The cystic artery is cleared for a 1-cm zone and its path followed onto the surface of the gallbladder. The clear zone is then doubly secured with metal clips both proximally and distally (Figure 13). The cystic artery may be divided with endoscopic heavy scissors. However, many prefer to wait until after the cystic duct cholangiogram, as the intact cystic artery may serve as a helpful tether should the cystic duct be transacted during its opening for the cholangiogram catheter.
The cystic duct is also cleared for about 2 cm or so such that the surgeon can clearly identify its continuity with the gallbladder and its junction with the common duct. A metal clip is applied as high as possible on the cystic duct where it begins to dilate and form the gallbladder. If a cholangiogram is not to be performed, then two clips are placed on the proximal cystic duct and the duct is divided. If a cholangiogram is to be performed, the surgeon should be certain that all the equipment is available. This includes a catheter of choice, two syringes (one for saline and one for contrast), a stopcock for the syringes, and extension tubing. All of the air must be emptied from the tubing prior to performing the cholangiogram. In preparation for insertion of the cholangiocath, using the endoscopic scissors through the middle port (Figure 14), the cystic duct is opened and bile is noted. If necessary, the opening may be dilated with the scissor tips. The cholangiogram catheter of choice is passed through the middle port and the duct cannulated (Figure 15). Some catheters are secured within a winged clamp, whereas others rely on an inflated intraluminal Fogarty-like balloon. A simple straight plastic catheter may be secured with a gently applied metal clip over the lower cystic duct containing the catheter. It should be snug enough to prevent leakage but loose enough to avoid crimping the catheter and thus preventing dye injection. Alternatively, a 14-guage angiocath is inserted into the abdominal wall between the midclavicular trocar and that in the anterior axillary line. A 4 French ureteral catheter or other similar catheter may be inserted into the abdominal cavity through this angiocath and then guided into the cystic duct and held in place with a clip.
In preparation for the cholangiogram, the videoscope and metal instruments are removed. The radiolucent ports are aligned in a vertical axis so as to minimize their appearance on the x-ray. The field is covered with a sterile towel and the x-ray equipment positioned. Simple dye injections with individual films or a sustained injection under fluoroscopy are performed. The principal ducts are visualized thus ensuring anatomic integrity, the absence of ductal stones, and flow into the duodenum. Upon completion of a satisfactory cholangiogram, the lower cystic duct is doubly clipped and the cystic duct divided with endoscopic scissors (Figure 16). However, should an abnormal or confusing cholangiogram be obtained, the surgeon should convert to an open procedure with full anatomic verification.
The cystic duct junction with the gallbladder is grasped with forceps through the middle port and the gallbladder is removed from its bed beginning inferiorly and carrying the dissection up the gallbladder fossa. Most surgeons score the lateral peritoneum for a centimeter or so with electrocautery (Figure 17) and then elevate the gallbladder from the liver bed. Appropriate traction, often to the sides, is required to provide exposure of the zone of dissection with an electrocautery instrument between the gallbladder and its bed (Figure 18). Vigorous traction with the forceps or dissection into the gallbladder wall may produce an opening with spillage of bile and stones. Such openings should be secured if possible using forceps, metal clips, or a suture loop, which is first placed over the forceps and then closed like a lasso over the hole and the adjacent gallbladder wall that is tented up by the forceps.