Plate 94

As the dissection proceeds well up the gallbladder bed, it may be necessary for the first assistant to actively position and reposition the two forceps on the gallbladder so as to provide good exposure for the surgeon. When the dissection is almost complete and traction on the gallbladder still allows superior displacement of the liver with a clear view of the gallbladder bed and operative site, the surgeon should reinspect the clips on the cystic duct and artery for their security and the liver bed for any bleeding sites. The region is irrigated with saline (Figure 19) and the diluted bile and blood are aspirated from the lateral gutter just over the edge of the liver. The final peritoneal attachments of the gallbladder are divided from the liver and the gallbladder is positioned above the liver, which has now fallen back inferiorly to its normal position.

The videoscope is removed from the umbilical port and inserted in the epigastric one. If a 5-mm port was used at the xiphoid site in order to reduce the incidence of incisional hernia, then a 5-mm laparoscope is substituted for the 10-mm scope. Consideration should be given to contain the gallbladder in a laparoscopic retrieval bag prior to removal, especially if the gallbladder is abnormal and there is a concern for malignancy, it is infected, or it has been opened.

A grasping forceps is passed through the umbilical port so as to pick up the end of the specimen in the region of the cystic duct or the specimen retrieval bag (Figure 20). This exchange may be somewhat disorienting to the surgeon and first assistant as left and right are now reversed in a mirror-image manner on the monitor screens. If the gallbladder stones are small, one is usually able to withdraw the gall-bladder, forceps, and umbilical port back out to the level of the skin where the gallbladder is grasped with a Kelly clamp (Figure 21). Bile and small stones may be easily aspirated whereupon the gallbladder will exit easily through the umbilical site under direct vision of the videoscope in the epigastric port.

Extraction of large stones or many medium-sized stones may require crushing prior to extraction (Figure 22) or require that the linea alba opening be enlarged. After extraction, the umbilical site is temporarily occluded with the assistant's gloved finger so as to maintain the pneumoperitoneum. The middle and lateral ports are removed as the videoscope inspects for any bleeding at these sites. The videoscope is removed and the pneumoperitoneum is evacuated so as to lessen postoperative discomfort.

The operative sites are infiltrated with a long-acting local anesthetic (bupivacaine) (Figure 23), and the fascia at the 10-mm port sites is resutured with one or two absorbable sutures (Figure 24). The skin is approximated with absorbable subcutaneous sutures. Adhesive skin strips and a dry sterile dressing are applied.

The orogastric tube is removed in the operating room prior to emergence from general anesthesia. Pain at the operative site is usually well controlled with oral medications. Although patients have some transient nausea, most are able to take oral liquids within 6 to 8 hours and may be discharged home within one day. Follow-up by the surgeon is important, as biliary injuries are often occult and delayed in presentation. Prolonged or new, unexpected pain should be evaluated with physical examination, laboratory tests, and a HIDA radionuclide scan.