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Mini-Laparoscopic Cholecystectomy with Intraoperative Cholangiogram for Symptomatic Cholelithiasis (Gallstones) - Extended
Authors: Brunt LM1, Singh R1, Yee A2
Published: September 26, 2017

AUTHOR INFORMATION
1 Department of Surgery, Washington University, St. Louis, Missouri
2 Division of Plastic and Reconstructive Surgery, Washington University, St. Louis, Missouri

DISCLOSURE
No authors have a financial interest in any of the products, devices, or drugs mentioned in this production or publication.

ABSTRACT
Minimal invasive laparoscopic cholecystectomy is the typical surgical treatment for cholelithiasis (gallstones), where patients present with a history of upper abdominal pain and episodes of biliary colic. The classic technique for minimal invasive laparoscopic cholecystectomy involves four ports: one umbilicus port, two subcostal ports, and a single epigastric port. The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) has instituted a six-step strategy to foster a universal culture of safety for cholecystectomy and minimize risk of bile duct injury. The technical steps are documented within the context of the surgical video for (1) achieving a critical view of safety for identification of the cystic duct and artery, (2) intraoperative time-out prior to management of the ductal structures, (3) recognizing the zone of significant risk of injury, and (4) routine intraoperative cholangiography for imaging of the biliary tree. In this case, the patient presented with symptomatic biliary colic due to a gallstone seen on the ultrasound in the gallbladder. The patient was managed a mini-laparoscopic cholecystectomy using 3mm ports for the epigastric and subcostal port sites with intraoperative fluoroscopic cholangiogram. Specifically, the senior author encountered a tight cystic duct preventing the insertion of the cholangiocatheter and the surgical video describes how the author managed the cystic duct for achieving a cholangiogram, in addition to the entire technical details of laparoscopic cholecystectomy.

There are twelve cranial nerves in total. The olfactory nerve (CN I) and optic nerve (CN II) originate from the cerebrum. Cranial nerves III – XII arise from the brain stem (Figure 1). They can arise from a specific part of the brain stem (midbrain, pons or medulla), or from a junction between two parts: Midbrain – the trochlear nerve (IV) comes from the posterior side of the midbrain. It has the longest intracranial length of all the cranial nerves. Midbrain-pontine junction – oculomotor (III). Pons – trigeminal (V). Pontine-medulla junction – abducens, facial, vestibulocochlear (VI-VIII). Medulla Oblongata – posterior to the olive: glossopharyngeal, vagus, accessory (IX-XI). Anterior to the olive: hypoglossal (XII). The cranial nerves are numbered by their loca

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