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Laparoscopic Cholecystectomy with Intraoperative Cystic Duct Cholangiogram Operative Sample

DESCRIPTION OF OPERATION:  The patient was taken to the operating room, and after induction of general endotracheal anesthesia, the abdomen was prepped and draped in the usual manner.  The patient had previous lower midline incision from a cesarean section, so we decided to proceed with open insertion with a Hasson blunt cannula in supraumbilical location and this was performed.  After the insertion of the cannula, the laparoscope was inserted, and initial exploration showed that there was no damage to visceral structures during the above procedures.

Attention was then turned to the right upper quadrant where two 5 mm trocars were placed in subcostal area, one in the anterior axillary line and one in the midclavicular line.  A 10 mm trocar and sleeve was placed in the upper abdomen, in the midline, approximately 7 cm inferior to the xiphoid process, subsequently entered the abdomen just to the right of the falciform ligament.  The patient was placed in a slightly reversed Trendelenburg position and turned toward the left.  Initial exploration showed a tensely distended gallbladder with a clearly gangrenous corpus and fundus.  Aspiration was performed and turbid fluid was sent for culture and sensitivity.

The gallbladder was extremely friable, as several areas of the wall were essentially dead, and therefore, it was difficult to deal with, but we were able to grasp the fundus and retract superiorly.  There was a good deal of very thick dense inflammation on Hartmann pouch.  There were also inflammatory adhesions of the entire area to the anterior duodenum, distal stomach, and omentum.  Using careful blunt dissection as well as some sharp dissection, the area was approached and we were able to gain access to the hepatoduodenal ligament.  The cystic duct was identified and clip placed on the gallbladder site.

A small ductotomy was made and a 19 gauge catheter was inserted medially through a separate puncture wound in the right upper quadrant and entered into the cystic duct, and a clip was applied for proximal tension over the duct and catheter.  A cystic duct cholangiogram showed that there was free flow of the duodenum, no stones.  The ductal system was intact.  The clip and catheter were then removed and two clips were placed distally in the cystic duct proximal to the center of common bile duct and the cystic duct was divided.  Anterior and posterior branches of the cystic artery were identified.  The clips were placed on both sides and the artery was divided.

The gallbladder was dissected free from its bed using electrocautery as well as blunt and sharp dissection.  In the inferior portion, dissection was difficult due to thick inflammatory tissue, and then more superiorly, the wall was essentially disintegrated with gray necrotic tissue.  On completion, the gallbladder was removed through the upper abdominal portal, and there was satisfactory control of the cystic duct and arteries and good hemostasis.  The operating field was copiously irrigated and aspirated.  The hemostasis was assured.

Because of the degree of inflammation and possibility of bile leakage from the severely inflamed cystic duct stump, it was decided to leave a drain in the area and a large round Jackson-Pratt drain was placed in the area and brought out through a separate puncture wound for which one of the lateral 5 mm port openings was utilized.  The upper abdominal vessel defect in the midline was closed with a single suture of 0-Vicryl using a Carter-Thomason device.  Then, the pneumoperitoneum was relieved as much as possible and the fascial defect in the supraumbilical area was closed with two sutures of 0-Vicryl.  All skin incisions were closed with subcuticular.  The patient tolerated the procedure well and was taken to the recovery room in satisfactory condition.

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