What are the steps for a laparoscopic cholecystectomy (Lap Chole)?

Laparoscopic Cholecystectomy: Step-by-Step Procedure

Laparoscopic cholecystectomy should be performed using the critical view of safety technique as the standard approach to minimize the risk of bile duct injury. 1

Preoperative Preparation

• Ensure appropriate patient selection (consider comorbidities, previous surgeries)
• Administer prophylactic antibiotics only if indicated:
  • Not necessary for uncomplicated elective cases 2
  • Required for complicated cholecystitis (Class C patients) 1, 3
• Position patient supine with arms extended
• Prep and drape abdomen in sterile fashion

Equipment Requirements

• High-resolution video endoscopy system with two monitors
• High-flow CO2 insufflator
• Light source (300W Xenon recommended)
• Electrocautery and/or laser equipment
• Endoscopic suction-irrigation system
• Specialized laparoscopic instruments:
  • Laparoscope (30° angled preferred)
  • Graspers and dissectors
  • Scissors
  • Clip appliers
  • Cholangiography equipment if needed 4, 5

Step 1: Establishing Pneumoperitoneum

• Create pneumoperitoneum using Veress needle or open Hasson technique
• Insert primary trocar (10mm) at umbilicus
• Insufflate abdomen with CO2 to 12-15 mmHg pressure
• Insert laparoscope through umbilical port 4, 5

Step 2: Port Placement

• Place three additional trocars under direct visualization:
  • 10mm epigastric port (for dissection instruments)
  • 5mm right subcostal port (for grasper to retract fundus)
  • 5mm right lateral port (for grasper to manipulate Hartmann's pouch) 4, 5

Step 3: Exposure and Initial Dissection

• Grasp fundus of gallbladder with atraumatic grasper and retract superiorly toward right shoulder
• Place second grasper on Hartmann's pouch and retract laterally to expose hepatocystic triangle
• Begin dissection at the hepatocystic triangle, starting at the infundibulum-cystic duct junction 1, 4

Step 4: Achieving Critical View of Safety

• Dissect and clear fat and fibrous tissue from hepatocystic triangle
• Identify and expose the following three elements:
  1. Cystic duct and artery must be clearly identified entering the gallbladder
  2. Lower third of gallbladder must be separated from liver bed
  3. Only two structures (cystic duct and artery) should be seen entering the gallbladder 1

Step 5: Clipping and Division of Cystic Structures

• Once critical view of safety is achieved, place clips on cystic duct (2-3 clips proximally, 1 distally)
• Place clips on cystic artery (2 clips proximally, 1 distally)
• Divide cystic duct and artery between clips using scissors 4, 5

Step 6: Gallbladder Dissection from Liver Bed

• Using electrocautery, dissect gallbladder from liver bed in a retrograde fashion (from neck to fundus)
• Maintain hemostasis throughout dissection
• Carefully control any bleeding with electrocautery 4, 5

Step 7: Gallbladder Extraction

• Place gallbladder in retrieval bag if available
• Extract gallbladder through umbilical port
• If gallbladder is too large, decompress contents using suction device before removal 4

Step 8: Final Inspection and Closure

• Irrigate operative field and inspect for hemostasis
• Check for bile leaks, especially at cystic duct stump
• Remove instruments and ports under direct visualization
• Release pneumoperitoneum
• Close fascial defects at 10mm port sites
• Close skin incisions 5

Bailout Procedures When Critical View Cannot Be Achieved

If the critical view of safety cannot be established due to severe inflammation or scarring:

1. Fundus-first (top-down) approach: Begin dissection from fundus toward neck
2. Subtotal cholecystectomy: Remove as much of gallbladder as safely possible
3. Conversion to open procedure: Consider when laparoscopic approach is unsafe 1

Intraoperative Cholangiography Considerations

• Not mandatory for all cases but consider for:
  • Patients with intermediate to high pre-test probability of common bile duct stones
  • Unclear anatomy
  • Suspected bile duct injury 1

Common Pitfalls to Avoid

• Misidentification of common bile duct as cystic duct
• Inadequate exposure of hepatocystic triangle
• Excessive traction causing avulsion of cystic structures
• Failure to recognize anatomical variations
• Proceeding with dissection despite unclear anatomy 1

Remember that achieving the critical view of safety is essential before clipping and dividing any structures to prevent bile duct injury, which is the most serious complication of laparoscopic cholecystectomy.