**4. Transcylindrical cholecystectomy**

In 1992, we started laparoscopic cholecystectomy in the Hospital Verge del Toro (Mahon, Menorca, Spain) after a training period at another hospital. The technique quickly settled in the hospital, in a time of full discussion of the validity of this approach and the need for prior training. We conducted a series of 11 laparoscopic cholecystectomy, until the absence of capnography and other circumstances prevented continuation of the procedure The laparoscopic view of Calot's triangle, with the camera close enough to the structures, as it's

Transcylindrical Cholecystectomy for the Treatment

included in the surgical waiting list.

for short stay surgery.

**4.2 The cylinders** 

together with the ASA I-III.

involved in ambulatory surgery

patients have been included in the study.

**day-case surgery under local anesthesia plus sedation** 

of Cholelithiasis and Its Complications: Cholecystectomy Under Local Anesthesia 11

Between 1993 and 2008 the patients with symptomatic cholelithiasis, recovering from mild/moderate acute biliary pancreatitis or acute cholecystitis were treated by

With the exception of a randomized study period for comparison with laparoscopic cholecystectomy this series of cases should be considered consecutive. In this way, 387

Although the 3.8 cm cylinder has been used in most cases, the 5 cm cylinder was used, primarily, in the following situations: diagnosis of acute cholecystitis, strong suspicion of choledocholithiasis (medical history jaundice, common bile duct dilatation greater than 12 mm) and when doubt exists in the identification of structures of the hepatocystic triangle with the cylinder of 3.8 cm. This was used in light of the diagnosis of biliary colic, regardless of the ultrasound findings (normal gallbladder or sclerotic) and in patients recovering from

From 2008 to the present day we exercise our practice in the Hospital Siberia-Serena (Badajoz, Spain), a public community hospital with short-stay and ambulatory surgical facilities. All of our patients are referred to us for elective surgery. The surgical emergencies are translated to de District General Hospital in the area, nevertheless, we accept hospitalized patients with complications of biliary lithiasis and are operated as a as soon as possible. Include patients with cholelithiasis, acute cholecystitis, acute pancreatitis before discharge and choledocholithiasis. We have 4 beds for patients who require hospitalization

Patients scheduled for day-case surgery must meet the general criteria of suitable personal and familiar environment and distance from the centre of not more than 45 minutes,

The selection of patients who would undergo transcylindrical cholecystectomy under local

1. Acceptance by the patient to undergo the procedure under local anaesthesia, and the

2. Assessment by the surgeon that the patient meets the general requirements to be

3. The assessment by the anaesthesiologist in charge of the case, the degree of patient anxiety, which might conspire with the necessary cooperation of the latter in the case of sedation and local anaesthesia, in addition to the usual pre-anaesthetic evaluation.

Initially we have designed and constructed a stainless steel cylinder with a polypropylene perforated plunger, like a piston, which protrudes from one end. It is 10 cm long and 3.8 cm

acute pancreatitis. Intraoperative cholangiography was performed selectively.

anesthesia plus sedation was done under the following assumptions:

possibility that it will be converted to general anaesthesia if necessary

**4.1 Selection of patients for transcyndrical cholecystectomy in hospitalization and** 

transcylindrical cholecystectomy. Since 1996 we treat choledocholithiasis in this way. Informed consent was requested for each patient explaining both the novelty of the transcylindrical cholecystectomy and its rationality, like a minilaparotomy, for aesthetic and functional benefits of a small incision, in order to prevent biliary colic and complications of lithiasis (acute cholecystitis, pancreatitis or recurrent pancreatitis and gallbladder cancer), with emphasis on uncertainty about other symptoms such as headache, dyspepsia, bitter taste, abdominal pain not related to gallstones and food intolerance. All possible and reasonable complications are listed in the informed consent of the Asociación Española de Cirujanos (Spanish Association of Surgeons), the patient read and sign before being

set to perform the dissection, does not focus more than a few square centimetres area, which is where the dissections and sections between clips of the cystic duct and cystic artery are performed. It crossed our minds that this limited field, but sufficient for the laparoscopic dissection, could be constructed in a straightforward manner, without camera, with a cylindrical or tubular separator that prevented the interposition of intraperitoneal mobile structures between the surgeon's eyes and structures hepatocystic triangle. Of course, the dissection should be performed through the cylinder with material that could be used in laparoscopic or open surgery. With these premises we entrust the construction of the first steel cylinder, 5 cm in diameter and 10 in length, with a polypropylene plunger, like a piston, which protruded from the distal end, with the purpose of helping to introduce and reject the intraperitoneal mobile structures, which could interpose and hinder the hepatocystic triangle. The first time we use it (August 1993) we were rewarded with the success of an intervention without mishap. With the cylinder of 5 cm in diameter were obtained an incision 6-7 cm in length, which could be reduced by a smaller diameter cylinder, therefore, we inquired the construction of another cylinder, 3.8 cm in diameter and with the same length. The choice of length is based on measurements made in emergency surgery, from skin to the triangle hepatocystic. Cholecystectomy with the new cylinder was still easy, but with an incision 4.5 cm length uniform in all the layers of the abdominal wall, aesthetics and a smooth postoperative period where they drew more attention to nausea and vomits than pain. Hepatocystic triangle dissection and recognition of the structures left us less uncertainty than in the laparoscopic approach, we could ensure the identity of the structures and fingertip exploration of the consistency of the organs. We considered it a safe, as it allowed the steps of the classical open cholecystectomy. We decided to call the technique *transcylindrical cholecystectomy.* The first communication in a conference dates back to 1994 when we presented a video communication with the first 20 cases in "The X Surgical Day of District Hospitals" (Tarragona, May 6, 1994). That same year it was admitted to the "XX National Congress of Surgery of the Surgical Spanish Association" Madrid, November, 1994 (Grau-Talens et al., 1994).

The review of the literature on minilaparotomy cholecystectomy and the method used by the authors showed no results of a technique similar to ours, although other types of separators or optical instruments have been developed (O´Dwyer et al.,1990), (O´Kelly et al., 1991) (Rozsos et al.,2003) (Russell & Shankar, 1987) (Shumacher & Kohaus 1994). Rozsos et al., 1997 distinguish between: microlaparotomy, where the incision is less than 4 cm in length, modern minilaparotomy, where it comes to 4-6 cm incision and classical minilaparotomy, with 6-8 cm.

The first operation of transcylindrical cholecystectomy under local anesthesia and sedation dates to 1996, in a patient with low body mass index and followed by other cases performed sporadically. The experience accumulated over 15 years and 387 interventions (Grau-Talens & Giner, 2010) showed us the safety and applicability of transcylindrical cholecystectomy and was applied to realization of the technique in outpatient surgery in the Hospital Siberia-Serena (Talarrubias, Badajoz, Spain), where we offer the transcylindrical cholecystectomy under local anesthesia and sedation to all patients with almost no exceptions (Grau-Talens et al., 2010). Patients greatly appreciate the possibility of not being entirely deprived of consciousness and not to be connected to a respirator during cholecystectomy perhaps resulting in a reduction of preoperative anxiety and stress.

#### **4.1 Selection of patients for transcyndrical cholecystectomy in hospitalization and day-case surgery under local anesthesia plus sedation**

Between 1993 and 2008 the patients with symptomatic cholelithiasis, recovering from mild/moderate acute biliary pancreatitis or acute cholecystitis were treated by transcylindrical cholecystectomy. Since 1996 we treat choledocholithiasis in this way.

Informed consent was requested for each patient explaining both the novelty of the transcylindrical cholecystectomy and its rationality, like a minilaparotomy, for aesthetic and functional benefits of a small incision, in order to prevent biliary colic and complications of lithiasis (acute cholecystitis, pancreatitis or recurrent pancreatitis and gallbladder cancer), with emphasis on uncertainty about other symptoms such as headache, dyspepsia, bitter taste, abdominal pain not related to gallstones and food intolerance. All possible and reasonable complications are listed in the informed consent of the Asociación Española de Cirujanos (Spanish Association of Surgeons), the patient read and sign before being included in the surgical waiting list.

With the exception of a randomized study period for comparison with laparoscopic cholecystectomy this series of cases should be considered consecutive. In this way, 387 patients have been included in the study.

Although the 3.8 cm cylinder has been used in most cases, the 5 cm cylinder was used, primarily, in the following situations: diagnosis of acute cholecystitis, strong suspicion of choledocholithiasis (medical history jaundice, common bile duct dilatation greater than 12 mm) and when doubt exists in the identification of structures of the hepatocystic triangle with the cylinder of 3.8 cm. This was used in light of the diagnosis of biliary colic, regardless of the ultrasound findings (normal gallbladder or sclerotic) and in patients recovering from acute pancreatitis. Intraoperative cholangiography was performed selectively.

From 2008 to the present day we exercise our practice in the Hospital Siberia-Serena (Badajoz, Spain), a public community hospital with short-stay and ambulatory surgical facilities. All of our patients are referred to us for elective surgery. The surgical emergencies are translated to de District General Hospital in the area, nevertheless, we accept hospitalized patients with complications of biliary lithiasis and are operated as a as soon as possible. Include patients with cholelithiasis, acute cholecystitis, acute pancreatitis before discharge and choledocholithiasis. We have 4 beds for patients who require hospitalization for short stay surgery.

Patients scheduled for day-case surgery must meet the general criteria of suitable personal and familiar environment and distance from the centre of not more than 45 minutes, together with the ASA I-III.

The selection of patients who would undergo transcylindrical cholecystectomy under local anesthesia plus sedation was done under the following assumptions:


#### **4.2 The cylinders**

10 Updated Topics in Minimally Invasive Abdominal Surgery

set to perform the dissection, does not focus more than a few square centimetres area, which is where the dissections and sections between clips of the cystic duct and cystic artery are performed. It crossed our minds that this limited field, but sufficient for the laparoscopic dissection, could be constructed in a straightforward manner, without camera, with a cylindrical or tubular separator that prevented the interposition of intraperitoneal mobile structures between the surgeon's eyes and structures hepatocystic triangle. Of course, the dissection should be performed through the cylinder with material that could be used in laparoscopic or open surgery. With these premises we entrust the construction of the first steel cylinder, 5 cm in diameter and 10 in length, with a polypropylene plunger, like a piston, which protruded from the distal end, with the purpose of helping to introduce and reject the intraperitoneal mobile structures, which could interpose and hinder the hepatocystic triangle. The first time we use it (August 1993) we were rewarded with the success of an intervention without mishap. With the cylinder of 5 cm in diameter were obtained an incision 6-7 cm in length, which could be reduced by a smaller diameter cylinder, therefore, we inquired the construction of another cylinder, 3.8 cm in diameter and with the same length. The choice of length is based on measurements made in emergency surgery, from skin to the triangle hepatocystic. Cholecystectomy with the new cylinder was still easy, but with an incision 4.5 cm length uniform in all the layers of the abdominal wall, aesthetics and a smooth postoperative period where they drew more attention to nausea and vomits than pain. Hepatocystic triangle dissection and recognition of the structures left us less uncertainty than in the laparoscopic approach, we could ensure the identity of the structures and fingertip exploration of the consistency of the organs. We considered it a safe, as it allowed the steps of the classical open cholecystectomy. We decided to call the technique *transcylindrical cholecystectomy.* The first communication in a conference dates back to 1994 when we presented a video communication with the first 20 cases in "The X Surgical Day of District Hospitals" (Tarragona, May 6, 1994). That same year it was admitted to the "XX National Congress of Surgery of the Surgical Spanish Association" Madrid, November,

The review of the literature on minilaparotomy cholecystectomy and the method used by the authors showed no results of a technique similar to ours, although other types of separators or optical instruments have been developed (O´Dwyer et al.,1990), (O´Kelly et al., 1991) (Rozsos et al.,2003) (Russell & Shankar, 1987) (Shumacher & Kohaus 1994). Rozsos et al., 1997 distinguish between: microlaparotomy, where the incision is less than 4 cm in length, modern minilaparotomy, where it comes to 4-6 cm incision and classical

The first operation of transcylindrical cholecystectomy under local anesthesia and sedation dates to 1996, in a patient with low body mass index and followed by other cases performed sporadically. The experience accumulated over 15 years and 387 interventions (Grau-Talens & Giner, 2010) showed us the safety and applicability of transcylindrical cholecystectomy and was applied to realization of the technique in outpatient surgery in the Hospital Siberia-Serena (Talarrubias, Badajoz, Spain), where we offer the transcylindrical cholecystectomy under local anesthesia and sedation to all patients with almost no exceptions (Grau-Talens et al., 2010). Patients greatly appreciate the possibility of not being entirely deprived of consciousness and not to be connected to a respirator during cholecystectomy perhaps resulting in a reduction of preoperative anxiety and

1994 (Grau-Talens et al., 1994).

minilaparotomy, with 6-8 cm.

stress.

Initially we have designed and constructed a stainless steel cylinder with a polypropylene perforated plunger, like a piston, which protrudes from one end. It is 10 cm long and 3.8 cm

Transcylindrical Cholecystectomy for the Treatment

Fig. 2. Methacrylate cylinder, 2,8 cm in diameter

**4.3 Technique and equipment** 

exploration.

diameter produces an almost imperceptible scar (Figure 2, 3).

of Cholelithiasis and Its Complications: Cholecystectomy Under Local Anesthesia 13

the ribs in the subdiaphragmatic space. In young people, the use of a cylinder of 2.8 cm in

To introduce the 3.8-cm cylinder one makes a right transversal-epigastric incision of 4.5 cm two fingerbreath lateral to the midline, approximately at the seventh or eighth costochondral cartilages level. One then proceeds with a longitudinal incision of the rectus sheath, splitting the muscle and cutting the posterior leaf and peritoneum. This is an uniform 4.5 cm section of all the abdominal wall layers. A suture of polypropylene (No. 1) is then passed through the whole thickness of the wall (not including the skin) on both side of the incision, which helps to guide the introduction of the cylinder. We make sure that there is nothing adhering and check the normality of neighbouring organs by two finger

Once it is past the surface of the skin it is softly slided and enters without difficulty to its full extent towards the hepatocystic triangle. While we are inserting the cylinder we are seeing the intraperitoneal structures through the transparent plunger, especially the white appearance of the anteromedial aspect of the gallbladder and Hartmann's pouch and we can see, with a little pressure , the cystic duct and common bile duct (Figures 4, 5). Any

gallbladder adherence to the hepatic flexure of the colon or omentum can be freed.

in diameter providing a surgical field area of 11.33 cm2, and another which is 10 cm long but 5 cm in diameter providing to surgical field area of 19.62 cm2 . These sizes have been based on the distance between the wall and the hepatocystic triangle, measured in open surgery, and the minimally area necessary for the identification and dissection of its structures.

We currently use a transparent methacrylate plunger that there exercises an effect of magnifying glass and once introduced into the abdomen allows visualization of the surgical field before unplugging (figure 1).

Fig. 1. Cylinders used in Transcylindrical cholecystectomy

The cylinder commonly used is made of stainless steel, though we occasionally use a cylinder totally made in methacrylate to facilitate intraoperative cholangiography. The size of cylinders is always 10.0 cm long and either 3.8 or 5 cm in diameter. But we have cylinders 12 and 14 cm in length, rarely needed in the bigest patients or abnormal liver depth under the ribs in the subdiaphragmatic space. In young people, the use of a cylinder of 2.8 cm in diameter produces an almost imperceptible scar (Figure 2, 3).

Fig. 2. Methacrylate cylinder, 2,8 cm in diameter
