StayCurrent Forums - Laparoscopic Cholecystectomy

For non-obese patients, Hassan technique is used for initial umbilical port placement; for patients with BMI over 32-35, Veress technique is preferred to avoid a large incision.

The epigastric port is placed last because it is the most important port in terms of angle for reaching the gallbladder and serves as the surgeon's right hand.

Dense omental adhesions to the gallbladder should be taken down using traction and low-wattage cautery at the junction of omentum with other structures, sometimes requiring harmonic shears if bleeding occurs.

Omental adhesions must be taken down completely off the gallbladder and away from the cystic duct and artery area, otherwise they will tether the right lobe of the liver and make exposure difficult.

Modified top-down dissection should start about one-third of the way up from the bottom of the gallbladder, staying right on the gallbladder wall.

Dissection should alternate between medial and lateral aspects of the gallbladder ('waving the flag') to achieve good three-dimensional visualization from both sides.

An angled laparoscope is essential for adequate visualization during laparoscopic cholecystectomy; zero-degree laparoscopes are inadequate.

The critical view of safety must be achieved before any irreversible steps such as clipping or cutting structures.

Keeping dissection symmetrical on both ventral and lateral sides of the gallbladder provides much more freedom to dissect underneath and move the gallbladder around, compared to staying on the ventral side for 99% of dissection.

Intraoperative ultrasound can be performed multiple times during a difficult case to identify where the gallbladder ends and where the bile duct is in relation to the dissection when the critical view of safety is difficult to achieve.

Irrigation-suction can be used as a blunt dissecting instrument (kittner dissection) in the surgeon's right hand to push along the gallbladder wall when there is significant blood or bile obscuring the field.

Indocyanine green fluorescence has limited utility in severely inflamed gallbladder cases because tissue characteristics prevent adequate visualization of the duct, and if given too early, everything appears uniformly bright green.

For the critical view of safety, all fatty material, peritoneal tissue, and scar tissue holding the gallbladder neck and infundibulum to the liver must be divided so the gallbladder is an inch and a half away from surrounding structures.

If the critical view of safety cannot be achieved, cholangiography must be performed to better understand the ductal anatomy.

All residents should learn how to perform intraoperative cholangiography and laparoscopic ultrasound, even though these techniques add time and cost and are not always necessary.

Laparoscopic ultrasound allows visualization beyond the visible surfaces of the abdomen, which is particularly valuable given that laparoscopy only shows visible surfaces.

Indications for intraoperative cholangiography include uncertain anatomy, cystic duct stones, jaundice, and dilated bile duct on preoperative ultrasound.

Before clipping and dividing the cystic duct, place a clip on the gallbladder side, make a small incision in the cystic duct, and milk it backwards to check for stones in the cystic duct.

Cystic duct stones are one of the prime indicators that common bile duct stones are also likely present.

Chronically inflamed gallbladders are usually intrahepatic with no plane between the gallbladder and liver.

For intrahepatic gallbladders, use 'controlled avulsion' technique: strong traction on the gallbladder with the left hand pulling away from the liver, while the right hand barely touches the gallbladder-liver junction with low-wattage cautery to carve it out.

For gallbladder bed bleeding, use irrigation-suction in the left hand to clear smoke and blood while applying cautery with the right hand to bleeding areas; this controls bleeding 99% of the time.

A small bile leak from the middle of the gallbladder bed, when ductal anatomy is otherwise clear, is likely a duct of Luschka and should be managed with attempted suture repair, though the stitch is unlikely to hold.

A drain should be placed for suspected ducts of Luschka or when dissection is deep into the bed of an intrahepatic gallbladder, and the patient should be kept overnight to ensure no bile accumulation.

95% of laparoscopic cholecystectomy patients are discharged the same day.

Postoperative pain management includes intraoperative IV acetaminophen, 5 hydrocodone tablets for home use (patients should call if they need more), and ibuprofen or acetaminophen for the first few days.

Pain requiring more than 5 hydrocodone tablets after laparoscopic cholecystectomy indicates a problem and warrants evaluation.