TULC (Laparoscopic Gallbladder Removal): Information & Specialists

A TULC (Total Umbilical Laparoscopic Cholecystectomy) is a minimally invasive laparoscopic procedure to remove the gallbladder. To perform the procedure, the surgeon makes a small incision near the navel.

Because of the small incision, surgical trauma is minimal and postoperative wound healing can occur more quickly. This also improves the cosmetic outcome.

Requirements for a TULC are:

• a body mass index (BMI) of less than 38 kg/m²
• no history of extensive abdominal surgery

The gallbladder is located on the underside of the liver. The main function of the gallbladder is to store and concentrate the bile produced by the liver. Bile primarily aids in the digestion of fats in the intestine.

The gallbladder is divided into the fundus, body, and neck. The neck of the gallbladder transitions into the cystic duct (ductus cysticus). At the junction, there is a spiral-shaped mucosal fold (Heister’s valve). This valve acts as a sphincter, particularly when pressure in the abdominal cavity increases (e.g., during a bowel movement).

The cystic duct joins with the common hepatic duct (ductus hepaticus communis) to form the common bile duct (ductus choledochus). This duct runs alongside the major blood vessels (portal vein and hepatic artery) within a common ligament (ligamentum hepatoduodenale).

The common bile duct usually empties into the duodenum together with the main pancreatic duct (ductus pancreaticus).

The cystic artery (Arteria cystica) branches off from the right branch of the hepatic artery and supplies the gallbladder with blood.

The location of the gallbladder © magicmine | AdobeStock

The primary indication for gallbladder removal via TULC is 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 reasons for gallbladder removal may include

• acute inflammation of the gallbladder with or without gallstones,
• a so-called atrophic gallbladder, and
• a gallbladder polyp

.

In rare cases, pancreatitis or gallbladder cancer may require gallbladder removal via TULC.

As part of the preoperative preparation for a TULC, 

• a review of all relevant patient data (primary and secondary conditions, medications, and age),
• laboratory tests,
• an abdominal ultrasound
• and, depending on the patient’s age and/or pre-existing conditions, an echocardiogram (ECG) and/or chest X-ray.

Preparations

Laparoscopic gallbladder removal (cholecystectomy) is performed under general anesthesia. The patient is positioned on their back with their legs spread apart (the so-called lithotomy position).

The surgical team cleans the abdomen from the pubic mound to the nipples with a sterile solution. They then cover the surgical site with sterile, disposable adhesive drapes. 

The patient is then injected with 10 ml of a local anesthetic (usually bupivacaine) to the left of and above the navel. After allowing sufficient time for the anesthetic to take effect, a 10-mm incision is made immediately next to the navel. Carbon dioxide is then introduced into the abdominal cavity through this incision using a special cannula (known as a Verres needle) (Figure 1). This causes the abdomen to distend, making the surgical site more clearly visible.

Figure 1: Creation of the so-called pneumoperitoneum (filling the abdominal cavity with CO₂)

The surgeon then inserts a 12-mm safety trocar through the incision next to the navel to perform a diagnostic laparoscopy. A trocar is an instrument used to keep a surgical incision open for the duration of the operation.

A 10-mm camera is inserted into the abdominal cavity through the safety trocar. This small camera allows the surgeon to view the interior of the abdominal cavity.

The surgeon 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 a TULC is possible, a 5-mm working trocar is inserted through an additional incision immediately above the camera trocar.

The patient is then positioned on the operating table. To do this, the anesthetized patient is positioned with the upper body raised approximately 30° using the electrically adjustable operating table, the legs slightly lowered, and the entire operating table tilted approximately 15° to the left. This positioning allows for optimal access to the gallbladder.

Insertion of Retention Sutures

Next, a suture thread is inserted into the abdominal cavity from the outside using a straight needle, just below the edge of the rib cage (Figure 2). This procedure is monitored laparoscopically. Inside the abdomen, the needle is grasped with a laparoscopic surgical instrument (needle holder). The surgeon uses it to pierce the neck of the gallbladder twice and then excises the gallbladder from the abdominal cavity at a slightly offset location from the entry point.

Figure 2: Insertion of the first suture into the abdominal cavity. Center: green suture; Right: ligamentum falciforme hepatis (ligament suspending the liver); Bottom left: liver; Top left: diaphragm

Figure 3: Suspending the gallbladder from the first suspension suture. Center: gallbladder; bottom right: neck of the gallbladder with the cystic artery (Arteria cystica) and cystic duct (Ductus cysticus)

This maneuver allows the assistant to hold the gallbladder upward like a marionette and move it left and right as directed by the surgeon.

In some cases (e.g., a very large gallbladder), a second suture is necessary. In this case, the same procedure is repeated with an additional suture, using offset entry and exit points (Figures 3 and 5).

Figure 4: Dissection of the cystic duct, the artery supplying the gallbladder, and the hepatic artery (the so-called Calot’s triangle)

Figure 5: Insertion of a second retention suture to facilitate clearer dissection of Calot’s triangle

Dissection of the Gallbladder

The procedure then continues with the dissection of the gallbladder. To begin, the surgeon identifies Calot’s triangle (Figures 4).

The cystic duct and the cystic artery are permanently ligated using laparoscopic clips directed toward the liver and the gallbladder, respectively, and then transected with scissors between the clips (Figure 6).

Figure 6: Ligation of the cystic duct twice at its junction with the common hepatic duct and once at its junction with the gallbladder itself using endoclips

Figure 7: Division of the cystic duct and the artery supplying the gallbladder, as well as initial mobilization of the gallbladder from the hepatic bed

The gallbladder is then further mobilized (Figure 7). While continuously controlling bleeding, the surgeon finally dissects it completely out of the gallbladder bed (Figure 8).

The gallbladder is now freely suspended at abdominal level by its suspension threads (Figure 9). To finally remove it from the abdominal cavity, the 10-mm camera lens is now replaced with a 5-mm camera lens. Using the 12-mm safety trocar, the surgeon inserts a so-called retrieval bag into the abdominal cavity. The gallbladder is placed into the retrieval bag, the suspension threads are cut off externally at skin level, and the retrieval bag is closed by pulling on a special tab.

The gallbladder is now securely contained in the retrieval bag and can be easily removed from the abdominal cavity.

Figure 8: Surgical site after complete detachment of the gallbladder from the hepatic bed

Figure 9: Gallbladder completely detached from the hepatic bed, suspended by the two sutures

Figure 10: Cosmetic result at the end of the operation: only a scar approximately 2.5 cm long remains

Closure and Follow-Up

The abdominal cavity is closed with a deep muscle suture (known as a fascial suture). Finally, a superficial skin suture approximately 2.5 cm long is placed using a self-dissolving suture.

The sites where the suspension sutures were inserted do not require wound closure (Figure 10). After applying three small bandages, the patient is transferred to the general ward after spending sufficient time in the recovery room.

On the first postoperative day, a clinical and laboratory evaluation is performed.

Patients can generally be discharged from the hospital on the second or third postoperative day.

Laparoscopic gallbladder removal is currently the gold standard in Germany and is considered a routine procedure. The procedure is very safe and has a very low complication rate.

The potential complications of gallbladder removal depend largely on various factors, such as

• the patient’s comorbidities,
• complications resulting from gallbladder disease, and
• whether the surgery is elective or emergency.

In addition to general surgical risks such as

• bleeding,
• postoperative bleeding,
• infections,
• wound healing complications, or
• thromboembolism

Injuries to the bile ducts or adjacent organ structures occur extremely rarely.

In very rare cases, potential intraoperative complications may necessitate a conversion to open surgery.

The complication rate for TULC is comparable to that of laparoscopic cholecystectomy. However,

• wound healing disorders,
• postoperative pain, and
• potential incisional hernias

.

It is entirely possible to live a normal life without a gallbladder. 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 complications
• Shorter hospital stay
• Low risk of postoperative incisional hernia
• Better postoperative cosmetic outcome
• No need for costly specialized surgical instruments
• No higher surgical costs

Disadvantages of TULC

• Not suitable for all patients (see requirements)
• Slightly longer operating times

TULC cholecystectomy is a safe, highly minimally invasive procedure. Unlike other modern minimally invasive surgical methods (e.g., through the colon or the vagina) for gallbladder removal, this procedure does not require perforation of a healthy organ, thereby avoiding all associated risks.

Patients report less pain postoperatively. TULC cholecystectomy provides the best possible cosmetic outcome for surgical removal of the gallbladder.