endoscopic retrograde cholangiopancreatography (ERCP) bile duct stenting done in all patients ,laparoscopic choledochoplasty was done in all patients, laparoscopic ports are kept respectively as normal laparoscopic cholecystectomy ,all cases having dense pericholecystic adhesions and frozen Calot's triangle
, after releasing of adhesions gallbladder opened at Hartman's pouch, impacted stone was removed, after removal of stone bile duct was identified , stent noticed in bile duct ,Hartman's pouch was sutured over bile duct defect with 2.0 Vicryl interrupted sutures, remaining gallbladder removed ,drain kept in all cases
The cystic artery and duct were clipped (two distally and one proximally) and cut after gentle and meticulous dissection of Calot's triangle
. Then, the gallbladder was dissected away from the liver bed and removed through the epigastric port.
Innovative Approach to a Frozen Calot's Triangle
During Laparoscopic Cholecystectomy.
0.2%.15 Currently, the CVS technique is accepted as a Gold Standard for reducing morbidity and mortality associated with LC by the European Association of Endoscopic Surgery (EAES).19,20 There are no randomized controlled trials published up-to-date to give us level-1 evidence that CVS prevents bile duct injuries.10,11 However, if we look at the large case series10,11,21 published so far, we believe that by strictly adhering to all the three criteria of CVS, BDI may be prevented because it helps in giving reliable exposure and identifying important structures of calot's triangle
Two Deaver retractors (25 mm width) were strategically placed to facilitate adequate exposure of Calot's triangle
. Raytec gauze swabs (35 x 10 cm) rather than tape swabs were used to enhance the exposure and dissection of Calot's triangle
and haemostasis of the gallbladder bed.
Peroperative degree of difficulty was evaluated depending on objective variables which included the presence of adhesions at Calot's triangle
and between omentum and GB, obvious injury to GB, biliary ducts, bowel, diaphragm or other abdominal viscera, stone/biliary spillage, injury to vessels, need of conversion to open procedure (OP), and post-operative complications in the early post-operative period arising as a result of intraoperative difficulty, for example, biliary fistula, biloma, biliary peritonitis, and bowel injury unmasking after surgery.
Extrahepatic bile duct injury (BDI) is a serious complication of laparoscopic cholecystectomy (LC), with an incidence ranging from 0.4% to 0.7%. A severely inflamed, fibrotic gallbladder can make identification of Calot's triangle
difficult and increase the risk of extrahepatic BDI.
Level 1-adherent omentum, level 2-oedematous gall bladder wall, level 3-necrotic gall bladder wall, level 4-adherent gut and level 5 - adherent Hartmann's pouch and oedematous Calot's triangle
having no defined planes.
By presenting this case, we wish to emphasize the importance of timely conversion and execution of intraoperative cholangiography in all cases when identification of the structures of Calot's triangle
is not clear enough.
Objective: Several damage-control procedures have been described in the literature in case of severe Calot's triangle
inflammation and fibrosis.
To prevent the incidence of clip migration, all the technical factors in the surgery should be considered: confirming the relationship of Calot's triangle
during dissection, minimizing the number of clips, and avoiding unnecessary surgical procedures .
We use to place trocar as in the North-American position, which permits an easier access to the CBD, facilitating transcystic introduction of the catheter for IOC, and a safer approach to the Calot's triangle