Laparoscopic Cholecystectomy in Pregnancy: A Video Case

Saad Shebrain, MD, MBBch; Elizabeth A. Steensma, MD; Dwight Slater, MD

Disclosures

April 21, 2011

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The Procedure

Video: Laparoscopic cholecystectomy in pregnant patient.

Position. The patient was placed in the supine position. She was intubated without difficulty. Sequential compression pneumatic devices were placed on both lower extremities, subcutaneous heparin was administered, and intravenous antibiotics were given. She was then mildly rotated to the left to offload compression on the inferior vena cava by the gravid uterus.

Port placement and pneumoperitoneum. An initial skin incision was made in the left subcostal region, midclavicular. Using a bariatric Veress needle, the pneumoperitoneal cavity was entered, and this was confirmed with saline drop test.

A pneumoperitoneum was created with CO2 gas at a low pressure of 12 mm Hg. A 5-mm trocar was then inserted, through which a 5-mm 45° laparoscope was placed. The layers of abdomen were visualized during this entry. The abdomen was then examined for any injury from this trocar insertion, and the rest of the abdomen was inspected. The gallbladder was mildly distended. The uterus was gravid with fundal level midway between umbilicus and xiphoid process.

Gallbladder dissection and critical view of safety. The patient was then placed in mild reverse Trendelenburg position with the left side down. The 12-mm epigastric trocar was placed under direct visualization. Another 5-mm trocar was placed under direct visualization in the right midclavicular line, taking care to avoid injury to the uterus. The gallbladder was then retracted superiorly and laterally, and a small amount of adhesions on the inferolateral aspect of the fundus and on the infundibulum were taken down gently.

The fourth port was placed in the right anterior axillary line and used to grasp and retract the infundibulum laterally. The critical view of safety was obtained where the cystic duct and cystic artery with cystic lymph node were seen in Calot's triangle.

The cystic artery was first dissected and isolated. Two clips were placed proximally and 1 distally, and the artery was transected between the second and third clip. At this point, the cystic duct was then completely dissected and isolated. Three clips were placed proximally and 1 distally and transected between the third and fourth clip. The gallbladder was taken off the liver bed with low-power electrocautery without difficulty, placed in a specimen retrieval bag, and brought out through the epigastric port.

Removal of gallbladder and closure. The gallbladder fossa was then inspected, and this was deemed hemostatic. No bile leakage was observed. All of the clips were in place. The 12-mm port was then to be closed; the skins were then closed with 4-0 Monocryl stitches, and sterile dressings were applied. The patient tolerated the procedure well. The operative time was 32 minutes.

Final Thoughts

Overall, laparoscopic surgery for appendicitis and cholelithiasis has been recommended as the new standard of care for the management of these conditions during pregnancy.[46] Although reported to be safe and feasible during all trimesters, advanced laparoscopic skills are crucial, to achieve good outcomes, especially with the anatomic and physiologic changes associated with pregnancy.

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