General anesthesia with endotracheal intubation is recommended. Preoperative prophylactic antibiotics for anticipated bile pathogens are administered such that adequate tissue levels exist.
Because 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. An orogastric tube should be placed for gastric decompression prior to initial insufflation.
The abdomen is palpated to find the liver edge or unsuspected intra-abdominal masses. The patient is placed supine, and an appropriate site for creation of the pneumoperitoneum is chosen. The initial port may be placed by an open, or Hasson, technique, which is preferred. Alternatively, especially in obese patients, a Veress needle technique is used, as described below. In the unoperated abdomen, this can be at the level of the umbilicus (FIGURE 2), but the safest place is Palmer’s point in the left upper quadrant, which is 2–3 cm below the left costal margin in the midclavicular line, especially in patients with previous laparotomy incisions and presumed adhesions. A 0.5- to 1.0-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 and is inserted 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 aspiration and 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 (see Chapter 13) if any difficulty is experienced with placement, irrigation, or insufflation with the Veress needle. The appropriate tubing and cables for the carbon dioxide (CO2) insufflation, the fiberoptic 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 1–2 L/min with a low-pressure limit of approximately 5–7 cm H2O. Once 1–2 L of CO2 are in, the ...