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Tips and tricks: standard case of laparoscopic cholecystectomy in an obese patient with a BMI of 49

Authors

Abstract

This video demonstrates a series of technical tricks designed to overcome the specific challenges of laparoscopic cholecystectomy in morbidly obese patients.

Classification

tips and tricks

Keywords

tips and tricks, standard case, laparoscopic cholecystectomy, obesity, laparoscopy

Media type

Duration

06'46''

Publication

2008-07

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Audio

Subtitles

E-publication

WeBSurg.com, Jul 2008;8(07).
URL: http://www.websurg.com/doi-vd01en2356.htm

Tips and tricks: standard case of laparoscopic cholecystectomy in an obese patient with a BMI of 49

1. Case presentation 00'20''

This video shows different tips and tricks during a laparoscopic cholecystectomy in an obese patient, with a BMI of 49 and no previous operations.

2. Patient positioning and set-up 00'29''

The patient is placed in a typical “French” position, in a dorsal decubitus with the legs apart. We use two types of different stirrups for the patient’s legs. We also place foot supports for the patient’s feet and the arms are also spread. We begin the operative set-up by placing an operative drape on either of the patient’s legs, then another infra-umbilical drape before adding one at the level of the patient’s head and sides. Because of the size of the patient’s abdomen, we cannot place an OpSite bandage.

3. Case commences with placement of optical port 00'59''

The surgeon is placed between the legs of the patient and the assistant to the surgeon’s right. The optical trocar is placed supra-umbilically using a mini open approach. To achieve good exposure in this type of patient, we use a 1cm large S-shaped retractor; this retractor has the functionality of retracting the tissues deeper and allows to better expose the aponeurosis. Once we have identified the aponeurosis, we grasp it with a Kocher forceps. We can then place traction that will allow us to use the scissors and incise the different planes in order to get access to the peritoneum. In this way, we position the optical trocar. We perform a panoramic exploration of the abdominal cavity that will be followed by the insertion of a 5mm working port at the junction between the anterior axillary line and umbilical line.

4. Placement of working ports 02'11''

This trocar placement is facilitated by the translucent aspect of the abdomen. A second operative trocar is placed at the para-medial left level, a few cm left to the umbilical line. To achieve triangulation, we need to insert a third 5mm trocar that will allow us to retract and expose the gallbladder. This trocar is placed in a sub-xiphoid position. In obese patients, the round ligament is often voluminous. For this reason, we use bipolar coagulation to decrease its volume.

5. Fundal retraction of gallbladder 02'49''

We grasp the gallbladder by the fundus and retract it cephalad. This allows us to expose the Calot’s triangle. Further to this, we perform the freeing of the gallbladder neck‘s attachments with a monopolar hook.

6. Skeletonization of Calot\'s triangle 03'00''

In this type of patient, the presence of fatty tissue is very common over the gallbladder and the hepatoduodenal ligament, which makes the identification of the biliary and vascular elements harder. The division of the posterior and anterior peritoneum at the level of the gallbladder’s neck allows us to identify the elements of the Calot’s triangle more easily. We continue the dissection at the level of the anterior peritoneum to open even more the operative field. The same procedure is performed at the level of the posterior peritoneum; as you can see here, we alternate between posterior and anterior dissection, with the objective of identifying the cystic duct and cystic artery. Once the peritoneum is dissected and with adequate traction, we can identify the cystic artery and duct. Before performing the division of these two elements, we continue the anterior dissection of the cystic duct towards the gallbladder. We perform the same manoeuvre on the posterior aspect. We must stay close to the cystic duct at all times in order to have a safe dissection. To obtain a perfect exposure of the elements located near the Calot’s triangle, we must still dissect the anterior and posterior peritoneum. Once freed and well identified, we can place clips at the level of the cystic duct and artery.

7. Clipping and division of cystic duct and artery 05'01''

Two clips are applied proximally and only one distally on both structures in order to divide them. We then grasp the gallbladder and perform a cephalad retraction, which allows us to free the posterior attachments using a monopolar hook.

8. Completion of gallbladder dissection 05'47''

Traction is the key element to achieve the freeing of the gallbladder from the liver bed. We do not hesitate to modify the traction points in order to complete the freeing of the gallbladder. We then introduce via the optical trocar an Endo-catch bag in order to remove the gallbladder.

9. Removal of specimen 06'13''

We place the specimen into the bag by grasping it by the fundus in order to keep the neck of the gallbladder at the top of the bag. We perform the extraction of the Endo-catch bag through the optical trocar. We grasp the gallbladder by its neck in order to facilitate the extraction.

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