Laparoscopic Cholecystectomy Fully Explained SkintoSkin Video with Near Infrared Cholangiography

Aaradhya Sharma

https://www.laparoscopyhospital.com/SERV01.HTM  This video demonstrates Laparoscopic Cholecystectomy Fully Explained Skin-to-Skin Video with Near Infrared Cholangiography performed by Dr R K Mishra at World Laparoscopy Hospital. A laparoscopic cholecystectomy is a minimally invasive surgical procedure that involves removing the gallbladder. It is typically performed using small incisions in the abdomen, through which a laparoscope (a thin tube with a camera and light) and surgical instruments are inserted. The surgeon uses the laparoscope to visualize the inside of the abdomen and to guide the instruments in removing the gallbladder.  Near-infrared cholangiography is a technique that uses a special camera and fluorescent dye to visualize the bile ducts during surgery. The dye is injected into the cystic duct (the tube that connects the gallbladder to the bile ducts) and the camera detects the fluorescence emitted by the dye, allowing the surgeon to see the bile ducts more clearly.  The combination of laparoscopic cholecystectomy and near-infrared cholangiography has become a standard of care in many hospitals and surgical centers. It allows for a more precise and efficient surgery, reducing the risk of complications such as bile duct injury.  The use of indocyanine green (ICG) with near-infrared imaging during laparoscopic cholecystectomy has several advantages. Here are some of them:  Better visualization of the biliary anatomy: ICG with near-infrared imaging allows for better visualization of the biliary anatomy during surgery. This helps the surgeon identify important structures, such as the cystic duct and the common bile duct, and avoid injuring them.  Reduced risk of bile duct injury: With better visualization of the biliary anatomy, the risk of bile duct injury during surgery is reduced. Bile duct injury is a serious complication that can occur during laparoscopic cholecystectomy and can lead to long-term health problems.  Improved surgical precision: ICG with near-infrared imaging also improves surgical precision. The surgeon can better see the tissues and structures being operated on, which can help reduce the risk of bleeding and other complications.  Shorter operating time: The use of ICG with near-infrared imaging can shorten the operating time for laparoscopic cholecystectomy. This is because the surgeon can more quickly and accurately identify the biliary anatomy, which can help streamline the surgery.  Overall, the use of ICG with near-infrared imaging is a valuable tool in laparoscopic cholecystectomy that can improve surgical outcomes and reduce the risk of complications.

Transcript

00:00Hello friends, this is a case of laparoscopic cholecystectomy and we will describe step

00:08by step the entire procedure.

00:11The first step is that 45 minutes before the surgery, the indostanine green has to be injected

00:18in any peripheral vein so that we can do the fluorescent cholangiography.

00:24So ICG is nowadays a standard procedure to perform the laparoscopic cholecystectomy so

00:30that you can rule out almost all the causes of the CBD injury.

00:35So this is the tourniquet applied vein was identified and cannula was introduced.

00:42And then you will put the IV and then you can inject the indostanine green.

00:47It is coming in a lyophilized powder by the name of Aurogreen.

00:52Then after injecting 2 ml, you will just flush some saline so that it should go to the peripheral

00:58vein and it will take 45 minutes time to illuminate the CBD and the gallbladder and cystic duct.

01:06After that, two alice forceps should be applied on either side of the umbilicus.

01:11Purpose is to avert the crease of the umbilicus.

01:14Then with a small elbow number knife, you will stab the inferior crease of the umbilicus to

01:20introduce a varice needle and varice needle should be held in such a way that there should

01:25be 4 plus thickness of abdominal wall.

01:28The varice needle should be naked and then lower abdomen should be lifted up so that varice

01:34needle should be perpendicular to the abdominal wall but oblique to the body of the patient.

01:39After that, you can do the irrigation suction and hanging drop test to make it sure that

01:46you are inside the abdomen.

01:50So this is hanging drop test.

01:53And now once it is 100% confirmed that you are inside the abdomen, then you can attach the

01:58tubing of the insufflator.

02:04And here we have kept the preset pressure 15 mmHg and the flow rate at the rate of 1 litre

02:11per minute.

02:13And slowly you have to wait for the pneumopetoneum to just established.

02:18And this pneumopetoneum minimum amount of the gas will be required 1.5 litre and maximum

02:24is 6 litre to insufflate a normal adult abdominal cavity.

02:30After that, once the pneumopetoneum preset pressure is reached to the actual pressure, then varice

02:35needle will be removed.

02:37And then the skin incision has to be enlarged to 11 mm to introduce the first optical port.

02:47So this is the smiling incision.

02:48It is enlarged for the first optical port.

02:52And after that, you will take the dilatation of the bitlointestinal duct, bitlointestinal

02:59tract should be dilated by opening the jaw of the Maryland.

03:04And after that, you can introduce the first trocar.

03:08That is the optical port for telescope.

03:10This is the first trocar which is introduced to the inferior crease of umbilicus.

03:17And with the screwing movement, this first trocar is introduced.

03:22After that, you will attach the gas again and the maximum flow rate should be adjusted

03:28to 10 litre per minute.

03:31Then the telescope will be reintroduced and after that, you will put the epigastic port.

03:38Epigastic port should be just below the GpH and little towards the left and this should

03:46be 11 mm because outer diameter of the cannula is 11 mm.

03:50So this will be introduced.

03:59This is the second port of the laparoscopic golysisectomy.

04:02Now third port is mid-clavicular line just below the fundus of the gallbladder.

04:08Here the patient is getting head up and right up so that all the bowel will go away and the

04:14left lobe of the liver also will be retracted away from your target of dissection.

04:21All the incisions should be made at the level of the Langer's line.

04:25And this is the third port of the laparoscopic golysisectomy.

04:29A standard laparoscopic golysisectomy should be performed by the three port.

04:34And this is the third port which is introduced.

04:36Now fourth port should be 7.5 cm lateral and 7.5 cm below the third port on anterior axillary

04:45line.

04:54And this is the fourth port is introduced.

04:57And then you can introduce one grasper to hold the fundus of the gallbladder and it will

05:02be retracted towards the right shoulder.

05:05This fundus of the gallbladder is held and retracted towards the right shoulder.

05:09After that the third port you will take an atraumatic rasper and you will do adhesiolysis.

05:14We can see there is little bit adhesion of the duodenum.

05:18This is the duodenum adhesion and duodenum is pulled up so you can slowly slowly you can

05:24separate all the duodenum and it can be separated down.

05:29And these adhesions also should be separated.

05:31The first step of the any collisusectomy is to separation of the adhesion.

05:40Antromedial traction should be given and here we can see this is a little peitoneum.

05:45This is roviate sulcus.

05:47This is roviate sulcus that is one of the very important landmark which separates the right

05:52lobe of the liver from the caudate lobe and this is called roviate sulcus.

05:57Now we will hold the hartsman pouch and you should give the antero-medial traction and

06:02posterior peritoneum should be separated from the body of the gallbladder.

06:07At that point you should try to separate it only peritoneum.

06:10You should remain as near as possible to the gallbladder and antero-medial traction is

06:16necessary and always this posterior peritoneum should be separated above the roviate sulcus.

06:22After that antero-lateral traction will be given and then anterior peritoneum also will

06:27be separated as near as possible to the liver and it should be only peritoneum should be

06:33separated and that will make your posterior window once you will separate it and here

06:38we can see posterior window will form.

06:41After that separation of the peritoneum of the cystic pedicle will be carried out and

06:46this cystic pedicle separation of the stripping of the peritoneum to skeletonize the cystic pedicle

06:52necessary.

06:53Once the entire peritoneum is skeletonized then we should take a maryland and we should

06:58enlarge the posterior window you can see this is the posterior window and inferior surface

07:03of the liver is clearly visible.

07:05After that tip of the this is a common hepatic duct as you can see and this is posterior window.

07:11Now tip of the maryland should be towards the liver and dissection should be done in between

07:17the cystic duct and cystic artery to create anterior window and we can see this is the

07:22anterior window which is in between the and critical view of safety you can see two structures

07:27are clearly inting into the gallbladder and two windows are clearly formed.

07:33After that we will turn the camera to the ICG mode and you can clearly see now the common

07:38hepatic duct is visible this is common hepatic duct after that here below you can see this

07:45is the common bile duct which is also clearly visible and above we can see the cystic duct

07:52is also originating from the CBD is nicely visible.

07:56So this is the advantage of the fluorescent cholangiography by the indochine in green which will show you

08:02all the structure and now anterior and posterior window is also nicely examined this is called

08:09nipple effect if you will if you will leave the horseman pouch you can see cystic duct is erect

08:14like a nipple that also is an important sign and this is anterior and posterior window is visible

08:20this is called a spy mode in the spy mode you can see the contrast and black and white color

08:25will be visible and ICG will be visible like a white color and none ICG like a black color

08:32so now everything is fine and after that we will tie the knot on the cystic duct generally in most of

08:37the our cases we use misra's knot on the cystic duct one of the biggest advantage of the knot is

08:43that you will not have any chance of the cystic duct clip stone or catea stone and this is the

08:49extracorporeal knot which is very secured up to 18 millimeter of the structure you can tie this knot

08:55with the confidence so this suture is fitted through the window and interior window and now the tip of

09:02the tail is taken out and then we will tie the misra's knot the configuration of misra knot is one

09:08one one one one one one this is one hitch and followed by the first wind and followed by the first lock

09:16this knot is one of the very important knot which has a one hitch one wind one lock then you have a

09:26second wind second lock and the third wind third lock you can use this knot for cystic duct cystic

09:32artery renal artery splenic artery appendix and you can use it for monofilament also as well as

09:40multi-filament also and now it is slided and you will apply it near the cvt and one knot is more than

09:47sufficient and this is the misra's knot which is applied on the cystic duct and after that you can

09:53cut the suture on the artery you can apply clip also because on the clip cystic duct clip stone chances

09:59are not there catea chances are not there both the limb of the applicator should be visible and then

10:05this clip is pressed for the three seconds so that plastic deformation should be there and it is

10:11clipped after that one more clip you will apply towards the gallbedder so that the bile should not

10:17leak out and then cystic artery followed by cystic duct will be separated from the gallbedder we can

10:24see this is cystic artery you can use harmonic as well as you can use seizures also to cut and cystic artery

10:30is cut out followed by cystic duct after that you will hold the horseman pouch and anteromedial and

10:38anterolateral traction will be given the peritoneal fold of the gallbedder peritoneal fold of the gallbedder

10:46has to be separated once you give anteromedial traction the left peritoneal fold you can separate

10:52and with the anterolateral right peritoneal fold can be separated and this way slowly slowly a

10:57aerular plane should be formed sometime you can use blunt dissection and slowly you can separate the gallbedder from the liver

11:04once you reach near the fundus of the gallbedder after that you should try to turn the light cable down

11:12at six o'clock position you so that you can see up and now the fundus grasper should be removed

11:18and then gallbedder should be pulled towards the right iliac fossa and remaining gallbedder should be separated

11:23from the liver if you will achieve a good angular plane there will be no puncture of the gallbedder

11:29and at the end of the procedure final inspection should be done we can see this is final inspection

11:34and after that final cut of the gallbedder will be done and then gallbedder will be separated from the

11:40liver and this way the entire cholecystectomy can be performed without any injury after that you will

11:47put a claw forcep and the clip of the gallbedder should be put in between the jaw of the claw forcep

11:53and then clip should be pulled into the cannula and then everything should be taken out once the

11:59entire neck of the gallbedder is out after that you will cut the neck of the gallbedder and suction

12:05of the bile should be done with the suction alternatively you can use a dough bag but this is a young

12:13patient there is no chance of any malignancy and now extraction of the stone will be done by

12:18crushing the stone with the ovum forcep so that it can be easily facilitate the removal of the gallbedder

12:25here there was large stone as you can see and you cannot directly pull it out so under vision you

12:30should crush with the ovum forcep and then ultimately gallbedder will come out so thank you very much for

12:36watching this simple video of laparoscopic cholecystectomy thank you very much have a nice day

12:43thank you

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