Kamthorn Yolsuriyanwong, MD, Eric Marcotte, MD, Bipan Chand, MD. Loyola University Chicago, Stritch School of Medicine
Background: In normal situations, laparoscopic cholecystectomy (LC) usually starts with dissection from the triangle of Calot upwards towards the dome of the gallbladder. However, the surgeon may encounter a difficult LC, which loss of anatomical details particularly in the triangle of Calot. Acute cholecystitis is one of those complicated conditions secondary to severe inflammation. The dome-down approach is a secondary technique to reduce the risk of complications and can be employed in this situation.
Methods: We present two cases of acute cholecystitis that underwent dome-down LC. Both patients were positioned in the reverse Trendelenburg position with tilt to the left. The procedures started with a standard four-port technique. Initially, attempts to identify the triangle of Calot could not be done in either case secondary to severe inflammation. In the first case with a markedly distended gallbladder, decompression was done before starting dissection. We started by retracting the fundus downwards (surgeons left hand) and retracting the liver upwards (assistant). Dissection was carried out by opening the peritoneum between the fundus and liver at the gallbladder bed. The procedure continued until Calot’s triangle was reached. These steps are similar to the open dome-down technique. After dissection of the gallbladder off the liver was complete, the triangle of Calot was exposed. We then changed to perform dissection using the infundibular approach, which is similar to conventional LC. However now, after proper dissection, the cystic duct and artery could be readily exposed and ligated.
In the second case, instead of changing to the infundibular technique, we continued dissection into Calot’s triangle. During dissection in this dome-down technique, the cystic artery is usually identified before the cystic duct. After both structures were clearly identified, metallic clips were applied and scissors were used to divide them. In both cases, hemostasis was achieved and the gallbladder removed.
Conclusion: Laparoscopic cholecystectomy with the dome-down approach is safe and feasible with standard equipment in scenarios of difficult cholecystectomy, particularly in acute cholecystitis. However, a learning curve for this laparoscopic technique is required and should not replace sound surgical judgment and the need to convert to open surgery if the skill set is not there.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 87005
Program Number: V006
Presentation Session: Biliary Session
Presentation Type: Video