# Laparoscopic cholecystectomy

Laparoscopic cholecystectomy

Laparoscopic cholecystectomy is the procedure of  choice for the majority of  patients. The indications and preparation for cholecystectomy are the same whether it is performed by laparoscopy or by open technique. The patient is placed supine on the operating table. Following induction and maintenance of  general anaesthesia, the abdomen is prepared in a standard fashion. Pneumoperitoneum is established. The authors’ preference is to use an open subumbilical cut down with direct visualisation of the peritoneum to place the initial port. This port will function as the camera port. An angled telescope (30°) is preferred. Many surgeons prefer a ‘closed’ technique using a Janos Verres , 1903–1979, chest physician and chief  of  the Department of  Internal Medicine, The Regional Hospital, Kapuvar, Hungary . V erres needle to establish pneumoperitoneum (see Chapter 7 ). Recently , single-port laparoscopic cholecystectomy has been described. Proponents report decreased postoperative pain and improved cosmesis. However, systematic reviews have reported a higher failure rate, longer operative time and increased blood loss without any substantive benefits with the technique. Additional operating ports are inserted in the subxiphoid area and in the right subcostal area. The patient is placed in a reverse T rendelburg position slightly rotated to the left. This exposes the fundus of  the gallbladder, which is retracted towards the diaphragm. The neck of  the gallbladder is then retracted towards the right iliac fossa, exposing Calot’s trian - gle. The key , as in open surgery , is the identification and safe dissection of  Calot’s triangle ( Table 71.5 ). This area is laid wide open by dividing the peritoneum on the posterior and anterior aspects. The cystic duct is carefully defined, as is the cystic artery . T he gallbladder is separated from the liver bed for about 2 /uni00A0 cm to allow confirmation of  the anatomy . Unless there are specific indications, routine cholangiogram is not performed. However, if  doubt exists regarding the anatomy , cholangiogram is warranted. Real-time intraoperative imaging using indocyanine green (ICG) fluorescence cholangiography (with special scopes and imaging system) improves visualisa - tion of  the biliary tree during laparoscopic cholecystectomy and enables better visualisation and identification of  the biliary tree. It can be considered a means of  increasing the safety of laparoscopic cholecystectomy . This is likely to reduce risk of biliary duct injury . Once the anatomy is clearly defined and the triangle of  Calot has been laid wide open, the cystic duct and artery are clipped and divided. The gallbladder is then removed from its bed by sharp or cautery dissection and, once free, removed via the umbilicus in a retrieval bag. 

stones.
Further
Abdominal
Liver
History of
Risk of
evaluation
USG: CBD
function
cholangitis or
CBD
required
diameter
tests
pancreatitis
stones
Low,
Absent Normal
≤
6
/uni00A0
mm None
2–3%
Medium,
Present 2
×
8–10
/uni00A0
mm MRCP +/–
20–40%
normal
ERCP stone
extraction
High,
Present, with
2
×
≥
10
/uni00A0
mm MRCP +/–
50–80%
jaundice
normal
ERCP stone
extraction
ERCP , endoscopic retrograde cholangiopancreatography; MRCP ,
magnetic resonance cholangiopancreatography;
USG, ultrasonography.