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INDICATIONS

The most common indication for laparoscopic cholecystectomy (LC) is symptomatic cholelithiasis. Classic biliary colic is characterized by severe right upper quadrant (RUQ) postprandial and nocturnal pain radiating to the right scapula and epigastrium, associated with nausea, and an ultrasound showing gallstones. This constellation of symptoms and signs is found in more than 50% of patients referred for cholecystectomy. Other presentations include acute cholecystitis (fever, leukocytosis, RUQ peritoneal irritation), acalculous cholecystitis, choledocholithiasis, cholangitis, and biliary dyskinesia. It is rarely necessary to remove asymptomatic gallstones.

Contraindications to the laparoscopic approach include previous right upper quadrant surgery, severe chronic liver disease, gallbladder necrosis, suspected gallbladder cancer, or massive bowel distention (ileus). Patients with previous laparotomy may have few intraabdominal adhesions, or the adhesions may be dense. Because it is difficult to predict the presence of these adhesions, this is procedure often started laparoscopically, then converted to laparotomy if 30 minutes have passed without completing the dissection of the cystic duct and artery.

PATIENT POSITIONING

The patient is positioned supine on a fluoroscopic operating table. It is often necessary to reverse the table to make sure the post will not be in the way of an operative fluoroscopic cholangiogram. Ideally both arms are tucked, but the right arm may be left out. Leaving the left arm extended on an armboard will often interfere with the C arm, so is not recommended (Figure 1).

OPERATIVE PROCEDURE

A carbon dioxide pneumoperitoneum is obtained through a periumbilical incision with a Veress needle or an open laparoscopy technique. A 10-mm port is placed adjacent to the umbilicus, and a 30-degree forward oblique-viewing laparoscope is introduced. Under laparoscopic visualization, another 10-mm port is placed through the epigastrium. This port starts in the midline, but is then angled to the right to enter the peritoneal cavity at the inferior edge of the liver, just to the right of the falciform ligament, at the “corner” created by the reflection of the peritoneum onto the right side of the falciform ligament. Two 5-mm trocars are placed in the right subcostal region. The first of these is just to the right of the gallbladder fundus, as visualized laparoscopically. The surface projection of this point is usually 2 to 5 cm below the right costal margin, just lateral to the midclavicular line (MCL). The fourth and last trocar is placed in the anterior axillary line, at about the level of the umbilicus. In thin patients this port is moved inferiorly and in obese patients it is moved superiorly (Figure 2).

With an aggressive toothed 5-mm grasper (“gallbladder grasper”) entering through the most lateral 5-mm port, the fundus of the gallbladder ...

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