OPERATION PERFORMED:
1. Laparoscopic cholecystectomy.
2. Open exploration, right kidney.
DETAILS OF PROCEDURE: The patient was positioned supine on the operating room table. Pneumatic compressing stockings were applied and inflated. After induction of adequate general endotracheal anesthesia, the area over the abdomen was prepped and draped in the usual sterile fashion. A small umbilical incision allowed for introduction of the Veress needle and insufflation of the abdomen. A 0 degree, 5 mm laparoscope was introduced through a 5 mm port at the umbilicus and three additional ports were placed in their usual anatomic positions. The gallbladder was absolutely normal. It was a clear Robin's egg blue with no evidence of inflammation. There was an inflammatory process just inferior to the right liver edge with adhesions to the liver surface. A firm mass thought to be the kidney was located at the inferior margin of the liver just cephalad to the hepatic flexure of colon. It was decided that open exploration would be necessary to exclude an abscess in this area.
An incision was made connecting the two lateral 5 mm port sites. Dissection was taken down through the anterior abdominal wall musculature and the peritoneum was carefully incised. Retractors were placed and dissection begun over the right kidney. The liver was separated from Gerota's fascia. Dissection continued into the perinephric fat and the renal parenchyma was identified, found to be pink and healthy in its appearance. The renal artery was palpably normal. The ureter and renal vessels were not visualized however. There was no evidence of an abscess in this area. The reason for the inflammatory changes in this region remain uncertain. The hepatic flexure of colon was normal. The ascending colon was palpably normal. Stool was noted within the colon itself. No other abnormalities were identified. The liver was otherwise normal. The decision was made to close.
The internal oblique muscle and fascia were closed using interrupted #1 Vicryl suture placed in a figure-of-eight fashion. The external oblique fascia and muscle were closed using simple interrupted #1 Vicryl suture. The abdomen was reinsufflated and both 5 mm ports were replaced. The decision was made to proceed with laparoscopic cholecystectomy.
The gallbladder was retracted cephalad. The triangle of Calot was brought into plain view. The cystic duct was skeletonized and two clips were used to control the cystic duct distal and one at the level of the gallbladder infundibulum. The cystic duct was transected with perfect hemostasis and no evidence of a bile leak. The cystic artery was dissected free and two clips were used control the artery distally and one proximally. A posterior branch was controlled in much the same fashion. The gallbladder was dissected away from the liver parenchyma in avascular plane and brought out through the upper midline port site fascial defect. The gallbladder was normal without evidence of stones. The upper midline fascial defect was closed using 0 Vicryl suture under direct vision with the aid of Endoclose apparatus. Hemostasis was perfect at the operative site. Both 5 mm ports were removed under direct vision with good hemostasis at both sites. The abdomen was desufflated through the umbilical port which was subsequently removed. All incisions were closed using 5-0 PDS suture placed in a subcuticular fashion. Dermabond skin glue was used to seal each of the incisions. Marcaine 0.25% with epinephrine was used to infiltrate the skin and subcutaneous tissue at all of the incisions. The patient was awakened, extubated, and moved to the recovery room in satisfactory condition. She tolerated the procedure well. There were no complications.
