Laparoscopic retrograde (fundus first) cholecystectomy

Abstract

BackgroundRetrograde ("fundus first") dissection is frequently used in open cholecystectomy and although feasible in laparoscopic cholecystectomy (LC) it has not been widely practiced. LC is most simply carried out using antegrade dissection with a grasper to provide cephalad fundic traction. A series is presented to investigate the place of retrograde dissection in the hands of an experienced laparoscopic surgeon using modern instrumentation.MethodsA prospective record of all LCs carried out by an experienced laparoscopic surgeon following his appointment in Bristol in 2004 was examined. Retrograde dissection was resorted to when difficulties were encountered with exposure and/or dissection of Calot's triangle.Results1041 LCs were carried out including 148 (14%) emergency operations and 131 (13%) associated bile duct explorations. There were no bile duct injuries although conversion to open operation was required in six patients (0.6%). Retrograde LC was attempted successfully in 11 patients (1.1%). The age ranged from 28 to 80 years (mean 61) and there were 7 males. Indications were; fibrous, contracted gallbladder 7, Mirizzi syndrome 2 and severe kyphosis 2. Operative photographs are included to show the type of case where it was needed and the technique used. Postoperative stay was 1/2 to 5 days (mean 2.2) with no delayed sequelae on followup. Histopathology showed; chronic cholecystitis 7, xanthogranulomatous cholecystitis 3 and acute necrotising cholecystitis 1.ConclusionsIn this series, retrograde laparoscopic dissection was necessary in 1.1% of LCs and a liver retractor was needed in 9 of the 11 cases. This technique does have a place and should be in the armamentarium of the laparoscopic surgeon.

Results of laparoscopic bile duct exploration via choledochotomy

“…The reoperation rate of 5% (3 of 56) is 16 times higher than that for the corresponding series of LC without LBDE where 3 of 910 (0.3%) were reoperated upon. The conversion rate of 2% (1 of 56) is five times higher than that of LCs without LBDE where 4 of 910 were converted (0.4%) 6 …”

Laparoscopic Cholecystectomy: Fundus First or Fundus Last-Which and Why?

“…4 RLC was resorted to when difficulties were encountered with exposure and/or dissection of Calot's triangle. RLC was attempted successfully in 11 out of 1,041 patients.…”

“…4 Regarding another study, RLC had shorter postoperative hospital stays by an average of 2 days when compared with CLC. 8…”

Retrograde ( Fundus First ) Laparoscopic Cholecystectomy in Situs Inversus Totalis = إستئصال المرارة العكسي بالمنظار الجراحي في حالة إنعكاس وضع الأحشاء الكلي

“…Retrograde ("fundus first") dissection is frequently used in open cholecystectomy and, although feasible in laparoscopic cholecystectomy (LC), it has not been widely practiced. 9 The dissection was difficult as we could not dissect the Calot's triangle because of dense adhesions obscuring the anatomy so we started fundus first. It was a safe procedure and we could complete the procedure laparoscopically.…”