**4.5 Surgical technique in acute cholecystitis and choledocholithiasis**

sate of the wound and the pain is assessed with a visual analog scale (VAS).

In acute cholecystitis we always use the 5 cm cylinder, the gallbladder is emptied with the help of an aspirator and a bile sample is send for culture. The dissection of the Calot triangle is done with a swab and if there are difficulties in closing the cystic duct is we use a ligature or stitch of poliglycolic acid. The cystic artery is treated in the same manner as above. The haemostasis of the liver may require more time. A Jackson-Pratt drain by counterincision is the norm in acute cholecystitis and common bile duct exploration.

If the intraoperative cholangiogram shows the presence of stones and a dilated bile duct (Figure 10 ), we prepare the field for a transcylindrical choledochotomy if the stone could not be pushed through the papilla with a Fogarty catheter. After the cholecystectomy and haemostasis of the liver, we proceed to vary the angle of the cylinder to direct medially, to put it in the hepatoduodenal ligament, taking as reference the cystic duct stump. Once in the position, the bile duct is seen on the lateral border of the ligament once the fat is cleared away with blunt dissection.

Fig. 10. Cholangiography with cylinder in place

Transcylindrical Cholecystectomy for the Treatment

Postoperative complications

laparotomy when facing at a reasonable difficulty.

satisfied.

**case surgery**

characteristics in Table 2.

days

of Cholelithiasis and Its Complications: Cholecystectomy Under Local Anesthesia 21

The results of surgery of the first stage have already been published. In summary:

Total no. of patients 387

Completed transcylindrical 364

Length postoperative hospital stay mean (range),

Ampliation to open cholecystectomy, no. (%) 23 (5.9)

Bile leakage, no. (%) 2 (0.5)

Reoperation for bleeding, no. (%) 2 (0.5)

Death, no. (%) 11 (0.3)

The 3.8 cm cylinder was used in 261 cases and the 5 cm in 103 as first choice or an alternatively because of difficulties in recognition of the structures. The main cause of enlargement to open surgery was the fibrotic alteration triangle hepatocystic. The number of conversion is not negligible, but our philosophy has been not to subject the patient to the risk of intervention with uncertainty in identifying the structures of the hepatocystic triangle in order to prevent complications. For that we have not hesitated to convert to a classic

A survey of satisfaction with the aesthetics of the procedure yielded a 90% satisfied or very

**4.6.1 Transcylindrical cholecystectomy under local anesthesia plus sedation in day-**

Today we are performing the majority of our cholecystectomies as day-case surgery. Local anesthesia and sedation is the anesthetic technique that we offer at all our patients and that we use unless the patient's preference for general anesthesia. A pilot study of 60 cases was published in Endoscopy (Grau Talens et al., 2010), but now we have performed the procedure in 222 patients, highlight a patient with choledocholithiasis too operated under local anesthesia and sedation, excellently tolerated; while that in 25 other general anesthesia was used for suspected acute cholecystitis (8 patients), suspected choledocholithiasis (3 patients) and specifically stated preference for the patient in the other cases (14 patients). Local anesthesia was initiated in 222 patients with demographic and anthropometric

Bile Duct injury, no. (%) 0

1Death from multiple organ dysfunction syndrome due biliary peritonitis Table 1. Overall results of cholecystectomy between 1993-2008

Duration of simple cholecystectomy, mean (SD) 43,5 (13.3)

2.0 (1-6)

We must ensure that we are below the confluence of the cystic duct (the duodenum can be see in the field), which will expose the common bile duct (keep in mind that the confluence may be low). Two stay sutures using polyglactin 3-0 are located on both sides of the midline of the common bile duct to pull at the time of a vertical choledochotomy as short as possible (2-3 cm), but enough for the manoeuvres of stone removal (Figure 11).

Fig. 11. Coledocotomy about to be performed. Two stay sutures pull the common bile duct.

Randall stone forceps can not be used, but the Fogarty catheter, catheter irrigation and flexible choledochoscope are used. Before performing any manoeuvre, we introduce a gauze ball referenced with a thread at the proximal end of the choledochotomy, to prevent the displacement of the stone proximal to the hepatic duct when dragging with the Fogarty catheter rather than externalized through the incision of choledochotomy. Finally, we introduce the flexible choledochoscope and confirm the absence of calculations. The closure of the choledochotomy we do it with polyglactin 3/0 on a Kehr T tube.

 Between the fifth and seventh postoperative day a control cholangiogram is performed, and the patient discharged. The T tube is left in place for 14 days.

### **4.6 Results**

We have to distinguish between two clearly defined periods in the evolution of the implementation of transcylindrical cholecystectomy. A first period, from 1993 to 2008, of the beginning of the technique and treatment of patient in hospitalization and a second period since 2008 until today as outpatient surgery and short stay, mainly under local anesthesia plus sedation. in total we performed 633 operations: 387 belonging to the first stage and 247 to the second.

We must ensure that we are below the confluence of the cystic duct (the duodenum can be see in the field), which will expose the common bile duct (keep in mind that the confluence may be low). Two stay sutures using polyglactin 3-0 are located on both sides of the midline of the common bile duct to pull at the time of a vertical choledochotomy as short as possible

Fig. 11. Coledocotomy about to be performed. Two stay sutures pull the common bile duct. Randall stone forceps can not be used, but the Fogarty catheter, catheter irrigation and flexible choledochoscope are used. Before performing any manoeuvre, we introduce a gauze ball referenced with a thread at the proximal end of the choledochotomy, to prevent the displacement of the stone proximal to the hepatic duct when dragging with the Fogarty catheter rather than externalized through the incision of choledochotomy. Finally, we introduce the flexible choledochoscope and confirm the absence of calculations. The closure

Between the fifth and seventh postoperative day a control cholangiogram is performed, and

We have to distinguish between two clearly defined periods in the evolution of the implementation of transcylindrical cholecystectomy. A first period, from 1993 to 2008, of the beginning of the technique and treatment of patient in hospitalization and a second period since 2008 until today as outpatient surgery and short stay, mainly under local anesthesia plus sedation. in total we performed 633 operations: 387 belonging to the first stage and 247

of the choledochotomy we do it with polyglactin 3/0 on a Kehr T tube.

the patient discharged. The T tube is left in place for 14 days.

**4.6 Results** 

to the second.

(2-3 cm), but enough for the manoeuvres of stone removal (Figure 11).


The results of surgery of the first stage have already been published. In summary:

1Death from multiple organ dysfunction syndrome due biliary peritonitis

Table 1. Overall results of cholecystectomy between 1993-2008

The 3.8 cm cylinder was used in 261 cases and the 5 cm in 103 as first choice or an alternatively because of difficulties in recognition of the structures. The main cause of enlargement to open surgery was the fibrotic alteration triangle hepatocystic. The number of conversion is not negligible, but our philosophy has been not to subject the patient to the risk of intervention with uncertainty in identifying the structures of the hepatocystic triangle in order to prevent complications. For that we have not hesitated to convert to a classic laparotomy when facing at a reasonable difficulty.

A survey of satisfaction with the aesthetics of the procedure yielded a 90% satisfied or very satisfied.

#### **4.6.1 Transcylindrical cholecystectomy under local anesthesia plus sedation in daycase surgery**

Today we are performing the majority of our cholecystectomies as day-case surgery. Local anesthesia and sedation is the anesthetic technique that we offer at all our patients and that we use unless the patient's preference for general anesthesia. A pilot study of 60 cases was published in Endoscopy (Grau Talens et al., 2010), but now we have performed the procedure in 222 patients, highlight a patient with choledocholithiasis too operated under local anesthesia and sedation, excellently tolerated; while that in 25 other general anesthesia was used for suspected acute cholecystitis (8 patients), suspected choledocholithiasis (3 patients) and specifically stated preference for the patient in the other cases (14 patients).

Local anesthesia was initiated in 222 patients with demographic and anthropometric characteristics in Table 2.

Transcylindrical Cholecystectomy for the Treatment

Table 4. Causes of conversion to general anesthesia

but not BMI which is slightly below the average (28.9 kg/m2).

general anesthesia.

the operative area.

acute cholecystitis.

**choledocholithiasis** 

of Cholelithiasis and Its Complications: Cholecystectomy Under Local Anesthesia 23

Only 6 patients have expressed some discomfort during the operation, but the procedure was well tolerated and there was satisfaction in all cases, even where they were converted to

The 5 cm cylinder was used in 2 cases of suspected choledocholithiasis and thirteen cases of postinflammatory anatomical distortion that hinders the recognition with the 3.8 cm cylinder The vast majority of cases that required intubation (Table 4) was due to poor anatomical conditions related to persistent inflammation or scarring, but it is also true that a patient with a bulky or potent abdominal muscles (even with normal BMI) is a factor in consideration, since the absence of relaxation of the abdominal wall increases distance from

the skin to the hepatocystic triangle and the cylinder of 10 cm length can be short.

Scarring or inflammatory anatomy 46 Big or muscular patient 16 Poor tolerance 6 Respiratory depression 1

In some cases we have changed the cylinder of 10 to 12 cm with satisfactory results. As previously mentioned, in 34 cases, of our patients had suffered a hospital admission for an attack of acute cholecystitis with ultrasound which showed a thickened gallbladder wall. Despite having passed more than 8 weeks after hospital discharge and be asymptomatic, we have found during the intervention that the process is not cured and present frank acute cholecystitis in 7 cases (20%). Of the 69 patients converted to general anesthesia, 29 were men in a series with 55 men. Obviously, the male sex is a definite risk factor for conversion to general anesthesia, as gallstone disease seems more severe in men while the abdominal muscles are larger. In our series both the height and weight is significantly higher in males,

In cases of conversion to a classical laparotomy incision the bad anatomy can also blame as responsible, in fact, five of seven cases converted belong to patients with acute cholecystitis previous and three of the 7 are male. In one case cystic clips were dislodged while reviewing

 However it is, starting the procedure under local anesthesia and sedation does not produce a significant delay in time, only a few minutes, since the decision to intubate the patient is taken quickly and everything is ready for this eventuality, but it is likely that in the future the general anesthesia be used from the begin in the men who have had an admisssion for

**4.6.2 Transcylindrical cholecystectomy in the treatment of acute cholecystitis and** 

In total 99 patients were operated for acute cholecystitis: 45 suspected prior to the intervention and operated in emergency basis or in the first 72 hours after admission (but not from the onset of symptoms, because in our experience, half of the patients came in a mean of 36 hours after the pain). The operation for acute cholecystitis is more laborious, with and greater needs of conversions to classic laparotomy, which in our series occurred in 13 cases. In all cases except one that ended with a cholecystostomy, the gallbladder has been removed. The duration of the intervention is significantly higher than cholecystectomy for


1Body mass index

2Acute cholecystitis with a Hospital General admission

Table 2. Demographic and clinical characteristics of patients operated under local anesthesia plus sedation

As it can be seen our patients are obese in almost half the cases and 35 patients had a BMI equal to or greater than 35 (15.8%). Previous acute cholecystitis was detected in 18 of 55 men (33%), but only in16 of 167 women (9%).

Convalescent patients of acute pancreatitis were operated on before hospital discharge and an intraoperative cholangiography was performed.The results of surgery can be read in Table 3.


\* a surgery completed under local anesthesia and sedation

\*\* An open surgery for carcinoma of the gallbladder

Table 3. Results of 222 patients scheduled for transcylindrical cholecystectomy under local anaesthesia plus sedation

Nausea and vomiting have virtually disappeared. Pain at rest on the fifth postoperative day is almost nonexistent, while the pain with the movements of sitting or standing is mild and all the patients are able to self care.

Table 2. Demographic and clinical characteristics of patients operated under local anesthesia

As it can be seen our patients are obese in almost half the cases and 35 patients had a BMI equal to or greater than 35 (15.8%). Previous acute cholecystitis was detected in 18 of 55 men

Convalescent patients of acute pancreatitis were operated on before hospital discharge and an intraoperative cholangiography was performed.The results of surgery can be read in

> No. Patients in day-case program 197 Postoperative hospitalization. No. (%) 15 (7.6) Converted to general anaesthesia. No. (%) 69 (31) Converted to open surgery. No. (%)\*\* 7 (3.1) Duration. Mean (SD) 49.4 (22.4) Intraoperative cholangiography. No. (%) 17 (7.6)

Common bile duct exploration. No. 2\* Wound infection. No. (%) 5 (2.2) Subhepatic collection. No. (%) 1 (0.4) Visual Analog scale. Mean (range) 2.0 (0-8)

Table 3. Results of 222 patients scheduled for transcylindrical cholecystectomy under local

Nausea and vomiting have virtually disappeared. Pain at rest on the fifth postoperative day is almost nonexistent, while the pain with the movements of sitting or standing is mild and

\* a surgery completed under local anesthesia and sedation \*\* An open surgery for carcinoma of the gallbladder

anaesthesia plus sedation

all the patients are able to self care.

Patients, no. 222 Men/woman 55/167

Acute pancreatitis, no. 21 Acute cholecystitis previous2 34

2Acute cholecystitis with a Hospital General admission

(33%), but only in16 of 167 women (9%).

1Body mass index

plus sedation

Table 3.

Age, mean (range) years 55.2 (17-90) BMI1, mean (range) kg/m2 29.9 (19-46) Height, mean (range) cm 160.5 (140-185) Eight, mean (range) kg 77.0 (43-122)

Only 6 patients have expressed some discomfort during the operation, but the procedure was well tolerated and there was satisfaction in all cases, even where they were converted to general anesthesia.

The 5 cm cylinder was used in 2 cases of suspected choledocholithiasis and thirteen cases of postinflammatory anatomical distortion that hinders the recognition with the 3.8 cm cylinder

The vast majority of cases that required intubation (Table 4) was due to poor anatomical conditions related to persistent inflammation or scarring, but it is also true that a patient with a bulky or potent abdominal muscles (even with normal BMI) is a factor in consideration, since the absence of relaxation of the abdominal wall increases distance from the skin to the hepatocystic triangle and the cylinder of 10 cm length can be short.


Table 4. Causes of conversion to general anesthesia

In some cases we have changed the cylinder of 10 to 12 cm with satisfactory results. As previously mentioned, in 34 cases, of our patients had suffered a hospital admission for an attack of acute cholecystitis with ultrasound which showed a thickened gallbladder wall. Despite having passed more than 8 weeks after hospital discharge and be asymptomatic, we have found during the intervention that the process is not cured and present frank acute cholecystitis in 7 cases (20%). Of the 69 patients converted to general anesthesia, 29 were men in a series with 55 men. Obviously, the male sex is a definite risk factor for conversion to general anesthesia, as gallstone disease seems more severe in men while the abdominal muscles are larger. In our series both the height and weight is significantly higher in males, but not BMI which is slightly below the average (28.9 kg/m2).

In cases of conversion to a classical laparotomy incision the bad anatomy can also blame as responsible, in fact, five of seven cases converted belong to patients with acute cholecystitis previous and three of the 7 are male. In one case cystic clips were dislodged while reviewing the operative area.

 However it is, starting the procedure under local anesthesia and sedation does not produce a significant delay in time, only a few minutes, since the decision to intubate the patient is taken quickly and everything is ready for this eventuality, but it is likely that in the future the general anesthesia be used from the begin in the men who have had an admisssion for acute cholecystitis.

#### **4.6.2 Transcylindrical cholecystectomy in the treatment of acute cholecystitis and choledocholithiasis**

In total 99 patients were operated for acute cholecystitis: 45 suspected prior to the intervention and operated in emergency basis or in the first 72 hours after admission (but not from the onset of symptoms, because in our experience, half of the patients came in a mean of 36 hours after the pain). The operation for acute cholecystitis is more laborious, with and greater needs of conversions to classic laparotomy, which in our series occurred in 13 cases. In all cases except one that ended with a cholecystostomy, the gallbladder has been removed. The duration of the intervention is significantly higher than cholecystectomy for

Transcylindrical Cholecystectomy for the Treatment

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uncomplicated lithiasis is related to the need for more time for dissection and hemostasis. Two superficial wound infections, 2 postoperative subhepatic collections and a third at 9 months after surgery treated by percutaneous puncture and a biliary leak through drainage for 15 days with spontaneous closure are noteworthy complications. At least 3 days of hospitalization and antibiotic treatment follow the surgery.

In our experience, common bile duct exploration presents no special difficulties except juxtapapillary interlocking stone, making it difficult to remove. The location of the bile duct, dissection, and preparation is as simple as in open laparotomy. In 30 cases we performed transcylindrical choledochotomy with an average of 119 minutes, with a range between 70 and 182 minutes of the proceedings. A stone inpacted in a dilated common bile duct required a choledochoduodenostomy. One patient experienced postoperative bleeding requiring intervention without finding the bleeding point.
