifythat during that and how difficult that dissection was,I did place an additional portto help with retraction and assistance,which was very helpful for me in this case.And I did place a stitch at the cystic duct orifice.He already has a common bile duct stent in place,so I knew that that would also helpwith the bilious drainage.And then I took off the anterior wall of the gallbladder.I then also cauterized the back wall,the posterior wall of the gallbladderthat I intentionally left in placeto prevent a future mucocele.And then I placed the JP drain at the end of the caseto help with any bilious drainage that I can monitor,and also, you know,just given how contaminated the field wasto also help with that.