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Number of Trocars, Types of Dissection, Exploration of Bile Duct, Drainage and Analgesia

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Laparoscopic Cholecystectomy

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Abstract

Laparoscopic cholecystectomy is a gold standard, but at this time several aspects of technique are not homogeneous and there are many differences in terms of indications, instruments, technologies involved, surgical techniques employed. So we decide to examine specifically the literature about five main topics, trying to solve some concern existing about.

Standard laparoscopic cholecystectomy is mainly done by using four trocars. With increasing surgeon experience, laparoscopic cholecystectomy has undergone many refinements including reduction in port size and number. It has been argued that the fourth trocar may not be necessary, and laparoscopic cholecystectomy can be performed safely without using it.

The occlusion of the cystic duct is one of the main steps of laparoscopic cholecystectomy. Usually it has been done by metal clips, but it could be done by several methods (absorbable clips, clipless with ultrasonic dissector, with stapler and so on). Currently, monopolar electrosurgical energy is the most commonly used energy undertaken for dissection of the liver bed. However, its application is associated with numerous risks, such as biliary compilations and thermal injuries.

Intraoperative cholangiography (IOC) was performed for first time by Mirizzi in 1931 during open cholecystectomy in a female patient with gallbladder hydrops (Mirizzi, Comunicación en la Sociedad de Cirugía de Buenos Aires, 1932; Mirizzi, Surg Gynecol Obstet 65:702–710, 1937). Since then, IOC has been advocated to reduce the risk of biliary injuries and of retained stones in the common bile duct (CBD). Drains are used after laparoscopic cholecystectomy to prevent abdominal collections and to help the surgeon in the management of bleeding and biliary injuries. However, drain use may increase infective complications and delay discharge. The value of surgical drainage in laparoscopic cholecystectomy is an issue that is not resolved clearly.

Postoperative pain has been an important limiting factor for ambulatory LC. To date, the exact mechanism of pain has not been clarified. The use of intraperitoneal local anesthetics as the use of a local anesthetic applied to the port wounds provide some benefit in pain reduction but their results are controversial. The origin of pain after laparoscopic cholecystectomy is multifactorial with pain arising from the incision sites (somatic pain), from the gallbladder bed (visceral pain) and as a consequence of a pneumoperitoneurn.

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Authors and Affiliations

  1. General Surgery Department, Evangelic Hospital Villa Betania, Via Argine, 80147, Naples, Italy

    Pietro Maida, Gianpaolo Marte, Marco Nunziante, Luigi Barra & Vittorio Di Maio

  2. Mazzoni Hospital, Ascoli, Piceno

    Gianluca Guercioni

  3. Santa Maria della Misericordia Hospital, Urbino, Italy

    Giuseppe Miranda

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  1. Pietro Maida
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  1. Department of General Surgery, ULSS19 del Veneto, ADRIA, Rovigo, Italy

    Ferdinando Agresta

  2. Division of General Surgery, Hospital S.Giovanni Decollato Andosilla, Civita Castellana, Viterbo, Italy

    Fabio Cesare Campanile

  3. Unit of Laparoscopic Surgery, Hospital Mellino Mellini, Chiari, Brescia, Italy

    Nereo Vettoretto

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Maida, P. et al. (2014). Number of Trocars, Types of Dissection, Exploration of Bile Duct, Drainage and Analgesia. In: Agresta, F., Campanile, F., Vettoretto, N. (eds) Laparoscopic Cholecystectomy. Springer, Cham. https://doi.org/10.1007/978-3-319-05407-0_6

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