Laparoscopic Subtotal Fenestrating Cholecystectomy in a Cirrhotic Patient
UMass Memorial Medical Center
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Table of Contents
In patients with difficult gallbladders due to anatomy prohibiting a clear critical view of safety, a subtotal cholecystectomy can be considered as a safer alternative to a total cholecystectomy.1, 2, 5 Subtotal cholecystectomies can be divided into “reconstituting” or “fenestrating.” Subtotal reconstituting cholecystectomies include closing off the lower end of the gallbladder to create a remnant gallbladder, while subtotal fenestrating cholecystectomies do not occlude the gallbladder and instead may involve suturing the cystic duct.1 The most common indication for subtotal fenestrating cholecystectomy is inflammation in the hepatocystic triangle, and subtotal fenestrating cholecystectomy has proven to be useful specifically for patients with a history of cirrhosis.1, 2, 6, 7
This case report describes the performance of a subtotal fenestrating cholecystectomy for the management of acute on chronic cholecystitis in a patient with cirrhosis initially managed with transcystic stent placement endoscopically. Management of this patient’s omental adhesions to the gallbladder required alterations to typical surgical technique, which will be described in this report. Additionally, we will discuss the indications for subtotal fenestrating cholecystectomy and the benefit of this technique to specific patient populations presenting with acute on chronic cholecystitis.
Minimally invasive surgery; subtotal cholecystectomy; cirrhosis; acute on chronic cholecystitis.
Patients with symptomatic cholelithiasis or calculous cholecystitis typically present with colicky right upper quadrant pain and are eligible for an elective cholecystectomy. Patients with a history of cirrhosis (especially patients qualifying as Child-Pugh category B or C) have a high risk of complications from laparoscopic cholecystectomy. Therefore, patients with cirrhosis may be candidates for alternative procedures such as advanced endoscopy interventions including transcystic stent placement. One recent study showed transcystic stent placement had a 97% clinical success rate in treating recurrent cholecystitis in cirrhotic patients.1 However, this procedure does carry the risk of the stent becoming obstructed. In the aforementioned study, 15% of patients had adverse events at some point in their recovery, with pancreatitis and cholangitis from recurrent obstruction of the biliary ducts being the most common events.1 If stenting fails, patients with challenging anatomy such as inflammation in the hepatocystic triangle may benefit from a subtotal fenestrating cholecystectomy.1 Subtotal cholecystectomy does pose a risk of recurrent cholelithiasis and cholecystitis in the remaining gallbladder tissue requiring completion cholecystectomy; however, this risk is small if the residual gallbladder remnant is less than 2.5 cm. The risks of subtotal fenestrating cholecystectomy in cirrhotic patients generally outweigh the benefits in patients due to their anatomy and physiology creating dangers in routine total laparoscopic cholecystectomy.2, 8
Here we present the case of a 62-year-old male who presented to the emergency department for right upper quadrant pain in the setting of recurrent acute cholecystitis status post transcystic duct stent placement 6 months prior to this admission. The patient had a past medical history of recurrent cholelithiasis and cholecystitis, biliary strictures, prior alcohol use disorder, end stage liver disease, hypertension, and deep venous thrombosis. The patient’s surgical history also includes inguinal hernia repair, bilateral cataract removal, knee arthroplasty, and shoulder repair surgery. He does not smoke tobacco products and smokes marijuana daily. His last alcoholic drink was in 2020.
His American Society of Anesthesiologist score (ASA) was 3. His preoperative complete blood count and basic metabolic panel were within normal limits with the exception of a blood glucose level of 144 and a platelet count of 108,000. His MELD score was 9 and his Child-Pugh score was 5 (Child class A).
The patient described severe, waxing and waning, sharp pain in the right upper quadrant of his abdomen. He had tenderness to palpation over the right upper quadrant, but a negative Murphy’s sign. He did not appear jaundiced and did not have ascites. All other physical exam findings were within normal limits. His BMI was 22.93.
The patient underwent right upper quadrant ultrasound during his evaluation. Ultrasound findings were notable for liver enlargement with cirrhotic morphology and coarsened echotexture. The gallbladder had circumferential wall thickening and contained multiple gallstones. There was a small amount of simple appearing pericholecystic fluid at the gallbladder tip. No sonographic Murphy’s sign was elicited. The common hepatic duct measured 0.3 cm.
Symptomatic cholelithiasis or biliary colic causing acute cholecystitis is treated with a minimally invasive cholecystectomy. In patients where standard total cholecystectomy may be contraindicated due to anatomy which obscures the critical view of safety, a subtotal cholecystectomy may be performed. Less than complete cholecystectomies have been described as early as 1938. These operations were originally termed subtotal or partial cholecystectomies, with the two terms being used interchangeably.1 In order to decrease confusion surrounding terms, it was proposed in 2016 to refer to all cholecystectomies that were less than complete cholecystectomies as subtotal cholecystectomies. Additionally, subtotal cholecystectomies were categorized into fenestrating and reconstituting types.1 Subtotal cholecystectomies still do not have a separate CPT code, which may lead to difficulties when conducting retrospective chart reviews. Further research surrounding subtotal cholecystectomies and stronger coding standardization for these procedures is needed.1 Current research suggests that the rate of total cholecystectomies to subtotal cholecystectomies is approximately 13:1.9
The patient had previously undergone several ERCP procedures with transcystic stent placement but still had recurrent pain from cholecystitis due to stent clogging, indicating the need for cholecystectomy. History of ERCP is not associated independently with the need for subtotal cholecystectomy versus a total cholecystectomy. However, history of cirrhosis and other preoperative morbidities causing inflammation of the hepatocystic triangle is associated with the need for a subtotal cholecystectomy over a total cholecystectomy.10
In one study, nearly 20% of subtotal cholecystectomies had postoperative complications including bile duct leakage. However, patients undergoing subtotal cholecystectomies have higher preoperative morbidity than patients undergoing total cholecystectomy, which may confound this statistic.11 In one prospective study, all 71 patients who underwent subtotal cholecystectomy had no complications at 1 year post-op.7 Subtotal cholecystectomies theoretically pose the risk of retained stones necessitating subsequent total cholecystectomy. However, one recent study showed all patients requiring repeat completion cholecystectomy after subtotal cholecystectomy had residual gallbladder remnants greater than the recommended size.8 The need for a completion cholecystectomy after a subtotal cholecystectomy is not an ideal outcome. However, in case reports where completion cholecystectomy was subsequently required, the patient was ultimately able to achieve complete resolution of symptoms. Therefore, in patients where total cholecystectomy is initially contraindicated it is reasonable to begin with a subtotal cholecystectomy.12
Some studies have shown an increased rate of retained stones and bile leaks in fenestrated subtotal cholecystectomies when compared to reconstituting subtotal cholecystectomies.5,9 However, contrasting research has shown no difference between rates of complications from reconstituting subtotal cholecystectomies and fenestrating cholecystectomies.11 Ultimately, the decision to conduct a fenestrating versus reconstructive subtotal cholecystectomy should be up to surgeon preference as there is no consensus on significant differences in postoperative complications.2
Elective cholecystectomy was recommended for this patient due to his recurrent cholecystitis and the ineffective management of his symptoms with transpapillary cystic duct stents. Subtotal cholecystectomy is the safest option for patients with cirrhosis if a critical view of safety cannot be achieved. In this case, a fenestrating subtotal cholecystectomy was performed over a reconstituting approach due to surgeon preference. A laparoscopic approach was chosen due to surgeon preference and in concordance with recent data which suggests converting to open cholecystectomy instead of proceeding with laparoscopic subtotal cholecystectomy had significantly higher rates of severe complications.3
Here we discuss the case of a 57-year-old male who presented with acute on chronic calculous cholecystitis in the setting of multiple failed transpapillary cystic duct stenting and a past medical history significant for alcoholic cirrhosis. The patient underwent a laparoscopic fenestrating subtotal cholecystectomy with removal of previously placed cystic duct stents.
For laparoscopic subtotal cholecystectomies, trocar placement is crucial for success so that instruments have adequate reach and the surgeon is able to discern appropriate exposure. For this patient, 5-mm ports were placed in the supraumbilical, right midclavicular line, and right lateral quadrant. An 11-mm port was placed in the epigastrium. Upon exposure of the gallbladder, omental adhesions to the gallbladder were slowly and carefully removed with hook electrocautery. Ultrasonic energy is an option in place of monopolar electrocautery in laparoscopic cholecystectomy, but recent studies do not advocate strongly for either approach and so monopolar electrocautery was chosen based on cost efficiency and surgeon preference.4 Many patients with recurrent cholecystitis will have a thickened gallbladder wall due to chronic inflammation. This was the case with our patient, and the thickened gallbladder wall was entered about one-third of the way down the gallbladder body, and the anterior wall of the gallbladder was therefore transected to fully expose the lumen of the gallbladder and visualization of the cystic duct orifice. Pigmented stones were removed completely from the gallbladder lumen. The two previously placed cystic duct stents that were across the cystic duct were removed and the cystic duct orifice was visualized. Subsequently, the surgeon placed a figure-of-eight stitch with 3-0 PDS to occlude the cystic duct orifice. In order to place the stitch with appropriate visualization, an additional 5-mm trocar was placed to aid in retraction and exposure of the cystic duct orifice. Following this stitch, the anterior wall of the gallbladder was removed to the level of the fundus, and this portion of the gallbladder and the stents were removed in a 10-mm Endo Catch bag. The posterior wall of the gallbladder was subsequently cauterized to prevent formation of a future mucocele. The fossa was then irrigated to clear debris from the dissected area. The surgeon elected to leave a 19 French JP within gallbladder fossa.
The operation lasted approximately 2 hours and was well tolerated. There was an estimated blood loss of 10 cc. Postoperatively, the patient’s pain was well controlled and his JP drain output remained serosanguinous. His liver function tests were within normal limits and no evidence of hepatic decompensation was identified clinically. The patient had a prothrombin time within normal limits at baseline and therefore did not require preoperative vitamin K or fresh frozen plasma products. He did have chronic thrombocytopenia (108,000); however, he did not receive any platelet transfusion. His albumin remained within normal limits and did not require albumin as part of resuscitation during his hospital stay. He was kept adequately hydrated by 30 mL/hour infusion of lactated ringer’s solution preoperatively and 100 mL/hour infusion of lactated ringer’s solution postoperatively with mindful consideration to stop IVF once adequate PO intake as achieved. He was discharged home on postoperative day 1. Following the procedure, his JP drain was removed on postoperative day 5 given its low serous output.
This laparoscopic subtotal fenestrating cholecystectomy was performed using Olympus laparoscopic tools including laparoscopic grasping forceps and electrocautery tools. The surgical field was visualized by an Olympus high-resolution video endoscopy system including two high-resolution color monitors. A 19 French JP catheter was left within the gallbladder fossa.
Nothing to disclose.
Citations
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- Fernando Santos B, Michael Brunt L, Pucci MJ. The difficult gallbladder: a safe approach to a dangerous problem. J Laparoendosc Adv Surg Tech A. 2017;27(6):571-578. doi:10.1089/LAP.2017.0038.
- Kaplan D, Inaba K, Chouliaras K, et al. Subtotal cholecystectomy and open total cholecystectomy: alternatives in complicated cholecystitis. Am Surg. 2014 Oct;80(10):953-5.
- Sasi W. Dissection by ultrasonic energy versus monopolar electrosurgical energy in laparoscopic cholecystectomy. JSLS. 2010 Jan-Mar;14(1):23-34. doi:10.4293/108680810X12674612014383.
- Koo JGA, Chan YH, Shelat VG. Laparoscopic subtotal cholecystectomy: comparison of reconstituting and fenestrating techniques. Surg Endosc. 2021;35(3):1014-1024. doi:10.1007/S00464-020-08096-0/METRICS.
- Palanivelu C, Rajan PS, Jani K, et al. Laparoscopic cholecystectomy in cirrhotic patients: the role of subtotal cholecystectomy and its variants. J Am Coll Surg. 2006;203(2):145-151. doi:10.1016/J.JAMCOLLSURG.2006.04.019.
- LeCompte MT, Robbins KJ, Williams GA, et al. Less is more in the difficult gallbladder: recent evolution of subtotal cholecystectomy in a single HPB unit. Surg Endosc. 2021;35(7):3249-3257. doi:10.1007/S00464-020-07759-2.
- Alser O, Dissanaike S, Shrestha K, Alghoul H, Onkendi E. Indications and outcomes of completion cholecystectomy: a 5-year experience from a rural tertiary center. Am Surg. Published online 2022. doi:10.1177/00031348221124331.
- Lunevicius R, Haagsma JA. Subtotal cholecystectomy: results of a single-center, registry-based retrospective cohort study of 180 adults in 2011-2018. J Laparoendosc Adv Surg Tech A. 2021;31(9):1019-1033. doi:10.1089/LAP.2020.0713.
- Kesgin YM, Gümüşoğlu AY, Kabuli HA, et al. Does the subtotal cholecystectomy rate for acute cholecystitis change with previous endoscopic retrograde cholangiopancreatography? Ulus Travma Acil Cerrahi Derg. 2023;29(7):772-779. doi:10.14744/TJTES.2023.54703.
- Ibrahim R, Abdalkoddus M, Mahendran B, Mownah OA, Nawara H, Aroori S. Subtotal cholecystectomy: is it a safe option for difficult gall bladders? Ann R Coll Surg Engl. 2023;105(5):455-460. doi:10.1308/RCSANN.2021.0291.
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Cite this article
Schneider RM, Cherng NB. Laparoscopic subtotal fenestrating cholecystectomy in a cirrhotic patient. J Med Insight. 2024;2024(442). doi:10.24296/jomi/442.
Procedure Outline
Table of Contents
- 1. Introduction
- 2. Laparoscopic Port Placement and Identification of Gallbladder
- 3. Lysis of Adhesions
- 4. Incision of Gallbladder Visceral Peritoneum and Exposure of the Infundibulum
- 5. Dissection of the Hepatocystic Triangle
- 6. Transition to Subtotal Cholecystectomy When Triangle of Safety Unable to be Visualized
- 7. Removal of Gallbladder Content
- 8. Transection of Gallbladder Wall
- 9. Removal of Internal Biliary Drainage Catheters, Inspection of Gallbladder, and Hemostasis
- 10. Identification and Ligation of Cystic Duct Orifice
- 11. Resection of Anterior Gallbladder Wall
- 12. Hemostasis of Remnant Posterior Gallbladder Wall, and Inspection of Ligated Cystic Duct
- 13. Removal of Specimen and Final Inspection
- 14. Drain Placement
- 15. Laparoscopic Port Removal and Closure
- 16. Post-op Remarks
Transcription
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.