Nashville Surgical Instruments


The Kumar PRE-VIEW* Cholangiography

DEVICE DESCRIPTION & USE

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.

Fig. 1: The Kumar Clamp

The Kumar Clamp is applied through the right mid-subcostal port and is used as a regular laparoscopic grasper for traction at the infundibulum during cystic duct dissection. The channel valve at the upper end is closed to maintain pneumo-peritoneum.

When the dissection is complete, the cystic duct is milked towards the gallbladder. This enhances cystic duct patency.

The Clamp is then re-applied all the way across the neck of the gallbladder--- just above the Hartmann's pouch (Fig. 2)

The channel valve at the upper end of the Clamp is opened and the Kumar PRE-VIEW* Cholangiography Catheter is introduced. This Catheter is different because it has a 1.25 cm 19 gauge needle at the end. The Catheter is advanced and the Hartmann's pouch of the gallbladder is punctured in a bull's eye manner. The Clamp can be tilted or rotated to center the needle.

As the Hartmann's pouch is punctured, bile is aspirated to confirm biliary access. Bile aspirate is clearly seen through the clear catheter.

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.


What You Will Love


Nashville Surgical Instruments
Phone: 615-382-4996           Fax: 615-382-4199  
2005 Kumar Lane
Springfield, TN. 37172

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