Keywords

Preference Cart

  • 15-blade scalpel

  • Adson forceps

  • Rat tooth grasping forceps

  • DeBakey forceps

  • Kocher clamps

  • Kelly clamps

  • Mayo scissors

  • Electrocautery (35/35)/grounding pad

  • Suction

  • General endoscopic drape and sterile towels

  • 10 mm scopes and 5 mm scope

  • Camera/light cord

  • Insufflation cord

  • Endocatch

  • Suction/irrigation and saline 1000 ml

  • Bupivacaine

  • 10 mm syringe, 25 G hypo

  • Steri-Strips 0.5 inch

  • Maryland grasper

  • L hook electrocautery

  • Ratcheted grasper

  • 2-0 Vicryl on UR-6 needle and 4-0 Vicryl on PS 2

  • Ligaclip applier 5 mm

  • Hassan blunt port, 5 mm ports x3

  • Anti- fog

Patient Positioning/Operating Room Setup (Fig. 32.1)

  • Patient position supine

  • Surgeon position on patient’s left

  • First assistant position patient’s right

  • Second assistant position surgeon’s left

  • Nurse position first assistant right

  • Anesthesiologist at patient’s head

  • Monitors position patient’s right and left shoulder

  • Trocars (Fig. 32.2)

    • 12 mm trocar at the level of the umbilicus

    • Three 5 mm trocars, one subxiphoid and two right upper and right lateral abdominal wall

Fig. 32.1
figure 1

Positioning the patient and the team. Patient is in supine position. Anesthesiologist (ANS), surgeon (S), assistants (A1, A2), nurse (N), monitor (M)

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Fig. 32.2
figure 2

Port placement for laparoscopic cholecystectomy

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Nodal Points

Exposure of the Gallbladder and Hepatoduodenal Ligament (Fig. 32.3)

  • Introduce right-hand Maryland grasper through subxiphoid port.

  • A ratcheted grasper is introduced by the assistant through the right lateral port.

  • Grasp the gallbladder fundus with the ratcheted instrument, and push cranially exposing the hepatoduodenal ligament.

  • Grasp and lift the Hartman pouch with left hand.

Fig. 32.3
figure 3

Exposure of the gallbladder and hepatoduodenal ligament

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Dissection of the Cystic Duct and Cystic Artery

  • Pull the Hartman pouch laterally to expose Calot’s triangle (Fig. 32.4).

  • Introduce a Maryland grasper through the subxiphoid trocar.

  • Pull the Hartman pouch medically to expose the lateral aspect, and peel the peritoneum.

  • Peel the anterior portion of the peritoneum that covers the medial aspect of Calot’s triangle.

  • With an open-and-close motion, the artery and cystic duct are skeletonized (Fig. 32.5).

  • Obtain the “critical view of safety” (only two structures are entering the gallbladder, the peritoneum between the two structures and medially until the liver is completely open, so the liver can be visualized in between, and dissect cystic duct all the way to the junction with the gallbladder).

Fig. 32.4
figure 4

Pull the Hartman pouch laterally to expose Calot’s triangle

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Fig. 32.5
figure 5

Cystic duct and artery are skeletonized

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Division of the Cystic Duct and Artery and Dissect the Gallbladder from Liver Bed

  • Through the subxiphoid port, introduce clip applier.

  • On the cystic duct, apply two clips distally and one proximally.

  • Introduce scissors and transect the cystic duct (Figs. 32.6 and 32.7).

  • Apply clips to the cystic artery, two clips proximally and one distally.

  • Introduce scissors and transect the cystic artery.

  • Pull the Hartman pouch to different direction to expose the attachment; dissect the gallbladder from the liver bed with hook electrocautery.

Fig. 32.6
figure 6

Cystic duct is clipped and is being transected

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Fig. 32.7
figure 7

Scissors diving the clipped cystic artery

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Irrigation, Hemostasis, and Specimen Removal

  • Switch to 5 mm camera and introduce it via right lateral port.

  • Introduce an endo bag through umbilical trocar site.

  • Place the gallbladder in the bag with a grasper from subxiphoid port (Fig. 32.8).

  • Remove bag through umbilicus.

  • Irrigation and hemostasis of liver bed area, check cystic duct and cystic artery stumps

  • Close umbilical port trocar site fascia with 2-0 Vicryl.

  • Close skin of other port sites with 4-0 Vicryl or Monocryl subcuticular suture.

Fig. 32.8
figure 8

Specimen removal

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Pearls and Pitfalls

  • Laparoscopic cholecystectomy has gained wide acceptance as a gold standard treatment since its introduction in 1987.

  • Despite the fact of being safe and effective, possible surgical complications, especially in the hands of inexperienced surgeons, are bile leaks, bleeding, and infection.

  • Obtaining the critical view of safety will prevent in most cases the most threatened complication of this procedure, a common bile duct injury.

  • Perioperative ultrasound and blood test of liver function are very important before surgery.

  • In the presence of possible common bile stones or unclear anatomy, intraoperative cholangiogram should be performed.

  • Incisionless fluorescence cholangiography is an easy technology that can help in the identification of the biliary anatomy prior to, or during, the dissection.

  • Patient history of prior pancreatitis, jaundice, or CBD stones should be taken into consideration before surgery. If the suspicion is high for CBD stones, an ERCP or an intraoperative cholangiogram should be performed.