Laparoscopic Cholecystectomy

Introduction

The skin is initially prepared with chlorhexidine from just below the nipple line to the inguinal ligaments and laterally to the anterior superior iliac spine. The operative field is then draped with sterile drapes.

Procedure

Placement of ports and instruments

A 1cm longitudinal incision is made at the inferior aspect of the umbilicus, then deepened through the subcutaneous fat to the anterior rectus sheath. A Kocher clamp is used to grasp the reflection of the linea alba onto the umbilicus and elevate it cephalad. A 1cm longitudinal incision is made in the linea alba with a No. 15 blade.

The peritoneum is elevated between two straight clamps and incised so as to afford safe entry into the abdominal cavity. An 11mm blunt Hasson trocar is placed into the abdominal cavity, and insufflation of carbon dioxide is initiated to a maximum pressure of 15mm Hg.

A 30° laparoscope as it gives better visualization of the cystic structures from multiple vantage points. A 30° scope requires a more skilled scope operator.

The laparoscope is advanced slowly into the abdominal cavity. A 5 mm incision is made three fingerbreadths below the xiphoid process and deepened into the subcutaneous fat. A 5 mm trocar is advanced into the abdominal cavity under direct vision in the direction of the gallbladder through the abdominal wall, with care taken to enter just to the right of the falciform ligament.

The table is then adjusted to place the patient in a reverse Trendelenburg position with the right side up to allow the small bowel and colon to fall away from the operative field.

A 5mm grasper is placed through the 5mm subxiphoid port and applied to the fundus of the gallbladder. The gallbladder is then elevated cephalad over the dome of the liver to facilitate the surgeon's choice of the optimal positions for the lateral 5-mm ports. After appropriate port sites are chosen, the lateral skin incisions are made, and 2 x 5mm are placed under vision.

Post-operative Instructions

Finally, the patient is extubated, transferred to the postanesthesia care unit, and monitored for 4-6 hours. In cases of elective cholecystectomy, the patient can be discharged home with a combination oral pain medication containing acetaminophen and an opiate.