JOURNAL OF LAPAROENDOSCOPIC SURGERY Volume 2, Number 3, 1992 Mary Ann Liebert, Inc., Publishers
Bipolar Electrocautery in Laparoscopic Cholecystectomy THOMAS L. BRYANT, M.D., F.A.C.S.
ABSTRACT
Laparoscopic cholecystectomy was undertaken in 100 patients using bipolar electrocautery for hemostasis. Cholecystectomy was completed laparoscopically in 94 patients. No deaths or common bile duct injuries occurred. In this single surgeon's experience, bipolar electrocautery is a safe, effective, and economical modality in laparoscpic cholecystectomy.
INTRODUCTION cholecystectomy has experienced phenomenal growth since its introduction. An early series described a technique using the KTP laser to dissect the gallbladder away from the liver.1 Subsequently, the usefulness of unipolar electrocautery was documented.2 Despite its efficacy, use of the KTP laser has some drawbacks. It requires the acquisition and maintenance of expensive equipment, as well as the cost of extra operating personnel. In addition, during dissection, the liver must be used as a backstop to prevent injury to other organs from "forward scatter" of the laser energy.3 Unipolar electrocautery has also been employed to dissect the gallbladder. It is more economical and its equipment is easier to maintain than the laser. Unipolar electrosurgical instruments allow current to flow from the point of tissue contact, through normal tissue, to the grounding plate. However, accidental contact between target tissue and adjacent organs may cause unexpected injury3 and contact between other metal instruments and the electrocautery may conduct destructive currents to other tissues. The use of unipolar electrocautery in gynecologic laparoscopy was curtailed in 1981 after significant safety questions were raised.4 The magnitude of the risk has subsequently been questioned.5 Nonetheless, it has been demonstrated in experimental animals that direct application of unipolar electrocautery to the intestine can easily cause perforation, while an equivalent dose of bipolar electrocautery rarely causes perforation.6 Bipolar electrocautery has been widely used in gynecologic laparoscopy for the last decade. It is comparable to unipolar cautery in terms of cost and ease of use. With bipolar electrocautery, electrical current flows between two small "paddles". Peripheral tissue does not serve as a conduit for current, thus, the potential for remote damage is small.
Laparoscopic
Marietta Memorial
Hospital, Marietta, OH. 155
BRYANT
MATERIALS AND METHODS All of the operations in the series were performed at Marietta Memorial Hospital, Marietta, OH, a 150-bed community hospital. Each elective patient was given a single two-gram dose of cefotetan disodium (Cefotan, Stuart Pharmaceuticals, Wilmington, DE) at the time of anesthesia induction. The four port placement ' technique of Reddick was used. The umbilical port was placed blindly after Veress needle insufflation in the first 80 cases. Subsequently, the open technique of Hassan was employed.7 The cystic duct and cystic artery were bluntly dissected free. Routine cholangiography was performed. A cholangiogram catheter was introduced via the lateral port and guided into the cystic duct using an instrument introduced via the subxyphoid port. The cystic duct and artery were controlled with Endoclips (Autosuture, Norwalk, CT). One particularly large cystic duct stump was controlled with a pre-tied loop ligature. Peritoneal reflections at the medial and lateral edges of the gallbladder were cauterized with a bipolar forceps (Richard Wolf, Rosemont, IL) and then divided with a hook scissors. Electrocautery was not used until the cystic duct and cystic artery had been controlled and divided. The gallbladder was dissected free from the liver with sharp and blunt dissection using bipolar cautery to control any bleeding points. Cautery was not used in the vicinity of the cystic duct or common duct. The freed gallbladder was removed via the umbilical incision. Beginning with the fifth laparoscopic cholecystectomy, a 15 Fr silicone multiperforated drain was placed into the gallbladder fossa at the end of the procedure. The drain was placed via the lateral port. Generally, drains were removed on the first post operative day. If drainage was bile-stained, the drain was maintained until drainage ceased. The drain was then usually removed during an out patient visit on the fourth or fifth post operative day. The umbilical fascia was closed with size "0" polyglycolic sutures. Skin incisions were closed with size 3-0 plain gut subcuticular sutures.
RESULTS
Laparoscopic cholecystectomy was undertaken in 100 cases by a single surgeon. There were 80 female and patients. The average age was 50 years (19 to 90 years). The heaviest patient, a 315 lb (143 kg)
20 male
laparoscopic cholecystectomy for acute cholecystitis. The first 30 patients were all operated upon electively. Subsequently, laparoscopic cholecystectomy was attempted in all gallbladder operations. A single exception was a patient with acute cholecystitis who underwent surgery on a night when insufficient support personnel were available to perform a laparoscopic woman, underwent successful
cholecystectomy.
Six cholecystectomies were converted from laparoscopic to open procedures. One patient, the fourth in the was converted to open cholecystectomy due to bleeding in the cystic artery which was divided before it had been controlled with clips. Two patients were converted to open operation for persistently abnormal cholangiograms. In one, an attempt had been made to clear the common bile duct with a fogarty catheter introduced via the cystic duct. Three patients were converted to open operation when their cystic duct was found to be encased in dense adhesions. One of these patients also had acute cholecystitis. Ninety four patients had completion of their operations laparoscopically. Cystic duct cholangiograms were attempted on 96 patients and completed on 94. One of these patients had a cholangiogram via the cystic duct, as well as a cholangiogram via an accessory bile duct. This case has been previously reported.8 Of the four patients in whom cholangiography was not attempted, three had been converted to an open procedure early in the operation and one had a normal ERCP pre-operatively. In two patients, attempts to perform cholangiography failed. In three patients, a fogarty catheter introduced via the cystic duct recovered small stone fragments, converting an abnormal cholangiogram to a normal cholangiogram. One of these patients had a postoperative ERCP which recovered additional stony fragments. Three patients had pre-operative ERCPs. One had a normal ERCP in the evaluation of acalculous biliary disease, while two had ERCPs to evaluate a history of elevated serum bilirubin—one of these patients had multiple stones removed via ERCP and the other patient had a normal study. All three patients underwent uneventful laparoscopic cholecystectomy. The second two had intraoperative cholangiograms which were normal.
series,
156
BIPOLAR ELECTROCAUTERY Five patients had acute cholecystitis. Operation was completed laparoscopically in four. Four patients had postoperative bile leaks averaging greater than 300 cc per day. One patient who had not been drained presented 3 days postoperatively with severe right upper quadrant pain. CT scan showed a large subhepatic fluid collection—the drain placed by the radiologist drained bile for 10 days without slowing. An ERCP revealed drainage from a duct of Luschka. Sphincterotomy was performed and a stent placed via ERCP. The drainage ceased immediately and the stent was removed at 2 weeks. In another patient, right upper quadrant pain was noted on the first postoperative day. The drain placed during laparoscopic cholecystectomy produced over 500 cc of bile in the first 24 h postoperatively. ERCP performed on the second postoperative day showed a leak from the cystic duct stump. The bile leak stopped immediately after sphincterotomy and stent placement performed during ERCP. The stent was removed at 2 weeks. Since no electrocautery was used on the cystic duct, it is not believed that it could have been a factor in the leak. The cystic duct leak could have been caused by a small tear made by a clip or perhaps displacement of the clip. The cystic duct which leaked had been controlled with two endoclips. Subsequently three endoclips were used on all the cystic ducts where sufficient room was available. Two patients had asymptomatic bile leaks of greater than 500 cc per day via drains placed at laparoscpic cholecystectomy. Both leaks stopped spontaneously within 3 days. All bile leaks in drained patients were obvious within 8 hours. In the absence of a bile leak, drains were removed within 24 h. None of the patients with the bile leaks had acute cholecystitis or difficult dissections. Mean estimated blood loss for completed laparoscopic cholecystectomy was 20 cc. In the series of 100 patients, only one required a transfusion. This was a patient who had been converted to open cholecystectomy for dense adhesions early in the operation. Bipolar cautery was not used and estimated operative blood loss was 250 cc. The patient had a transient episode of bleeding around the drain site 30 h postoperatively. Her hemoglobin 36 h postoperatively was 6.3 %gm (pre-operative value 12.6 gm%). Coagulation studies were normal. She was transfused with two units of packed red blood cells and recovered without further event. Of all operations completed laparoscopically, the average postoperative hospitalization was 1.3 days. The time of operation averaged 98 min. The average time for the first 20 cases was 134 min. In the last 20 uncomplicated laparoscopic cholecystectomies, average operating time was 71 min (this did not include one patient with acute cholecystitis and one who underwent extensive enterolysis due to previous operations). Current instrumentation requires changing instruments when alternating between cauterizing, cutting, and irrigating. This is not a significant disadvantage. An instrument change can be accomplished in 5 sec. If 20 instrument changes are required while excising the gallbladder, the operating time will only be increased by less than 2 min. Inadvertent perforation of the gallbladder occurred in approximately 15% of all laparoscopic gallbladder dissections. This was the result of either tearing the gallbladder with blunt instruments or cutting it with a scissors. Bipolar cautery current, even when applied directly to the gallbladder wall, was never responsible for a perforation. Any spilled bile was aspirated and the field irrigated and suctioned dry. No modification was made in postoperative care. No morbidity occurred from intraoperative bile spills.
DISCUSSION For this single surgeon's experience, bipolar electrocautery is a safe and cost effective modality for laparoscopic cholecystectomy. It has theoretical safety advantages over laser and unipolar cautery. It effectively cauterized the attachments between the gallbladder and the liver bed. At the settings used, this method of cautery application did not perforate the gallbladder and was not used to divide the cystic duct or artery. Applied in this fashion, it is a useful tool for the laparoscopic general surgeon.
ACKNOWLEDGMENTS We are grateful to Edward Scileppi, M.D., F. A.C.O.G. for his assistance in initiating this series. Drs. R. Edgin, M. Thurman, G. Gibbons, and James Mohr of the Columbus Gastroenterology Group, Inc. supported our efforts with their skill in therapeutic ERCP. 157
BRYANT
REFERENCES
Laparoscopic laser cholecystectomy. Surg Endose 1989;3:131-133. Zucker KA, Bailey RW, et al: Laparoscopic guided cholecystectomy. Am J Surg 1991;161:36-44. Hertzmann P: Thermal instrumentation for laparoscopic general surgical procedures. In Zucker K, (ed): Surgical Laparoscopy. Quality Medical Publishing, 1991:57-75. Deaths following female sterilization with unipolar electrocoagulating devices. MMWR 1981;30:149-151. Levy BS, et al: Bowel injuries during laparoscopy. J Repro Med 1985;30:168-172. Soderstrom RM, et al: Bowel injuries during laparoscopy: causes and medicolegal questions. Contemporary OB/GYN
1. Reddick EJ, Olson DO: 2. 3. 4. 5. 6.
1986;27:41-47.
Gynecol 1971;110:886-887. Bryant TL: Laparoscopic cannulation of an accessory hepatic duct: A case report. J Laparoendosc Surg 1991 ; 1:207—
7. Hasson JM: A modified instrument and method for 8.
laparoscopy.
Am J Obstet
209.
Address reprint requests to: Thomas L. Bryant, M.D., F.A.C.S. Marietta Memorial Hospital 400 Matthew Street Marietta, OH 45750
158
Bipolar Electrocautery in Laparoscopic Cholecystectomy THOMAS L. BRYANT, M.D., F.A.C.S.
ABSTRACT
Laparoscopic cholecystectomy was undertaken in 100 patients using bipolar electrocautery for hemostasis. Cholecystectomy was completed laparoscopically in 94 patients. No deaths or common bile duct injuries occurred. In this single surgeon's experience, bipolar electrocautery is a safe, effective, and economical modality in laparoscpic cholecystectomy.
INTRODUCTION cholecystectomy has experienced phenomenal growth since its introduction. An early series described a technique using the KTP laser to dissect the gallbladder away from the liver.1 Subsequently, the usefulness of unipolar electrocautery was documented.2 Despite its efficacy, use of the KTP laser has some drawbacks. It requires the acquisition and maintenance of expensive equipment, as well as the cost of extra operating personnel. In addition, during dissection, the liver must be used as a backstop to prevent injury to other organs from "forward scatter" of the laser energy.3 Unipolar electrocautery has also been employed to dissect the gallbladder. It is more economical and its equipment is easier to maintain than the laser. Unipolar electrosurgical instruments allow current to flow from the point of tissue contact, through normal tissue, to the grounding plate. However, accidental contact between target tissue and adjacent organs may cause unexpected injury3 and contact between other metal instruments and the electrocautery may conduct destructive currents to other tissues. The use of unipolar electrocautery in gynecologic laparoscopy was curtailed in 1981 after significant safety questions were raised.4 The magnitude of the risk has subsequently been questioned.5 Nonetheless, it has been demonstrated in experimental animals that direct application of unipolar electrocautery to the intestine can easily cause perforation, while an equivalent dose of bipolar electrocautery rarely causes perforation.6 Bipolar electrocautery has been widely used in gynecologic laparoscopy for the last decade. It is comparable to unipolar cautery in terms of cost and ease of use. With bipolar electrocautery, electrical current flows between two small "paddles". Peripheral tissue does not serve as a conduit for current, thus, the potential for remote damage is small.
Laparoscopic
Marietta Memorial
Hospital, Marietta, OH. 155
BRYANT
MATERIALS AND METHODS All of the operations in the series were performed at Marietta Memorial Hospital, Marietta, OH, a 150-bed community hospital. Each elective patient was given a single two-gram dose of cefotetan disodium (Cefotan, Stuart Pharmaceuticals, Wilmington, DE) at the time of anesthesia induction. The four port placement ' technique of Reddick was used. The umbilical port was placed blindly after Veress needle insufflation in the first 80 cases. Subsequently, the open technique of Hassan was employed.7 The cystic duct and cystic artery were bluntly dissected free. Routine cholangiography was performed. A cholangiogram catheter was introduced via the lateral port and guided into the cystic duct using an instrument introduced via the subxyphoid port. The cystic duct and artery were controlled with Endoclips (Autosuture, Norwalk, CT). One particularly large cystic duct stump was controlled with a pre-tied loop ligature. Peritoneal reflections at the medial and lateral edges of the gallbladder were cauterized with a bipolar forceps (Richard Wolf, Rosemont, IL) and then divided with a hook scissors. Electrocautery was not used until the cystic duct and cystic artery had been controlled and divided. The gallbladder was dissected free from the liver with sharp and blunt dissection using bipolar cautery to control any bleeding points. Cautery was not used in the vicinity of the cystic duct or common duct. The freed gallbladder was removed via the umbilical incision. Beginning with the fifth laparoscopic cholecystectomy, a 15 Fr silicone multiperforated drain was placed into the gallbladder fossa at the end of the procedure. The drain was placed via the lateral port. Generally, drains were removed on the first post operative day. If drainage was bile-stained, the drain was maintained until drainage ceased. The drain was then usually removed during an out patient visit on the fourth or fifth post operative day. The umbilical fascia was closed with size "0" polyglycolic sutures. Skin incisions were closed with size 3-0 plain gut subcuticular sutures.
RESULTS
Laparoscopic cholecystectomy was undertaken in 100 cases by a single surgeon. There were 80 female and patients. The average age was 50 years (19 to 90 years). The heaviest patient, a 315 lb (143 kg)
20 male
laparoscopic cholecystectomy for acute cholecystitis. The first 30 patients were all operated upon electively. Subsequently, laparoscopic cholecystectomy was attempted in all gallbladder operations. A single exception was a patient with acute cholecystitis who underwent surgery on a night when insufficient support personnel were available to perform a laparoscopic woman, underwent successful
cholecystectomy.
Six cholecystectomies were converted from laparoscopic to open procedures. One patient, the fourth in the was converted to open cholecystectomy due to bleeding in the cystic artery which was divided before it had been controlled with clips. Two patients were converted to open operation for persistently abnormal cholangiograms. In one, an attempt had been made to clear the common bile duct with a fogarty catheter introduced via the cystic duct. Three patients were converted to open operation when their cystic duct was found to be encased in dense adhesions. One of these patients also had acute cholecystitis. Ninety four patients had completion of their operations laparoscopically. Cystic duct cholangiograms were attempted on 96 patients and completed on 94. One of these patients had a cholangiogram via the cystic duct, as well as a cholangiogram via an accessory bile duct. This case has been previously reported.8 Of the four patients in whom cholangiography was not attempted, three had been converted to an open procedure early in the operation and one had a normal ERCP pre-operatively. In two patients, attempts to perform cholangiography failed. In three patients, a fogarty catheter introduced via the cystic duct recovered small stone fragments, converting an abnormal cholangiogram to a normal cholangiogram. One of these patients had a postoperative ERCP which recovered additional stony fragments. Three patients had pre-operative ERCPs. One had a normal ERCP in the evaluation of acalculous biliary disease, while two had ERCPs to evaluate a history of elevated serum bilirubin—one of these patients had multiple stones removed via ERCP and the other patient had a normal study. All three patients underwent uneventful laparoscopic cholecystectomy. The second two had intraoperative cholangiograms which were normal.
series,
156
BIPOLAR ELECTROCAUTERY Five patients had acute cholecystitis. Operation was completed laparoscopically in four. Four patients had postoperative bile leaks averaging greater than 300 cc per day. One patient who had not been drained presented 3 days postoperatively with severe right upper quadrant pain. CT scan showed a large subhepatic fluid collection—the drain placed by the radiologist drained bile for 10 days without slowing. An ERCP revealed drainage from a duct of Luschka. Sphincterotomy was performed and a stent placed via ERCP. The drainage ceased immediately and the stent was removed at 2 weeks. In another patient, right upper quadrant pain was noted on the first postoperative day. The drain placed during laparoscopic cholecystectomy produced over 500 cc of bile in the first 24 h postoperatively. ERCP performed on the second postoperative day showed a leak from the cystic duct stump. The bile leak stopped immediately after sphincterotomy and stent placement performed during ERCP. The stent was removed at 2 weeks. Since no electrocautery was used on the cystic duct, it is not believed that it could have been a factor in the leak. The cystic duct leak could have been caused by a small tear made by a clip or perhaps displacement of the clip. The cystic duct which leaked had been controlled with two endoclips. Subsequently three endoclips were used on all the cystic ducts where sufficient room was available. Two patients had asymptomatic bile leaks of greater than 500 cc per day via drains placed at laparoscpic cholecystectomy. Both leaks stopped spontaneously within 3 days. All bile leaks in drained patients were obvious within 8 hours. In the absence of a bile leak, drains were removed within 24 h. None of the patients with the bile leaks had acute cholecystitis or difficult dissections. Mean estimated blood loss for completed laparoscopic cholecystectomy was 20 cc. In the series of 100 patients, only one required a transfusion. This was a patient who had been converted to open cholecystectomy for dense adhesions early in the operation. Bipolar cautery was not used and estimated operative blood loss was 250 cc. The patient had a transient episode of bleeding around the drain site 30 h postoperatively. Her hemoglobin 36 h postoperatively was 6.3 %gm (pre-operative value 12.6 gm%). Coagulation studies were normal. She was transfused with two units of packed red blood cells and recovered without further event. Of all operations completed laparoscopically, the average postoperative hospitalization was 1.3 days. The time of operation averaged 98 min. The average time for the first 20 cases was 134 min. In the last 20 uncomplicated laparoscopic cholecystectomies, average operating time was 71 min (this did not include one patient with acute cholecystitis and one who underwent extensive enterolysis due to previous operations). Current instrumentation requires changing instruments when alternating between cauterizing, cutting, and irrigating. This is not a significant disadvantage. An instrument change can be accomplished in 5 sec. If 20 instrument changes are required while excising the gallbladder, the operating time will only be increased by less than 2 min. Inadvertent perforation of the gallbladder occurred in approximately 15% of all laparoscopic gallbladder dissections. This was the result of either tearing the gallbladder with blunt instruments or cutting it with a scissors. Bipolar cautery current, even when applied directly to the gallbladder wall, was never responsible for a perforation. Any spilled bile was aspirated and the field irrigated and suctioned dry. No modification was made in postoperative care. No morbidity occurred from intraoperative bile spills.
DISCUSSION For this single surgeon's experience, bipolar electrocautery is a safe and cost effective modality for laparoscopic cholecystectomy. It has theoretical safety advantages over laser and unipolar cautery. It effectively cauterized the attachments between the gallbladder and the liver bed. At the settings used, this method of cautery application did not perforate the gallbladder and was not used to divide the cystic duct or artery. Applied in this fashion, it is a useful tool for the laparoscopic general surgeon.
ACKNOWLEDGMENTS We are grateful to Edward Scileppi, M.D., F. A.C.O.G. for his assistance in initiating this series. Drs. R. Edgin, M. Thurman, G. Gibbons, and James Mohr of the Columbus Gastroenterology Group, Inc. supported our efforts with their skill in therapeutic ERCP. 157
BRYANT
REFERENCES
Laparoscopic laser cholecystectomy. Surg Endose 1989;3:131-133. Zucker KA, Bailey RW, et al: Laparoscopic guided cholecystectomy. Am J Surg 1991;161:36-44. Hertzmann P: Thermal instrumentation for laparoscopic general surgical procedures. In Zucker K, (ed): Surgical Laparoscopy. Quality Medical Publishing, 1991:57-75. Deaths following female sterilization with unipolar electrocoagulating devices. MMWR 1981;30:149-151. Levy BS, et al: Bowel injuries during laparoscopy. J Repro Med 1985;30:168-172. Soderstrom RM, et al: Bowel injuries during laparoscopy: causes and medicolegal questions. Contemporary OB/GYN
1. Reddick EJ, Olson DO: 2. 3. 4. 5. 6.
1986;27:41-47.
Gynecol 1971;110:886-887. Bryant TL: Laparoscopic cannulation of an accessory hepatic duct: A case report. J Laparoendosc Surg 1991 ; 1:207—
7. Hasson JM: A modified instrument and method for 8.
laparoscopy.
Am J Obstet
209.
Address reprint requests to: Thomas L. Bryant, M.D., F.A.C.S. Marietta Memorial Hospital 400 Matthew Street Marietta, OH 45750
158
