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 Hospital in Worcester, Massachusetts. Today the case that I will be presenting is a laparoscopic cholecystectomy in 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 candidate for endoscopic placement of transcystic stents. This was done, and the patient did have good relief; however, he then had clogging of the stents and he had recurrent cholecystitis, so he underwent an exchange of those stents as well as the placement of a common bile duct stent. He continued to have multiple admissions with recurring cholecystitis, and it was deemed that the transcystic stents were failing, so it was decided that we would proceed with a cholecystectomy for definitive care with the higher risks, and my plan for the operating room would be a laparoscopic cholecystectomy and also removal of the transcystic stents.

CHAPTER 2

Here, we enter the abdomen with a Veress needle to 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 trocars in the right upper quadrant, it is immediately obvious the severely cirrhotic liver that is visualized. This is not surprising given the patient's history. After placing all of my ports, I then positioned the patient in reverse Trendelenburg with the left side down. Visualization of the right upper quadrant does show evidence of the omental adhesions to the gallbladder. Part of these omental adhesions easily come off with positioning as well as gentle retraction. I am able to visualize the gallbladder and able to retract the fundus towards the right shoulder.

CHAPTER 3

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

CHAPTER 4

I continue to lyse the band of tissue that is tethering the duodenum to the infundibulum of the gallbladder. I'm sure to stay closer to the gallbladder side as the duodenum falls away. I carry my dissection medially towards the liver such that I can continue to expose the cholecystic triangle. Here, you can tell that the patient's tissue is very pliable and very inflamed. It's very oozy. This is not surprising given the patient's cirrhosis and likely predisposing coagulopathy and thrombocytopenia. I continue my dissection bed towards 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 peritoneum of the anterior and posterior portion of the infundibulum, generally for most patients, we would have a sense of where the cystic duct and the cystic artery lie, and we would then proceed to skeletonize those two structures. However, here it's very evident that this is incredibly inflamed and fused and scarred in as well, so I therefore then with good retraction of the infundibulum in my left hand with the laparoscopic grasper, I continue to use the hook electrocautery. I continue to use the hook electrocautery to take down the second layer of incredibly thickened peritoneum in hopes that it'll show me the critical structures.

CHAPTER 5

I do the similar move on the lateral backside of the gallbladder. At this point, the interface of the infundibulum to 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 peritoneum in 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 there and moved to another part of the gallbladder. I continue on the lateral backside, staying high along the gallbladder to 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 hole within the body of the gallbladder just above the level of the infundibulum. At this point, what is going through my head is now at the hole within the gallbladder, I am committed to having to move forward. I know that at the minimum I will need to do some form of subtotal cholecystectomy. So what is critical for me now is to find the cystic duct and cystic artery. I go back and forth between the hook electrocautery as well as the suction irrigator as a blunt dissector. Here along the backside of the gallbladder I have a sense based off of haptic feedback as well as visualization, that I am coming down to the level of the edge of the infundibulum of the gallbladder. And I continue to sweep bluntly this very thickened peritoneum off of it to further expose it. Within the hole of the gallbladder that I made, I visualize the plastic transcystic transpapillary stents that 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 deemed that within the cholecystic triangle it will not be feasible for me to skeletonize the critical view of safety. I therefore elect that I will do a subtotal fenestrating cholecystectomy. In order to do so, I know that I need to develop the window between the gallbladder and the liver plate. I therefore transition along the body of the gallbladder to stay safe to find this window. Here, I am bluntly dissecting the posterior wall of the gallbladder off of the peritoneal edge. I transitioned to the lateral backside of the gallbladder in 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 hand to find that same plane so that I can meet the two.

CHAPTER 7

However, now the retraction of the gallbladder and the amount of force that has been placed and thinned out the gallbladder wall, I have created a hole in the backside of the gallbladder as well. Once again, the transpapillary plastic stent is visualized, as well as multiple pigmented gallstones are now coming out of the gallbladder. I know that both holes are 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 point that any danger has been done. As I try to develop a plane between the posterior wall of the gallbladder from the liver plate, I continue to cause a fair amount of shear injury to the wall of the gallbladder, such that it continues to become - that hole becomes wider.

CHAPTER 8

So at this point, I elect that instead I'll just connect those two holes, which means transecting the anterior wall of 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 gallbladder has been essentially transected, about 80% of it. The two previously placed transpapillary transcystic ducts stents 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 out and remove the multiple pigmented black stones seen. My goal at this point is to identify the cystic duct orifice and suture that off with plans for a drain. The patient had a preoperative common bile duct stent placed as well. I will often have the advanced gastroenterologist place the common bile duct stent before these very difficult gallbladders who've had multiple interventions such as either transpapillary cystic duct stents, or percutaneous cholecystostomy tube placements, because I know that these oftentimes cause significant chronic inflammation and scarring, and therefore will pose a fairly difficult gallbladder, and the patients are counseled that oftentimes the subtotal cholecystectomy is more likely than not to be performed, and so by placing the common bile duct stent before the surgery, I know that therefore I can minimize the amount of bile leakage if anything does occur, postoperatively. Here, I continue to clean out multiple pigmented stones, and just achieving hemostasis here before we move on with our subtotal cholecystectomy. Clearly, we can see where the catheter is sitting within 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 elect to place an additional 5-mm trocar along the right lateral abdomen. That's where you see the additional blunt grasper holding the cuff of the infundibulum of the gallbladder, such that I could easily visualize the cystic duct orifice and then have two hands to 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 Vicryl to ligate the cystic duct orifice. Depending on the angle, I either place a figure-of-8 stitch or I'll do interrupteds. While this part is tedious because 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 time as this area scars down. However, I do think that this helps to prevent the spillage of bile and 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 orifice after the stitch is placed. It should be noted that it was only very minimal bile even before. To complete the subtotal cholecystectomy, the remainder of the fundus in the body of the gallbladder is removed, and any remainder of the back wall of the gallbladder that stays on is generally fulgurated with the hook electrocautery to prevent a future mucocele.

CHAPTER 11

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

CHAPTER 12

That portion of the gallbladder is ultimately sent off to pathology, and for this patient it did show acute-on-chronic cholecystitis. Here, we see some more significant bleeding along 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 patient is not surprising given his liver cirrhosis and baseline coagulopathy. And while the bleeding looks fairly impressive on the video, the actual estimated blood loss in this case was less than 100, and he did not require any transfusions. Here, we use the hook electrocautery to fulgurate the mucosa of the posterior wall of the gallbladder. I reexamined the area of dissection as well as the placement of the stitch. No bilious output from the cystic duct orifice is really appreciated. Once everything is cleaned up and I remove the specimen as 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 overnight in 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 output and only minimal serous output thereafter. Final inspection of the gallbladder fossa shows good hemostasis.

CHAPTER 14

Here, in the last steps of the case, we see the placement of the 19th French JP that 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 safe in patients with cirrhosis; secondly, that while we have come far with our advanced endoscopy techniques, in that transpapillary stents do play a role - they often do lead to a fair amount of scarring and inflammation of the gallbladder, should a surgeon choose to proceed with a definitive cholecystectomy. And lastly, that for a subtotal fenestrating cholecystectomy, I think technically having an additional port helps with any suturing and ligating of the cystic duct orifice, and either preoperatively or soon postoperatively, placement of a common bile duct stent can help with any form of a bile leak and accelerate its healing process. Placement of a few pieces of Surgicel within 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 see that the gallbladder was severely chronically inflamed and had a very thickened gallbladder wall. Given this, it was unsafe to proceed with trying to skeletonize the 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 gallbladder to identify the cystic duct orifice. I think it's important to identify that during that and how difficult that dissection was, I did place an additional port to 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 help with 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 gallbladder that I intentionally left in place to prevent a future mucocele. And then I placed the JP drain at the end of the case to help with any bilious drainage that I can monitor, and also, you know, just given how contaminated the field was to also help with that.