George Crawford, MD
Laparoscopic Cholecystectomy
Procedure Overview
The gallbladder serves as a storage bin for bile, a digestive agent produced by the liver. Laparoscopic cholecystectomy is minimally invasive surgical removal of a gallbladder.
INDICATIONS & OBJECTIVES:
- Biliary Colic
- Cholelithiasis (gallstones in the gallbladder, commonly due to high cholesterol)
- Choledocholithiasis (gallstones in the common bile duct)
- Cholecystitis (inflammation of the gallbladder)
- Gallbladder Cancer
- Pancreatitis (Biliary)
Relevant Anatomy
Key anatomical structures and landmarks:
The Triangle of Calot (Hepatocystic Triangle) is anatomical space located near the porta hepatis. It is an area of focus during cholecystectomy.
The Triangle of Calot is defined by three structures:
- Superior: Inferior surface of the liver
- Lateral: Cystic Duct
- Medial: Common Hepatic Duct
The cystic artery normally resides within the Triangle of Calot.
Pre-operative Patient Care
Typical recommendations for pre-operative care may include, but are not limited to, any of the following:
- Abdominal ultrasound and liver function tests.
- HIDA\PIPIDA scan to evaluate for biliary dyskinesia.
- Nothing by mouth (NPO) for 8 hours before surgery.
- Cardiopulmonary evaluation as needed.
- Anesthesiology consultation as needed.
- Prophylactic antibiotics for patients with acute cholecystitis.
- Preoperative endoscopic retrograde cholangiopancreatography (ERCP) for patients with clinical, laboratory, or radiographic evidence of choledocholithiasis. (Some surgeons with advanced laparoscopy experience may prefer laparoscopic common duct exploration.)
Prep & Patient Positioning
Common patient positioning:
- The patient is supine with the arms perpendicular to the body or tucked to the side.
- The surgeon stands on the patient's left side, while the assistant stands on the patient's right.
Common port placement:
- Periumbilical/camera port
- Lateral subcostal
- Medial subcostal
- Subxiphoid port
Operative Steps
Access
Access
- Access is generally obtained by making an incision in the umbilicus.
- Usually, a 12 mm port is placed through the umbilical incision under direct visualization.
- The abdomen is insufflated.
- Generally, a subxiphoid 5mm trocar and two right subcostal trocars are placed.
- Any adhesions to the gallbladder are taken down using electrocautery or ultrasonic shears.
Repair
Repair
- The gallbladder is retracted superiorly and lateral.
- Electrocautery as well as blunt dissection is used to identify the Triangle of Calot.
- The cystic duct is identified. Two clips are placed proximally, and one is placed distally.
- The cystic artery is identified. Two clips are placed proximally, and one is placed distally.
- The cystic duct and the cystic artery are transected using scissors.
- The gallbladder is removed from the gallbladder fossa using electrocautery or an ultrasonic energy device such as HARMONIC™ 1100.
- Hemostasis is obtained while removing the gallbladder.
NOTE: Adjunctive hemostats such as SURGICEL SNoW™ or SURGICEL Powder™ may be used if the liver bed is oozing and where primary methods (energy, staples, sutures, or clips) are ineffective or impractical.
- The gallbladder is placed in an endoscopic specimen retrieval bag and removed through the 12 mm port.
Closure
Closure
- Commonly, a size 0 absorbable synthetic suture, like Vicryl™ Plus Antibacterial suture is used to close the fascia of the 12 mm trocar site.
- The remaining trocars are removed. The wounds are closed using synthetic absorbable suture, such as Monocryl™ Plus Antibacterial suture, and a topical skin adhesive such as DERMABOND™ MINI™ Topical Skin Adhesive, or any appropriate dressing.
Post-operative Patient Care
Typical recommendations for post-operative care may include, but are not limited to, any of the following:
- Discharge home as this is usually an out-patient procedure.
- Follow-up with surgeon in 1-3 weeks.
- Pain Medication as prescribed.
- Nausea Medication if necessary.
- Instructions per protocol.
Additional resources
