PMC5588253_01
Preoperative images. a The axial view by computed tomography with contrast enhancement showed the wall thickness of the gallbladder (broken arrows) and gallstones (solid arrows). b The coronal view by computed tomography with contrast enhancement showed the wall thickness of the gallbladder (broken arrows) and a small amount of ascites around the liver surface (solid arrows). c Endoscopic retrograde cholangiography revealed an obstruction of the cystic duct (solid arrow). d A 6-Fr catheter (solid arrow) was inserted into the gallbladder through the cystic duct.
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F1
C reactive protein, and body temperature were 19,500/mul, 23.18 mg/dl, and 39.2 C, respectively. Computed tomography with contrast enhancement showed the wall thickness of the gallbladder including gallstones (fig. 1a) and a small amount of ascites around the liver surface (fig. 1b). The endoscopic retrograde cholangiography revealed an obstruction of the cystic duct (fig. 1c), and an ENGBD was then performed to release the obstruction (fig. 1d).
Intraoperative findings. a A SILS Port (Covidien) was placed through the umbilical incision, and the 3 holes of the SILS Port were placed at the 1, 5, and 9 o'clock positions of the umbilical incision. b Rouviere's sulcus could not be identified because the lift of the infundibulum was insufficient. c Calot's triangle could not be identified because of severe inflammation. d Initial dissection of the gallbladder was started from the fundus using laparosonic coagulating shears. e After dissecting the gallbladder from the gallbladder bed, the cystic artery (red arrow) and the cystic duct (green arrows) were encircled together; however, the fat tissue around the cystic duct (yellow arrows) could not be separated from the cystic duct (colors refer to the online version only). f After the cystic duct and the cystic artery were cut together by an endoscopic linear stapler (Endo GIA , Tri-Staple , Covidien), neither bile leakage nor bleeding from the stump of both structures (white arrows) was observed.
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F2
The SILS Port was placed through the umbilical incision, and the 3 holes of the SILS Port were placed at the 1, 5, and 9 o'clock positions of the umbilical incision (fig. 2a). Because severe inflammation stiffened the gallbladder wall, neither Rouviere's sulcus (fig. 2b) nor Calot's triangle (fig. 2c) could be identified under a favorable laparoscopic view. To avoid a bile duct injury, the initial dissection of the gallbladder was begun from the fundus using laparosonic coagulating shears (fig. 2d). After dissecting the gallbladder from the gallbladder bed and removing the ENGBD catheter, encirclement of the cystic artery and the cystic duct could be performed (fig. 2e). Tri-Staple , Covidien), based on our previous report (fig. 2f). The gallbladder was placed inside a retrieval bag.