Training Overview >> Preoperative & Intraoperative

   

 

Preoperative

 
1. Surgeon's diagnosis
The patient's initial contact with the surgeon usually is after referral from a primary care provider. Before admission to the hospital, the patient undergoes a thorough history, physical examination, and screening for potential anesthetic complications. Preoperative testing includes an electrocardiogram(ECG), chest x-ray, complete blood count, chemistry profile, and blood type and screen. Additional testing may be ordered by the surgeon or anesthesia care provider if needed.

2. Patient's education
Patient education begins when surgery is scheduled. The surgeon explains the indications for surgery, the procedure, and the risks and benefits to the patient. The nurse provides verbal and written information about the upcoming surgery to the patient in the preoperative interview, and the surgery date and time are selected. preoperative interview, preoperative interview,

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Intraoperative

1. Insufflation
A pneumoperitoneum is created by introducing Veress needle into the peritoneal cavity. Four options exist for initial entry into the peritoneum. The Veress needle has a hollow center and a blunt tip controlled by a spring loaded mechanism to protect the intestine. After the Veress needle is inserted infraumbilically, the surgeon aspirates the syringe and then instills saline to rule out intra vascular or preperitoneal placement, respectively. Insufflation commences followed by the introduction of a trocar (generally a 5, 10, 11 or 12mm device). Placing the patient in the Trendelenberg position minimizes risk to hollow viscera, and directing the device caudally avoids the aortic and iliac bifurcation's.

2. Pre-surveillance
Complete 360-degree surveillance of the abdomen is performed. This maneuver rules out occult injury during placement of the initial trocar and checks for distant unrelated pathology elsewhere in the abdomen.

3. Trocar Placement

Three additional trocars are then placed under direct vision - one 10mm port in the epigastric area, and two more lateral and inferior 5mm ports. The epigastric port is preferentially placed through the falciform ligament to avoid post-operative hernia formation. The more superior lateral trocar is placed directly over the gallbladder fundus. The instrument placed through this trocar will be used for manipulation of cystic/infundibular junction. The last trocar is placed inferior and lateral to the first. The instrument place through this trocar will be used for superior retraction of the gallbladder fundus. Each of the secondary trocars are placed sequentially. The operator uses two hands. The heel of dominant hand is used to apply force - and the non-dominant hand is used to "break" this force and to guide the trocar placement. To avoid occult injuries, the sharp end of the trocar obturator should always be kept in plain view of the videoscope (Tip). In summary, after placement of the initial trocar, three additional trocars are placed - one 10mm cannula in the epigastric region and two 5mm trocars in the right lateral position.

4. Gallbladder Retraction
Using the lateral 5mm trocars the gallbladder is first retracted superiorly and then laterally. An atraumatic grasper then placed through the inferior most 5mm port. This grasper is used for superior retraction and exposure of the Triangle of Calot. Another atraumatic grasper is then placed through the superior 5mm. This grasper is used for manipulation of cystic/infundibular junction. Initially, the cystic infundibular junction is grasped and retracted medially. Attachments to the fundus of the gallbladder are removed by pulling them down using the electrocautery sparingly.

5. Preliminary Dissection

The lateral portion of the cystic infundibular junction (Calot Triangle) is typically freed first. Dissection begins with the peritoneal attachments on the superior surface of the cystic duct, or where a free peritoneal edge can be visualized laterally near the cystic/infundibular junction. The hook cautery is used to release this peritoneal edge laterally. Once these lateral attachments are freed, there is more mobility of the cystic infundibular junction allowing for accurate identification of the cystic duct.
The Bovie electrocautery is used sparingly in short burst only(tip). Otherwise, the electric current can conduct directly onto underlying structures such as small bowel or duodenum. And the hook should move opposite to the gallbladder and the liver when removing the peritoneal attachments(tip).

6. Isolation of Cystic Duct/Artery
Once there is good mobility of the cystic/infundibular junction, a blunt dissector is used to 'skeletonize' the cystic duct. Gentle pressure is applied on the medial side of the cystic duct with a wide, blunt dissector or grasper. Rubbing up and down and gentle spreading action helps the blunt dissector pierce through the 'armpit' or Calot's triangle. Sharp dissectors should be avoid using this maneuver has they have a tendency to find the inside of the gallbladder preferentially over the lateral free space around the cystic duct. It is at this time that the "homework done" during the previous dissection and division of the lateral peritoneal attachments of the cystic/infundibular junction "pays off". Once the 'armpit' is open - or the grasper has 'pierced through', the hook cautery is used to completely skeletonize the cystic duct. The hook is placed within the 'armpit' and dissection is carried out toward the tip of the grasper on the cystic/infundibular junction. To avoid injuring the gallbladder, only transparent attachments should be divided. The cystic duct is now completely cleared.
Next, attention is turned toward the cystic artery. The cystic artery is located medial to the cystic duct. Typically, the cystic artery is found as a branch off of the right hepatic artery; however, there are several normal variants of this structure. Calot's lymph node - or the lymph node within Calot's triangle is a helpful landmark for finding the cystic artery as the cystic artery is routinely found behind this lymph node. Calot's node is seen here…and the cystic artery is seen coursing in this direction. The lateral portion of the cystic artery is cleared first. Just as with the dissection of the cystic duct, dissection of the cystic artery begins first within the "armpit". Dissection then moves superiorly toward the gallbladder taking care to only divide transparent attachments. The "elbow" of the cystic artery seen here - - is "released" during the dissection of the lateral side of the cystic artery. This straightens the artery. Following dissection of the lateral portion of the artery, attention turns to the medial portion. The medial portion is freed by starting directly over the artery at a point where the peritoneal edge is visible. The medial side of the artery is dissected free from its peritoneal attachments. Here the cystic artery is seen to be identified and completely skeletonized.

7. Dissection of Cystic Duct/Artery
Once both the cystic duct and artery are completely skeletonized, the 10mm clip applier is introduced through the epigastric port. Three clips are placed on the cystic duct. The most inferior clip is placed first - - followed by an additional re-enforcing one immediately above and parallel to the first. Prior to placing the last clip, the clip applier is withdrawn slightly out of the 'armpit', rotated 180 degrees and re-placed into the same space. The closure of each clip as it passes around the cystic duct should be ensured under direct visualization. The 30-degree scope facilitates this visualization.Once completed, the clips are inspected. The operator verifies that there is no leakage of bile, good placement of clips, and that each clip is completely closed.
*When the artery is cut, there is a pulse in the cystic artery stump - verifying once more that it is a vascular structure.

8. Fundus Dissection
The cystic infundibular junction is then grasped just above the clip. Movement of this grasper in the lateral and medical direction provides the operator with the "third dimension" - the motion helps with depth perception. Slow, deliberate movement of this grasper helps to identify the correct plane for dissection. The hook cautery is used for dissection. Care must be taken to avoid using the "heel" of the hook for "soldering" as this action often leads to gallbladder perforation. The plane of dissection for the fundic dissection should be approximately 1-5mm above the obvious interface of the gallbladder and liver - and onto the gallbladder. Adhering to this line of dissection helps to avoid liver bed injury and bleeding. The gallbladder is manipulated with the retracting grasper to show the operator specific areas of tension. The hook cautery then divides these attachments. Only transparent attachments should be divided. Once the attachments in the "armpit" are released, to the point where over half of the gallbladder fundus has been dissected, the lower grasper on the fundus is relaxed. Simultaneously, the one on the cystic/infundibular junction is pushed in, up and over the liver edge. This maneuver helps to expose the superior fundic attachments more readily - it identifies the remaining attachments 'under tension'. Just prior to disconnecting the gallbladder from its final hepatic attachment, the gallbladder is first retracted in the extreme superiorly direction. This maneuver allows the operator to inspect the liver bed for bleeding. Any hepatic bed bleeding can be controlled with electrocautery. The cystic duct and artery clips are inspected for one final time. Do not irrigate or suction directly over this region, as this could dislodge the clips. The final hepatic attachment is divided.

9. Gallbladder Removal
A retrieval bag is placed through the periumbilical port. Using the lateral graspers, the gallbladder is placed inside the plastic bag and the entire apparatus is removed from the patient through the periumbilical port.

10. Post-surveillance
Prior to desufflation of the abdomen, the camera is used for one final 360-degree look-around. This maneuver inspects for occult injuries. Visualize directly under the periumbilical port to make that there are no evolving injuries that may have occurred initially during placement of the primary trocar.

11. Trocal Removal & Close Incision
Each trocar is removed under direct vision to inspect for troublesome bleeding.
Each port site is irrigated copiously with saline solution. The 10mm periumbilical port is closed with suture. The skin is closed with a 4-0 absorbable suture in the subcuticular fashion.