Merseyside laparoscopic cholecystectomy course, Royal Liverpool Academy, 2019.

1. Laparoscopic cholecystectomy
Lunevicius R, MD, PhD, FRCS
Department of General Surgery
Liverpool University Hospitals NHS Foundation Trust
Cheshire and Mersey Major Trauma Collaborative
24th October 2019
22/10/20 1

2. 22/10/20 2
70,000 cholecystectomies in England per year
Symptomatic cholecystolithiasis: the commonest indication
LC rate 90%-95%: the proportion is fluctuant
Overall morbidity: 2% (>30% in STC)
BD injury rate: 0.4-0.5% (fluctuant; don’t include leaking CDs,S-VDs)
Incidence of injury to RHA: unknown (not-described, under-reported)

3. Therefore, the consent process for cholecystectomy needs to be
as transparent and informative as possible
Audit results
Amongst 17 consultant the overall completeness of
consenting was
27.6%
22/10/20 3
21.6 22.7 22.7 22.7
25.3 25.9 27.1 27.6 28 28.1 28.4 30.7 30.7 30.7 31 32
34.7
0
10
20
30
40
50
60
70
80
90
100
Consent Average Quality, %

4. 22/10/20 4
RHV
MHV LHV
CHA
LHA
PHA
CBD
IVC
PV
P6
P7
P5
P4
P3
P2
GB
LC is not a straightforward operation
Anatomy of the liver and juxtahepatic vessels: Anterior-left lateral view
Illustrated by Kenzo YASUI MD,PhD

5. 22/10/20 5
By Raimundas Lunevicius, 2019
Liverpool University Hospitals

6. LC: lateral fusion of the
CD into CHD >50%
Comments, please:
Re Hepatocystictriangle
(Window of Safety)
22/10/20 6

7. Callot triange
22/10/20 7
Cystic artery
Cystic duct
Lateral branch of CA
Medial branch of CA
Inside Callot triangle
Lateral branch of CA

8. Cystic duct:
Lateral and parallel courses of the CD / calculi
22/10/20 8

9. Cystic duct:
spiral course of anteroductal or retroductal CD with medial fusion with CHD
22/10/20 9

10. RPD is in between CD and CHD (within area of Callot):
RPD drains 30% of bile from the liver
No Classical Right Hepatic Duct
The attempt to achieved WOS should be regarded as dangerous
22/10/20 10
CD
RPD
CBD
RAD
LHD

11. Other so called ‘small’ important things
Provide PIL obtaining the informed consent
Inspect umbilicus before LC: as….
11

12. Total laparoscopic cholecystectomy: How I do it
Don’t grab umbilical skin with Littlewoods tissue
forceps (graspers)
Incise skin, firstly
12

13. Laparoscopic cholecystectomy: How I do it
45 degree for 11 mm trocar
(the remainder as it is a standard)
Inspect all abdominal cavity (attention to
peritoneum - carcinosis)
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14. Laparoscopic cholecystectomy: How I do it
5 mm trocar above the anterior margin
of the normal liver
3 trocars of 5 mm diameter
14

15. 21 metallic clips on LC wounds (once found)
Subcuticular 3-0 or 4-0 monocril sutures: less pain,
nicer scars
Never metallic skin clips around umbilicus
15
Subcuticular monocril 3-0 or 4-0

16. Always think what is better for a patient
16