Tài liệu Hội thảo Quốc tế về Nội soi và Phẫu thuật nội soi

• generally avascular and may be lysed bluntly by grabbing attachment to gallbladder wall and gently stripping them down toward the. infundibulum[r]

• Acute or subacute cholecystitis

• Empyema or gangrenous cholecystitis

• Chronic cholecystitis

Gold standart : Lap Cholecystectomy

Philippe Mouret 1987

• Cirrhosis and/or portal hypertension

• Chronic obstructive pulmonary disease

• Acute or subacute cholecystitis

• Previous upper abdominal operation

• Liver cirrhosis

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Imaging criteria

• Thick walled gallbladder

• Contracted or calcified gallbladder

• Retraction of gallbladder into hepatic bed

• Impacted stones with mark distended GB

• Cholecystoduodenal fistula

• Mirizzi’s syndrome

Operative finding criteria

• Severe adhesion around gallbladder

• Anterior abdominal wall bowel

adhesion

• Empyema or gangrenous cholecystitis

• Severe cirrhotic liver

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Gallstone with CBD stone

• ERCP  LC (Rajavithi and gen.standard)

• ERCP+LC (same setting- difficult)

• LC+IOC+Lap.explore CBD *****

• LC  ERCP (Take risk)

• OC+IOC+Explore CBD

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How to do for SAFE LC

• Training, Hands-on model, animal and do as

surgeon under experienced trainer

• Ports- 1,2,3,4 safe technique

• Fundus, Hartmann grasping, dissection

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VIDEO

• generally avascular and may be lysed bluntly

by grabbing attachment to gallbladder wall and

gently stripping them down toward the

infundibulum

Intraoperative Gallbladder Perforation

• Perforation of the gallbladder with bile or

stone leakage should not ordinarily require

conversion to OC

• Perforation may occur

– secondary to traction

– electrosurgical thermal injury during dissection

• Patients with a bile leak

– No increased incidence of infection, prolongation

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Spilled Gallstone

• Incidence - 10-30%

• Low morbidity of spilled stones

– conversion to open not justified

• Complications:

– Mostly seen with pigmented stones

• postulated to be due to the release of

bacteria from within the stones

– Port insertion sites

Ultrasonic dissector,APC,Surgicel,Gauze pack

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DO NOT

• Clip or cauterize in the lake

• Cauterize-Unseen tip of instrument

Conclusion

Difficult LC is still challenging, it can be

done safely by experienced surgeon

who always keeps carefulness in all

steps

Gallstone with CBD stone- options of

treatment depend on

-patient

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Thank you