Laparoscopic Cholecystectomy - Surgical Steps

Step 1: Preoperative Preparation and Patient Positioning

• General anesthesia with muscle relaxation is required
• Patient is positioned supine, with one arm tucked to allow for potential intraoperative cholangiogram
• An orogastric tube is placed to decompress the stomach
• A Foley catheter may be inserted for prolonged or high-risk cases
• The abdomen and lower chest are prepped and draped to allow conversion to open if needed
• Patient is well secured to the table for steep reverse Trendelenburg positioning

Surgeon stands to the left of the patient (American technique); in the French technique, the surgeon stands between the patient's legs with the table split.

Step 2: Pneumoperitoneum

• CO2 is used - non-combustible and rapidly absorbed
• Peritoneal entry is at the midline near the umbilicus (supraumbilical or infraumbilical)
• Two methods:
  • Closed technique: Veress needle inserted blindly, CO2 insufflated, then replaced with a trocar
  • Open (Hasson) technique: trocar inserted under direct vision via a small incision before insufflation
• Target intra-abdominal pressure: typically 12-15 mmHg

Step 3: Port Placement (Standard 4-Port)

• A 30- or 45-degree angled laparoscope is preferred over 0-degree for better visualization
• The patient is placed in reverse Trendelenburg (30 degrees) and tilted left 15 degrees so the colon and duodenum fall away from the liver

Step 4: Gallbladder Exposure and Retraction

• The fundus is grasped and retracted cephalad (toward the right shoulder, over the superior edge of the right liver lobe)
• The infundibulum/Hartmann's pouch is grasped and retracted inferolaterally - this is the key maneuver
• Inferolateral traction on the infundibulum opens the triangle of Calot and exposes the hepatocystic triangle
• If the gallbladder is acutely distended, needle aspiration or an angiocatheter through an RUQ stab incision decompresses it first
• Any adherent omentum, duodenum, or colon is gently peeled away by dissecting parallel to the gallbladder wall (not perpendicular)

Step 5: Dissection of the Hepatocystic Triangle (Triangle of Calot)

• The peritoneum on both the anterior and posterior aspects of the hepatocystic triangle is incised and cleared
• Fibrofatty tissue attaching the infundibulum to the liver is dissected free
• Dissection proceeds "stay on the gallbladder" - always keep close to the gallbladder wall to avoid bile duct injury
• The Calot node (cystic lymph node) overlies the cystic artery and serves as a useful landmark; dissection should stay on the gallbladder side of this node
• The cystic duct is separated anteriorly from the cystic artery behind using a Maryland grasper (gently opening the jaws between duct and artery)

Step 6: Critical View of Safety (CVS)

1. The hepatocystic triangle is completely cleared of fat and fibrous tissue
2. The lower one-third of the gallbladder is dissected free from the liver (cystic plate visible)
3. Only two structures are seen entering the gallbladder (cystic duct and cystic artery)

• If CVS cannot be achieved, perform intraoperative cholangiogram (IOC) or consider bailout (subtotal cholecystectomy or conversion to open)
• Fluorescence cholangiography (ICG/NIR) is available at many centers for real-time biliary anatomy identification

Step 7: Clipping and Division of Cystic Duct and Artery

• The cystic duct is clipped at its junction with the gallbladder (1 clip proximally, 2 clips distally) and divided between clips
• The cystic artery is similarly double-clipped proximally and divided
• The duct is divided close to the gallbladder, leaving adequate length of stump
• IOC can be performed via the cystic duct before division if anatomy is unclear or choledocholithiasis is suspected

Step 8: Dissection of the Gallbladder from the Liver Bed

• The gallbladder is dissected off the gallbladder fossa using electrocautery (hook or spatula)
• Dissection proceeds in the avascular plane between the gallbladder serosa and the liver
• Hemostasis of the liver bed is achieved with electrocautery
• The area is inspected for bile leak or bleeding

Step 9: Specimen Retrieval

• The gallbladder is placed in an extraction bag (endobag) to prevent bile/stone spillage
• It is extracted through the umbilical (12-mm) port
• If the gallbladder is too large, the incision may be extended
• Spilled bile and stones must be retrieved - lost stones can cause late perihepatic abscess

Step 10: Final Inspection and Port Closure

• The operative field is irrigated and inspected for hemostasis and bile leak
• The cystic duct stump and artery clips are confirmed in position
• Pneumoperitoneum is released
• Fascia at the 10-12 mm umbilical port is closed (fascial closure required for ports >10 mm to prevent port-site hernia)
• Skin incisions are closed with absorbable sutures or skin glue

Key Safety Principles

When to Convert to Open

• Inability to obtain CVS after adequate dissection
• Unclear anatomy at the porta hepatis
• Suspected bile duct injury
• Uncontrolled bleeding
• Dense adhesions from prior surgery
• End-stage liver disease with portal hypertension

Conversion is not a complication - it is sound surgical judgment and should be discussed with the patient preoperatively.