Conversion in single-port cholecystectomy: lesson learned from hemorrhage

The objective of this video is to illustrate the potential difficulties that may be encountered during the dissection of Calot’s triangle in the management of acute cholecystitis performed through a single port. The video demonstrates when to convert and how to manage hemorrhage in single port cholecystectomy.

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Conversion in single-port cholecystectomy: lesson learned from hemorrhage

Authors

E Khiangte, I Newme, P Phukan

Abstract

The objective of this video is to illustrate the potential difficulties that may be encountered during the dissection of Calot’s triangle in the management of acute cholecystitis performed through a single port. The video demonstrates when to convert and how to manage hemorrhage in single port cholecystectomy.

Classification

single port, contribution

Keywords

Conversion, single port cholecystectomy, hemorrhage

Media type

Surgical video

Duration

08'53''

Publication

2012-02

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E-publication

WeBSurg.com, Feb 2012;12(02).
URL: http://www.websurg.com/doi-vd01en3472.htm

Conversion in single-port cholecystectomy: lesson learned from hemorrhage

1. Introduction 00'09''

This video demonstrates the single port treatment of an acute calculus cholecystitis in a patient aged 46 who had to be converted to conventional laparoscopy due to hemorrhage. The potential difficulty that may be encountered during the dissection of Calot’s triangle in the management of acute cholecystitis is illustrated in this video.

2. Dissection of the gallbladder 00'30''

We follow the principle of posterior dissection followed by anterior dissection around the Calot’s triangle. The monopolar hook is routinely used to achieve this. This posterior dissection leads us to inadvertently injure an artery. We feel that the retraction is inadequate, the gallbladder is edematous and we hooked too deep so we injured the vessel. An inappropriate vascular control could have harmful consequences for the patient. However, it is difficult to identify the artery with certainty since it is bleeding, as can be seen here. The maneuver through the single port turns to be inadequate at this point, and the importance of additional port is warranted.

3. Fundus retraction 01'26''

Adequate gallbladder retraction is achieved by a toothed grasper passed through the EK glove port in the umbilicus. The 5mm suction cannula proved to be inadequate; a 10mm suction cannula is used to suck out the blood and make the operative field clean. A fresh gauze pad is introduced and an effective compression is achieved by means of the rolled up gauze pad.

4. Additional port 01'52''

At this juncture, we thought it would be prudent to place another 5mm port in the right mid-clavicular region. Indeed, a proper identification of the area cannot be achieved using only 2 ports.

5. Identification and clipping of bleeding artery 02'06''

The bleeding vessel is now identified and grasped with the left hand grasper. A metallic clip is applied to the vessel under vision. After controlling the bleeding, the area is cleaned using the suction cannula.

6. Dissection around Calot’s triangle 02'28''

Anterior dissection is carried out with the suction cannula. The acute inflammation of the gallbladder allows for an easy and safe dissection using the suction cannula. Repeated, intermittent suction keeps the operating field clean. The anterior leaf of the peritoneum is now dissected with the monopolar hook. Care is taken not to use excessive diathermy current in this area. The critical view is achieved with the suction cannula. The bleeding artery, which was clipped earlier, is now visualized. An additional metallic clip is reinforced.

7. Separation of cystic duct and cystic artery 03'29''

Further dissection around Calot’s triangle allowed to separate the cystic artery from the cystic duct. The Maryland grasper proved to be an excellent instrument to separate the cystic artery from the cystic duct. A metallic clip is applied to the cystic artery and is divided using the monopolar hook. The dissection and skeletonization of the cystic duct will allow for easy application of the metallic clips. Three metallic clips are applied in the cystic duct distally. The cystic duct is now divided using a pair of scissors.

8. Dissection of gallbladder from gallbladder fossa 04'30''

The gallbladder is now dissected out from the gallbladder fossa using the monopolar diathermy hook. Traction and counter traction with right lateral and left medial twist facilitates the dissection. During separation of the gallbladder, fundal traction is gradually released down. The liver bed is re-inspected for adequate hemostasis or bile leakage.

9. Placement of gallbladder in retrieval bag 05'10''

The gallbladder is now placed in a plastic retrieval bag. All the blood clots are sucked out and good peritoneal cavity irrigation is achieved with warm normal saline.

10. Introduction of drainage tube 05'23''

An 18 French Ryle’s tube is placed in the sub-hepatic space, which acts as a drain.

11. Conclusion 05'32''

It is said that “A smart man learns from his own mistakes but a wise man learns from the mistakes of others.” We hope there will be more wise men to learn from our mistake and not repeat the same.