Mirroring dynamic gallbladder retraction of conventional laparoscopic cholecystectomy at the transumbilical approach

Background

Although single incision laparoscopic cholecystectomy is feasible, ¹ it is associated with a higher rate of bile duct injury (0.72%) than standard cholecystectomy (0.4–0.5%). ² The main factor responsible seems be suboptimal exposure of Calot’s triangle due to lack of independent retraction of the gallbladder fundus and infundibulum, especially for a ‘floppy’ fundus/large liver overlapping the extrahepatic biliary tree. ³ Various innovative methods are described for gallbladder retraction. ^2,4,5 However, they lack the ability of dynamic manipulation. We describe a simple technique of fundal retraction.

Technique

After transumbilical port placement, the gallbladder fundus is grasped with a catgut loop (Fig 1). A standard port closure needle is introduced under laparoscopic vision via a 2mm stab incision in the right hypochondrium in the anterior axillary line (Fig 2). This is used to grasp the catgut loop tail in such a way that it locks the jaws of the port closure needle and prevents it from slipping during retraction (Fig 3). It can now be manipulated in any direction to fulfil the traction–countertraction principle during gallbladder dissection (Figs 4–6).

Figure 1.

Gallbladder fundus being grasped with a catgut loop

Figure 2.

Standard port closure needle being inserted through right hypochondrium. Note the transumbilical 10mm port for laparoscopic monitoring

Figure 3.

The needle grasp. Gradual to-and-fro movement while entangling the catgut tail locks the jaws of the needle and prevents slipping during retraction

Figure 4.

The transumbilical laparoscopic view. Note the independent two-point traction of gallbladder similar to conventional four-port laparoscopic cholecystectomy

Figure 5.

The multidirectional fundal retraction. Note the inferior traction aiding the safe completion of gallbladder dissection

Figure 6.

Gallbladder manipulation at will. Note the medial traction for posterior peritoneal incision

Discussion

This method mirrors the fourth retracting port of conventional laparoscopic cholecystectomy, which allows perpendicular rather than tangential cystic duct clipping, an important step to minimise postoperative bile leak. ³ As the gallbladder wall is not traversed by needle, it does not violate basic principles. ³ Furthermore, this site can also be used for a mini-laparoscope to visualise umbilical adhesions before siting the ports. However, careless movement can traumatise the surrounding viscera. We have used it in 316 cases without any bile duct injury. It has the potential to reduce the rate of bile duct injuries without adding any extra ports.