FACTOR SHOULD BE CONSIDER IN LAPAROSCOPIC CHOLECYSTECTOMY IN A CIRRHOTIC PATIENTS

1. LAPAROSCOPIC CHOLECYSTECTOMY AND
LIVER CIRRHOSIS
DR. MASFIQUE AHMED BHUIYAN
MBBS , FCPS
INTERVENTIONAL ENDOSCOPIC & LAPAROSCOPIC SURGEON
DEPARTMENT OF SURGERY
DHAKA MEDICAL COLLEGE & HOSPITAL

2. MAJOR CONCERN
•ADHESION
•DIFFICULT IN RETRACTION OF LIVER
•INADEQUATE EXPOSURE OF
CHOLECYSTOHEPATIC TRIANGLE
VASCULAR GALLBLADDER BED
VASCULAR HILUM
INCREASED NEOVACULARITY

3. UMBILICAL PORT
BECAUSE OF UMBILICAL RECANALIZATION ,
UMBILICAL PORT SHOULD BE MADE AWAY
FROM THE FALCIFORM LIGAMENT AND IT
MUST BE COMPLETELY AVAIDED

4. RETRACTION AVOIDED
THE LIVER PARECHYMA IS HARD AND FIBROTIC
AND DIFFICULT TO RETRACT CRANIALLY.
RETRACTION ON THE BODY JUST ABOVE THE
INFUNDIBULUM TO EXPOSE THE CALLOT’S
TRIANGLE.

5. TROCAR POSITIONS
ROTATING ALL TROCAR POSITIONS TO THE RIGHT IS USEFUL
BECAUSE WHEN THERE IS SIGNIFICANT RIGHT HEPATIC LOBE
ATROPHY,THE HEPATIC HILUM STRUCTURES TEND TO BE
TWISTED TO THE RIGHT SIDE .EXTRA ONE ADDITIONAL PORT
SITE CAN HELP TO EXPOSE THE HILUM,HOLDING LEFT LOBE
OR THE DUODENUM.USING ASPIRATOR IN ADDITIONAL
PORT SITE IS HELPFUL TO KEEP THE SURGICAL FIELD CLEAN
AND ALWAYS READY TO INJECT SOME IRRIGATION FOR
IMPROVING BIPOLAR ACTION

6. FUNDUS FIRST METHOD MAY BE
USEFUL
IF ABOVEL MENUVER FAIL

7. BIPOLAR ELCTROSURGERY IS
REAL FRIEND
USE OF BIPOLAR, HARMONIC OR
ADVANCED BIPOLAR DEVICE IS
HELPFUL.ARGON OR THROMBIN SPRAY
USEFUL FOR HEMOSTASIS.

8. AVOID BLUNT DISSECTION

9. TOPICAL HAEMOSTATIC AGENT
OXIDIZED CELLULOSE
HEMOSTATIC MATRIX SEALANT
THROMBIN
TRANEXAMIC ACID

10. ALWAYS USE DRAIN
SUBHEPATIC DRAIN IS USUALLY PLACED BECAUSE
POSTOPERATIVE OOZING IS LIKELY IN THE
PRESENCE OF COAGULOPATHY. A CLOSED
DRAINAGE SYSTEM IS PREFERRED TO AVOID
ASCITES CONTAMINATION.DRAINS ARE USUALLY
REMOVED IN 24 TO 48 HOURS.

11. NEEDLE BIOPSY TO ASSIST
HEPATOLOGIST
CONSIDER LAPAROSCOPIC NEEDLE
BIOPSY OF THE LIVER TO EVALUATE
EXTENT OF CIRRHOSIS AND ASSIST
HEPATOLOGIST TEAM.

12. PORT CLOSURE FOR ENCOUNTER
BLEEDING AND ASCITES
BEFORE COMPLETION OF THE PROCEDURE ,ALL
ACCESS PORTS SHOULD BE CHECKED FOR
BLEEDING AND ALL OF THEM SHOULD BE
CLOSED,EVEN THE 5 OR 3 MM ONES, BECAUSE
OF POSTOPERATIVE ASCITES.

13. LAPAROSCOPIC SUBTOTAL
CHOLECYSTECTOMY TYPE 1
THE SEPARATION OF THE GALLBLADDER FROM THE LIVER BED
MAY BE DIFFICULT AND THE SOURCE OF MASSIVE BLEEDING
WHEN TORTUOUS,DILATED VESSELS OCCUR IN THE
GALLBLADER BED. IN SUCH CASES, THE POSTERIOR WALL MAY
BE LEFT INTACT WITH THE LIVER AND REMNANT MUCOSA IS
REMOVED EITHER BY MUCOSECTOMY OR BY
ELECTROFULGURATION. THIS MENEUVER IS CALLED
LAPAROSCOPIC SUBTOTAL CHOLECYSTECTOMY(LSC)TYPE 1

14. LAPAROSCOPIC SUBTOTAL
CHOLECYSTECTOMY TYPE 2
CIRCUMFERENTIAL DIVISION OF THE INFUNDIBULUM AS CLOSE AS POSSIBLE TO THE
JUNCTION OF THE GALLBLADDER AND CYSTIC DUCT, FOLLOWED BY THE REMOVAL OF
THE MUCOSA BY MUCOSECTOMY OR ELECTROFULGURATION AND CLOSURE OF THE
STUMP BY WITH HARMONIC SCALPEL OR CONTINUOUS POLYGLACTIN SUTURE.IT
SHOULD BE USED WHEN HILAR DISSECTION IS DIFFICULT DUE TO DEEPLY PLACED
HILUM,INFLAMMATORY PHLEGMON,PERICHOLECYSTIC FIBROSIS OR ABERRANT
ANATOMY AND VASCULATURE IN THE CHOLECYSTOHEPATIC TRIANGLE. THESE ARE MORE
ASSOCIATED WITH A CAVERNAMATOUS TRANSFORMATION OF THE PORTAL VEIN.IN
PATIENT WITH HIGH RISK GALLBLADDER BED AND HIGH RISK HILUM, A COMBINATION OF
LSC 1 AND LSC 2 SHOULD BE USED, A VARIENT THAT IS CALLED LSC TYPE 3