Surgical workshop Br. J. Surg. 1992, Vol. 79, March, 233-234
Laparoscopic cholangiography: an effective and inexpensive technique R . H. K. Gompertz, M. Rhodes and T. W. J. Lennard Academic Surgical Unit, Royal Victoria Infirmary, Newcastle, UK Correspondence to: Mr R. H. K. Gompertz, Department of Surgery, The Medical School, University of Newcastle, Framlington Place, Newcastle upon Tyne NE2 4HH, UK
The practice of intraoperative cholangiography as an adjunct to laparoscopic cholecystectomy Several techniques have been described but all require special instrumentation or purpose-designed and expensive cannulae. A simple and effective technique for the procedure is described which requires no special equipment or instrumentation beyond that routinely available in the operating theatre for laparoscopic surgery.
Figure 1 The cannula has been introduced through the abdominal wall between the anterior axillary and mid-clavicular cannulae. The Jine forceps (midline epigastric cannula) is holding the cannula over the opened cystic duct. The fundus-holding forceps (anterior axillary cannula) is being transferred to hold Hartmann’s pouch so that tension is maintained as the mid-clavicular forceps is transferred to the cystic duct
Surgical technique During laparoscopic cholecystectomy the normal arrangement of instruments is for the telescope to occupy the subumbilical cannula, the fundus of the gallbladder to be steered towards the diaphragm by a grasping forceps in the anterior axillary cannula and for the remaining midline epigastric and mid-clavicular cannulae to be used for the surgeon’s instruments. Practice in this unit is to use an atraumatic grasping forceps on Hartmann’s pouch to prevent tearing of the gallbladder wall. Operative cholangiography is performed by introducing a Cava-Fix cannula (Braun, Melsungen, Germany) through the abdominal wall between the mid-clavicular and anterior axillary cannulae (under direct vision). The cost of the cannula at the time of writing is around f200 for 50 (€4.22 each). The cystic duct is occluded at the gallbladder end with a Ligaclip (Ethicon, Edinburgh, UK), introduced via the midline epigastric cannula. The cystic duct is opened distal to the gallbladder using microscissors. A fine forceps is then introduced through the midline epigastric cannula which is used to pick up the cholangiogram cannula. The fundus-holding forceps (anterior axillary cannula) is transferred to hold the gallbladder just above Hartmann’s pouch and tension is maintained (Figure I ) . The fine forceps (midline epigastric cannula) is then used to steer the cholangiogram cannula into the cystic duct, whereupon the atraumatic forceps from Hartmann’s pouch (mid-clavicular cannula) is transferred to hold the cholangiogram cannula in place, and to seal the orifice of the cystic duct (Figure 2). Two points of technique facilitate difficult cannulation. First, if there is too small an opening in the cystic duct this may be dealt with by introducing the tip of the microscissors into the orifice and then opening them, thus stretching the hole. This avoids the risk of dividing a small duct by cutting it further. Second, the cannula should be presented to the duct at right angles and not obliquely; once the cannula tip is engaged in the orifice the angle can be changed to allow deep penetration of the cystic duct. Some surgeons bevel the cannula tip with scissors to make introduction easier although this is not routinely done in this unit because the cannula is more likely to get caught up in the spiral valve or to perforate the posterior wall of the cystic duct. Once the cannula has been placed the stilette is removed while the cannula is kept in vision; this often requires slight relaxation of the grasp of the forceps. Bile usually fills the cannula as the stilette is withdrawn but slight aspiration with a syringe will fully clear the duct of air bubbles. Saline is then flushed through the cannula to ensure that there is no leakage (again relaxing the grasp of the forceps slightly) and the syringe containing contrast (Omnipaque; iodine 300 mg mlNycomed, Birmingham, U K ) is attached to the cannula ready for
’,
0007-1323/92/030233-02
Q 1992 Butterworth-Heinemann Ltd
Figure 2 The final position. The cannula has been introduced into the cystic duct and the mid-claviculur forceps is holding it in position. The other instruments have been removed cholangiography. Instruments are withdrawn under direct vision with the exception of the forceps holding the cannula in place, and the laparoscope is then withdrawn. Radiographic technique may be adapted according to available resources. Conventional films may be exposed, a method used in this unit with success. Alternatively, C-arm screening using the image intensifier with hard-copy capability has several advantages. First, the beam can be easily centred in the correct site. Second, the volume of contrast to give the best image can be precisely titrated (this will vary according to duct size). Third, any overlap between radio-opaque instruments and the bile duct can be dealt with. Fourth, and perhaps most importantly, any distortion of the duct by the cannula or by the forceps can be corrected, otherwise radiographs suggesting incorrect anatomy or common bile duct or hepatic duct occlusion may be obtained (Figures 3 and 4 ) . If C-arm screening is not available, two further technical variations may facilitate successful cholangiography. First, the cannula may be secured with a 9-mm Ligaclip to reduce distortion of the duct. This method is not routinely used because the forceps gives better control over the cholangiogram cannula. Second, the midline epigastric cannula may either be removed over a rrldiolucent
233
Surgical w o r k s h o p
Figure 3 Cholangiogram showing apparent occlusion of the common hepatic duct due to tension on the forceps
Figure 4 duct
rod or replaced by a radiolucent disposable cannula to prevent superimposition of the steel cannula.
References 1.
Discussion This unit has pursued a prospective policy of operative cholangiography at laparoscopic cholecystectomy for gallstones. Successful cannulation of the cystic duct has been achieved in 32 of 35 attempts using the technique described, the ease and speed of cannulation having undoubtedly improved with practice. Failures have been due to an obliterated cystic duct (two cases), and cannulation of Hartmann’s pouch (one case ) where cholangiography allowed confirmation of anatomy during a difficult dissection. The technique described is commended for its simplicity and effectiveness.
234
2. 3. 4.
Repeat cholangiogram with forceps aa)usted to show normal
Berci G, Sackier J M , Paz-Partlow M . Routine or selected intraoperative cholangiography during laparoscopic cholecystectomy? Am J Sury 1991; 161: 355-60. Reddick EJ, Olsen DO. Outpatient laparoscopic laser cholecystectomy. A m J Sury 1990; 160: 485-7. Cuschieri A, Dubois F, Mouiel J et al. The European experience withldparoscopiccholecystectomy. A m J S u r y 1991 ; 161: 385-8. Wilson P, Leese T, Morgan WP, Kelly JF, Brigg J K . Elective laparoscopic cholecystectomy for ‘all-comers’. Lancet 1991 ; 338: 795-7.
Paper accepted 13 November 1991
Br. J. Surg., Vol. 79, No. 3. March 1992
Laparoscopic cholangiography: an effective and inexpensive technique R . H. K. Gompertz, M. Rhodes and T. W. J. Lennard Academic Surgical Unit, Royal Victoria Infirmary, Newcastle, UK Correspondence to: Mr R. H. K. Gompertz, Department of Surgery, The Medical School, University of Newcastle, Framlington Place, Newcastle upon Tyne NE2 4HH, UK
The practice of intraoperative cholangiography as an adjunct to laparoscopic cholecystectomy Several techniques have been described but all require special instrumentation or purpose-designed and expensive cannulae. A simple and effective technique for the procedure is described which requires no special equipment or instrumentation beyond that routinely available in the operating theatre for laparoscopic surgery.
Figure 1 The cannula has been introduced through the abdominal wall between the anterior axillary and mid-clavicular cannulae. The Jine forceps (midline epigastric cannula) is holding the cannula over the opened cystic duct. The fundus-holding forceps (anterior axillary cannula) is being transferred to hold Hartmann’s pouch so that tension is maintained as the mid-clavicular forceps is transferred to the cystic duct
Surgical technique During laparoscopic cholecystectomy the normal arrangement of instruments is for the telescope to occupy the subumbilical cannula, the fundus of the gallbladder to be steered towards the diaphragm by a grasping forceps in the anterior axillary cannula and for the remaining midline epigastric and mid-clavicular cannulae to be used for the surgeon’s instruments. Practice in this unit is to use an atraumatic grasping forceps on Hartmann’s pouch to prevent tearing of the gallbladder wall. Operative cholangiography is performed by introducing a Cava-Fix cannula (Braun, Melsungen, Germany) through the abdominal wall between the mid-clavicular and anterior axillary cannulae (under direct vision). The cost of the cannula at the time of writing is around f200 for 50 (€4.22 each). The cystic duct is occluded at the gallbladder end with a Ligaclip (Ethicon, Edinburgh, UK), introduced via the midline epigastric cannula. The cystic duct is opened distal to the gallbladder using microscissors. A fine forceps is then introduced through the midline epigastric cannula which is used to pick up the cholangiogram cannula. The fundus-holding forceps (anterior axillary cannula) is transferred to hold the gallbladder just above Hartmann’s pouch and tension is maintained (Figure I ) . The fine forceps (midline epigastric cannula) is then used to steer the cholangiogram cannula into the cystic duct, whereupon the atraumatic forceps from Hartmann’s pouch (mid-clavicular cannula) is transferred to hold the cholangiogram cannula in place, and to seal the orifice of the cystic duct (Figure 2). Two points of technique facilitate difficult cannulation. First, if there is too small an opening in the cystic duct this may be dealt with by introducing the tip of the microscissors into the orifice and then opening them, thus stretching the hole. This avoids the risk of dividing a small duct by cutting it further. Second, the cannula should be presented to the duct at right angles and not obliquely; once the cannula tip is engaged in the orifice the angle can be changed to allow deep penetration of the cystic duct. Some surgeons bevel the cannula tip with scissors to make introduction easier although this is not routinely done in this unit because the cannula is more likely to get caught up in the spiral valve or to perforate the posterior wall of the cystic duct. Once the cannula has been placed the stilette is removed while the cannula is kept in vision; this often requires slight relaxation of the grasp of the forceps. Bile usually fills the cannula as the stilette is withdrawn but slight aspiration with a syringe will fully clear the duct of air bubbles. Saline is then flushed through the cannula to ensure that there is no leakage (again relaxing the grasp of the forceps slightly) and the syringe containing contrast (Omnipaque; iodine 300 mg mlNycomed, Birmingham, U K ) is attached to the cannula ready for
’,
0007-1323/92/030233-02
Q 1992 Butterworth-Heinemann Ltd
Figure 2 The final position. The cannula has been introduced into the cystic duct and the mid-claviculur forceps is holding it in position. The other instruments have been removed cholangiography. Instruments are withdrawn under direct vision with the exception of the forceps holding the cannula in place, and the laparoscope is then withdrawn. Radiographic technique may be adapted according to available resources. Conventional films may be exposed, a method used in this unit with success. Alternatively, C-arm screening using the image intensifier with hard-copy capability has several advantages. First, the beam can be easily centred in the correct site. Second, the volume of contrast to give the best image can be precisely titrated (this will vary according to duct size). Third, any overlap between radio-opaque instruments and the bile duct can be dealt with. Fourth, and perhaps most importantly, any distortion of the duct by the cannula or by the forceps can be corrected, otherwise radiographs suggesting incorrect anatomy or common bile duct or hepatic duct occlusion may be obtained (Figures 3 and 4 ) . If C-arm screening is not available, two further technical variations may facilitate successful cholangiography. First, the cannula may be secured with a 9-mm Ligaclip to reduce distortion of the duct. This method is not routinely used because the forceps gives better control over the cholangiogram cannula. Second, the midline epigastric cannula may either be removed over a rrldiolucent
233
Surgical w o r k s h o p
Figure 3 Cholangiogram showing apparent occlusion of the common hepatic duct due to tension on the forceps
Figure 4 duct
rod or replaced by a radiolucent disposable cannula to prevent superimposition of the steel cannula.
References 1.
Discussion This unit has pursued a prospective policy of operative cholangiography at laparoscopic cholecystectomy for gallstones. Successful cannulation of the cystic duct has been achieved in 32 of 35 attempts using the technique described, the ease and speed of cannulation having undoubtedly improved with practice. Failures have been due to an obliterated cystic duct (two cases), and cannulation of Hartmann’s pouch (one case ) where cholangiography allowed confirmation of anatomy during a difficult dissection. The technique described is commended for its simplicity and effectiveness.
234
2. 3. 4.
Repeat cholangiogram with forceps aa)usted to show normal
Berci G, Sackier J M , Paz-Partlow M . Routine or selected intraoperative cholangiography during laparoscopic cholecystectomy? Am J Sury 1991; 161: 355-60. Reddick EJ, Olsen DO. Outpatient laparoscopic laser cholecystectomy. A m J Sury 1990; 160: 485-7. Cuschieri A, Dubois F, Mouiel J et al. The European experience withldparoscopiccholecystectomy. A m J S u r y 1991 ; 161: 385-8. Wilson P, Leese T, Morgan WP, Kelly JF, Brigg J K . Elective laparoscopic cholecystectomy for ‘all-comers’. Lancet 1991 ; 338: 795-7.
Paper accepted 13 November 1991
Br. J. Surg., Vol. 79, No. 3. March 1992
