George Crawford, MD

Laparoscopic Cholecystectomy

Liver Image

 

 

 

Procedure Overview

Pre-operative
 Patient Care

Prep & Patient Positioning

Operative Steps

Post-operative
 Patient Care

 

 

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:
 

  • Bilary 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)

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Surgeon Image

 

 

 

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.)

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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

 

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Lap Chole Port Placement Image

 

Operative Steps
 

1. 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.

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2. Repair

  • The gallbladder is retracted superiorly and lateral.
  • Electrocautery as well as blunt dissection is used to identify the Triangle of Calot.
Repair Step 1 Image

 

 

  • The cystic duct is identified. Two clips are placed proximally, and one is placed distally.
Repair Image

 

 

  • The cystic artery is identified. Two clips are placed proximally, and one is placed distally.
Repair Image

 

  • The cystic duct and the cystic artery are transected using scissors.
     
Repair Image

 

 

  • 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.
     

Repair Image

 

 

  • The gallbladder is placed in an endoscopic specimen retrieval bag and removed through the 12 mm port.

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Repair Image

 

 

3. Closure

  • A suture like a size 0 Vicryl™ Plus Antibacterial suture, is used to reapproximate the fascia of the umbilicus.
  • Commonly, a size 0 absorbable synthetic suture, like Vicryl™ Plus Antibacterial suture is used to close the fascia of the 12 mm trocar site.

     
Closure Image

 

 

  • 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.

 

  • The patient is extubated and taken to the recovery room.

     

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Closure Image


 

 

 

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.

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Additional resources

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