HOW I DO IT DIFFERENTLY?
|Year : 2017 | Volume
| Issue : 4 | Page : 318-320
Gall bladder flip technique in laparoscopic cholecystectomy
Munish Sharma, Anubhav Vindal, Pawanindra Lal
Department of General Surgery, Division of Minimal Access Surgery, Maulana Azad Medical College, New Delhi, India
|Date of Submission||06-May-2017|
|Date of Acceptance||17-May-2017|
|Date of Web Publication||5-Sep-2017|
House No. 259, G-Block, Preet Vihar, New Delhi - 110 092
Source of Support: None, Conflict of Interest: None
Background: The precise steps for the removal of gall bladder from the gall bladder bed are not well standardised. The dissection becomes more difficult near the fundus where the assistant's grasper holding the fundus creates a 'tug of war' like situation.
Materials and Methods: This is a description of a simple technique that aids in accurate dissection of the gallbladder from liver bed. As the gallbladder dissection approaches fundus and more than two-third of gallbladder is dissected from liver bed, the medial and lateral peritoneal folds of gall bladder are further incised. The assistant is asked to leave the traction from the gallbladder fundus, while the surgeon holds the dissected surface of gall bladder around 2–3 cm away from its attachment with liver and flip it above the liver. Further dissection is carried out using a hook or a dissector till it is disconnected completely from the liver bed.
Results: We have employed 'Flip technique' in around 645 consecutive cases of laparoscopic cholecystectomy operated in the past 3 years. Only one case of liver bed bleeding and two cases of injury to gall bladder wall were noted during this part of dissection in this study. Ease of dissection by surgeons was rated as 9.6 on a scale of 1–10.
Conclusion: Gallbladder 'Flip technique' is a simple and easily reproducible technique employed for dissection of gall bladder from liver bed that reduces complications and makes dissection easier.
Keywords: Flip technique, gallbladder dissection, laparoscopic cholecystectomy
|How to cite this article:|
Sharma M, Vindal A, Lal P. Gall bladder flip technique in laparoscopic cholecystectomy. J Min Access Surg 2017;13:318-20
| ¤ Introduction|| |
With the advent of improved optics and video laparoscopy in the late 1980s, the technique of laparoscopic cholecystectomy was introduced and was soon widely adopted by practicing general surgeons. The National Institute of Health consensus development conference in the year 1992 concluded that laparoscopic cholecystectomy provides a safe and effective treatment for most patients with symptomatic gallstones. Overall, over 90% of cholecystectomies are now done using the minimally invasive approach worldwide and laparoscopic cholecystectomy is now the gold standard treatment for gallstone disease. The technique of performing laparoscopic cholecystectomy has undergone subtle changes and variations in technique over the last two decades, and the basic principles have remained unchanged.
| ¤ Standard Laparoscopic Cholecystectomy|| |
Traditional laparoscopic cholecystectomy is performed using the four-port technique., The pneumoperitoneum is achieved by either closed veress needle technique or open technique using a blunt trocar or a Hasson's trocar. A 10 mm telescope usually 30° is used at the umbilicus. Another 10 mm trocar is used in the epigastrium which is the main working port for the surgeon. One 5 mm trocar in the right lumbar region is used for gallbladder fundus traction, and another 5 mm trocar in the right hypochondrium is used as left hand working port. The dissection is done using left and right-hand instruments to delineate the Calot's triangle, cystic artery and duct.
'Critical view of safety' is most widely adopted technique and was described in 1995 by Strasberg et al. This method requires complete dissection of the cholecystohepatic triangle and separation of the base of the gallbladder infundibulum from liver bed such that there are two and only two structures entering the gallbladder which is still attached only by the upper part of the liver bed. Cystic artery and duct are then clipped and cut. The gallbladder is then dissected off the liver bed and extracted from either umbilical or epigastric port.
The precise steps for the removal of gallbladder from the gall bladder fossa/bed are not well standardised. The dissection becomes more difficult near the fundus where the assistant's grasper holding the fundus and pushing the fundus away from surgeon creates a 'tug of war' like situation and not infrequently results in erroneous dissection into the liver bed causing bleeding or into the gall bladder wall causing bile and stone spillage which not only contaminates the peritoneal cavity but also makes the extraction of gall bladder challenging due to continuous dripping of bile and necessitates additional use of an endobag.
| ¤ Modification to the Standard Technique|| |
MAMC Flip technique
With the cystic duct and artery secured and divided [Figure 1], the gallbladder is dissected from the liver bed. Dissection is facilitated by placing the areolar tissue attaching the gallbladder to the liver bed under tension with appropriately directed traction and counter-traction.
|Figure 1: Schematic diagram of gall bladder after clipping of cystic artery and duct|
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As the gallbladder dissection approaches fundus and more than two-third of gallbladder is dissected from liver bed, further dissection becomes tedious as discussed earlier. We routinely employ the flip technique at this stage. The assistant is asked to leave the traction from the gall bladder fundus (i.e. anterior axillary line port) while the surgeon holds the dissected surface of gall bladder with a grasper and flip it [Figure 2] above the liver [Figure 3].
|Figure 2: Schematic diagram of gall bladder being 'flipped' above the liver|
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The traction so caused at lateral and medial peritoneal folds of gall bladder makes dissection of gall bladder quite easy using the electrocautery hook [Figure 4]. The last bit of the attachment between the fundus and liver is preserved till the end which helps in providing traction to liver using the left-hand instrument of the surgeon. This aids in accurate dissection of the gallbladder from liver bed.
| ¤ Results|| |
The MAMC Flip technique was used in 645 consecutive cases of laparoscopic cholecystectomy operated during the past 3 years in our unit. Only one case of liver bed bleeding and two cases of injury to gall bladder wall were noted during this part of dissection in the study. Ease of dissection as rated by surgeons on scale of 1–10 was 9/10 by four surgeons and 10/10 by six surgeons (average score 9.6/10) in the surgical unit.
| ¤ Benefits|| |
We routinely follow gall bladder flip technique during laparoscopic cholecystectomy that avoids typical 'tug of war' between surgeon and assistant during the last phase of gallbladder dissection from the liver bed. Flip technique makes the dissection significantly easier and reduces the complications associated with this part of dissection.
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Conflicts of interest
There are no conflicts of interest.
| ¤ References|| |
NIH Consensus conference. Gallstones and laparoscopic cholecystectomy. JAMA 1993;269:1018-24.
Olsen DO. Laparoscopic cholecystectomy. Am J Surg 1991;161:339-44.
Litynski GS. Profiles in laparoscopy: Mouret, Dubois, and Perissat: The laparoscopic breakthrough in Europe (1987-1988). JSLS 1999;3:163-7.
Strasberg SM, Hertl M, Soper NJ. An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg 1995;180:101-25.
Phillips E, Daykhovsky L, Carroll B, Gershman A, Grundfest WS. Laparoscopic cholecystectomy: Instrumentation and technique. J Laparoendosc Surg 1990;1:3-15.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]