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Laparoscopic Cholecystectomy - Operative Notes Interpretation

From your handwritten notes (transcribed):

• Position: Prone + ... (likely Supine in reverse Trendelenburg - standard for lap chole; the "p & b" likely refers to positioning details)
• Incision: Port placement
• Procedure:
  • GB distended, long c̄ (with) stone in Hartmann's pouch
  • Dissection of Calot's triangle (△)
  • Ligation of cystic duct
  • Coagulation of cystic artery
  • GB dissected from GB fossa
  • Removal of GB
  • Closure of port c̄ (with) 2-0 Ethilon
  • Dressing

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Step-by-Step Explanation

1. Position & Setup

• Patient is placed supine in steep reverse Trendelenburg (head-up, feet down), tilted slightly to the left.
• This displaces bowel away from the upper abdomen and improves visualization of the right upper quadrant.
• An orogastric tube decompresses the stomach for better field of view.
• General anesthesia with muscle relaxation is mandatory.

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2. Port Placement (Incision)

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3. Findings: GB Distended + Stone in Hartmann's Pouch

• The gallbladder was distended - consistent with obstruction (acute cholecystitis or biliary colic with impacted stone).
• A stone in Hartmann's pouch (the infundibulum, the widest part of the GB just before the cystic duct) is a common cause of obstruction.
• The fundus is grasped with the lateral port instrument and retracted cephalad toward the right shoulder.
• The infundibulum is grasped with the midclavicular port instrument and retracted inferolaterally - this opens up Calot's triangle.

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4. Dissection of Calot's Triangle (△)

• Calot's triangle (hepatocystic triangle) is bounded by:
  • The cystic duct (inferiorly)
  • The common hepatic duct (medially)
  • The inferior surface of the liver (superiorly)
• Fibrofatty tissue is cleared from this triangle until a Critical View of Safety (CVS) is achieved.
• CVS criteria (Strasberg):
  1. Only 2 structures are seen entering the gallbladder
  2. The lower 1/3 of the gallbladder is dissected free from the liver (cystic plate visible)
  3. The hepatocystic triangle is cleared of fat and fibrous tissue
• The Calot's node (lymph node) overlies the cystic artery and serves as a useful landmark.
• This step is the most critical for preventing common bile duct (CBD) injury - the most feared complication of lap chole.

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5. Ligation of Cystic Duct

• Once CVS is confirmed, the cystic duct is clipped with metal or absorbable clips (typically 2 clips proximally, 1 distally).
• The duct is then divided between the clips.
• If stones are present in the cystic duct (as here with the Hartmann's pouch stone), gentle milking proximally or additional clips may be needed.
• An intraoperative cholangiogram (IOC) can be performed through the cystic duct at this stage if anatomy is unclear.

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6. Coagulation of Cystic Artery

• The cystic artery (usually a branch of the right hepatic artery) runs in Calot's triangle.
• It is identified, clipped, and divided - often with diathermy/cautery as noted ("coagulation").
• Variant anatomy is common: the cystic artery may be duplicated or arise anomalously - careful identification before division is essential.

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7. GB Dissected from GB Fossa

• Using hook diathermy or ultrasonic dissector, the gallbladder is dissected off the hepatic (gallbladder) fossa in a retrograde fashion.
• The plane is just below the GB serosa, keeping close to the gallbladder wall to avoid liver bleeding.
• Any bile leakage from the fossa (Luschka ducts) is coagulated.

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8. Removal of GB

• The gallbladder is removed through the umbilical port (largest, 10-12 mm).
• If the specimen is large or stones are numerous, an endobag (retrieval bag) is used to prevent port-site contamination and stone spillage.
• The abdomen is inspected for bleeding and bile spillage, and the operative field is irrigated if needed.

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9. Closure of Port with 2-0 Ethilon

• 2-0 Ethilon = non-absorbable monofilament nylon suture.
• The 10-12 mm umbilical port fascia is closed with this to prevent port-site hernia.
• 5-mm port sites typically only need skin closure.
• Skin is closed (usually with subcuticular absorbable suture or skin clips).

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10. Dressing

• Standard adhesive dressings applied to all port sites.

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Key Complications to Know

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