The Fear of Transgastric Cholecystectomy: Misinterpretation of the Biliary Anatomy

The prevention of major injury at cholecystectomy relies on the accurate dissection of the cystic duct and artery, and avoidance of major biliary and vascular structures.
The advent of NOTES cholecystectomy has led to a new look and insights into biliary anatomy especially of the Calot’s triangle. Here we show the clinical case of a NOTES transgastric cholecystectomy for uncomplicated cholelithiasis, in which misinterpretation of biliary anatomy occurred.
Methods and procedure:
After induction of pneumoperitoneum using a Veress needle, a single 5mm transparietal port was introduced at the umbilicus to ascertain the feasibility of transgastric cholecystectomy ensure safe gastrotomy creation and closure, insufflation and monitoring of the pneumoperitoneum and to allow the use of a 5mm laparoscopic clip applier. Transgastric access was obtained using a double channel endoscope (KARL STORZ® Endoskope, Germany) under laparoscopic visual control. An endoscopic needle-knife was used to create a full thickness puncture on the anterior wall in the mid-body of the stomach expanded using a 18mm balloon dilator to allow passage of the 12mm gastroscope. The laparoscopic optic could then be switched to a 5mm laparoscopic grasper to expose the gallbladder. Dissection started using the endoscopic flexible tools at the junction between the infundibulum and what was thought to be the cystic duct. During the dissection the size and the orientation of the cystic duct appeared unclear. Decision was made to switch to a laparoscopic view to re-orient the dissection and define the correct planes. At this point we realized that the dissection of the triangle of Calot although started in close proximity to the gallbladder, was far to low and that we had mistaken the common bile duct with the cystic duct. Fortunately the dissection maneuvers had been performed with extreme care and no injury to the CBD occurred. Once the biliary anatomy was clarified the vision was switched back to the endoscope but a 2mm grasper was introduced to improve retraction. Cholecystectomy was performed in a standard fashion. A laparoscopic hook was used to skeletonized, the cystic duct and artery that were clipped using a laparoscopic clip applicator. At the end of the dissection, the operative site was checked to ensure haemostasis and biliostasis. The gallbladder was extracted through the gastrotomy under laparoscopic control and the gastrotomy closed with extracorporeal stitches by means of a 2mm laparoscope and a 3mm needle holder inserted side by side into the 5mm umbilical port.
Specific anatomical distortions due to the NOTES technique, along lack of exposure,with the present methods of retraction tend to distort the Calot’s triangle by actually flattening it rather than opening it out. Their contribution in producing injury and a preventive strategy based need to be investigated . At this stage whenever the anatomy of the biliary tract is confusing as happened in this case, a temporary “conversion” to a laparoscopic view, more familiar to the surgeon’s eye and therefore clearer that will provide a better understanding of the location of the common bile duct in respect to the cystic duct.

Session: Podium Video Presentation

Program Number: V026

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