General anesthesia with endotracheal intubation is recommended. Preoperative prophylactic antibiotics for anticipated bile pathogens are administered such that adequate tissue levels exist.
As laparoscopic cholecystectomy makes extensive use of supporting equipment, it is important to position this equipment such that it is easily visualized by all members of the surgical team (figure 1).
The skin of the entire abdomen and lower anterior chest is prepared in the routine manner.
The abdomen is palpated to find the liver edge or unsuspected intra-abdominal masses. The patient is placed in a mild Trendelenburg position and an appropriate site for the creation of the pneumoperitoneum is chosen. The initial port may be placed by an open or Hasson technique which is preferred. Alternatively, a Veress needle technique is used as described below. In the unoperated abdomen this is usually at the level of the umbilicus (figure 2); however, previous laparotomy incisions with presumed adhesions may suggest a more lateral approach site which avoids the epigastric vessels (figure 2 at X). A 1-cm vertical or horizontal skin incision is made and the abdominal wall on either side of the umbilicus is grasped by the surgeon and first assistant either by thumb and forefinger or by towel clips so as to elevate the abdominal wall (figure 3). A Veress needle is held like a pencil by the surgeon who inserts it through the linea alba and peritoneum where a characteristic popping sensation is felt (figure 4). An unobstructed free intraperitoneal position for the Veress needle is verified by easy irrigation of clear saline in and out of the peritoneal space (figure 5) and by the hanging drop method where the saline in the translucent hub of the Veress needle is drawn into the peritoneal space when the abdominal wall is lifted.
If one does not obtain a free flow or an unobstructed saline irrigation, then the Veress needle may be removed and reinserted. In general it is safer to convert the umbilical site into the Hasson open approach (Chapter 11) if any difficulty is experienced with the placement, irrigation, or insufflation of the Veress needle. The appropriate tubing and cables for the CO2 insufflation, the fiber optic light source, and the laparoscopic videoscope with its sterile sheath are positioned as are the lines for the cautery or laser, suction, and saline irrigation. The pneumoperitoneum begins with a low flow of about 1 or 2 L/min with a low-pressure limit of approximately 5 to 7 cmH2O. Once 1 to 2 L of CO2 are in, the abdomen should be hyperresonant to percussion. The flow rate may be increased; however, the pressure should be limited to 15 cmH2O. Three to four ...