What are the steps involved in a cholecystectomy procedure?

Steps of Cholecystectomy Procedure

Laparoscopic cholecystectomy is the gold standard approach for gallbladder removal, with specific steps that should be followed to ensure safety and minimize complications. 1, 2

Preoperative Assessment

• A thorough preoperative work-up is mandatory to detect at-risk conditions (such as scleroatrophic cholecystitis or Mirizzi syndrome) and choose the best surgical approach 1
• Patient selection is important for success, with consideration of factors such as advanced cholecystitis, bleeding disorders, and pregnancy 3
• Laparoscopic cholecystectomy is indicated for symptomatic gallstones and can be safely performed in patients with Child's A and B cirrhosis, advanced age, and during pregnancy 1

Standard Laparoscopic Cholecystectomy Steps

1. Establishment of pneumoperitoneum:

   • Usually performed using a closed technique with a Veress needle 4, 5
   • Carbon dioxide is used to insufflate the abdomen 5

2. Trocar placement:

   • Four-cannula technique is commonly used 4
   • Placement typically includes umbilical port for camera and three working ports 6

3. Identification of critical structures:

   • The Critical View of Safety (CVS) technique is recommended to identify the gallbladder elements and hepatocystic triangle 1
   • This requires clearing the lower third of the gallbladder from the liver bed and dissecting the hepatocystic triangle free of fat and fibrous tissue 1

4. Dissection of the cystic duct and artery:

   • Only after achieving the CVS should the cystic duct and artery be clipped and divided 1
   • Intraoperative cholangiography may be performed through the gallbladder or cystic duct in selected patients 4

5. Removal of gallbladder from liver bed:

   • Performed using electrocautery for dissection and hemostasis 4
   • Dissection proceeds from the infundibulum toward the fundus 6

6. Extraction of the gallbladder:

   • The gallbladder is removed through one of the port sites, typically the umbilical port 6
   • Large stones may require crushing or enlarging the incision 6

7. Final inspection and closure:

   • Check for hemostasis and bile leakage 6
   • Remove trocars under direct vision 6
   • Close fascial defects and skin incisions 6

Alternative Techniques for Difficult Cases

• When the Critical View of Safety cannot be achieved, alternative techniques should be considered 1:

  • "Fundus-first" (top-down) approach - starting dissection from the fundus rather than the hepatocystic triangle 1
  • Subtotal cholecystectomy - removing most but not all of the gallbladder when anatomy is unclear 1
  • Conversion to open surgery if necessary for patient safety 1

• Intraoperative cholangiography may be used to recognize choledocholithiasis and define biliary anatomy, though its routine use is not universally recommended 1

Open Cholecystectomy Steps

When laparoscopic approach is not feasible or safe:

1. Incision:

   • Right subcostal (Kocher) incision is most commonly used 3

2. Exposure:

   • Retraction of the liver to expose the gallbladder 3
   • Packing of surrounding structures 3

3. Dissection and removal:

   • Similar principles of identification of cystic duct and artery before division 3
   • Removal of gallbladder from liver bed 3

4. Closure:

   • Layered closure of the abdominal wall 3

Complications to Be Aware Of

• Bile duct injuries occur in 0.4-1.5% of laparoscopic cholecystectomies and are associated with significant morbidity and mortality 7
• Wound infections are more common in open cholecystectomy but can occur in laparoscopic procedures, particularly at the umbilical port site 7
• Combined bile duct and vascular injuries often occur after conversion from laparoscopic to open cholecystectomy 7
• Risk factors for complications include acute cholecystitis, cirrhosis, advanced age, and conversion to open surgery 7

Special Considerations

• For patients with gallstones in the common bile duct, options include laparoscopic bile duct exploration or postoperative ERCP 1, 2
• In cases of acute gallstone pancreatitis, laparoscopic cholecystectomy during index admission is recommended for mild cases 1
• When ERCP and sphincterotomy are performed during index admission, same admission cholecystectomy is still advised to prevent other biliary complications 1
• In patients with peripancreatic fluid collections due to gallstone pancreatitis, cholecystectomy should be deferred until fluid collections resolve or stabilize 1