Friday, April 3, 2009

Lap Chole Tips

In General Surgery News (a free throwaway publication we get monthly in the mail), there's an opinion piece from one Arnold Seid, MD, a general surgeon in California who discusses his own personal "five key rules" to avoid potential bile duct injury during a laparoscopic cholecystectomy. Dr. Seid is a veteran surgeon; he's done thousands of lap choles over the years and he has been serving as an expert witness in LC malpractice cases for the past 15 years. So it's worthwhile to read his take. Here're his rules:

1) Never perform a lap chole without a skilled surgeon as your assistant. (He always books his LC cases with his partner, another board certified general surgeon.)

2) Slow Down (He claims that he never finishes a LC in less than an hour.)

3) Knowledge is power, don't be afraid to open.

4) Don't try to repair a bile duct injury. (Place a drain and refer to a specialist.)

5) Don't ignore post-operative complaints. (Pain/fevers/nausea/etc deserves a thorough evaluation to rule out bile leak or CBD injury.)

Now I'll grant him the last three rules. Opening ought not to be considered a "complication". If you're not progressing, if there's any doubt, NEVER hesitate to put the tiny tools away and open the patient. To some extent I agree with rule #4 as well. If you've injured a bile duct, best to cut your losses, place a drain and let someone with expertise correct the problem. Most of time, you only get one chance to repair a bile duct injury. And I strongly support rule #5. Anytime a patient calls me after a LC with complaints of seemingly excessive pain they get a stat HIDA scan and blood work. 99.9% of the time it's overkill but you just can't afford to miss anything.

I'm not so sure about the first two rules however. With all due respect to Dr. Seid, having two board certified general surgeons scrub into every LC seems almost absurd. The idea of course is that two sets of eyes are better than one. But that logic is self-defeating. Why not get three surgeons in there? Why not have the entire surgical staff come into the room when everything is exposed and have everyone vote on whether or not it's safe to clip and cut? An infinite number of eyes are better than two sets right? Ultimately, the attending surgeon needs to take responsibility for what he/she sees and make the correct call. It's very simple. We have to be able to trust that, given appropriate exposure and technique, that any board certified general surgeon will be able to interpet the anatomy correctly.

As for rule #2, I have a hard time understanding how one could spend 60 minutes on EVERY SINGLE laparoscopic cholecystectomy. I don't rush. I don't cut or clip anything until I'm 110% certain of what I'm looking for. I do a cholangiogram on probably 95% of my cases. Even with all that, my LC cases invariably take somewhere between 20-45 minutes. I have done LC that took over an hour (adhesions/extensive inflammation/etc) but those are the rare cases.

I love LC. If I had to do 3-4 a day for the next 20 years I would be a happy general surgeon. It's an elegant operation. I haven't done thousands, but I've done enough where it's become almost automatic. I try not to waste any moves. Every act is purposeful. Rarely is there struggling or the sort of futzing around that can occur when doing a laparoscopic colon resection. So here are my tips:

1) Never use a Veress needle. Why blindly stick a needle into your patient's belly? It's ridiculous. I do an open Hasson insertion. It's not slower. It's definitely safer. It's a no brainer.

2) Don't use cautery while doing the initial dissection. I gently tease down first the peritoneum, then the fibroadipose tissue with a Maryland dissector. Don't do it roughly. Don't rip things. Be patient. A single strand at a time if you have to. It will reveal itself to you.

3) Don't forget to do a posterior dissection. In other words, flip the infundibulum to the patient's left and open up that peritoneum and space behind and to the right of the cystic duct/infundibular interface.

4) Cholangiogram! Really no excuse not to do one. You'll feel better about the case if you make cholangiography a routine part of your technique. I didn't do many at all as a resident (attending choice) but since I've been in practice I plan to do one on every LC. It doesn't add much time. It really doesn't. And the more you do, the faster it goes. Anymore, if I don't do a cholangiogram for some reason (dye leakage, patient body habitus, etc.) I feel like you would if you went to work one day and realized at noon that your zipper had been down all day. A nice cholangiogram just makes me feel all warm and fuzzy inside.

5) I use the 10mm clips on the duct. I just don't like the 5mm clip devices. Maybe I'm using the wrong product, but I just feel that the smaller clips don't go on as well. The subxiphoid incision I make is consequently a little larger, but it's worth it to my sense of well-being.

6) Hook cautery when dissecting the gallbladder out of the liver bed. It's better than the spatula. You can actually sort of dissect with the hook, which allows you to get into the exact tissue plane, thereby minimizing bleeding/bile spillage.

7) I use a bag to retrieve the gallbladder on every case. Studies suggest that at least 20% of gallbladders (even non-inflamed ones) are colonized with bacteria. So why pull a potentially dirty, devascularized specimen out through a clean umbilical incision?

8) I'm pretty conservative when it comes to placing Jackson-Pratt drains. I leave one in for 24 hours for nasty, pus-filled gallbags or if there's a lot of bile spillage or bleeding. Also, if I'm worried about the cystic duct stump (friable, inflamed, ischemic). The drain helps me identify an early stump leak.


Anonymous said...

you never fail to deliver a perfect ratio of technical, emotional and controversial posts. Keep em coming buckeye

Anonymous said...

oh and too bad about missing out on Jay Cutler

Anonymous said...

Agree with all of the above. We have a small group of general surgeons, down to 4, one left. We don't have the luxury of having two general surgeons for every case, except maybe the really complicated ones (rare). Also, opening is not a sign of failure, can't believe anyone ever got sued on opening after a laparoscopic cholecystectomy. Love using a ranfac catheter for IOCs. K

Joseph Sucher, MD FACS said...

I really like General Surgery News and I like your review on this article.

I also agree with most of what you're saying. How can we possibly justify having 2 board-certified surgeons for every LC? Geeze... might as well spit on the whole risk/benefit and cost control push.

I too share the same feeling about the Veress needle approach. However, I know 2 excellent surgeons that use it routinely and safely. That being said, this is a timely topic as there was an article published in the last issue of Surgical Endoscopy. Despite my bias for the open Hasson approach, I will leave you with the abstract.

Primary access-related complications in laparoscopic cholecystectomy via the closed technique: experience of a single surgical team over more than 15 years.

Prakash Kumar Sasmal, Om Tantia, Mayank Jain, Shashi Khanna, Bimalendu Sen

Background Laparoscopic cholecystectomy (LC), a common laparoscopic procedure, is a relatively safe invasive procedure, but complications can occur at every step, starting from creation of the pneumoperitoneum. Several studies have investigated procedure-related complications,
but the primary access- or trocar-related complications generally are underreported, and their true incidence may be higher than studies show. Major vascular or visceral injury resulting from blind access to the abdominal cavity, although rare, has been reported. Of the two methods for creating pneumoperitoneum, the open access technique is reported to have the lower incidence of these injuries. The authors report their experience with the closed method and show that if performed with proper technique, it can be as
rapid and safe as other techniques. However, injuries still happen, and the search for the predisposing factors must be

Methods Between January 1992 and December 2007, a retrospective study examined 15,260 cases of LC performed for symptomatic gallstone disease in the authors’
institution by a single team of surgeons. The primary access-related injuries in these cases were retrospectively analyzed.

Results In 15,260 cases of LC, 63 cases of primary access-related complications were identified, for an overall incidence of 0.41%. Major injuries in 11 cases included
major vascular and visceral injuries, and minor injuries in
52 cases included omental and subcutaneous emphysema.

For the closed method, the findings showed an overall incidence of 0.14% for primary access-related vascular injuries and 0.07% for visceral injuries.

Conclusion Primary access-related complications during LC are common and can prove to be fatal if not identified early. The incidence of these injuries with closed methods is no greater than with open methods.

No evidence suggests abandonment of the closed-entry method in laparoscopy.

Anonymous said...

The cholangiogram is the second pair of eyes for the single surgeon. It may open a different perspective and like the author states, if omitted there is a sense of incompleteness. I like the cholecystocholangiogram and the cystic duct marking technique. 2 or 3 clips are placed next to the proposed cystic duct before shooting the cholangiogram. It helps eliminate ambiguity and helps create an anatomic proof of identity. JACS 203:257,2006.

Anonymous said...

I'm having a lap chole on Friday. How do I push my surgeon to do the dye test and use a bag without making him angry that I'm telling him how to do his job?

Anonymous said...

I do cholangiograms selectively (probably 10-15%) and will continue to do it that way. To me, an unnecessary operative step is inelegant - I get no warm fuzzies from doing a gram. And they do not reduce complication rate.

There is only one maneuver which reduces biliary complication and that is conversion to open prior to cutting any ductal structure. I think we as a group probably do not do this often enough, and I include myself in that assessment.

I don't use Veress for lap chole, but I do use it for lap appy - that's because I take the GB out through the umbilical site (Hasson) but I take the appy out through the LLQ port site and prefer to minimize the size of the umbo site for appy. I thank Joe S. for the reference from Surg Endos. I remember a prior article in British J Surg (2001-3 roughly) comparing complication rates from Veress and Hasson and finding them essentially equal at 0.1%. This was a very well done review with very large numbers of patients and I recall completely buying into the data. That's another reason why I do not advocate one way or the other of getting access. Just do it carefully.

For anonymous having a lap chole - please don't try to suggest to your surgeon how to do the procedure from a technical standpoint (unless you are board certified in surgery).

Anonymous said...

I'm a surgical tech in Cincinnati and have found your tips to be helpful for me while I'm doing some pre-op research. While I know every surgeon will have his or her own methods, I like how straightforward you've been in this post, and it's given me another perspective on biliary surgery.

Ramesh said...

we as a surgeon never do cholangiogram if USG shows normal CBD and LFT. And to our research no problems in lap chole, if conversion cases are kept apart. So wrong idea

Ramesh said...

we never do cholangiogram if USG and LFT are normal. And as per our research outcomes didnt differ in terms of post-op complications if we keep conversion cases apart. So wrong idea to do cholangiogram in every case. Also it may precipitate pancreatitis, am not sure.