How to gain safe entry for laparoscopic cholecystectomy in the multi‐scarred abdomen

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Laparoscopic approach to cholecystectomy is the gold standard, with shorter length of stay and earlier return to usual duties than open cholecystectomy.1 However, when operating on patients with previous operations, safe midline entry to the abdomen can be challenging in the multi‐scarred abdomen.
Midline incisions invariably cause adhesions in the proximity of where usual Hassan port entry would take place. It is unpredictable as to whether there will be bowel and other important structures amongst the adhesions adherent to the abdominal wall (Fig. 1).
The literature describes multiple approaches to gaining abdominal access in patients with previous abdominal surgery. Ahmad et al. propose open midline entry,2 still with risk of visceral complications, while Tinelli et al. argue that, compared with an open approach, a modified direct optical entry technique is more time efficient with equivalent complication rates.3
Palmer's Point,4 first described in 1974, is located in the left midclavicular line 3 cm inferior to the costal margin. The potential for this approach has been evaluated in gynaecological surgery.5 However, it is not as applicable for gallbladder surgery given it is usually left‐sided, and is commonly described with either direct optical port entry or Veress needle insufflation, techniques not favoured by the authors. Also, if the splenic flexure or spleen is adherent to the anterolateral abdominal wall, these organs are at risk on entry.
This article describes a safe alternative to routine infra‐ or supraumbilical entry using a yet to be described open cut down technique in the right upper quadrant, with several advantages.
An open cut down technique is used in the right upper quadrant, lateral to the midclavicular line, two fingerbreadths below the costal margin. This position can be adjusted by correlating fundus position on preoperative imaging or on‐table ultrasound. A Hassan port is inserted and pneumoperitoneum is created. Laparoscopy is carried out to assess the midline.
Using a 5 mm port in the right lumbar region, later to be for the assistant to retract the gallbladder fundus cephalad, midline adhesions can be safely divided under vision. Once the midline is cleared and assessed to be safe for port entry, the umbilical port can be inserted. The authors’ preference is a periumbilical approach.
Closure of the posterior rectus sheath is carried out with one Vicryl, while one Nylon is used for the anterior sheath.
In the authors’ experience of 125 cholecystectomies from 1994 to 2016, even in the presence of recurrent cholecystitis, the right upper quadrant was free of adhesions to the abdominal wall. Using this technique, 125 cases with previous midline laparotomy incisions underwent safe laparoscopic cholecystectomy. No acute or long‐term complications occurred including bowel and vascular injury, or incisional hernia.
There are multiple advantages to this technique, in addition to avoiding an open cholecystectomy. An extra incision is not required. This right upper quadrant port will subsequently be the working port of the surgeons left hand, facilitating the procedure to be performed using the routine four ports.
In the event of a frozen abdomen where proceeding with laparoscopic surgery is not appropriate due to increased risk of complications, the right upper quadrant incision is extended via a Kocher's incision to carry out open cholecystectomy. This was necessary in 23 patients and the cholecystectomy was completed without incident.
Using a right upper quadrant open cut down technique, safe entry to the abdomen can be achieved in the patient with previous midline incisions, not only preventing iatrogenic omental or visceral entry, but facilitating safe laparoscopic division of midline adhesions, without additional incision.

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