8.1. Patient Positioning and Logistics in the Operating Room During Laparoscopic Biliary Surgery
George Berci, M.D., F.A.C.S., F.R.C.S, ED. (Hon.)
A. Cholecystectomy
The preoperative standard labs are routine and should be known to the oper- ator in advance. Important information are the ultrasound findings, the status of the gallbladder (stones?), and the size and appearance of the common bile duct (CBD) (stones)?
Checklist
The surgeon must know what instruments will be needed, and make sure that the scrub nurse also knows them and that they are available in the OR. Every- thing should be in functioning order, including the video system. A checklist includes confirmation of the following:
1. That in case of a suspected CBD stone, the additional instruments are in the room.
2. These tools and the choledochoscope should be kept on a separate table.
Elective Cholecystectomy Without Preoperative Signs and Symptoms of CBD Stones
In the United States, the operator stands on the patient’s left side. In Europe and other countries, the French technique was adopted with the surgeon posi- tioned between the legs of the patient. Two TV towers are required: one for the operator (on the patient’s right) and one for the assistants (on the patient’s left).
The nurse can follow the procedures from one of the monitors (Figure 8.1.1).
After the patient is intubated and the pneumoperitoneum is established, the trocar is successfully introduced and the telescope with the video camera is advanced, and the entire abdominal cavity is inspected. After this step, the anes- thesiologist is asked to put the patient in a reversed Trendelenburg position,
Figure 8.1.1. Schematic scaled diagram of a 20 by 16 foot operating room (OR).
which facilitates the intestinal organs and omentum to be displaced toward the pelvic area and exposes the liver with the gallbladder. Situs inversus is fortu- nately rare but should be considered if the gallbladder could not be located on the right side. The second, third, and fourth trocars are introduced under visual control. The anesthesiologist is asked at this time to rotate the table to the left.
If hemodynamic or cardiac changes are discovered and reported by the anes- thesiologist, it is necessary to put the patient back into the normal horizontal position, desufflate the abdomen, and wait until normal values are obtained. The surgeon must then start over with a slower refill mode of pneumoperitoneum, not exceeding the standard intraabdominal pressure (12–14 mmHg). Make sure that the nurse prepares defogging adjuncts, such as a thermos with hot sterile water (Applied Medical Company) or the DeFogger (Novaplus Company).
Patients with a Suspicious History, Slightly Elevated Liver Function Tests, or Dilated CBD
If there exists the possibility that the surgeon will need to explore the CBD, a fluoroscope and the instrumentation for CBD exploration must be in the OR.
It is highly advisable that the OR keep the necessary tools in sterile trays that are readily available. Two trays should be available (one tray: the additional accessories; the second tray: the choledochoscope.) Sometimes you can find unexpected stones (4%–5%) by routine cholangiography.
Tray 1: Two guidewires, dilating balloon catheter 5-Fr., two 3-Fr. baskets (preferably the Segura type), two 3-Fr. Fogarty balloon catheters, one stone retrieval forceps, and two 3-Fr. (blue ureteral) catheters with an end tip for cholangiography. The unused instruments can be resterilized.
Tray 2: The choledochoscope is a crucial component of transcystic or trans- CBD exploration and stone removal. It is the most accurate and suc- cessful tool for this procedure. It should be kept in a separate tray. A reducer should be included in case you insert a small choledochoscope (2.8-mm or 3.1-mm diameter) through a 5-mm trocar. A padded grasper should be available if you manipulate the scope with a grasper so that you do not break the fibers.
Transcystic Approach
After cholangiography documents there are stones that can be removed via the cystic duct, the cholangio catheter should be left in position. A guidewire can then be introduced under fluoroscopy through the cholangio catheter into the CBD and the cholangio catheter removed.
The next step is to introduce the dilating balloon catheter over the guidewire into the cystic duct. Inflate it to the predetermined pressure (see manufacturer instructions) and keep the cystic duct dilated for 2–3 minutes to 5.0 mm. This
step will also facilitate passing the choledochoscope through any valves of Heister.
After dilation, deflate the balloon catheter, withdraw it over the guidewire, and thread the guidewire through the choledochoscope instrument channel. The guidewires are now available with soft tips on both sides (Cook Company), which make the introduction through the scope easier. If the scope is in posi- tion, you can remove the guidewire. The scope is already attached to a saline bag that is inserted into a Fenwell bag (used for emergency transfusions). The pressure applied is approximately 200 mmHg. This is required to obtain an ade- quate flow through this narrow channel (instrument channel diameter is only 1.2 mm). If the stone is visualized, decrease or shut off the irrigation, introduce the basket beyond the stone, open it up, and with some movements it can be easily entrapped. It is required that you have a trained assistant. Laparoscopic choledocholithotomy requires teamwork. You need a minimum of four hands and coordinated movements.
Before you start manipulations in the CBD, ask the anesthesiologist to administer 1–2 mg glucagon to relax the sphincter. If there are smaller calculi, they can be flushed through the relaxed sphincter into the duodenum using warm saline. The “push-through maneuver” with the scope is not recommended because you have to be extremely careful not to cause perforation or damage to this critical area. If stones are in the hepatic ducts or in the common hepatic duct, it is probably not possible to remove them through the transcystic duct approach because it is extremely difficult to turn around with the scope. In case of anatomic difficulties (10%), you can always inject a few milliliters of contrast material through the scope and observe the position of the scope with the fluo- roscope related to the anatomy. After evacuating the duct, pull the scope back into the cystic duct, inject contrast medium through the instrument channel, and observe it on the fluoroscope to make sure that you have extracted all the stones.
Laparoscopic common bile duct exploration can successfully clear the duct in 80%–90% of cases. This eliminates additional morbidity and cost of an endo- scopic retrograde cholangiopancreatography (ERCP) and papillotomy.
B. Intraoperative Fluorocholangiography (IFC)
Operative cholangiography has been debated since Mirizzi in 1933 intro- duced this static technique. Only a minority of surgeons accepted this important adjunct. It is also true that a static mobile unit produces only two or three films.
This technique is a time-consuming process (10–20 minutes). Unfortunately, some films are not informative due to technical problems (over- or underexpo- sure, “cutting” the anatomy due to unknown positioning, sphincter spasm, pseudocalculus sign, no contrast in the proximal ductal system). The repetition rate is 20%–30%.
The introduction of operative fluoroscopy in orthopedic surgery and the further improvement of digitized fluoroscopy in recent years made this proce- dure easier and faster to apply with a higher diagnostic accuracy. If the duct is cannulated it takes only a few (2–3) minutes to complete the fluorocholan-
giogram. The image can be immediately observed. Interesting moments can be recorded on film.
It is a prerequisite that you have a fluoroscope available on the floor. In general surgery in the majority of hospitals, orthopedic procedures are per- formed, and a C-arm is available in the OR. The usage has to be determined in respect to scheduling. Make sure that you get the recent model (digitized image with pulsed fluoroscopy).
Technique of Cholangiography
The patient must be repositioned in a horizontal or normal position. Dilute the contrast half and half with saline. Inject very slowly. If you inject quickly, you will immediately fill the entire ductal system and produce an overfilled or completion cholangiogram, which can result in missing stones. Go slowly, and after each 1 or 2 mL, if you see that the appearance is suspicious, expose a film.
The CBD sometimes is overlying the spine. If this is the case, the C-arm may be rotated during fluoroscopy to get the CBD into a better position. Alter- natively, the patient may be rotated to the right side.
If no contrast is seen in the proximal ducts, ask the anesthesiologist to put the patient in a Trendelenburg position and repeat the cholangiogram with a slightly larger injection pressure (which should close the sphincter). If you cannot fill the proximal ductal system, then you must reevaluate why the prox- imal ducts have not filled. The most worrisome reason for nonfilling would be a bile duct injury. If there is extravasation of contrast material, you must repo- sition the catheter. However, if extravasation is significant, be aware of the pos- sibility of ductal injury.
If contrast does not flow into the duodenum, you can administer 1 mg glucagon. The patient should be in a horizontal position for this phenomenon.
In the majority of cases, the glucagon effect will open up the sphincter and con- trast will flow into the duodenum. If flow into the duodenum is not accomplished, exploration (laparoscopic) is indicated.
C. Selected References
Berci G. Static cholangiography vs. digital fluoroscopy. J Surg Endosc 1995;9:1244–1248.
Berci G, Cuschieri A. Techniques of laparoscopic fluorocholangiography. In: Berci G, Cuschieri A, eds. Bile Ducts and Bile Duct Stones. Philadelphia: Saunders, 1997:
60–78.
Berci G, Hamlin GA. X-ray equipment. In: Berci G, Hamlin GA, eds. Operative Biliary Radiology. Baltimore: Williams & Wilkins, 1981:13–27.
Berci G, Morgenstern L. Laparoscopic management of common bile duct stones: a multi- institutional SAGES study. Surg Endosc 1994;8:1168–1175.
Berci G, Paz-Partlow. Laparoscopic ductal stone clearance; instrumentation. In: Berci G, Cuschieri A, eds. Bile Ducts and Bile Duct Stones. Philadelphia: Saunders, 1997:
83–97.
Carroll BJ, Friedman RL, Leiberman MA, Phillips EH. Routine cholangiography reduces the sequelae of common bile duct injuries. Surg Endosc 1996;10:1194–1197.
Hamlin GA, Berci G. The fluorocholangiogram. In: Berci G, Hamlin GA, eds. Operative Biliary Radiology. Baltimore: Williams & Wilkins, 1981:63–109.
Petelin BJ. Laparoscopic ductal stone clearance, transcystic approach. In: Berci G, Cuschieri A, eds. Bile Ducts and Bile Duct Stones. Philadelphia: Saunders, 1997:
97–109.
Traverso WL, Hauptmann E, Lynge D. Routine intraoperative cholangiography and its con- tribution to the selective cholangiographer. Am J Surg 1994;167:464–468.
