Cole

DIFFICULT CHOLECYSTECTOMY

Simple cholecystectomy

DIFFICULT CHOLECYSTECTOMY Difficult Surgery

Difficult Anatomy

DIFFICULT CHOLECYSTECTOMY Difficult Pathology

Difficulty predicting factors Clinical parameters (Patient factors and Disease factors)

Radiological parameters Intra operative parameters

Clinical parameters Patient factors

Disease factors: • • • •

Acute cholecystitis Pancreatitis Pre operative ERCP Palpable GB

Radiological parameters

Intra operative parameters

Patients with significant visceral obesity

The Critical View of Safety, only 2 tubular structures entering the GB

Improper retraction of GB tents common hepatic/bile duct

Horizontal plane created by Rouviere’s sulcus  landmark

Surgical decision-making on Difficult Cholecystectomy Clues:

Call for help Conversion to open

Scoring Index/Prediction of difficulty

Bailout options on Difficult Cholecystectomy

Subtotal “fenestrating” cholecystectomy Leave Hartmann’s pouch, If unable to identify the cystic duct. Remove all the stones from the gallbladder.

Subtotal “fenestrating” cholecystectomy Leave posterior wall of gallbladder. Suture closed cystuc duct orifice from inside GB.

Take home message:

Thank You