Plate 92

The CO2 source is attached to this port and the videoscope with its sterile light source cord inserted after white-balancing and focusing the system. Topical antifog solution is applied to the optical end of the telescope, which may be either angled (30 degrees) or flat (0 degrees) (Figure 7). A general examination of the intra-abdominal organs is performed taking special note of any organ pathology or adhesions. The finding of any trocar-related injuries to intra-abdominal viscera or blood vessels requires an immediate repair using advanced laparoscopic techniques or more commonly open laparotomy.

Three additional trocar ports are placed, using direct visualization of their sites of intra-abdominal penetration. The second 10-mm trocar port is placed in the epigastrium about 5 cm below the xiphoid, with its intra-abdominal entrance site being just to the right of the falciform ligament (Figure 8). Some surgeons use a 5-mm port at this site. Two smaller 5-mm trocar ports for instruments are then placed: one in the right upper quadrant near the midclavicular line several centimeters below the costal margin and another quite laterally at almost the level of the umbilicus. These sites may be varied according to the anatomy of the patient and the experience of the surgeon. The skin of each selected site is infiltrated with a long-acting local anesthetic. This needle can then be advanced into the peritoneal cavity under direct vision of the videoscope to verify proper positioning for the planned port. The skin is opened with a scalpel, hemostasis is obtained, and the subcutaneous fat is dilated with a small hemostat. The patient is placed in a mild (10 to 15 degrees) reverse Trendelenburg position, although some surgeons prefer to rotate the patient slightly to the left (right side up) for better visualization of the gallbladder region.

The apex of the gallbladder fundus is grasped with a ratcheted forceps (A) through the lateral port. The gallbladder and liver are then lifted superiorly (Figure 9). This maneuver provides good exposure of the undersurface of the liver and gallbladder. Omental or other loose adhesions to the gallbladder are gently teased away by the surgeon (Figure 9).

The infundibulum of the gallbladder is grasped with forceps (B) through the middle port. Lateral traction with the middle forceps exposes the region of the cystic duct and artery. Dissecting forceps (C) are used by the surgeon through the epigastric port to open the peritoneum over the presumed junction of the gallbladder and cystic duct (Figure 10). With gentle teasing and spreading motions, the cystic duct and artery are exposed (Figure 11). Each structure is exposed circumferentially. If possible both structures are dissected free and identified prior to clipping and division. It is helpful to obtain the critical view. To minimize bile duct injury the concept of the “critical view of safety” is helpful. In this technique, the neck of the gallbladder must be dissected off the liver bed (i.e., unfolding Calot's triangle) to achieve conclusive identification of the two structures to be divided: the cystic duct and cystic artery. In the classic view the liver is seen posterior to Calot's triangle (Figure 12).

The clear zone may be verified and elongated by sweeping back and forth (Figure 12). The importance of the second assistant manning the videoscope now becomes apparent. He or she must pull back and visualize the entrance of each new delicate instrument through the ports and then follow the instrument down to the area of dissection, which is maintained in the center of the field. Suitable magnification is controlled by the closeness of the videoscope to the dissection site. At this point, if the dissection is difficult because of inflammatory swelling and scarring, the surgeon should consider conversion to an open procedure.

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