PMC5043398_01
Chest and abdominal CT (a) The gallbladder was entirely covered by the thoracic cage. The gallbladder presented marked swelling with small stones (arrow). (b) The common bile duct was dilatated with a bile duct stone (arrow). (c) The left lung presented pneumonia. (d) Sliding esophageal hiatal hernia was detected (arrow).
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C-reactive protein, 23.57 mg/dl. Chest and abdominal computed tomography (CT) revealed pneumonia, sliding esophageal hiatal hernia, wall thickening, edema and enlargement of the gallbladder with small stones, and a stone in the common bile duct (Fig. 1).
Contrast radiography of the biliary tract by PTGBD showed gallbladder stones (arrowhead) and common bile duct stones (arrow).
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Contrast radiography of the biliary tract by PTGBD performed again just before surgery revealed gallbladder stones and remnant stones in the common bile duct (Fig. 2), which were removed by ERC on the 20th day after first PTGBD.
The patients could be placed in Fowler's position under general anesthesia with thick pillows beneath her head and body.
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Under general anesthesia, the patient was placed in Fowler's position with thick pillows beneath her head and body (Fig. 3).
Operative findings (a) Only the liver (white arrow) was observed between bilateral low-lying costal arches (arrowhead). The gallbladder was not visible. (b) The gallbladder was visualized in the surgical field using the rib-lifting method. However, a grasper through the right abdominal port prevented lifting of the fundus of the gallbladder by the right low-lying costal arch (arrowhead). (c) The critical view was established by lifting of the fundus using a grasper through the left abdominal ports. Arrows show the clips of the cystic duct and the cystic artery. (d) Retrograde dissection of the gallbladder was performed by lifting of the fundus using a grasper through the transumbilical multi-port. A good surgical view was created using a 5 mm angled laparoscope through the left abdominal port.
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Only the edge of the liver was seen between bilateral costal arches (Fig. 4a). However, the surgical instrument through the right abdominal port was interrupted by a right low-lying costal arch, which could not be sufficiently lifted using the rib-lifting method (Fig. 4b). Under a good surgical view, the critical view could be established using the transumbilical multi-port and the right abdominal port (Fig. 4c). Retrograde dissection of the gallbladder was performed using the transumbilical multi-port and the right abdominal port (Fig. 4d).
Port site scars (a) Port site scars were hidden in the fold of the abdominal wall. (b) Arrows show three port site scars.
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The port site scars on the abdomen are shown in Fig. 5.