What is the step-by-step method for performing a laparoscopic (minimally invasive surgical procedure using a laparoscope) cholecystectomy (surgical removal of the gallbladder)?

Laparoscopic Cholecystectomy: Step-by-Step Operative Technique

Laparoscopic cholecystectomy should be performed using the Critical View of Safety technique with careful dissection of Calot's triangle, skeletonization of the cystic duct and artery, followed by clipping and division of these structures before retrograde dissection of the gallbladder from the liver bed. 1

Preoperative Setup and Equipment

• Ensure availability of high-resolution video endoscopy system with two color monitors, high-flow CO2 insufflator, 300W Xenon light source, electrocautery and/or laser, and endoscopic suction-irrigation system 2
• Required instruments include laparoscope, graspers, dissectors, cholangiography equipment, scissors, and clip appliers 2
• For cases with suspected common bile duct stones, have choledochoscope with light source, camera, and disposable instrumentation (baskets, balloons, stents) available 3

Step 1: Patient Positioning and Port Placement

• Induce CO2 pneumoperitoneum 2
• Insert four trocars in standard positions 2
• Position patient appropriately to optimize visualization of the hepatocystic triangle 2

Step 2: Initial Exposure and Retraction

• Place grasping retractor to set the operative field 2
• Place additional retractor on Hartmann's pouch to provide countertraction for dissection of the hilum 2
• This retraction is critical for achieving adequate exposure of Calot's triangle 1

Step 3: Achieve Critical View of Safety (MANDATORY)

This is the most crucial step to prevent bile duct injury 3, 1

The Critical View of Safety requires three criteria:

• Clear the hepatocystic triangle (bounded by cystic duct, common bile duct, and liver) of all fat and fibrous tissue 3
• Clear the lower third of the gallbladder from the liver bed 3
• Visualize only two structures (cystic duct and cystic artery) entering the gallbladder 1

Critical pitfall: CVS can only be achieved in approximately 50% of cases; the most commonly incomplete component is clearance of the lower third of the gallbladder from the liver bed 3

Step 4: Dissection of Cystic Structures

• Perform careful dissection around the cystic duct and cystic artery using a combination of electrocautery and blunt dissection 2
• Skeletonize both the cystic duct and cystic artery completely 2, 1
• If CVS cannot be achieved and biliary anatomy cannot be clearly defined, STOP and convert to fundus-first approach or subtotal cholecystectomy 3, 1

Step 5: Intraoperative Cholangiography (Selective)

• Perform intraoperative cholangiography (IOC) or laparoscopic ultrasound (LUS) if there is intraoperative suspicion of bile duct injury or unclear anatomy 3
• IOC is suggested for patients with intermediate to high pre-test probability of common bile duct stones who have not had preoperative confirmation 3
• Note: Routine IOC is not advisable as it does not significantly reduce complication or bile duct injury rates 3
• Confirm anatomy before proceeding to clipping 1, 2

Step 6: Clipping and Division

• After confirming anatomy (either visually with CVS or with IOC), clip the cystic artery proximally and distally 2
• Divide the cystic artery between clips 2
• Clip the cystic duct proximally and distally 2
• Divide the cystic duct between clips 2

Step 7: Gallbladder Dissection from Liver Bed

• Use electrocautery or laser techniques to perform retrograde dissection of the gallbladder from the liver bed 2
• Ensure complete hemostasis during dissection 2
• Maintain careful technique to avoid perforation and bile spillage 2

Step 8: Gallbladder Removal

• Detach the gallbladder completely from the liver bed 2
• Remove the gallbladder intact through the large trocar site 2
• If the gallbladder is too large or inflamed, it may need to be placed in a retrieval bag before extraction 2

Step 9: Final Inspection and Closure

• Irrigate the surgical field and ensure hemostasis 2
• Inspect the liver bed and Calot's triangle for any bleeding or bile leakage 2
• Remove trocars under direct visualization 2
• Close trocar sites appropriately 2

When to Convert or Modify Technique

Indications for conversion to open surgery include: 3

• Septic shock or absolute anesthetic contraindications 3, 1
• Severe local inflammation with inability to achieve CVS 3, 1
• Dense adhesions preventing safe dissection 3, 1
• Bleeding from Calot's triangle that cannot be controlled laparoscopically 3
• Suspected bile duct injury 3

Consider subtotal cholecystectomy when: 3

• CVS cannot be achieved due to advanced inflammation 3
• Gangrenous gallbladder with unclear anatomy 3
• Contracting fibrosis affecting the hepatocystic angle 3
• Approaching areas of danger where continued dissection risks bile duct injury 3

Special Populations

• Acute cholecystitis: Laparoscopic approach should still be attempted first unless contraindications exist 3
• Elderly patients (>65 years): Age alone is not a contraindication; laparoscopic cholecystectomy is safe and feasible with low complication rates 3
• Cirrhosis Child's A or B: Laparoscopic approach can be performed but requires extra caution for bleeding 3

Critical Safety Points

• Misidentification of biliary anatomy is the most common cause of bile duct injuries 1
• Bile duct injuries are only identified intraoperatively in one-third to one-half of cases 1
• Failure to achieve Critical View of Safety is a major risk factor for bile duct injury 1
• If trainee is performing the procedure, both trainee and supervising surgeon must confirm CVS before clipping any structures 3
• When in doubt, convert rather than persist with difficult dissection 3, 1