Cholecystectomy techniques and postoperative problems

Operating room setup

Before beginning any procedure, the surgeon must ensure that all equipment is present and functional, which includes equipment for potentially necessary procedures such as cholangiography or need for conversion to laparotomy ( Box 36.1 ).

Port placement and exposure

Once pneumoperitoneum is obtained, a 5- or 10-mm port is placed in the periumbilical region. A 30-degree laparoscope is inserted, and the abdominal cavity is inspected. One 5-mm trocar is placed along the right anterior axillary line 2 centimeters below the costal margin. The other 5-mm port is placed at the midclavicular line on the right at the edge of the liver. A fourth port (5- or 10-mm) is placed in the subxiphoid region and should be placed 2 to 4 centimeters below the xiphoid depending on the location of the gallbladder and falciform ligament ( Fig. 36.1 ). A fifth port can be placed in the location deemed most appropriate for additional retraction, if necessary.

Dissection and critical view of safety

An atraumatic grasper is placed through the most lateral port and grasps the fundus of the gallbladder to retract it cephalad and laterally. This raises the liver edge and exposes the neck of the gallbladder and the porta. With the gallbladder retracted cephalad, a second atraumatic grasper is placed through the midclavicular port to manipulate the infundibulum of the gallbladder. Adhesions should be taken down until the gallbladder infundibulum can be seen. Retraction of the infundibulum caudally and to the right exposes the triangle of Calot. A cautery instrument placed through the xiphoid port opens the peritoneum in the triangle of Calot ( Fig. 36.2 ). This should be started at the edge of the gallbladder neck to avoid iatrogenic injury to aberrant hepatic vasculature or bile ducts. Dissection of the peritoneum is continued on both sides of the gallbladder 1 to 2 mm from the liver edge.

Attention is next turned to obtaining the critical view of safety (CVS). This technique has been shown to reduce the rates of iatrogenic bile duct injuries (see Chapters 32 and 42 ). In fact, a recent multisociety consensus statement recommended CVS for identification of the cystic duct and cystic artery during laparoscopic cholecystectomy, and when CVS was not attainable, a subtotal cholecystectomy should be performed rather than attempting a fundus-first approach (see Chapter 34 ).

Attachments at the neck of the gallbladder are dissected using a combination of blunt and cautery assisted dissection. It is useful to serially retract the infundibulum medially and laterally to fully dissect the triangle of Calot. Carrying dissection to the level of the common bile duct (CBD) is not indicated because this only increases the risk for iatrogenic injury. Blunt dissection with a Maryland grasper or right-angle grasper can help create a window behind the cystic duct by spreading in the avascular tissue. The gallbladder is dissected off the liver edge, exposing the cystic plate. The criteria for CVS have been met when (1) there are only two structures seen entering the gallbladder, the cystic duct and cystic artery; (2) the lower third of the cystic plate is exposed; and (3) tissue has been cleared from the hepatocystic triangle so that all structures can be clearly identified anteriorly and posteriorly ( Box 36.2 ). These views are demonstrated in Fig. 36.3 . If any question or doubt about the anatomy is encountered, a cholangiogram should be performed to reorient the surgeon (see Chapter 24 ).

Most surgeons attempt the CVS during laparoscopic cholecystectomy, but in practice it is rarely achieved. An evaluation of 160 online videos of laparoscopic cholecystectomy found only one video accomplished a passing CVS score. The safe cholecystectomy curriculum can be found free of charge at the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) website.

Completion of cholecystectomy

Once all critical anatomy is confirmed, the cystic artery and duct are clipped and divided. Care should be taken to avoid tenting the CBD with clips placed too distally on the cystic duct. The tips of the clip should be directly visualized to be free before closing to avoid inadvertent injury to other structures and ensure the clip completely occludes the artery or duct. If it is not possible to secure a clip completely across a structure, an Endoloop device can be used to ligate it. Scissors are used to divide the cystic artery and duct. In rare cases with a large inflamed cystic duct that cannot accommodate clips, endovascular staplers can be used to divide and secure the duct. These situations, however, should raise the level of concern regarding possible injury to the CBD, and the surgeon should consider intraoperative cholangiography if there is any concern whatsoever regarding the anatomy. Cautery is avoided for division because of the increased risk for necrosis resulting in clip slippage. The gallbladder is dissected off the cystic plate from the infundibulum to the fundus with electrocautery. Blindly placing clips, clamps, or cauterizing at this time risks causing hemorrhage or inadvertent injury to the hepatic blood supply, superficial biliary pedicles, or middle hepatic vein branches and should be avoided ( Fig. 36.4 ). Before completely freeing the gallbladder from the liver, the gallbladder is used for retraction to inspect the cystic plate for hemostasis and inspect that clips are still securely placed on the cystic duct and artery.

Specimen removal is performed through the periumbilical incision because it is easy to enlarge this incision to extract large gallstones. Bag extraction is performed with videoscopic visualization to ensure the bag does not rip and specimen contents are not lost. Spilled bile or debris should be completely irrigated and cleared with suction to prevent subsequent migration or abscess formation. The fascia of port sites greater than 10 mm are closed to prevent development of incisional hernias although some surgeons elect not to close the epigastric site because herniation is unlikely in that location.