1. Difficult Cholecystectomy Dr. V Gandhi DNB (GI Surgery), DNB (Gen Surgery), MNAMS Consultant GI & HPB Surgeon Pune surgical Society

3. Preview • What is safe cholecystectomy ? • What is difficult cholecystectomy ? • Predict difficult gall bladder • Management options

4. Safe Cholecystectomy Critical View of Safety

5. Difficult Cholecystectomy • Procedure with an increased surgical risk compared with standard Cholecystectomy • One taking longer that 90 minutes, tearing the gallbladder, spending more that 20 minutes dissecting the gallbladder adhesions, or more than 20 minutes dissecting Calot’s triangle Lal P ; JSLS 2002

6. Surgeon • Surgical carrier • Four port • Three port • Single port • SILS • NOTES

7. Patient factors • Male • obesity • Mirrizi syndrome • Ascitis • Portal hypertension • Acute cholecystitis & sequelae • Anatomical anomalies • Intrahepatic GB • Previous surgery

9. Severity assessment of acute cholecystitis TOKYO Guidelines Grade 2 MODERATE Grade 1 MILD Grade 3 SEVERE

12. Damage Control • Cholecystostomy • Fundus first approach • Subtotal Cholecystectomy – lap/open • Endoscopic sphincterotomy

13. Ideal Procedure – Safe cholecystectomy not possible • Does not leave a remnant gallbladder that will become symptomatic and require a later operation. • Has low morbidity due to bile fistula. If a fistula occurs it should resolve spontaneously over a short period • Can be done laparoscopically • Can be done by a surgeon without additional training in HPB surgery

14. Removal vs Non removal of posterior wall of gall bladder Haemorrhage – no difference in both groups Subhepatic collections , bile leak , retained stones – more in group with non removal of posterior wall

15. Closure vs non closure of GB stump for subtotal cholecystectomy Non closure of GB stump – more collections & bile leak Closure of stump – more retained stones No significant difference in weighted analysis

16. Open vs lap subtotal cholecystectomy Lap SC associated with less risk of sub hepatic collections, retained stones , wound infections and re operations Lap SC associated with more bile leaks

17. Subtotal Fenestrating Cholecystectomy

18. Subtotal Reconstituting Cholecystectomy

19. Prevention of bile leak using omental plug technique after subtotal cholecystectomy for difficult gall bladders

20. Problems Adhesions and neovascularity – harmonic, ligasure Difficult traction of the liver – additional ports Inadequate exposure of the cholecystohepatic triangle – retraction on the GB body Fundus first approach High risk gallbladder bed High risk Hilum

21. High risk GB bed – Type 1 Lap SC High risk Hilum – Type 2 Lap SC

22. High risk GB bed + High risk Hilum – Type 3 Lap SC

23. Advantages of Lap in Cirrhotic • Wound infection, dehiscence & postoperative hernia are less • Inadvertent bacterial seeding & contamination of ascitis is significantly reduced • Magnification inherent in lap surgery makes identification of the presence of dilated vascular channels • Needle stick injuries are reduced • Less post op adhesions – benefit for future transplantation

24. Lap chole in cirrhotic patients is associated with a higher complication rate than in non cirrhotic patients, due to several inherent risk factors. Improvements in operating skills, equipment and accumulating experience in performing LC in difficult conditions over the years has made LC in cirrhotic patients a safe proposition when used judiciously. The postoperative complications are related primarily to Child-Pugh class, being maximum in patients of Child-Pugh class C . Proper selection of the patients, adequate preoperative optimization, and appropriate instrument use have led to lower morbidity and significantly less mortality

25. Acalculous cholecystitis AAC Percutaneous Transhepatic cholecystostomy Tube cholangiography No gall stones Gall stones + Elective cholecystectomy Tube removal No cholecystectomy

26. Mirrizi syndrome Type 1 – Lap / open cholecystectomy Type 2 - subtotal cholecystectomy / choledochoplasty / T tube Type 3/ 4 – biliary bypass

27. Gall Bladder Perforation - Type I Generalized biliary peritonitis

28. Gall Bladder Perforation - Type 2 Type II GBP Stones eroding into the liver with abscess Perforated GB with abscess in the liver Patient had jaundice on presentation Cholecystectomy & T tube drainage of CBD was done

29. Anatomical variants Vascular anomalies Biliary tract variants Left sided gall bladder Bilobed gall bladder Double cystic duct

30. Nagral S : JMIS 2005

31. Difficult cystic duct • Metal clips • Hemolock • Endoloop • Tie • Intracorporeal suturing • Endo GIA staplers • Bipolar sealant • Harmonic ultrasonic shears

32. LEFT SIDED GALL BLADDER Methods of safe laparoscopic cholecystectomy for left-sided (sinistroposition) gallbladder: A report of two cases and a review of safe techniques Int J Surg Case Rep. 2014; 5(10): 769–773

33. When to convert ….. • Unable to proceed • Ongoing Bleeding • Suspected biliary injury • Anatomical variations • Poor instrumentation • Operating in periphery – low threshold When in doubt !

34. Conclusion • Anticipate trouble • Open subtotal/total cholecystectomy is safe and effective • Be Wary of: – Difficult anatomy – Difficult pathology

35. Choose well, Cut well, Get well drgandhivv@gmail.com