Fig. 2

Dye is injected for a quick and easy Cholangiogram!

 

The Aspiration Advantage 

After cholangiography is done, the Clamp jaws are opened and the gallbladder can be aspirated. This will make it much easier to separate the gallbladder from the liver bed and to extract from the portsite. This is a great collateral benefit.

 When the Catheter is removed, the Channel valve can be closed—or left open as a smoke vent!

 The clamp can again be used as a grasper to finish the operation, usually grasping the gallbladder at the needle puncture site. This assures no bile leakage from the needle puncture site although the gallbladder has already been aspirated and is empty.

CYSTIC DUCT OBSTRUCTION

Cystic duct obstruction can occur with or without Hydrops (Acute Cholecystitis):

 a. In the absence of Hydrops:

This happens when the cystic duct is partially obstructed by mucous, sludge or a tiny stone. The maneuvers of cystic duct dissection and milking of the cystic duct towards the gallbladder will help dislodge the small stone, sludge or mucous. This will allow cystic duct patency and flow of dye for cholangiography.

b. When there is Hydrops (or Acute Cholecystitis):

This happens when the cystic duct is completely obstructed by a stone that is impacted at the neck of the gallbladder. The gallbladder is distended and cannot even be grasped.

 

This is also called a Hot Gallbladder. The following method is recommended: 

 

i)               The gallbladder is pushed upwards with an open grasper through the right lateral port. The jaws of the grasper are kept open since the gallbladder cannot be grasped.

ii)             The Kumar Clamp is applied through the right mid-subcostal port. The jaws of the Kumar Clamp are also kept open for the same reason. The Kumar Clamp is moved as low as possible on the body of the gallbladder.

iii)           If exposure is not satisfactory, it may be necessary to insert a fan shaped retractor (through an additional port). 

iv)           The Catheter is then introduced and gallbladder is punctured and aspirated at a point as low as possible on the body of the gallbladder.

 This relieves the pressure that was pushing the stone in to the neck of the gallbladder.                                 

 In fact, a negative pressure has been created behind the stone, physiologically. The stone should fall back in to the gallbladder,

v)             The decompressed gallbladder can now be grasped.

vi)           The stone can additionally be manipulated with a grasper through the midline port and dislodged.

vii)         Dye is injected for cholangiography, preferably, through the same access that was used for aspiration.

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