What are the steps involved in a laparoscopic (lap) cholecystectomy procedure?

Laparoscopic Cholecystectomy: Procedural Steps

Laparoscopic cholecystectomy is performed using a standardized four-trocar technique with pneumoperitoneum, achieving the Critical View of Safety before clipping and dividing the cystic duct and artery, followed by retrograde dissection of the gallbladder from the liver bed. 1

Preoperative Setup and Equipment

• Establish a 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
• Ensure availability of laparoscope, graspers, dissectors, cholangiography equipment, scissors, and clip appliers 2
• Position the patient supine with the surgeon standing on the patient's left side 3

Port Placement and Pneumoperitoneum

• Induce CO2 pneumoperitoneum using closed technique (Veress needle) in almost all patients 3
• Insert four trocars: umbilical port for the laparoscope, epigastric port for retraction, and two right subcostal ports for dissection and retraction 2, 3
• Maintain pneumoperitoneum throughout the procedure to provide adequate visualization 2

Exposure and Retraction

• Place a grasping retractor on the gallbladder fundus and retract cephalad over the liver edge to expose the operative field 2
• Position an additional retractor on Hartmann's pouch to provide lateral countertraction for dissection of the hilum 2
• This two-retractor technique sets up the critical exposure needed for safe dissection 2

Critical View of Safety (CVS)

The CVS must be achieved before any structures are clipped or divided—this is the single most important step to prevent bile duct injury. 1

• Clear the hepatocystic triangle (Calot's triangle) of all fat and fibrous tissue using a combination of electrocautery and blunt dissection 1, 2
• Clear the lower third of the gallbladder from the liver bed 1
• Visualize only two structures (cystic duct and cystic artery) entering the gallbladder with no other structures present 1
• Skeletonize the cystic duct and cystic artery completely before proceeding 2

Intraoperative Cholangiography (Optional)

• Perform cholangiography through the gallbladder or cystic duct in selected patients to confirm anatomy before clipping structures 2, 3
• Use IOC if there is intraoperative suspicion of bile duct injury or unclear anatomy 1
• This step is easily performed but not universally required 3

Division of Cystic Structures

• Only after achieving CVS, apply clips to the cystic artery and divide it 1, 2
• Apply clips to the cystic duct (typically 2-3 clips proximally, 1-2 distally) and divide it 2
• Confirm that only the intended structures have been clipped by re-verifying the CVS 1

Gallbladder Dissection

• Perform retrograde dissection of the gallbladder from the liver bed using electrocautery or laser techniques 2
• Cautery provides excellent hemostasis during dissection 3
• Maintain meticulous hemostasis throughout the dissection to ensure a clear operative field 2
• Completely detach the gallbladder from its hepatic attachments 2

Specimen Removal and Closure

• Remove the gallbladder intact through the umbilical or epigastric trocar site 2
• Irrigate the surgical bed and inspect for hemostasis 2
• Evacuate the pneumoperitoneum and remove trocars under direct visualization 3
• Close fascial defects at trocar sites ≥10mm to prevent hernias 3

Management of Difficult Cases

When CVS cannot be achieved due to severe inflammation, adhesions, or unclear anatomy, immediately consider subtotal cholecystectomy or conversion to open surgery rather than persisting with dangerous dissection. 4, 1

• Subtotal cholecystectomy (laparoscopic or open) is recommended when anatomic identification is difficult and risk of iatrogenic injury is high 4
• Risk factors predicting conversion include age >65 years, male gender, acute cholecystitis, thickened gallbladder wall, diabetes, and previous upper abdominal surgery 4
• Consider "fundus-first" approach as an alternative technique when standard dissection is not feasible 1
• Conversion to open surgery is the safest approach when in doubt—this is not a failure but rather sound surgical judgment 1

Critical Safety Points

• Failure to achieve CVS is the major risk factor for bile duct injury 1
• 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
• If severe local inflammation, adhesions, or bleeding occurs in Calot's triangle, conversion to open surgery should be strongly considered 4

Postoperative Considerations

• Mean operative time is 75 minutes (range 25-147 minutes) with decreasing time as experience increases 5
• Hospital stay averages less than 24 hours with minimal perioperative care required 3
• Among patients with uncomplicated cholecystitis, no postoperative antimicrobial therapy is necessary if source control is complete 4