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Nashville
Surgical Instruments The
Kumar Clamp (Fig.1) is
a 5 mm laparoscopic grasper with · Non-traumatic jaws that are 4 cm long. · A channel for introduction of a patented · Cholangiography Catheter that carries a 1.25
cm long 19 ga. needle.
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. 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): 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. WHAT YOU WILL LOVE 1. Versatility Applied through the right mid-subcostal port, the Kumar
Clamp is used as a
No need to introduce and remove different instruments for different parts of the same operation. 2. No Cystic Ductotomy Injury due to mistaken ductotomy of the common bile
duct (Type I injury) is eliminated!
The Concept and the Napkin Sketch Did you ever meet Dr. Hackensmith? He practiced surgery in the warmth of South Florida, many years ago. He was well known as the "biggest surgeon in town", based mainly on his size. Well, I did meet him when he was "getting on up in years" and wanted to take in a young surgeon to join his practice. I was a young surgeon and I needed a job. We were quite a contrast. He was really big, and I happen to be so short that I have a tendency to lie about my height. He was kind and courteous. After a few stories about the good old days in the surgical lounge, he liked me enough to invite me to scrub in on a cholecystectomy. He made a swift cut. Exposure was plenty and dissection was routine. He thought cannulation of the cystic duct was a "pain". This was in 1976 which is believed to be the pre-laparoscopy era for general surgeons. Little did I know that Dr. Hackensmith was ahead of his time by almost two decades. To me, cystic duct cannulation did not become a "pain" until 1991 when I tried it laparoscopically. Immediately I remembered Dr. Hackensmith and his solution to the " pain" of cystic duct cannulation: a Kelly clamp across the gallbladder just above the Hartmann's pouch and dye injection in to the Hartmann's pouch with a 23 gauge butterfly needle:
*Patent & Trademark
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Fig.
1: The Kumar Clamp
Fig.
2
