Is She a good patient for a Laparoscopic Cholecystectomy? - Forum

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Chirurgia

Is She a good patient for a Laparoscopic Cholecystectomy? - Ärzteforum

Post#1 »

A woman, 31 years old, with diagnosis of Cholelitiasis, has an anormal ERCP; because it show a congenital defect; we saw cistic duct finished into the right hepatic duct, near of the confluence (< 1").

Question: Is She a good patient for a Laparoscopic Cholecystectomy? Yes, Not, Why?


canadian

Re: Is She a good patient for a Laparoscopic Cholecystectomy? - Ärzteforum

Post#2 »

Why wouldn't she be a candidate for lap chole? I question your calling her anatomy a congenital defect; I would call it an anatomic variant of normal. Why did she have an ERCP?

forceps

Re: Is She a good patient for a Laparoscopic Cholecystectomy? - Ärzteforum

Post#3 »

Why was the ERCP done in the first place? For liver function test abnormalities?

Assuming that the ERCP was otherwise normal (without choledocholithiasis or choledochal cysts)...I would proceed with laparoscopic cholecystectomy, with a LOW threshold to proceed with open cholecystectomy, if the intraoperative anatomy was note crystal clear.

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Old surgeon

Re: Is She a good patient for a Laparoscopic Cholecystectomy? - Ärzteforum

Post#4 »

To respond to your question, the ductal anatomy that you describe on ERCP, in my mind, is not a contra- indication to the laparoscopic technique. As we all know, an important principle of cholecystectomy (whether laparoscopic or open) is to carefully dissect Calot's triangle to clearly identify the cystic duct (and artery) gall bladder junction....In your case, I assume that your patient is symptomatic from her gallstones and that cholecystectomy is indicated.

I believe that laparoscopic cholecystectomy has not been extensively studied. The apparent excellent results with the laparoscopic technique may be an advance for patients or it may just reflect different expectations for shorter recovery. With different expectations and the use of smaller incisions and self retaining retractors, it is possible that this type of open procedure may be nearly equivalent to the laparoscopic technique. In fact, there was an interesting paper in this month's or last month's Surgery where a prospective, randomized, blinded, controlled trial was reported that compaired the open and laparoscopic techniques. I recall that the outcome of both groups was nearly identical.....I am not advocating that laparoscopic cholecystectomy should be abandoned, just subjected to rigorous investigation....just as we would ask the Italian oncologist to investigate his "magic" coctail that cures all carcinomas. So, I think it is important that we openly discuss therapies and their scientific validity....time for me to get off my soap box and do a lap chole.

Hans

Re: Is She a good patient for a Laparoscopic Cholecystectomy? - Ärzteforum

Post#5 »

It seems to me, despite the frequency of bile duct injury in lap chole, that one of its advantages is the excellent view it can give of the anatomy if care and time is taken to demonstrate it. If the usual rules of dissection are followed then I can think of no reason why not to do a lap chole, and hope this instance will not be used to justify the routine use of pre op ERCP, as it has added nothing of real note to one's operative approach. We all know congenital anomalies of the biliary system are common and should always be on the alert for them.

bonjorno

Re: Is She a good patient for a Laparoscopic Cholecystectomy? - Ärzteforum

Post#6 »

Of course she is a good patient for LC, because nowadays you must try to do LCs and convert if it is not possible. A cistic conected to the right hepatic duct is not a contraindication for doing it, why it should be? If, during the LC you can't identify the elements then you might or must convert to open cholecystectomy.

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Surgeon

Re: Is She a good patient for a Laparoscopic Cholecystectomy? - Ärzteforum

Post#7 »

I would start laparoscopically. With aforeknowlege of the anatomy, it should not be too difficult. If it is, I never feel bad about opening the abdomen taking the GB top-down.

Dottore

Re: Is She a good patient for a Laparoscopic Cholecystectomy? - Ärzteforum

Post#8 »

If cistic duct is too short there is the potential risk of confusion with CBD or right hepatic duct. Surgeon's experience must play an important role in decision making. I would clearly choose open lap.

Please, let us know the outcome in this case.

Chirurgia

Re: Is She a good patient for a Laparoscopic Cholecystectomy? - Ärzteforum

Post#9 »

"ERCP-file" (Rx-Photo)
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ERCP2 (1).jpg
ERCP2 (1).jpg (16.95 KiB) Viewed 957 times

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