**4.3 Technique and equipment**

12 Updated Topics in Minimally Invasive Abdominal Surgery

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 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 exploration.

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.

Transcylindrical Cholecystectomy for the Treatment

Fig. 5. View of the hepatocystic triangle through the plug

dissected using conventional material (Figure 6).

Part of the gallbladder with its infundubulum is visible at the bottom of the cylinder, as well as the omentum, duodenal bulb or colon. The infundibulum or Hartmann Pouch is grasped with tissue Foerster forceps and is drawn anterior and laterally and a medium swab inside the cylinder is used to displace the organs that impede the sight of the angle between the gallbladder and the hepatoduodenal ligament. Afterwards the hepatocystic triangle is

The peritoneum is incised on the hepatocystic triangle, close to the gallbladder neck, and the fat is carefully dissected away on the free edge of the angle between the infundibulum and the hepatoduodenal ligament using gauze pledget held in an other Foerster forceps, until the cystic duct (Figure 7) and common bile duct are clearly defined (no always this later). Afterwards, we check that the cystic duct follows clearly from the gallbladder neck. If the cystic duct lymph node and cystic artery are not yet visible, the dissection is done gently upwards to discover the cystic artery, which will be followed up to its entrance into the

of Cholelithiasis and Its Complications: Cholecystectomy Under Local Anesthesia 15

Before reaching a working position of the cylinder, this is gently moved inside of the abdomen. The blunt shape of the plunger end, slightly protruding from the intra-abdominal side of the cylinder, facilitates this movement. The plunger can be withdrawn and reintroduced as many times as necessary to identify anatomical structures. Lamp lights usually suffice to illuminate the operative field, but a cold light may be of help occasionally.

Fig. 3. Incision of 3,5 cm in length

Fig. 4. Cylinder bottom through the methacrylate plug

Fig. 3. Incision of 3,5 cm in length

Fig. 4. Cylinder bottom through the methacrylate plug

Before reaching a working position of the cylinder, this is gently moved inside of the abdomen. The blunt shape of the plunger end, slightly protruding from the intra-abdominal side of the cylinder, facilitates this movement. The plunger can be withdrawn and reintroduced as many times as necessary to identify anatomical structures. Lamp lights usually suffice to illuminate the operative field, but a cold light may be of help occasionally.

Fig. 5. View of the hepatocystic triangle through the plug

Part of the gallbladder with its infundubulum is visible at the bottom of the cylinder, as well as the omentum, duodenal bulb or colon. The infundibulum or Hartmann Pouch is grasped with tissue Foerster forceps and is drawn anterior and laterally and a medium swab inside the cylinder is used to displace the organs that impede the sight of the angle between the gallbladder and the hepatoduodenal ligament. Afterwards the hepatocystic triangle is dissected using conventional material (Figure 6).

The peritoneum is incised on the hepatocystic triangle, close to the gallbladder neck, and the fat is carefully dissected away on the free edge of the angle between the infundibulum and the hepatoduodenal ligament using gauze pledget held in an other Foerster forceps, until the cystic duct (Figure 7) and common bile duct are clearly defined (no always this later). Afterwards, we check that the cystic duct follows clearly from the gallbladder neck. If the cystic duct lymph node and cystic artery are not yet visible, the dissection is done gently upwards to discover the cystic artery, which will be followed up to its entrance into the

Transcylindrical Cholecystectomy for the Treatment

Fig. 7. Cystic duct with right angle dissector

min.

All patients were fitted to the following protocol:

**4.4 Transcylindrical cholecystectomy under local anaesthesia plus sedation** 

and was given 50 mg ranitidine and metoclopramide 10 mg intravenously.

1. In the preparation area an intravenous cannula was placed, vital signs were monitored,

2. Once in the operating room after the patient monitor ECG, pulse oxymetry (SpO2), BIS (bispectral index) and noninvasive blood pressure we proceeded to the supply of oxygen with nasal cannula with the end tidal CO2 (ETCO2), Midazolam 0.05 mg/kg/ev and initiation of infusion of remifentanil in doses of 0.05 mcg/kg/min to 0.1 mcg/kg/

The objective was to obtain a sedation 2-3 on the Ramsay scale and/or a BIS value of 70 to 85 before the application of local anesthesia. For anesthesia of the abdominal wall surgical area was used 300-500 mg of mepivacaine 1% was used. The infiltration began in the line previously marked for incision, which is located in the epigastrium about 4 cm to the right of the midline and 3 cm from the costal margin. Follows the infiltration of the muscular plane and transverse oblique, lateral to the incision site with the intention of blocking the intercostal nerves VII-IX in the lateral costal margin. Finally we infiltrate the rectus muscle

of Cholelithiasis and Its Complications: Cholecystectomy Under Local Anesthesia 17

restrained by gentle pressure of a moist gauze pad through the cylinder or electrocautery. The subhepatic space is irrigated with saline solution through the cylinder and after closing

the posterior wall (polydioxanone sulphate) the wound is irrigated again.

gallbladder (a right angle dissector is required). The cystic artery can be sectioned between two distal clips and a proximal one.

Fig. 6. Calot's triangle (as shown by the arrow) after extracting the plug

At this time, surgeon and assistant must agree on the identity of the visible anatomic structures and make sure that there are no more tubular structures above the cystic duct, other than the cystic artery. Accessory extrahepatic ducts and ductus subvesicularis have to be taken into account, as well as the double cystic artery or any abnormal situation or origin. Once the cystic duct has been identified, a silk ligature is passed around it and prepared for cholangiography (performed selectively) and sectioned with two distal clips. To finish the dissection of the hepatocystic triangle we retract the infundibulum or corpus with the help of a pledget gauze, as much as we can, from its bed in the liver, keeping the dissection close to the gallbladder wall (to avoid structures of the hilum). Separation of the gallbladder from the hepatic bed follows in a retrograde fashion using electrocautery. Perhaps, this is de more laborious part of the procedure because we needs to change the point of traction to free the corpus and fundus that are attached to the liver in a somewhat posterior position. The puncture and emptying of the gallbladder helps freeing it and, finally, we extract it from the interior of the cylinder.

We check out the hepatocystic zone and the gallbladder bed by means of the reintroduction of the cylinder and check for oozing and bile spill from the gallbladder bed. Bleeding can be

gallbladder (a right angle dissector is required). The cystic artery can be sectioned between

Fig. 6. Calot's triangle (as shown by the arrow) after extracting the plug

At this time, surgeon and assistant must agree on the identity of the visible anatomic structures and make sure that there are no more tubular structures above the cystic duct, other than the cystic artery. Accessory extrahepatic ducts and ductus subvesicularis have to be taken into account, as well as the double cystic artery or any abnormal situation or origin. Once the cystic duct has been identified, a silk ligature is passed around it and prepared for cholangiography (performed selectively) and sectioned with two distal clips. To finish the dissection of the hepatocystic triangle we retract the infundibulum or corpus with the help of a pledget gauze, as much as we can, from its bed in the liver, keeping the dissection close to the gallbladder wall (to avoid structures of the hilum). Separation of the gallbladder from the hepatic bed follows in a retrograde fashion using electrocautery. Perhaps, this is de more laborious part of the procedure because we needs to change the point of traction to free the corpus and fundus that are attached to the liver in a somewhat posterior position. The puncture and emptying of the gallbladder helps freeing it and, finally, we extract it from the

We check out the hepatocystic zone and the gallbladder bed by means of the reintroduction of the cylinder and check for oozing and bile spill from the gallbladder bed. Bleeding can be

two distal clips and a proximal one.

interior of the cylinder.

restrained by gentle pressure of a moist gauze pad through the cylinder or electrocautery. The subhepatic space is irrigated with saline solution through the cylinder and after closing the posterior wall (polydioxanone sulphate) the wound is irrigated again.

Fig. 7. Cystic duct with right angle dissector
