From the Guidelines
The essential instrument set for a laparoscopic cholecystectomy should include a laparoscope, trocars, atraumatic graspers, a dissector, scissors, a hook electrocautery device, clip appliers, a specimen retrieval bag, and suction/irrigation equipment, with the routine use of a critical view of safety (CVS) technique to minimize the risk of iatrogenic intraoperative complications 1.
Instrumentation Details
- A laparoscope (typically 10mm, 30-degree angle) is crucial for visualization, and trocars (one 10mm umbilical port, two 5mm ports, and one additional 5mm or 10mm epigastric port) provide access for the instruments.
- Atraumatic graspers and a dissector (such as Maryland or right-angle) are necessary for gentle tissue handling and dissection.
- Scissors and a hook electrocautery device are used for cutting and coagulation, while clip appliers (medium-large titanium clips) are essential for securing the cystic duct and artery.
- A specimen retrieval bag is vital for preventing wound contamination during gallbladder extraction, and suction/irrigation equipment helps maintain a clear visual field.
Additional Considerations
- The use of a liver retractor can be helpful in exposing the operative field, and ultrasonic energy devices like Harmonic scalpel or LigaSure can facilitate tissue dissection and vessel sealing, reducing operating time and blood loss.
- Intraoperative cholangiography may be planned, in which case a cholangiogram catheter would be included in the instrument set.
- The critical view of safety (CVS) technique, as recommended by the 2020 WSES guidelines 1, should be routinely used to identify the cystic duct and artery, minimizing the risk of bile duct injury, especially during the early learning curve in laparoscopic cholecystectomy.
From the Research
Instrument Sets for Laparoscopic Cholecystectomy
The following instrument sets are recommended for a laparoscopic cholecystectomy:
- Laparoscopic ports (number and position may vary) 2
- Harmonic shears or ultrasonic dissectors for dividing cystic artery and duct 3, 4
- Clipless ligation or clipping devices for cystic duct and artery ligation (although insufficient evidence exists to compare these methods) 2, 3
- Retrieval bag for gallbladder extraction (although its use may result in minimal benefit) 2
- Cholangiography or ultrasound equipment for obtaining a critical view of safety and identifying the cystic duct and artery 2, 5
- Suture material for stump closure during subtotal cholecystectomy (to reduce rates of bile leak and reoperation) 2
Key Considerations
When selecting instrument sets for laparoscopic cholecystectomy, consider the following:
- The number and position of laparoscopic ports may affect operative time, cosmesis, and pain 2
- The use of harmonic shears or ultrasonic dissectors may reduce the risk of thermal injuries and bile duct injuries 3, 4
- A systematic approach to opening a window beyond the triangle of Calot is essential for safe completion of the operation 5