A TULC (total umbilical laparoscopic cholecystectomy) is a minimally invasive laparoscopic removal of the gallbladder. The surgeon makes a small incision in the area of the navel.
Due to the small incision, the surgical trauma is minimal and post-operative wound healing can take place more quickly. This also improves the cosmetic result.
Prerequisites for a TULC are
- a body mass index (BMI) of less than 38 kg/m²
- No previous extensive abdominal surgery
The gallbladder is located on the underside of the liver. The main function of the gallbladder is to store and thicken the bile produced by the liver. The bile is mainly used to digest fats in the intestine.
The gallbladder is divided into a gallbladder floor, body and neck. The neck of the gallbladder merges into the gallbladderduct (ductus cysticus). A spiral-shaped mucosal fold (Heister valve) is located in the transition area. This performs a sealing function, particularly when the pressure in the abdominal cavity increases (e.g. during a bowel movement).
The gallbladder duct joins with thecommon bile duct from the liver(ductus hepaticus communis) to form the common bile duct(ductus choledochus). This runs together with the important blood vessels (portal vein and main hepatic artery) in a commonligament (hepatoduodenal ligament).
The common bile duct usually flows into theduodenum together with thepancreatic duct.
The gallbladderartery (cystic artery) branches off from the right branch of the main hepatic artery and supplies the gallbladder with blood.
The location of the gallbladder © magicmine | AdobeStock
The main indications for removal of the gallbladder using TULC are clinical symptoms such as
- Pain in the right upper abdomen,
- biliary colic and
- a feeling of pressure,
caused by gallstones (so-called symptomatic gallstones).
Other causes for the removal of the gallbladder can be
can be.
In rare cases, pancreatitis or gallbladder cancer require removal of the gallbladder using TULC.
As part of the preparation for a TULC operation
- all important patient data (main and secondary diseases, medication and age) is collected,
- a laboratory chemical examination,
- an ultrasound examination of the abdomen
- and, depending on age and/or previous illnesses, an echocardiography (ECG) and/or X-ray examination of the chest.
Preparations
The laparoscopic removal of the gallbladder (cholecystectomy) is performed under general anesthesia. The patient is positioned on their back with their legs spread apart (so-called lithotomy position).
The surgical team washes the abdomen from the pubic mound to the nipples with a sterile liquid. The surgical area is then covered with sterile disposable adhesive drapes.
The patient is now injected with 10 ml of a local anesthetic (usually bupivacaine) to the left of and above the navel. After sufficient exposure time, a 10 mm incision is made directly next to the navel. Carbon dioxide is then introduced into the abdominal cavity through this incision via a special cannula (so-called Verres needle) (Fig. 1). This inflates the abdomen and the surgical site becomes more clearly visible.
Image 1: Creation of the so-called pneumoperitoneum (filling the abdominal cavity with CO2)
The surgeon now inserts a 12 mm safety trocar through the incision next to the navel for diagnostic laparoscopy. A trocar is an instrument that can be used to keep a surgical incision open for the duration of the operation.
A 10 mm optical system is inserted into the abdominal cavity via a safety trocar. This small camera allows the surgeon to look inside the abdominal cavity.
He checks for the presence of adhesions that would make a TULC impossible. In this case, a conventional laparoscopic or even open gallbladder removal is performed.
If TULC is possible, a 5 mm working trocar is inserted immediately above the camera-optic trocar after a further incision.
The patient is then positioned on the operating table. To do this, the anesthetized patient is positioned with the upper body at about 30° using the electrically adjustable operating table, the legs are lowered slightly and the entire operating table is tilted about 15° to the left. This position allows optimal access to the gallbladder.
Insertion of retaining sutures
A suture is now inserted into the abdominal cavity from the outside using a straight needle just below the edge of the costal arch (Fig. 2). This procedure is controlled laparoscopically and optically. The needle is grasped in the abdomen with a laparoscopic surgical instrument (needle holder). The surgeon punctures the neck of the gallbladder twice and then removes it from the abdominal cavity slightly offset to the puncture.
Figure 2: Insertion of the first holding suture into the abdominal cavity. Center: green suture; right: falciform hepatic ligament (ligament on which the liver is suspended); bottom left: Liver; top left: Diaphragm
Figure 3: Suspension of the gallbladder from the first holding thread. Center: Gallbladder; bottom right: Neck of the gallbladder with artery (cystic artery) and gallbladder duct (cystic duct)
This maneuver allows the assistant to hold the gallbladder upwards like a marionette and move it to the left and right as directed by the surgeon.
Under certain circumstances (e.g. very large gallbladder), a second holding suture may be necessary. In this case, the same procedure is repeated with another suture, with offset insertion and removal positions (Figures 3 and 5).
Figure 4: Dissection of the gallbladder duct and the artery supplying the gallbladder as well as the hepatic artery (so-called Calot's triangle)
Figure 5: Insertion of a second holding suture for clearer dissection of the Calot's triangle
Preparation of the gallbladder
In the further course of the operation, the gallbladder is now dissected. At the beginning, the surgeon identifies Calot's triangle (Fig. 4).
The cystic duct and the cystic artery are finally ligated with laparoscopic clips towards the liver and the gallbladder and placed between the clips with scissors (Fig. 6).
Figure 6: Ligation of the gallbladder duct twice to the common bile duct from the liver and once to the gallbladder itself using endoclips
Figure 7: Removal of the gallbladder duct and the artery supplying the gallbladder and initial mobilization of the gallbladder from the liver bed
The gallbladder is then mobilized further (Fig. 7). With constant hemostasis, the surgeon then completely dissects it out of the gallbladder bed (Fig. 8).
The gallbladder is now freely suspended in the abdominal cavity by the retaining sutures (Fig. 9). To finally remove it from the abdominal cavity, the 10 mm camera lens is now replaced with a 5 mm camera lens. The surgeon inserts a so-called retrieval bag into the abdominal cavity via the 12 mm safety trocar. The gallbladder is inserted into the retrieval bag, the retaining sutures are cut off on the outside at skin level and the retrieval bag is closed by pulling on a special flap.
The gallbladder is now securely in the retrieval bag and can be easily removed from the abdominal cavity.
Image 8: Surgical site after complete removal of the gallbladder from the liver bed
Image 9: Gallbladder completely removed from the liver bed, suspended on the two holding sutures
Image 10: Cosmetic result at the end of the operation: only an approximately 2.5 cm long scar remains
Closure and follow-up
A deep muscle suture (so-called fascial suture) is used to close the abdominal cavity. Finally, a superficial skin suture about 2.5 cm long is made with a self-dissolving suture.
The suture insertion points do not require wound closure (Fig. 10). After three small plasters have been applied, the patient goes to the normal ward after sufficient time in the recovery room.
A clinical and laboratory examination is carried out on the first postoperative day.
As a rule, patients can be discharged from inpatient treatment on the second to third postoperative day.
The removal of the gallbladder using the "keyhole technique" is currently the gold standard in Germany and an absolutely routine procedure. The procedure is very safe and has a very low complication rate.
The possible complications of gallbladder removal depend crucially on various factors, such as
- Secondary diseases of the patient,
- secondary diseases due to the gallbladder disease and
- whether the operation is planned or an emergency operation.
In addition to general surgical risks such as
- Bleeding,
- post-operative bleeding,
- infections,
- wound healing disorders or
- thrombo-embolisms
Injuries to the bile ducts or neighboring organ structures are extremely rare.
Possible intraoperative complications may very rarely necessitate a switch to an open surgical procedure.
The complication rate of TULC corresponds to that of laparoscopic cholecystectomy. However, there are fewer
occur.
Life without a gallbladder is possible without any impairment. The quality of life without a diseased gallbladder is higher than with a diseased gallbladder.
Advantages of TULC
- Less postoperative pain
- Lower risk of postoperative wound healing disorder
- Shorter hospital stay
- Lower risk of postoperative scar hernia
- Better postoperative cosmetic result
- No need for cost-intensive special surgical instruments
- No higher surgical costs
Disadvantages of TULC
- Not possible for all patients (see prerequisites)
- Slightly longer operation times
TULC cholecystectomy is a safe, highly minimally invasive procedure. In contrast to other modern minimally invasive surgical methods (e.g. through the colon or vagina) for removing the gallbladder, it is not necessary to cut through (perforate) a healthy organ with all the associated risks.
Postoperatively, there is subjectively less pain. TULC cholecystectomy enables the best possible cosmetic result with surgical removal of the gallbladder.
