Cholecystectomy, laparoscopic

Small skin incision inferior to left lower costal arch near the xiphoid. Introduce the Verres needle through this incision and establish the pneumoperitoneum. Limit maximum pressure to 12 mm Hg.

Optionally establish pneumoperitoneum by introducing the Verres needle through a 1 cm periumbilical skin incision or opt for open insertion of the first trocar and establish the pneumoperitoneum through the trocar.

Bluntly insert the trocar for the laparoscope (10 mm) through a small umbilical incision. Tilt the table to the reverse Trendelenburg position and slightly to the left; this ensures better exposure of Calot’s triangle. Inspect the abdominal cavity. Now insert three additional trocars in the following sequence and under direct vision:

5 mm working trocar (T2) inferior to the xiphoid and right of the midline; 10 mm working trocar (T3) in left medioclavicular line (superior to the umbilicus); 5 mm working trocar (T4) in right anterior axillary line (inferior to the costal arch)

Tip: For better cosmesis of any 10 mm incisions, the umbilical incision may be placed directly in the umbilicus and the left lateral trocar could be reduced to a 5 mm trocar, if a 5 mm laparoscope is used.

Grasp the gallbladder at its fundus (forceps through T2) and retract it cephalad over the liver margin. With another forceps (through T4) grasp the infundibulum and retract it laterally. This will stretch out Calot’s triangle.

With scissors through T3 transect the peritoneal cover in Calot’s triangle and then start the exposure by blunt dissection and with the hook electrode.

After blunt dissection of the cystic duct verify its course (from the infundibulum of the gallbladder to its union with the CBD). Expose and underrun the cystic over a distance of at least 1 cm.

Bluntly expose the cystic artery as well. Beware of the (numerous) variants, particularly do not mistake the right hepatic artery for the cystic artery!

Important: If unequivocal identification of the anatomical structures is not possible or if CBD calculi are suspected, perform intraoperative cholangiography.

Tip: In intraoperative cholangiography grasping forceps can temporarily clamp the distal CBD thereby ensuring excellent contrast enhancement of the biliary tree.