When assistance is limited, an external ring self-retaining retractor with adjustable retracting blades (such as a Bookwalter type) may be used advantageously, or an ordinary retractor of the Halsted type may be used on the right side to retract the costal margin. A half-length clamp is applied to the falciform ligament and another to the fundus of the gallbladder (Figure 4). Most surgeons prefer to divide the falciform ligament between half-length clamps, and both ends should be ligated; otherwise, active arterial bleeding will result. Downward traction is maintained by the clamps on the fundus of the gallbladder and on the round ligament. This traction is exaggerated with each inspiration as the liver is projected downward (Figure 4). After the liver has been pulled downward as far as easy traction allows, the half-length clamps are pulled toward the costal margin to present the undersurfaces of the liver and gallbladder (Figure 5). An assistant then holds these clamps while the surgeon prepares to wall off the field. If the gallbladder is acutely inflamed and distended, it is desirable to aspirate some of the contents through a trocar before the half-length clamp is applied to the fundus; otherwise, small stones may be forced into the cystic and common ducts. Adhesions between the undersurface of the gallbladder and adjacent structures are frequently found, drawing the duodenum or transverse colon up into the region of the ampulla. Adequate exposure is maintained by the assistant, who exerts downward traction with a warm, moist sponge. The adhesions are divided with curved scissors until an avascular cleavage plane can be developed adjacent to the wall of the gallbladder (Figure 6). After the initial incision is made, it is usually possible to brush these adhesions away with gauze sponges held in thumb forceps (Figure 7). Once the gallbladder is freed of its adhesions, it can be lifted upward to afford better exposure. In order that the adjacent structures may be packed away with moist gauze pads, the surgeon inserts the left hand into the wound, palm down, to direct the gauze pads downward. The pads are introduced with long, smooth forceps. The stomach and transverse colon are packed away, and a final gauze pack is inserted into the region of the foramen of Winslow (Figure 8). The gauze pads are held in position either by a large S retractor along the lower end of the field or by the left hand of the first assistant, who, with fingers slightly flexed and spread apart, maintains moderate downward and slightly outward pressure, better defining the region of the gastrohepatic ligament.