JOURNAL OF LAPAROENDOSCOPIC SURGERYVolume 1, Number 1, 1990Mary Ann Liebert, Inc., Pubiishers

Laparoscopic Cholecystectomy:Instrumentation and Technique

EDWARD PHILLIPS, M.D., LEON DAYKHOVSKY, M.D.,BRENDAN CARROLL, M.D., ALEX GERSHMAN, M.D., and

WARREN S. GRUNDFEST, M.D.

ABSTRACT

Laparoscopic cholecystectomy is rapidly evolving as a therapeutic modality for the treatmentof gallstone disease. The technical details of this procedure and the method by which thegallbladder is dissected and removed are critical to the safe, effective execution of theprocedure. Our technique has been developed through extensive practice in porcine modelsand through experience with more than 250 patients. To perform laparoscopic cholecystec-tomy we employ a high-resolution video endoscopy system, two high-resolution colormonitors, a high-flow C02 insufflator, a 300 W Xenon light source, electrocautery and/orlasers, and an endoscopie suction-irrigation system. This equipment permits the surgeon toobtain a clear field of view within the abdomen. With these tools, appropriately designed forlaparoscopic surgery, including a laparoscope, graspers, dissectors, cholangiography equip-ment, scissors, and clip appliers, the surgeon can remove the gallbladder without opening theabdomen. The procedure requires the induction of a C02 pneumoperitoneum, insertion offour trocars, and placement of a grasping retractor to set the operative field. An additionalretractor placed on Hartmann's pouch provides countertraction for dissection of the hilum.Careful dissection around the cystic duct and cystic artery with a combination of electrocau-tery and blunt dissection allows the surgeon to skeletonize the cystic duct and artery. Afterintraoperative cholangiography confirms the anatomy, the cystic artery and cystic duct areclipped and divided. Electrocautery or laser techniques can be used to perform retrogradedissection of the gallbladder from the liver bed and insure hemostasis. The gallbladder isdetached and removed intact through the large trocars. This basic technique can be applied ina wide variety of patients with cholelithiasis. The surgeon proficient in this technique mayapply it to a broad range of patients with gallbladder disease.

From the Laser Research Center and the Department of Surgery, Division of General Surgery, Cedars-Sinai MedicalCenter, Los Angeles, California.

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INTRODUCTION

Surgical removal OF the gallbladder as first reported by Lagenburch in 1882 in Berlin has been astandard therapy for the treatment of symptomatic cholelithiasis and cholecystitis. The standard surgical

procedure can be performed with a surgical mortality of 0.3-1% for elective cholecystectomy and 3-10% forcholecystectomy in acute cholecystitis. ' However, the average hospital stay of 8 days2 and the need for a 3-4week postoperative recuperative period account for a major portion of the expense incurred by the patient.Thus, while standard surgical cholecystectomy is safe and effective in the treatment of gallstone disease, thismethod incurs significant cost both in dollars and time. Several authors have reported a modification of thestandard surgical operation. The technique utilizes laparoscopic instrumentation to achieve successfulremoval of the gallbladder,3-5 and may reduce costs by decreasing the length of hospital stay and recuperativetime. Since "laparoscopic cholecystectomy" permits complete removal of the gallbladderwithout the need forlarge incisions into the abdominal wall and the surgeon's hands do not enter the peritoneal cavity, there isminimal manpulation of the abdominal anatomy. The resultant decrease in morbidity, hospital stay, andrecuperative time suggests that this methodology will gain acceptance within the surgical community.In order to safely perform this procedure with morbidity and mortality rates that are equal to or less than

current surgical standards, the general surgeon must undergo additional training. This training must includeboth extensive hands-on experience with laparoscopic instrumentation and a thorough understanding of thetechnique of laparoscopic cholecystectomy. If only 1 in 20 surgeons incurs a serious complication during thelearning curve and as many as 20,000 general surgeons learn the procedure, there will be at least 1000 seriousinjuries. This is an unacceptably high rate of complication for treatment of this disease. A detailedunderstanding of the instrumentation and surgical technique is necessary to perform this operation safely.This report outlines the laparoscopic instrumentation needed to perform laparoscopic cholecystectomy and

discusses in detail the surgical techniques employed to perform the procedure. The technique we present is theresult of extensive laboratory investigation in a porcine model and clinical experience in more than 250patients. The reader should be aware that the technique described is based upon currently availableinstrumentation. As the instrumentation evolves, so will the technique.

EQUIPMENTTo perform laparoscopic cholecystectomy, five major types of capital equipment which function together

as a system are essential. Lasers also included in the following discussion, but are not essential for performingthe procedure. The categories of equipment include: (1) insufflators, (2) suction-irrigation systems, (3) videoendoscopy systems, (4) endoscopie light sources, (5) electrosurgical units, and (6) lasers. Each type ofequipment has a specific function. A peritoneal insufflator is required to deliver C02 into the abdomen undercontrolled conditions. Once the pneumoperitoneum has been created and the laparoscope is inserted into theabdomen, a laparoscopic video endoscopy camera displays the image on high-resolution video monitors.Electrocautery or laser techniques are then used to assist the dissection. Thus, appropriate generators must bepresent and functioning properly.The following paragraphs describe the operating parameters and functions of the equipment listed above.

A High-Flow C02 Peritoneal InsufflatorInsufflators are available from several manufacturers. For laparoscopic cholecystectomy the insufflator

must be capable ofdelivering flow rates of at least 6 L/min, but 8-10 L/min is preferable. The operator shouldbe able to see the flow rate, the intraabdominal pressure, and the total gas delivered. At least three flow ratesettings should be available, permitting gentle insufflation (1-2 L/min) at the start of the procedure, moderateinsufflation (4-6 L/min) during the procedure, and high-flow insufflation (8-10 L/min) should a major loss ofpneumoperitoneum occur. This high-flow feature can save considerable time since the introduction ofinstruments can occasionally result in a significant loss of intra-abdominal gas. The ability to control the flow

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rate and prevent overinsufflation of the abdomen is a critical safety feature. The surgeon must not increase the¡ntra-abdominal pressure above 18 mmHg. Overinsufflation results in significant compression of the pleuralcavities, making respiration difficult.The insufflator tubing should be of sufficient length (2-4 meters) to permit easy placement on the operative

field without kinking. At least two C02 tanks of 300 L capacity each should be available for each procedure.Insufflators which permit simultaneous attachment to both tanks are preferable, because switching tanks in themiddle of the procedure can result in considerable loss of time.

A SuctionlIrrigation System Designed Specifically for Endoscopie Use

These combined suction/irrigation devices are commonly used in flexible endoscopie procedures. Standardsurgical suction is not sufficiently controlled for laparoscopic applications. The ability to simultaneouslydeliver fluid and aspirate it from the abdominal cavity is essential. The tubing for both suction and irrigationmust be of sufficient length to allow easy placement on the surgical field. Kinking of the tubing may causemalfunction of the instrumentation. Although this problem may seem trivial, it can interrupt or delay theprocedure.

A Video Endoscopy SystemThis system is composed of a "chip camera," a camera controller, two high-resolution video monitors, and

a videotape recorder. A video printer is optional.The "chip cameras" which are used for video endoscopy are specially modified for endoscopie use. They

are a modification of the CCD (charge-coupled device) which is used for current camcorders. These camerasare available in 1/2 and 2/3 inch diameters and are based on either a single or a triple chip design. The singlechip cameras can now provide 450 lines of horizontal resolution. The newer triple chip designs provide inexcess of 700 lines of horizontal resolution but are more expensive. The "chip camera" and its controllershould be designed specifically for laparoscopic applications. Cameras which attach directly to thelaparoscope are preferable to those which require additional couplings. The additional couplings often comeloose or hamper focusing. A zoom feature on the camera is highly desirable; however, the zoom controlsshould not interfere with the focusing adjustment. Focusing is critical and should be easy to achieve. A loosefocus adjustment may slip during the procedure, producing a blurry image.The image produced from the camera should fill the entire screen at maximum magnification. The camera

should feature at least 400 lines of horizontal resolution, and more than 600 lines is preferable. Automaticwhite balance and color bars are essential features. The white balance automatically optimizes the appearanceof the color image. The color bars permit the surgeon to adjust the monitor against a known standard. Thecamera should be gas-sterilizable and have a sufficiently long cord (5 meters) to permit easy placement of thecamera controller. The more sophisticated cameras have controls of the camera head which permit gain boost(increased sensitivity) for dealing with low light levels and electronic zoom for high magnification of aparticular area of the field.The output from the "chip camera" is fed directly to a high-resolution monitor. If the resolution of the

monitor is less than the resolution of the camera, the image will be degraded. Current SVHS half-inchvideotape systems can record at a maximum of400 lines of horizontal resolution; therefore the camera outputshould route first to the monitor and then to the videotape recorder. This provides the best possible image. Anadditional useful feature on some cameras is the ability to control the videotape recorder from the camerahead.Many camera systems are designed with automatic image control systems. Two types, automatic gain

control and automatic illumination adjustment, are available. Automatic gain control sets the gain or intensityof the camera response to the available light. At normal levels, amplification of the signal is sharp and crisp.At lower light levels, amplification of the electronic signal from the "chip camera" is increased to improvevisualization within the abdomen. However, this produces a corresponding increase in the noise or electronicsnow in the image. Automatic illumination controls boost the light in response to the signal generated by the

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camera. Such systems integrate the light source output, the intensity of the video signal, and the brightness ofthe image on the screen, and therefore require electrical connections between the light source, camera, andmonitor. The additional complexity of these systems can present operating difficulties. However, thesesystems provide a better image of the operative field.The video monitors should have a screen dimension of at least 13 inches diagonally with 400 lines of

horizontal resolution. We prefer two monitors, which makes the procedure safer and simpler, allowing thesurgeon and the assistant as well as the rest of the operating team a constant view of the surgical field. Theability to display the operative field at high resolution is critical to the success of the laparoscopic technique.Onemonitor should be positioned for the surgeon and the second monitor (slave monitor) should be positionedfor the assistant surgeon. Monitors larger than 10 inches diagonally are often too cumbersome for use in theoperating room. Standard commercial television sets which contain both receiver and monitor are generallyinappropriate for use in this procedure because the resolution is less than 300 lines. Brightness and contrastcontrols should be easily accessible to permit adjustment during the procedure.All procedures should be recorded on videotape for subsequent review. This permits the surgeon to assess

his own technique, an essential step in developing proficiency with laparoscopic techniques. Videodocumentation provides an accurate, permanent record of the procedure and can also be used for educationalpurposes.A video printer permits the surgeon to produce a photograph of the video image. This feature allows the

surgeon to place photographs of the operative images in the patient's chart. The combination of a videotaperecorder and a video printer allows the surgeon to share the operative findings with the patient and the referringphysician.

Endoscopie Light SourceWe employ a 300 W Xenon endoscopie light source for laparoscopic cholecystectomy. The output of the

light source is delivered into the illumination bundles of the laparoscope. Proper connection of these opticalelements is essential to achieve the lighting intensity necessary for video endoscopy. A 150W source providesinsufficient illumination for this procedure. Damaged or incorrectly connected optical cables are often thecause of insufficient illumination. When disconnected from the laparoscope, lighting cables should always beturned off and should never be placed on surgical drapes; to do so might cause the drapes to ignite.

Electrosurgical UnitElectrosurgical instrumentation is available from a variety of manufacturers. Units currently available in

most operating rooms are sufficient for laparoscopic surgery. Although some physicians prefer bipolarelectrocautery, we have found that unipolar electrocautery devices are sufficient for laparoscopic techniques.As with open surgery, the groundplate should be attached firmly to the patient. The electrosurgical unit shouldhave independent controls for coagulation and cutting. Connection of the active electrode to the instrument iscritical and often requires a special plug. The surgeon should verify the presence of a sterilized electrosurgicalcable which connects to all of the laparoscopic instruments prior to the start of the procedure.

Lasers

Two basic types of lasers delivery systems are applicable to laparoscopic cholecystectomy. Both theNd:YAG and the KTP-Nd:YAG lasers rely upon the conversion of light to heat for their effectiveness. Beforeusing a laser fora laparoscopic procedure, the surgeon should adapt appropriate safetymeasures.When usingeither the KTP or the YAG laser, it is advisable to install the appropriate filter in front of the chip camera.These filters block laser light, which can damage the chip. Under no circumstances should the surgeon lookat the laser beam either through the laparoscope or directly without appropriate eye protection.The Nd:YAG laser (produced by various manufacturers) emits an infrared beam of light which can be used

to cut or coagulate tissue. This wavelength penetrates deeply into body tissues. As such, it is a very effective

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coagulating device. Laser light is transmitted to the tissue through a thin strand(s) of fiberoptic cable. The endof this cable may be used to deliver.the light directly to the tissue. However, direct contact of the fiber with thetissue often results in the destruction of the fiberoptic tip. This limitation of YAGlaser delivery systems hasbeen solved by two approaches. The first is the development of specialized tips made of sapphire, hardenedquartz, or other heat-resistant optically transparent materials. These tips permit direct contact with the tissue.The tips come in various shapes and sizes appropriate for different applications. Highly pointed tips are usedfor precise dissection while chisel-shaped tips can be used to develop the tissue plane between the gallbladderand liver bed. Unfortunately, these tips are expensive and tend to deteriorate after several applications. Morerecently, "hardened fibers" have been developed which permit direct contact with the tissue withoutinstantaneously melting the tip of the fiber.A more expensive alternative laser source is the KTP-Nd:YAG laser. This laser produces a green beam of

light in addition to the infrared beam of the YAG laser. The green wavelength is strongly absorbed by livertissue and blood. This strong absorption limits the depth ofpenetration. Physicians who are well trained in theuse of these lasers find them to be effective tools in laparoscopic cholecystectomy. However, these lasers arenot required to perform a laparoscopic cholecystectomy. Surgeons who do not routinely use lasers in theircurrent practice must obtain the appropriate additional training.

LAPAROSCOPIC INSTRUMENTATION

The instrumentation described below is listed in the approximate order in which each is first used inperforming laparoscopic cholecystectomy. The function of each instrument is described. A completesummary of the technique is presented at the end of the instrumentation section. This procedure should beperformed only by operating room staff and an assistant surgeon who are familiar with the instrumentation.A Veress needle is used to induce the pneumoperitoneum. This needle is available in either reusable or

disposable versions. The needle has one important safety feature. Once it penetrates the peritoneum, a

spring-loaded obdurator advances in front of the needle point. When used properly, this safety featureprevents perforation of intra-abdominal organs. To confirm the correct placement, a needle aspiration with a10 cc syringe is performed. If the aspirate is negative, 5-10 cc of normal saline are injected. If this injectionproceeds smoothly and if a column of fluid easily drains into the abdomen, the tubing from the insufflator isattached. However, if the injection of saline requires excessive pressure or if the fluid drains slowly into theabdomen, two additional tests can be performed. First, the syringe can be used to drip saline into the open endof the Veress needle. If the needle fills with fluid, it should be removed and repositioned. Alternatively, thecolumn of fluid in the needle can be observed to vary with respiratory motion. Even with these tests, it isimportant to carefully observe the abdomen during insufflation. Asymmetric distention or pressures above 12mmHg suggest that the needle is not in the proper position. Often gentle back-and-forth manipulation willresult in better positioning of the needle. However, if high pressures or asymmetric insufflation persist, theneedle should be removed. Once a pneumoperitoneum is created, a large trocar is used to provide access intothe abdomen.Two sizes of trocars (5 and 10 mm) are generally used for laparoscopic cholecystectomy. These trocars

consist of ametal or plastic tube with a diaphragm and a trumpet or gate valve to prevent the escape ofgas. Topermit penetration of the abdominal wall the trocar has a slightly tapered distal end, which fits snugly arounda pointed obdurator. This obdurator is the diameter of the interlumen of the trocar tube. The trocars are alsomanufactured in reusable and disposable versions. Disposable trocars have an additional safety feature; theobdurators have a spring-loaded plastic safety shield which retracts during insertion through the abdominalwall. Once the obdurator passes through the peritoneum, the plastic safety shield snaps forward to preventinjury to underlying organs. While there are differences in the valves of the various types of trocars, theyperform the same function. These trocars allow the surgeon to insert instruments into the peritoneal cavitywhile maintaining the pneumoperitoneum. All trocars should be equipped with stopcocks to permit C02insufflation of the abdomen. Once the infraumbilical trocar has been placed, a laparoscope is inserted toexplore the abdominal contents.It is often necessary to use a 5 mm diameter instrument through a 10 mm trocar. In order to prevent escape

ofC02 a reducer tube or gasket must be placed into the trocar. This "reducer" serves to narrow the lumen and

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provide a tight seal around smaller diameter instruments. For reusable instruments, the reducers tend to belong tubes with gaskets at the proximal end. For disposable instruments the reducers are plastic and silicondisks which fit on top of the trocars. Care should be taken with either instrument to insure that a tight seal doesexist. These reducers may cause gas leaks, which prevent proper visualization with the laparoscope.A classical laparoscope uses a rod lens system to transfer the image from inside the abdomen to the lens at

the proximal end of the laparoscope. Light is transmitted into the abdomen through fiberoptic waveguides.These waveguides must provide sufficient illumination to the entire field of view. Insufficient or irregularillumination jeopardize the safety of the procedure. Newer laparoscopes are designed to connect directly to thevideo endoscopy cameras.

Laparoscopes are available in end-viewing and angle-viewing versions. The so-called "zero-degree" scopeprovides an image of what is directly in front of the instrument. Various angled scopes (25,30, or 45°) deliveran off-axis image at 25,30, or 45° from the long axis of the scope. These angled scopes are more difficult forthe novice laparoscopist to use, but provide a more useful view of the operative field than the 0° scopes.Ideally, the image should be in focus at all times. However, current lens systems provide a depth of field thatranges from 1 mm to 10 cm. The near field focus, when the distal tip of the laparoscope is 1-5 cm from theoperative field, should be sharp and clear. Scopes which cannot focus at 2 cm should not be used.After an initial exploration, the remaining trocars are inserted into the abdomen. Via the trocar in the right

lower anterior axillary line a heavy duty grasper with a locking mechanism is inserted to grasp the dome of thegallbladder and displace it anteriorly and superiorly up and over the liver toward the shoulder. This grasper isthen secured to the table or a mechanical instrument holder and serves the same function as the Denverretractor used in open cholecystectomy. Critical features of this grasper are appropriate sized teeth and thelocking mechanism. If the teeth are too large or too sharp, the gallbladderwill be punctured. If the teeth are toosmall or the grasping surface is too limited, the gallbladderwill slip out of the grasper. The locking mechanismpermits the assistant surgeon to leave the grasper fixed in place and manipulate other instruments.A more delicate grasper is inserted through the subxyphoid trocar, and is used to define the anatomy around

the cystic duct gallbladderjunction. Graspers of various shapes and sizes are available. Needle-nosed or sharpgraspers are inappropriate for use as dissectors and are associated with a high probability of perforation.Dissection is best performed with round-edged graspers. These graspers should have small teeth or ridges toprevent perforation, but should be capable ofmaintaining a firm hold on the tissue. The peritoneum overlyingthe cystic duct is firmly grasped and retracted toward the common duct. This procedure is repeated until asufficient opening in the peritoneum is created to allow access for the hook dissector.A variety of graspers are available to perform multiple functions. Micrograspers with small surface areas

and fine ridges are best used while working around the cystic duct or cystic artery. They can be used tostabilize a structure while clipping or cutting it, but they have insufficient grasping surface area for use as a

primary dissection tool. Pancake graspers have broad, flat, finely serrated surfaces which are used tocompress structures. These long-handled "forceps" are very effective in controlling hemorrhage from anavulsed cystic artery or a leak from the gallbladder. However, they have only minimal strength and are

relatively ineffective for heavy duty retraction or dissection.The final dissection around the cystic duct and cystic artery is performed with a small hook dissector. This

device can be connected to electrocautery and in some cases to suction and irrigation equipment. The "hook"dissector can perform multiple functions. The shape of the hook and the thickness of the distal metal tip arecritical to effective functioning of the device. Minor modifications in construction produce major changes inthe effectiveness of the probe. The best hooks extend approximately 7 mm past the blunt end of the probe.They are approximately 1 mm in diameter and have a base that is 4-5 mm in length. The upward or returningprojection of the hook should be 2-3 mm in length and have a blunt termination. This J-like hook constructionis the critical element of this tool. In the broad axis the tool is 5 mm wide and can be used to push tissue muchlike a peanut dissector. In the narrow axis the metal strut can be used as a sharper dissector to develop tissueplanes. When encircling a structure the point of the hook can be used much like a right-angle clamp fordissection. These three uses, a broad dissector, a narrow dissector, and a right-angle dissector, allow thesurgeon to delicately separate the connective tissue surrounding the cystic duct and cystic artery. This tool canbe manipulated in a variety of ways. When used as a broad dissector, a gentle back-and-forth motion along theaxis of the duct is employed. When used as a fine dissector, the motion is similar, but can also be extended in

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the vertical axis. When used as a hook or right-angle, a combination of rotation, back-and-forth, andup-and-down motions are employed to pull the hook through the overlying connective tissue. As with alllaparoscopic procedures, good visualization, gentle motion, and patience are required to insure safety andeffectiveness.

When dissecting around fine structures, such as the cystic duct and artery, the suction and irrigationfunctions can be most helpful in improving visualization. Small amounts of blood can be easily removed bya combination of irrigation and aspiration. Electrocautery can be used to obtain hemostasis, but first, the probeshould be tested on the dome of the liver or the abdominal wall to confirm the electrocautery coagulationsettings. Alternatively, a laser fiber can be passed through a gasket at the proximal end of the instrument downthe central channel. A combination laser/hook is now under development and may have several versionswhich will permit a combination of laser and electrocautery.

Once the cystic duct has been tentatively identified, a clip is placed as high up on the duct as possible towardthe gallbladder. Even when the anatomy appears clear, we are careful not to transsect structures until we haveobtained a cholangiogram. Clip appliers are available in reusable and disposable versions. The reusableversions allow for placement of only one clip at a time and require repeated loading during the procedure. Incontrast, the disposable clip appliers contain 20 medium-sized clips, load automatically, and can be rotatedwithout turning the handle. The later feature permits the surgeon to rotate the tips of the clip applier into viewbefore placing the clip. Both prongs of the clip applier should be visible before the clip is placed. Currently,the clip appliers are available in only one size (medium). However, multiple sizes are in development. Priorto cholangiography, a single clip is placed on the cystic artery as close to the gallbladder as possible. Thismarks the medial aspect of the dissection and serves as a position indicator during cholangiography.We routinely perform cholangiography to define the anatomy and to identify potential common duct stones.

In our experience, cholangiography is possible in most cases if the appropriate instrumentation is available. Amicroscissor is used to make a transverse incision in the cystic duct. If the cystic duct is not sufficientlyisolated from surrounding tissue, the transverse incision may be of insufficient length to permit passage of thecholangiography catheter, or the ductal lumen may be obscured from view. For ducts of diameter 2 mm or

greater, an appropriately sized taut catheter can be passed into the duct. Alternatively, a ureteral catheter canbe used to obtain the cholangiogram. These catheters are best applied through a specially designed cystic ductcatheter delivery instrument. These instruments, however, are in short supply and if unavailable can bereplaced by a straight hollow lumen suction-irrigation tool. Both the suction-irrigation and the cholangiogra-phy guide have a proximal gasket to permit passage of the cholangiography catheter without escape of gas.The cholangiography guide has a centering interlumen which allows more accurate positioning and control ofthe cholangiography catheter. The end of the cholangiography guide terminates in amodified soft, flat grasperto secure the cholangiography catheter within the duct.At the time of cholangiography, it is important to remove all unnecessary metal instruments from the field.

The use of disposable plastic trocars is an advantage here. The metal trocars must be rotated parallel to thespine and out of the field of the cholangiogram. Alternatively, the trocars can be fixed in place and the patientmoved to permit unobstructed visualization of the duct. Care must be taken not to introduce air into the tautcatheter or cholangiography tubing. Once inside the abdomen, we flush the cholangiography catheter to insurethat no air bubbles are trapped in the tubing. A theoretical problem is the potential escape ofC02 into the opencystic duct. However, this possibility has not been observed in our experience and has not interfered withcholangiography.

Placement of the cholangiography catheter in the cystic duct can be an exercise in frustration, particularlyif the duct is small and the catheter is large. Gentle and careful manipulation of Hartmann's pouch is criticalfor safe and successful cannulation of the cystic duct. Choosing the appropriate size catheter and inserting itat the proper angle are essential to the procedure. Attempting to force a stiff catheter into the duct at rightangles often fails. However, engaging the catheter into the duct at a right angle and then shifting the cystic ductparallel to the cholangiogram catheter allows the cholangiogram catheter to slip into the duct. If the duct isaccidentally transsected, it still is possible to obtain a cholangiogram. A grasper can be used to hold the distalend of the duct while another transverse incision is made with a microscissors. Passage of the cholangiocath-eter is attempted again. However, the surgeon should be very careful not to avulse the cystic duct from thecommon duct and not to leave a cystic duct stump which is too short to clip safely. When performing

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cholangiography in a shortened duct, the cholangiocatheter can be held in place with a single clip. Thismethod can be used in lieu of the cholangiography grasper described above.An alternative approach is to use an 0.35 inch guidewire inside a 6 Fr catheter. A variety of guidewires and

catheters are available in addition to those already mentioned. While multiple combinations of catheters andwires can be employed to cannulate the duct, we reserve these techniques for use during cystic duct dilatationand subsequent common duct exploration. A variety of cholangiocatheters with balloon tips are underdevelopment. These balloons serve two functions: they hold the catheter in positionwithin the duct, and theymay be used to dilate the duct if further exploration is necessary.

Once cholangiography has identified the anatomy and the surgeon is sure that the lumen entered is indeedthe cystic duct, the cholangiography catheter is withdrawn and two clips are placed on the proximal cysticduct. The duct is divided with laparoscopic scissors. These scissors are available in "hot" and "cold" versions.The "hot" version connects to electrocautery and permits its use as both a sharp dissector and a electrocauterycoagulator. Once the cystic artery is ligated, it too, is transsected with the scissors. Neither the cystic duct northe cystic artery should be transsected with electrocautery, as the electrical currentmay travel through the fluidin the interlumen causing injury that may not be immediately apparent. We recommend that the scissors beused for transsecting both the duct and the artery.Dissection of the gallbladder from the liver bed requires that countertraction be applied to the proximal end

of the gallbladder. A heavy duty grasper should be used.to manipulate the gallbladder. Manipulation isfacilitated and the risk of gallbladder perforation is reduced if the clips on the cystic duct and cystic arterystumps are not placed within the grasper's jaws. Using the electrocautery hook the initial dissection frees theproximal end of the gallbladder from its attachment to the liver. Once the plane has been established, the hookdissector is used to coagulate small blood vessels. Large vessels may occasionally need clips prior to ligation.For patients with edematous thick-walled gallbladders, a spatula-shaped electrocautery dissector is available.This broad, flat dissector permits relatively bloodless dissection through edematous tissue. It works mosteffectively when used in a pushing manner and in a sweeping motion.Alternatively, this dissection can be accomplished with a variety of laser tips. Both the electrocautery and

the laser tips provide amechanism for cutting and coagulation while removing the gallbladder from the liverbed. The most effective technique with either device is a sweeping motion from left to right, creating ahorizontal line of dissection. Both techniques are effective, and good results can be achieved with eithermodality.A wide variety of other instruments is available for laparoscopic applications. However, they usually are

not necessary for laparoscopic cholecystectomy. Biopsy forceps, snares, spoon and claw forceps, andcombination instruments are all designed for pelvic applications of laparoscopy. These tools can be adaptedfor upper abdominal use. Care must be taken not to choose instruments with sharp teeth which may puncture

FIG. 1. A laparoscopic image obtained after the heavy duty grasper is used to secure the dome of the gallbladder andmove it superiorly and anteriorly. This maneuver lifts the gallbladder and liver into view and secures the operative field.The grasper extends from the 9:00 position into the center of the field. The gallbladder in this patient has typical omentaladhesions at Hartmann's pouch.FIG. 2. The electrocautery hook is seen prominently extending from the 2:00 position into the center of the field. Thecystic artery and cystic duct are seen traversing the field. The hook has been used to skeletonize these structures. The arteryis superior to the duct.FIG. 3. The cholangiocatheter extends through the suction-irrigation cannula into the cystic duct. A heavy duty grasperextends behind the suction-irrigation catheter and is fixed to Hartmann's pouch, retracting it superiorly and laterally.FIG. 4. As the dissection of the gallbladder proceeds the electrocautery hook is used to dissect the gallbladder from theliver bed. With this technique there is minimal blood loss and minimal damage to adjacent tissue.FIG. 5. This laparoscopic view illustrates the almost completed dissection of the gallbladder from its bed. Theremaining attachment of the gallbladder to the liver is maintained until inspection confirms that the liver bed is dry and bilestasis and hemostasis have been achieved.FIG. 6. This laparoscopic image shows the gallbladder after it has been transferred from the heavy duty grasper to theextraction grasper which has been inserted through the subxyphoid trocar in this case. The neck of the gallbladder has beenpulled into the trocar prior to removal of the entire gallbladder from the abdomen.

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hollow organs. In general, instruments with sharp points should be used with great care, particularly aroundthe common duct. Large scissors, microscissors, and dissecting instruments can all cause perforation of thecommon duct or traumatic injury to the liver or other organs. No sharp instrument should be moved unless itis visualized by the laparoscopy camera.

These basic instruments, the Veress needle, 5 and 10 mm trocars, reducer gaskets, laparoscope, graspers,dissectors, scissors, clip applier, and cholangiography equipment, should be available before any attempt atlaparoscopic cholecystectomy is made. If these instruments are not available or not in perfect working orderthe procedure should be postponed.

OPERATIVE TECHNIQUEThe patient is placed in a supine position on an operating table which will permit intraoperative

cholangiography. The procedure is performed under general anesthesia with the patient in the 5-10° reverseTrendelenburg position. Sequential compression stockings are placed on both legs, to avoid pooling of bloodin the lower extremities caused by the reverse Trendelenburg position. After placement of an endotrachealtube and preparation of the abdomen, drapes are arranged to expose the entire abdomen. Once the abdomen isprepared, the surgeon should assemble the laparoscopic system. The light cable should be tested andconnected to the laparoscope. The video camera should be attached to the laparoscope and focused using a4x4 white sponge or gauze as a target. The individual threads should be clearly visible. With the sponge orgauze as a target, the camera should be white-balanced. At this time the laparoscope should be placed into a

laparoscope warmer, which is simply a cylinder filled with warm (37°C) saline. This prevents fogging of thelens after insertion into the abdomen. Should fogging persist, sterile antifog solution can be applied to thedistal lens.If the patient has had no prior abdominal surgery, a Veress needle is placed into the peritoneum at the

midline just below the umbilicus. The Veress needle should be inserted at right angle to the abdominal wall.The surgeon and assistant should firmly grasp the abdominal wall with one hand and pull upward while theneedle is inserted. The surgeon will feel the click of the obdurator as the needle passes through the peritoneum.Often this occurs as a "double click" as the catheter passes first through the fascia and then the peritoneum. A5-10 cc syringe is used to aspirate the needle. If the aspiration is negative, 5-10 cc of saline are flushedthrough the Veress needle and then several additional cc are dripped into the open end. If the saline drainsrapidly into the interperitoneal space ora column of fluid is seen to vary with respiration, the position of theneedle is confirmed. Insufflation is started at low flow rates. If the pressure rises above 18 mmHg the needleismanipulated. Further insufflation is not performed unless the pressure drops below 12 mmHg. The abdomenis observed for symmetrical distention, and percussion should be used to confirm the tympany associated withintraperitoneal C02. The abdomen is insufflated to 18 mmHg pressure and the Veress needle is withdrawn.The first trocar is placed in the infraumbilical position using the same entrance hole as the needle. At this

site an 8-10 mm incision is made with a # 10 blade. The incision can be stretched using a mosquito clamp. Thetrocar is then brought onto the field and held like an awl or corkscrew. The surgeon should inspect the trocarprior to insertion and the stopcock should be in the closed position. The trocar is inserted at right angles orangled toward the gallbladder. Its position can be confirmed by the rush of gas as the obdurator is withdrawn.The C02 gas line is then connected to the trocar and the stopcock is opened.A laparoscope is inserted through the trocar and a survey of the abdomen is made. The surgeon should

develop his own routine for this exploratory maneuver. The next 10 mm trocar is placed in the subxyphoidposition in the midline at the level of the inferior edge of the liver. Under laparoscopic observation gentlefinger pressure is used to deform the anterior abdominal wall at the placement site for this trocar. The trocaris inserted with the laparoscope, providing the view of the peritoneal surface of the abdominal wall. Directvisualization of trocar placement should prevent puncture of the liver or damage to intra-abdominal contents.After the trocars have been placed, the patient's right side should be rotated upward 10-15°. For obesepatients, a soft bumper or roll may be placed under the right flank to help elevate the right side. Nasogastrictubes and urinary catheters are placed if a lengthy procedure is anticipated (greater than 1/1-2 h).The laparoscope is now rotated to view the right abdominal wall. In the anterior axillary line, approximately

halfway between the 12th rib and the iliac crest, a 5 mm trocar is placed under direct vision. Through this

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INSTRUMENTATION AND TECHNIQUE OF LAPAROSCOPY

trocar, a heavy duty locking grasper is used to grasp the dome of the gallbladder. If the gallbladder adheres tothe duodenum or other adhesions are seen, they are divided at this time by dissection through the subxyphoidtrocar. With the gallbladder free, the heavy duty grasper is used to move the gallbladder up and over the domeof the liver. Direction of this grasper superiorly and anteriorly toward the shoulder brings the proximal end ofthe gallbladder into view. The grasper is then fixed to the table or the patient to maintain this retraction on thegallbladder. This maneuver is essential for securing the operative field and providing adequate exposure forfurther dissection. The handle of the instrument is pointed toward the midline to facilitate fixation to thepatient. This maneuver is illustrated in Fig. 1.After retraction is secured, a 5 mm trocar is placed just medially and 2-3 cm inferiorly to the costal margin.

This trocar is used to grasp Hartmann's pouch. Adhesions are common between the gallbladder and omentumor duodenum. Usually these adhesions can be dissected bluntly, sweeping them toward the common duct.Clear visualization of the proximal end of the gallbladder should be possible at this time. If the proximal endof the gallbladder is not visible further retraction of Hartmann's pouch and a combination of blunt and sharpdissection should permit the surgeon to identify the origin of the gallbladder.Using the dissecting grasper, the tissues overlying the cystic duct are gently separated. The motion

employed for this dissection should always be toward the common duct. A lymph node usually overlies thecystic artery, and occasionally, it is necessary to use electrocautery to obtain hemostasis as the lymph node isswept away. The grasping dissection is withdrawn and replaced by the electrocautery hook. The hook is usedto further separate the tissues. At this point, the cystic duct and cystic artery should be tentatively identified.The hook is used to skeletonize the duct and the artery (Fig. 2). The hook is then used to encircle the cystic ductand remove any remaining connective tissue. The hook is withdrawn and a single clip is placed at the junctionof the cystic duct to the gallbladder and a clip is also placed on the proximal cystic artery.The microscissor is now inserted through the subxyphoid trocar and used to make a transverse incision into

the cystic duct. The cholangiography catheter should be attached to the cholangiography guidewire or thesuction-irrigation catheter or reducer system. The line should be checked for bubbles. The catheter is theninserted into the abdomen through the 5 mm trocar on the anterior wall of the abdomen. The cholangiographycatheter (either a taut catheter or a 4 Fr ureteral catheter) is placed into the cystic duct. If the introducer has a

specially designed tip, it can be used to secure the catheter into the duct. Alternatively, a clip can be used tosecure the cholangiography catheter in place (Fig. 3). Cholangiography should be performed routinely.The cholangiogram is reviewed, and if the anatomy is confirmed and there are no stones in the common

duct, the catheter is withdrawn. The cystic duct and artery are clipped twice proximally and once distally andthen divided with scissors. No dissection is carried medially to the proximal cystic artery clip. At this point,the surgeon should confirm that hemostasis is adequate. The suction-irrigation catheter removes any debris orblood which accumulates during the dissection of the cystic duct.Via the 5 mm trocar a heavy duty grasper is placed onto the proximal end of the gallbladder at Hartmann's

pouch. The gallbladder is retracted superiorly and the scissors or the electrocautery hook is used to initiate thedissection between the gallbladder and the liver. Once the appropriate plane has been identified, the dissectioncan be performed with the electrocautery hook orwith laser-based instruments (Fig. 4). Occasionally a spatulais used to perform dissection with an edematous gallbladder. Small vessels are divided with electrocautery.Occasionally a large vessel or bile canaliculus will require a clip for hemostasis. These clips must be placedprior to transsection of the vessel. Once transsected, these tiny vessels retract, making hemostasis moredifficult. The dissection proceeds until the gallbladder is attached by only 1-2 cm of tissue (Fig. 5). At thispoint, the gallbladder bed and the hilum are inspected for hemostasis and bile stasis. If small bleeding pointsare found they can be coagulated with electrocautery or laser. With hemostasis confirmed the hilar area andliver bed are copiously irrigated and the irrigation fluid is aspirated. The gallbladder is then detached from theliver and 0.5% Marcaine with epinephrine is injected systematically at each trocar site. The injection shoulddevelop wheals on the peritoneal surface. We use 5-10 cc per site to insure adequate relief of postoperativepain.The gallbladder is withdrawn either at the subxyphoid site or at the umbilical site. In order to withdraw the

gallbladder it is necessary to release the fixed heavy duty grasper and transfer the gallbladder to a second heavyduty grasper (Fig. 6). Care should be taken to insure that the second grasper maintains a firm grip on the

13

PHILLIPS ET AL.

gallbladder. If the stones in the gallbladder are larger than 1 cm, the laparoscope is switched to the subxyphoidsite and the gallbladder is grasped through the umbilical site. If necessary, the fascial opening at the umbilicalsite can be enlarged to extract the gallbladder. In our experience enlarging the umbilical site produces lesspostoperative pain than enlarging the subxyphoid site. After the gallbladder is extracted, a finger is used toocclude the trocar site and a suction catheter is inserted via the trocar in the anterior axillary line. Fluid isaspirated from the subphrenic and subhepatic spaces and C02 insufflation is discontinued. The laparoscope ispulled into the trocar and the lateral trocars are removed. Suction is used to deflate the abdomen as thelaparoscope is withdrawn. The pneumoperitoneum is released from the trocar. The fascia at the 10 mm trocarsites is closed with a single absorbable 0 or 2-0 suture. All skin incisions are closed with subcuticularabsorbable 4-0 sutures.The patient receives no injectable narcotics postoperatively, but is encouraged to take oral pain medication

as required. Nurses must be specifically instructed for this program, since they are accustomed to givinginjectable narcotics after a cholecystectomy. Administration of injectable narcotics negates some of thebenefits of this procedure. Similarly, Marcaine injections are important in reduction of initial postoperativepain. Most of our patients require only oral pain medications and are discharged within 24-48 h after theprocedure.

We have used this technique successfully in more than 250 patients. The first 20 patients selected had no

prior history of acute cholecystitis. Patients with a history of fever, right upper quadrant tenderness, andrepeated attacks have all been found to have adhesions obscuring the hilar anatomy. Dissection in thesepatients requires more experience and skill. A history of common duct stones or prior biliary pancreatitisfurther complicates the procedure. Such patients should not be attempted until a surgeon has performed thistechnique in at least 25 uncomplicated procedures.Obesity does not necessarily make the operation more difficult. However, placement of the trocars may be

altered in order to reach the operative site. Patients who are of round muscular habitus, generally overweightmen between the ages of 30 and 50, tend to present the most difficult operative field. In these patients a fullretroperitoneum tends to push the abdominal contents into the operative field. In these patients an extra trocarcan be inserted into the flask to hold the transverse colon and duodenum out of the operative field. This permitsbetter visualization of the cystic duct and the gallbladder.

Patients with a history of prior upper abdominal and midabdominal surgery are difficult candidates forinitial attempts at laparoscopic cholecystectomy. The dissection of these anterior wall adhesions can betime-consuming. Combined with the 2-1/2 to 3 h for the first procedures, operative time becomes extensive.Initial placement of the trocar in these patients is into an area that is free of scar and is least likely to haveadhesions. The laparoscope is inserted to define the operative field, and often, a second trocar is inserted in an

adjacent area. The adhesions are detached from the abdominal wall and the dissection is carried toward thegallbladder. When sufficient space on the anterior abdominal wall permits, additional trocars are placed.

DISCUSSION

The instrumentation and techniques described have been safely and successfully used to performlaparoscopic cholecystectomy in more than 250 patients. We have trained more than 300 surgeons to performthe procedure using these techniques. This training includes assisting in or performing laparoscopiccholecystectomy in 6 pigs over a 2-3 day period. The combination of extensive didactic and hands-on trainingpermits the surgeon to become facile with the instrumentation. However, it is not a substitute for operativeexperience with patients. We urge all surgeons learning this procedure to assist a skilled operator for their first5-10 procedures and then have an experienced surgeon assist them on their first few cases. Careful review ofcases from the surgeon's own video record is critical in the learning process. Surgeons who have had priorexperience with video laparoscopy or video endoscopy have an advantage as they are accustomed to operatingbased on the information obtained by observing a video monitor. This procedure requires a team approach andthe surgeon's assistant should be well versed in the technique.

Surgeons should have a low threshold for converting a laparoscopic cholecystectomy to an open procedure.Extensive scarring, unclear anatomy, uncontrolled hemorrhage, injury to common duct, bowel, or duodenum

14

INSTRUMENTATION AND TECHNIQUE OF LAPAROSCOPY

should prompt conversion of the laparoscopic procedure to open surgery. In this regard, we always have a

laparotomy tray of instruments open and ready for use. The surgeon must not consider "opening a patient" afailure, since this may prevent or ameliorate major complications. This is still a major operation, even thoughthe skin incisions are minor. The potential risk of common duct or right hepatic artery injury still exists; theextent of this risk is currently unknown. All patients should be advised that circumstances may arise whichrequire an open procedure.The rapid dissemination of laparoscopic cholecystectomy techniques is forcing a major réévaluation of

general surgery procedures.6 Our own group is investigating laparoscopic lymphadenectomy and othergroups7,8 are gaining experience with laparoscopic appendectomy and laparoscopic hernia repair. Laparo-scopic surgical staplers now in development will permit the surgeon to perform laparoscopic bowelanastomoses. As the instrumentation evolves, additional laparoscopic techniques will be added to thearmamentarium of the surgeon.

REFERENCES

1. Cuschieri A, Bouchier IAD: The biliary tract. In: Cuschieri A, Giles GR, and Moossa AR (eds): Essential SurgicalPractice. London: Wright Publishers, 1988, pp 1051-1056.

2. Table C-10: Average length of stay for selected operative procedures for patients discharged from short-stay hospitals1987. American College of Surgeons Socioeconomic Factbook for Surgery 1989, p 39.

3. Buess G, Mentges B, Melzer A, Gutt C, Schafer D: Laparoscopic microsurgical cholecystectomy in gallstone disease.Surg Endose 1990; 4:55,32A.

4. Ko ST, Airan MC: Technique and early experience of laparoscopic cholecystectomy and cholangiogram. Surg Endose1990; 4:58-59,49A.

5. Perissat J, Collet D, Belliard R: Gallstones: laparoscopic treatment—cholecystectomy, cholecystostomy, andlithotripsy. Surg Endose 1990; 4:1-5.

6. Reddick EJ, Olsen DO: Laparoscopic laser cholecystectomy. Surg Endose 1989; 3:131-133.7. Götz F, Pier A, Bacher C: Modified laparoscopic appendectomy in surgery: a report on 388 operations. Surg Endose

1990;4:6-9.8. Leahy P: Laparoscopic esophagogastrectomy using laparoscopic staplers. Personal communication and lectures

delivered at "New Interventional Technologies: Laparoscopic Cholecystectomy" course at New Jersey College ofMedicine and Dentistry, August 3-5, 1990.

Address reprint requests to:Dr. Warren S. Grundfest

Assistant Director ofSurgeryDirector, Laser Surgery

Cedars-Sinai Medical Center8700 Beverly Boulevard, Room 1739

Los Angeles, ÇA 90048

15

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