Ann Hepatobiliary Pancreat Surg.  2021 Nov;25(4):523-527. 10.14701/ahbps.2021.25.4.523.

Laparoscopic ‘D2 first’ approach for obscure gallbladders

• Gadiyaram S
• Nachiappan M

• KMID: 2523057
• DOI: http://doi.org/10.14701/ahbps.2021.25.4.523

Abstract

Laparoscopic cholecystectomy has a reported incidence of 4%–15% of conversion to an open procedure and one of the main reasons behind the conversion is a gallbladder (GB) wrapped with dense adhesions. It is prudent to convert the procedure to an open operation in patients with particularly dense adhesions when the GB is not visible, preventing safe dissection which carries a potential risk of duodenal or colonic injury. The technique described, namely laparoscopic ‘D2 first’ approach, enables the completion of laparoscopic procedure in patients with ‘obscure’ GBs.

Keyword

Gallbladder; Cholecystectomy; Laparoscopy; Pericholecystic adhesions

Figure

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  Fig. 1 Illustration demonstrating the additional port placement apart from the standard four ports for laparoscopic cholecystectomy. C, camera; R, right hand; L, left hand; A, assistant; E, additional port placed for laparoscopic ‘D2 first’ approach.

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  Fig. 2 (A) Dense sub hepatic adhesions, (B) obscure gallbladder, (C) division of the O to gain access into the lesser sac, (D) tunnel created by sweeping the O off the transverse mesocolon (Mc). Note the traction provided by the left-hand instrument forming the apex of the triangle. Second part of the duodenum is visible at the far end of the tunnel (arrow). TC, transverse colon; Rp, omentum; O, greater omentum.

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  Fig. 3 (A) Triangle formed by the duodenum (D) and the head of pancreas, mesocolon (Mc) and O is well defined. (B) Visualization of the gallbladder (GB). Note that the Mc is completely separated from the GB with only O remaining attached. (C) Colon free and away from the operative field. (D) Critical view of safety. O, greater omentum.

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  Fig. 4 (A) Peritoneal attachments. The procedure of laparoscopic ‘D2 first’ approach involves opening of the lesser sac and dissection along the virgin, non-inflamed, fused embryonal avascular planes of the transverse mesocolon (Mc) and the leaves of the greater omentum to identify the second of the duodenum and then to enter the general peritoneal cavity. This identifies the critical structures during laparoscopic cholecystectomy—colon and duodenum. Thus, helps in separating the colon from the gallbladder (GB). (B) Bare area of the duodenum, corresponding to the Mc (block arrow) and the pancreas (line arrows). To the left of the bare area is the lesser sac and to the right is the greater sac or the generalized peritoneal cavity. Laparoscopic ‘D2 first’ approach involves traversing from the lesser sac to the greater sac. (C) Diagrammatic representation showing adhesions between the GB and the transverse colon (TC) and the first part of the duodenum (D1). The area (triangle) between the Mc and the second part of the duodenum (D2) is free from adhesions with maintained tissue planes, this forms the basis of laparoscopic ‘D2 first’ approach.

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