| |
Phase
4: Dissecting the Gallbladder Off of the Liver Bed
After clipping and dividing the cystic artery and duct, the infundibulum
is grasped near its junction with the cystic duct stump and retracted
upward, being careful not to dislodge the clips. Further painstaking
dissection is performed in this region to ensure that all vascular
structures have been controlled. Occasionally, an accessory cystic
artery is identified which requires clipping and dividing. The
peritoneum along the lateral and medial edges of the gallbladder is
incised carefully using electrocautery or endo-scissors. This maneuver
increases the mobility of the gallbladder fundus, making further
dissection easier. The cautery instrument of choice (hook, spatula,
dissector) is then used to create and dissect along the surgical plane
between the gallbladder and the liver bed. The difficulty of this
portion of the operation is inversely proportional to the experience of
the assistant, particularly in cases of acute or chronic cholecystitis.
Cautery dissection will generate a smoke plume that can impair the
surgeon's visualization. Vapor can be evacuated by opening the stopcock
of one of the lateral trocars. Dissection is continued to the top of the
gallbladder. As the dissection proceeds, it is helpful if the assistant
changes retraction angles frequently to keep the dissection plane on
gentle tension. Once the dissection is nearly complete, the surgeon
inspects the liver bed for bleeding and any evidence of bile leak. The
retraction provided at this stage of the operation gives the operator
the best view of the liver bed and the clips placed in Calot’s
triangle. The gallbladder is then completely dissected off of the liver
bed and placed on the liver surface using one or both of the retraction
graspers.
Phase 5: Extracting the Gallbladder
Depending on the appearance of the gallbladder and the degree of
contamination, an endoscopic retrieval bag may or may not be required.
The gallbladder is extracted through the 10mm port not occupied by the
endoscopic camera. Some surgeons prefer the subxiphoid route, while
others use the infraumbilical incision for gallbladder extraction.
Regardless, the gallbladder is grasped with a large grasper placed
through the appropriate port and delivered into the intracorporeal end
of the trocar. The gallbladder-trocar complex is then delivered through
the associated incision. Bulky gallbladders or those containing large
stones may require dilation or extension of the skin and fascial
incisions. Alternatively, the gallbladder can be decompressed with
scissors and the stones removed, facilitating extraction.
The trocar removed for gallbladder extraction is replaced. The
intraabdominal cavity is thoroughly irrigated with normal saline.
Instruments may be reinserted and the liver edge elevated to permit a
second look at the surgical clips and liver bed. Any spilled stones
should be carefully retrieved to avoid infectious complications. This is
most easily accomplished with stone extraction forceps. Local anesthetic
may be injected into the peritoneum at the trocar sites prior to their
removal. Trocars are then removed sequentially under direct vision to
evaluate for bleeding from the insertion sites. The abdomen is then
deflated and the trocar sites closed in the usual fashion.
|
|
