What is the operative technique for a laparoscopic cholecystectomy?

Laparoscopic Cholecystectomy Operative Technique

Laparoscopic cholecystectomy is the recommended first-line surgical approach for gallstone removal due to its lower complication rate and shorter hospital stay compared to open cholecystectomy. 1

Equipment Requirements

• High-resolution video endoscopy system with two color monitors 2
• High-flow CO2 insufflator for pneumoperitoneum creation 2
• 300W Xenon light source 2
• Electrocautery and/or laser equipment 2
• Endoscopic suction-irrigation system 2
• Specialized laparoscopic instruments:
  • Laparoscope (typically 5mm, 30-degree) 2, 3
  • Graspers and dissectors 2
  • Clip appliers 2
  • Scissors 2
  • Cholangiography equipment 2

Standard Four-Port Technique

Port Placement

• Create pneumoperitoneum using Veress needle or open (Hasson) technique 2
• Place four trocars:
  • One 10-12mm umbilical port (camera) 2
  • One 10mm subxiphoid port (working port) 2
  • Two 5mm ports in right upper quadrant (for retraction) 2

Operative Steps

1. Patient Positioning and Setup

   • Place patient in reverse Trendelenburg position with slight left lateral tilt 2
   • Surgeon stands on patient's left side 2

2. Exposure and Initial Dissection

   • Grasp fundus of gallbladder and retract cephalad toward right shoulder 2
   • Grasp Hartmann's pouch with a second grasper and retract laterally to expose Calot's triangle 2

3. Critical View of Safety

   • Carefully dissect Calot's triangle using combination of electrocautery and blunt dissection 1, 2
   • Skeletonize cystic duct and cystic artery 2
   • Identify the Critical View of Safety: clear visualization of only two structures (cystic duct and cystic artery) entering gallbladder 4

4. Cholangiography (if indicated)

   • Perform intraoperative cholangiography to confirm anatomy before clipping and dividing structures 2

5. Division of Cystic Structures

   • Apply clips to cystic duct (typically 2 proximal, 1 distal) 2
   • Apply clips to cystic artery (typically 2 proximal, 1 distal) 2
   • Divide cystic duct and artery between clips 2

6. Gallbladder Dissection

   • Perform retrograde dissection of gallbladder from liver bed using electrocautery 2
   • Maintain hemostasis throughout dissection 2

7. Specimen Retrieval

   • Place gallbladder in retrieval bag 2, 5
   • Remove intact through umbilical port (may require enlarging port site) 2

8. Final Steps

   • Irrigate and ensure hemostasis of liver bed 2
   • Remove trocars under direct visualization 2
   • Close fascial defects (particularly at 10mm port sites) 2

Alternative Approaches

Single-Incision Laparoscopic Cholecystectomy

• Utilizes a single 2-3cm transumbilical incision 5, 3
• Three ports placed through the single incision 5
• May require specialized curved or articulating instruments 3
• Benefits include improved cosmesis and potentially reduced wound complications 6, 3
• Limitations include longer operative time (average 80 min vs 51 min for traditional approach) 6, 5

Special Considerations

Difficult Gallbladder Situations

• In cases of severe inflammation, adhesions, or unclear anatomy, consider: 1
  • Subtotal cholecystectomy (when Critical View of Safety cannot be achieved) 1
  • Conversion to open procedure 1

Indications for Conversion to Open

• Severe local inflammation 1
• Dense adhesions 1
• Bleeding from Calot's triangle 1
• Suspected bile duct injury 1

Common Pitfalls and Safety Measures

• Failure to achieve Critical View of Safety is a major risk factor for bile duct injury 4
• Misidentification of biliary anatomy is the most common cause of bile duct injuries 4
• Bile duct injuries are only identified intraoperatively in 1/3-1/2 of cases 4
• Consider subtotal cholecystectomy rather than persisting with difficult dissection in severe inflammation 1
• Conversion to open surgery should not be considered a failure but a sound judgment for patient safety 1

Contraindications

• Septic shock 1
• Absolute anesthesiology contraindications 1
• Advanced cholecystitis, abdominal sepsis, and bleeding disorders may be relative contraindications 7