Me and DR Khalid
Me and DR Khalid
Me and DR Khalid
It should be the aim of the surgeon to employ the type of incision considered to be the
most suitable for that particular operation to be
performed. In doing so, three essentials should be achieved (Zinner et al, 1997):
1. Accessibility
2. Extensibility
3. Security
The incision must not only give ready and direct access to the anatomy to be
investigated but also provide sufficient room for the operation to be
performed (Velanovich, 1989).
Cosmetic end results of any incision in the body are most important from patients’ point
of view. Consideration should be given wherever possible, to
siting the incisions in natural skin creases or along Langer’s lines. Good cosmoses help
patient morale.
Classification of open cholecystectomy incisions:
Midline Incision
Almost all operations in the abdomen and retroperitoneum can be performed
through this universally acceptable incision (Guillou et al, 1980).
Advantages
(a) It is almost bloodless
(b) No muscle fibers are divided
(c) No nerves are injured
(d) it affords goods access to the upper abdominal viscera
(e) It is very quick to make as well as to close; it is unsurpassed when speed is
essential (Clarke, 1989)
Paramedian incision
I. The first is that it offsets the vertical incision to the right or left, providing
access to the lateral structures such as the spleen or the kidney.
II. The second advantage is that closure is theoretically more secure because
the rectus muscle can act as a buttress between the reapproximated
posterior and anterior fascial planes (Cox et al, 1986).
Disadvantages:
1. It tends to weaken and strip off the muscles from its lateral vascular and nerve
supply resulting in atrophy of the muscle medial to the incision.
2. The incision is laborious and difficult to extend superiorly as is limited by
costal margin.
3. It doesn’t give good access to contra lateral structures.
Mayo-Robson
The Mayo-Robson extension of the Paramedian incision is accomplished by curving
the skin incision towards the xiphoid process. Incision of the fascial planes is
continued in the same direction
to obtain a larger fascial opening (Pollock, 1981).
Transverse incisions
Transverse incisions include the Kocher
Kocher incision
Procedure
References :
1. Askew, A.R. (1975) : The Fowler-Weir approach to appendicectomy. British Journal
of Surgery, 62(4): 303-4.
2. Ayers, J.W., Morley, G.W. (1987): Surgical incision for caesarean section. Obstetrics
Gynaecology, 70(5): 706-8.
3. Brand, E. (1991): The Cherney incision for gynaecologic cancer. American Journal of
Obstetrics and Gynaecology, 165(1): 235.
4. Brennan, T.G., Jones, N.A., Guillou, P.J. (1987): Lateral paramedian incision. British
Journal of Surgery, 74(8): 736-7.
5. Brodie. T.E., Jackson, J.T., McKinnon, W.M. (1976): A muscle retracting subcostal
incision for cholecystectomy. Surgery Gynaecology Obstetrics 143(3): 452-3.
6. Brooks, M.J., Bradbury, A., Wolfe, H.N. (1999) : Elective repair of type IV thoraco-
abdominal aortic aneurysms; experience of a subcostal (transabdominal) approach.
European Journal of Vascular Endovascular Surgery, 18(4): 290-3.
7. Burnand, K.G., Young, A.E.: The New Aird’s Companion in Surgical Studies. Churchil
Livingstone Edinburgh (1992).
8. Carlson, M.A., Ludwig, K.A., Condon, R.E. (1995): Ventral hernia and other
complications of 1,000 midline incisions. Southern Medical Journal Apr; 88(4): 450-3
9. Chino, E.S., Thomas, C.G. (1985): An extended Kocher incision for bilateral
adrenalectomy. American Journal of Surgery, 149(2): 292-4.
10. Chute, R., Baron, J.A. Jr., Olsson, C.A. (1968): The transverse upper abdominal
“chevron” incision in urological surgery. Journal of Urology, 99(5): 528-32.
11. Chuter, T.A., Steinberg, B.M., April, E.W. (1992): Bleeding after extension of the
midline epigastric incision. Surgery Gynaecology Obstetrics, 174(3): 236.
12. Clarke, J.M. (1989): Case for midline incisions. Lancet, Mar 18; 1 (8638): 622.
13. Coelho, J.C., de Araujo, R.P., Marchensini, J.B., Coelho, I.C., de Araujo, L.R.
(1993): Pulmonary function after cholecystectomy performed through Kocher’s incision,
a mini-incision, and laparoscopy. World Journal of Surgery. 17(4): 544-6.
14. Cox, P.J., Ausobsky, J.R., Ellis, H., Pollock, A.V. (1986): Towards no incisional
hernias: lateral paramedian versus midline incisions. Journal of Royal Society of
Medicine, Dec. 79(12): 711-12.
15. Delany, H.M., Carnevale, N.J. (1976): A “Bikini” incision for appendicectomy.
American Journal of Surgery; 132(1): 126- 27.
16. Denehy, T.R., Einstein, M., Gregori, C.A., Breen, J.L. (1998): Symmetrical
periumbilical extension of a midline incision: a simple technique. Obstetrics
Gynaecology 91(2): 293-94.
17. Didolkar, M.S., Vickers, S.M. (1995): Perixiphoid extension of the midline incisions.
Journal of American College of Surgery, 180(6): 739-41.
18. Dorfman, S., Rincon, A., Shortt, H. (1997): Cholecystectomy via Kocher incision
without peritoneal closure. Investigation Clinics, 38(1): 3-7.
19. Dudley, H.: Robe and Smith’s Operative Surgery. In: Alimentary Tract and
abdominal wall. Volume 1 General Principles, 4th edn. Butterworths London: (1983).
20. Ellis, H. (1984): Midline abdominal incisions. British Journal of Obstetrics and
Gynaecology; 91(1): 1-2.
21. Fink, D.L., Budd, D.C. (1984): Rectus muscle preservation in
oblique incisions for cholecystectomy. American Journal of
Surgery. 50(11): 628-36.
22. Fry D.E., Osler, T. (1991): Abdominal wall considerations and
complications in reoperative surgery. Surgery Clinics of North
America, 71(1): 1-11.
23. Funt, M.I. (1981): Abdominal incisions and closures. Clinical
Obstetrics Gynaecology, 24(4): 1175-85.
24. Gauderer, M.W.L. (1981): A rationale for the routine use of
transverse abdominal incision in infants and children. Journal
of Paediatric Surgery 16 (Sup.1): 583.
25. Grantcharov, T.P., Rosenberg, J. (2001): Vertical compared with transverse incision
in abdominal surgery. European Journal of Surgery: 167(4): 260-7.
26. Greenall, M.J., Evans, M., Pollock, A.V. (1980): Midline or
transverse laparotomy ? A random controlled clinical trial. Part I: Influence on healing.
British Journal of Surgery, 67(3): 188-90.
27. Grriffiths, D.A. (1976): A reappraisal of the Pfannenstiel incision. British Journal of
Urology, 46(6): 469-74. 28. Guillou, P.J., Hall, T.J., Donaldson, D.R., Broughton, A.C.,
Brennan, T.G. (1980): Vertical abdominal incisions – a choice ? British Journal of
Surgery, 67(6): 395-9.
29. Gupta, S., Elanogovan, K., Coshic, O., Chumber, S. (1994): Minicholecystectomy:
can we reduce it further ? Journal of Surgery Oncology, 56(3): 167.
Intra-Operative Detection of Complications and their
Management (with evidence based)
Abstract
(The incidence of biliary injury after laparoscopic cholecystectomy (LC) has
shown a declining trend though it may still be twice that as with open
cholecystectomy.)
Major biliary or vasculobiliary injury is associated with significant morbidity. As
prevention is the best strategy, the concept of a culture of safe cholecystectomy has
been recently introduced to educate surgeons and apprise them of basic tenets of safe
performance of LC. Various aspects of safe cholecystectomy include:
(1) Thorough knowledge of relevant anatomy, various anatomical landmarks, and
anatomical variations;
(2) An understanding of the mechanisms involved in biliary/vascular injury, the most
important being the misidentification injury;
(3) Identification of various preoperative and intraoperative predictors of difficult
cholecystectomy;
(4) Proper gallbladder retraction;
(5) Safe use of various energy devices;
(6) Understanding the critical view of safety, including its doublet view and
documentation;
(7) Awareness of various error traps (e.g., fundus first technique);
(8) use of various bailout strategies (e.g., subtotal cholecystectomy) in difficult
gallbladder cases;
(9) Use of intraoperative imaging techniques (e.g., intraoperative cholangiogram) to
ascertain correct anatomy; and
(10) Understanding the concept of time-out. Surgeons should be facile with these
aspects of this culture of safety in cholecystectomy in an attempt to reduce the
incidence of biliary/vascular injury during cholecystectomy.
AVOIDANCE OF BILIARY/VASCULAR INJURY DURING CHOLECYSTECTOMY
Basic tenets of performing a safe LC include:
(1) Thorough knowledge of surgically relevant anatomy;
(2) Identification of factors predictive of difficult cholecystectomy;
(3) Understanding and execution of correct technique that includes: Correct
exposure/display of hepatocystic (HC) triangle in preparation of dissection; Judicious
use of energy sources; Achieving the critical view of safety (CVS); Remembering error
traps;
(4) Strategies to handle a difficult situation: Stopping rules; Second opinion/surgical
assistance; Use of intraoperative imaging to clarify the anatomy;Bail-out procedures;
and
(5) Documentation.
Anatomical variations
Vascular anomalies: The cystic artery and the right hepatic artery (RHA) are two
important vessels of concern during LC.
The cystic artery is usually single (approximately 79%), originates from RHA, and
most commonly (81.5%) traverses the HC triangle to supply the gallbladder through its
two branches - superficial and deep[23]. However, this artery may have variations in
its origin, number, or course. The most important of these variations includes: (1) the
cystic artery passing anterior to the common hepatic/bile duct (17.9%); (2) a short (< 1
cm) cystic artery (9.5%); (3) multiple cystic arteries (8.9%); and (4) the cystic artery
located inferior to the cystic duct (4.9%)[23].
Clinical importance: During dissection in the HC triangle, a replaced right hepatic
artery may appear as a large cystic artery, and might be injured if not identified
correctly[23]. The right hepatic artery may take a tortuous course (Caterpillar
turn/Moynihan’s hump) within the HC triangle, and it may lie very close to the
gallbladder and the cystic duct before giving off a short cystic artery[21]. Again, this
aberrant course makes the right hepatic artery prone to injury during
cholecystectomy.
Biliary ductal anomalies
Important ductal anomalies relevant to LC involve variations in the cystic duct and
right hepatic ductal system[35].
The cystic duct is usually 2-4 cm long and 2-3 mm wide[21,36]. It may be congenitally
absent (very rare) or very long (5 cm or more)[21,36]. Usually it joins the CHD at an
angle (angular insertion, 75%) but its course may be parallel (20%) or spiral (5%)
[21,24,35].
It usually enters the CHD but there are variations: it may enter the right hepatic duct
(0.6%-2.3%), anomalous right sectional duct, or CHD quite low near the ampulla
(Figure 6)[21,22]. An anomalous right sectional duct, especially a right posterior
sectional
duct, may join the biliary tree at a level lower than usual. Rarely, there might be
duplication of the CBD[37]
UNDERSTANDING AND EXECUTION OF CORRECT
TECHNIQUE
The basic essential steps of LC cholecystectomy include gallbladder retraction (to
open up and expose HC triangle in preparation for next step), dissection in the HC
triangle to achieve the CVS, clipping and division of the cystic duct and the cystic
artery, and dissection of the gallbladder from its bed (Figure 8)
Concept of the CVS
A common cause of biliary injury during LC is misidentification of structures in the
HC triangle. The CBD or an aberrant right sectional duct may be misidentified as the
cystic duct and then, if not correctly appreciated, may be clipped and divided[50].
Similarly the right hepatic artery may be misidentified as the cystic artery if the latter
is short or if the right hepatic artery has an aberrant course.
To avoid such misidentification injury, it is of utmost importance that these two
structures (the cystic artery and the cystic duct) must be identified conclusively before
they are clipped and divided. The concept of the “CVS” was introduced in an attempt
to decrease the misidentification injury[12].
The aim of the CVS is conclusive identification of the cystic duct and the cystic
artery (two targets) to avoid misidentification injury[48,52,53].
What is the CVS?
It is not the dissection technique. It is the final view that is achieved after a thorough
dissection of the HC triangle to delineate the cystic duct and the cystic artery before
they are clipped and divided[12,48,49]. The CVS has three components (Figure 13),
and all
must be met before the surgeon declares that the CVS has been achieved[12].
1 Clearance of the HC triangle: The HC triangle should be cleared of all the fibrofatty
and soft areolar tissue. Once adequately cleared of all fibro-fatty tissue, the
under surface of the liver is easily seen across this triangle.
2 Exposure of the lower cystic plate: The gallbladder should be separated from its
liver bed to expose at least the lower third of the cystic plate.
3 Two and only two tubular structures should be seen entering the gallbladder:
the Cystic duct and the cystic artery.
WHAT TO DO IN A DIFFICULT SITUATION? STRATEGIES
TO HANDLE A DIFFICULT SITUATION
Understand “Stopping rules”
It is important for the operating surgeon to be able to recognize during the procedure
when the dissection is becoming unsafe with a high potential for biliary/vascular
injury.