1. LAPAROSCOPIC CHOLECYSTECTOMY

2. LAPAROSCOPIC CHOLECYSTECTOMY
1987 –
Phillipe Mouret, performed the first video-laparoscopic cholecystectomy in Lyons, France.

3. SURGICAL ANATOMY of GALL BLADDER

9. VARIATIONS IN CYSTIC ARTERY
75 PERCENT CASES ARISES FROM RT.HEPATIC ARTERY
25 PERCENT CASES VARIATIONS IN COURSE & ORIGIN OCCUR
ANTERIOR BRANCH IS THE MAIN BRANCH
LOOK FOR POSTERIOR BRANCH AFTER DIVISION OF CYSTIC DUCT

11. INDICATIONS SYMPTOMATIC GALL STONES
CLASSICAL BILIARY COLIC – POSTPRANDIAL FULLNESS
NONSPECIFIC SYMPTOMS
- FATTY FOOD INTOLERANCE
- FLATULENT DYSPEPSIA
- NONSPECIFIC ABDOMINAL PAIN OR DYSPEPSIA

12. 2. ACUTE CHOLECYSTITIS
CALCULUS / ACALCULOUS
3. ASYMPTOMATIC GALL STONES
PATIENTS WITH DIABETES MELLITUS
PATIENTS FOR RENAL TRANSPLANTATION

13. 4. BILIARY DYSKINESIA
with Classic Biliary Pain
5. GALLSTONE PANCREATITIS
6. POLYPS OF GALL BLADDER

14. Gall stones

15. PATIENTS NOT FIT FOR GENERAL ANESTHESIA
CONTRAINDICATIONS
PATIENTS NOT FIT FOR GENERAL ANESTHESIA
SEVERE PORTAL HYPERTENSION
BLEEDING DIATHESIS
CARCINOMA GALL BLADDER
NIH Consensus Conference 1992

16. RELATIVE CONTRAINDICATIONS
PREGNANCY
GENERALISED PERITONITIS
SEPTIC SHOCK FROM CHOLANGITIS
ACUTE PANCREATITIS

17. INDICATIONS FOR CONVERSION TO OPEN 1. ADHESIONS 2. CIRRHOTIC LIVER 3
INDICATIONS FOR CONVERSION TO OPEN ADHESIONS 2. CIRRHOTIC LIVER 3. THICKENED CONTRACTED GALL BLADDER 4. ABNORMAL ANATOMY 5. SEVERE CHOLECYSTITIS WITH FRIABLE G B 6. NO PROGRESS AFTER 15 MINS

18. FACTORS PREDICTING DIFFICULTY
ACUTE CHOLECYSTITIS
EMPYEMA GALL BLADDER
PREVIOUS ABDOMINAL SURGERY
CIRRHOSIS LIVER
AGE MORE THAN 65 YEARS
MALE PATIENT
OBESE PATIENTS B.M.I > 27.5

19. ULTRASONOGRAPHIC FACTORS
WALL THICKENING > 4 MM
CONTRACTED GALL BLADDER
PERICHOLECYSTIC COLLECTION
CALCULUS > 20 MM, PACKED G.B
STONE IMPACTED IN HARTMAN’S
C.B.D > 7 MM DIAMETER
EVIDENCE OF PANCREATITIS

20. PRE OPERATIVE EVALUATION
ROUTINE SURGICAL PROFILE & L F T
E.C.G & 2 D ECHO
U.S SCAN – SIZE OF STONES
THICKNESS OF G B WALL
4. E R C P H/O JAUNDICE
DILATED C B D & STONES
U G I SCOPY- COEXISTING D ULCER
ANY OTHER RELEVANT INVESTIGATION

21. ULTRASOUND EXAMINATION
calculus

22. Consent Form — Laparoscopic Cholecystectomy
Patient Name: ________________________________________________
I authorize Dr. ______________________________ to do laparoscopic cholecystectomy
I understand the reason(s) for the procedure is(are) _____________________________
Risks
The reason(s) for the procedure have been discussed with me. The usual risks, pains, and
benefits have been explained, and I know about the following problems which may occur:
(i) redness and/or swelling, infection in the tissue or bone around the area of the procedure
or other parts of the body; (ii) opening of incision or blood vessels after the procedure;
(iii) damage to nerves at or near the procedure area, numbness, pain or paralysis in body
organs may result; (iv) loss of blood requiring blood transfusion; (v) the heart may stop or a
heart attack may occur; (vi) blood vessels in the area of the procedure or elsewhere may plug;
(vii) pneumonia; and (viii) allergic reactions. These risks can be serious, extending hospital
stay, and can possibly be fatal.
The significant risks of this procedure include: damage to liver, bowel, bile ducts, or bile leak
(both higher than open surgery); retained stones; open cholecystectomy
Alternatives
Other methods of treatment, including not having this procedure done, have been discussed
with me and this is the method I have chosen.
Additional Procedures
I understand that during the procedure problems may arise. These problems may require a
procedure different than that listed above. If another procedure is needed, I authorize my
doctor to do whatever procedure is considered to be in my best interest.
Anesthesia
Risks and problems of anesthesia have been discussed including an allergic reaction which
may cause death. I consent to the use of such anesthetics as may be considered necessary.
Guarantee
I understand that no guarantee has been made and that the procedure may not cure my
condition.
I have been allowed to ask questions about the procedure. In addition, I have read this form
and/or it has been explained to me. I understand the risks and intend to have the procedure
done.
Date: ___________ Time: ___________ Signature: _______________________________
Witness: _________________________________ Relationship: _______________________
Physician’s Statement
The patient (guardian) and I have discussed the procedure, the risks, complications and
alternatives. To the best of my knowledge, the patient (guardian) understands the procedure
and consents to it.
Date: ___________ Physician’s Signature: _______________________________
NOTE: Any changes or strike-outs must be initialed by both patient(guardian) and physician.

23. EQUIPMENT HIGH DEFINITION CAMERA XENON LIGHT SOURCE
HIGH PRESSURE CO2 INSUFFLATOR
MEDICAL MONITOR
30 degree TELESCOPE
( HARMONIC SCALPEL )
TROLLEY

24. TROLLEY

25. INSTRUMENTATION

26. Veress Needle

27. TROCAR TIPS

28. TYPES OF VALVES Trumpet valve might damage distal tip Flap valve
Sealing lip / membrane valve
Magnetic Ball valve

29. OPTIVIEW TROCAR

30. 5mm TOOTHED GRASPER

31. 5mm Toothed Grasper
traumatic Grasper

32. DISSECTOR - GRASPER

33. ATRAUMATIC GRASPERS

34. SCISSORS

35. SCISSORS

36. ELECTRODES

37. 10-mm CLIP APPLICATOR

38. 10 mm Spoon Forceps

39. 10 mm toothed extractor

40. BIPOLAR FORCEPS

41. 3 PRONGED TISSUE RETRACTOR

42. PORT DILATOR

43. CLOSED VERESS NEEDLE METHOD OPEN HASSANS TECHNIQUE
POSITION OF PATIENT
SUPINE DEGREE
ANTI TRENDELENBERG
RIGHT SIDE UP
PNEUMOPERITONEUM
CLOSED VERESS NEEDLE METHOD
OPEN HASSANS TECHNIQUE
VISUAL TROCAR

44. PORTS POSITION
5mm
10mm
5mm
10mm

45. PORTS POSITION

46. HOLD THE FUNDUS WITH GRASPER
STEPS
HOLD THE FUNDUS WITH GRASPER
CRANIAL TRACTION IN MID CLAVICULAR LINE

47. DECOMPRESS THE G B IF GROSSLY DISTENDED

48. ADHESIOLYSIS
OMENTAL
COLONIC
HEPATIC
DUODENAL

49. OBESE PATIENT WITH INVISIBLE CALOT’S
PLACE THE PATIENT IN STEEP REVERSE TRENDELENBERG
INSERT AN EXTRA 5 MM TROCAR IN LEFT UPPER ABDOMEN
USE A FAN RETRACTOR / SUCTION CANNULA
PUSH DOWN THE DUODENUM & GREATER OMENTUM

50. DISSECT CALOTS TRIANGLE TO EXPOSE DUCT & ARTERY

51. ALWAYS START DISSECTION POSTERIORLY

52. LATERAL TRACTION OF HARTMANS

53. IDENTIFY THE JN OF HARTMANS WITH CYSTIC DUCT
( SAFETY ZONE )

54. IDENTIFY THE CYSTIC ARTERY-
SKELETONISE

55. MAKE A BIG WINDOW BEHIND THE HARTMANS POUCH
QUADRANGULAR SPACE

56. CLIP / LIGATE THE ARTERY & DUCT

57. DIVIDE THE ARTERY & DUCT

58. DETACH THE GALL BLADDER FROM BED

59. HOW TO USE A HOOK

60. PRINCIPLES OF BED DISSECTION
STAY AWAY FROM PORTA HEPATIS
HUG THE GALL BLADDER
DO NOT ENTER THE LIVER PARENCHYMA
AVOID PERFORATING THE GALL BLADDER
MINIMISE THE BILE & /OR CALCULI SPILLAGE

61. BEFORE FINAL DETACHMENT
INSPECT THE BED
BEFORE FINAL DETACHMENT

62. IRRIGATION OF BED & SUCTION WITH SALINE

63. SPECIMEN EXTRACTION -? PORT
UMBELICAL Vs EPIGASTRIC PORT
EPIGASTRIC PORT :
COSMETIC IN INDIAN WOMEN
CAN BE EASILY EXTENDED
TRACT CAN BE RINSED THOROUGHLY
CAN BE CLOSED EASILY
LESS INCIDENCE OF HERNIA

64. EXTRACT THE SPECIMEN
ENLARGE THE INCISION IF REQUIRED

65. SUCK BILE / REMOVE STONES TO DECOMPRESS
EXTRACT THE SPECIMEN
SUCK BILE / REMOVE STONES TO DECOMPRESS

66. INSPECT THE DIVIDED DUCT & ARTERY

67. DRAIN THRU MID AXILLARY PORT IF REQ

68. PORT CLOSURE ALL TROCARS REMOVED UNDER VISION
10 MM PORTS CLOSED WITH VICRYL 2826
PORT CLOSURE NEEDLE IN OBESE PATIENTS
SKIN CLOSURE WITH CLIPS
INJECT TROCAR SITES WITH BUPIVACAINE

69. COMPLICATIONS during surgery
BLEEDING
a. ABDOMINAL WALL
b. CALOT’S TRIANGLE
c. BED OF GALL BLADDER
2. SPILLAGE OF STONES / BILE / INFECTED BILE
3. INJURY TO VISCERA / BILIARY TREE

70. CONTROL OF ABD WALL BLEEDING
PREVENT BLEED BY IDENTIFYING VESSELS
( DIAPHONOSCOPY )
APPLY PRESSURE BY ANGULATING TROCAR
COMPRESS ABD WALL OVER TROCAR
PRESSURE WITH GUAZE SWAB
INJECT ADRENALINE (1:1000)
USE BIPOLAR ENERGY
TRANSFASCIAL SUTURING IF NECESSARY

71. DIAPHONOSCOPY

72. BLEEDING FROM CALOT’S TRIANGLE
RETRACT THE TELESCOPE FOR WIDER VIEW
COMPRESS THE BLEEDER WITH GUAZE
CLEAR THE CLOTS WITH SUCTION & IRRIGATION

73. BLEEDING FROM CALOT’S TRIANGLE
IDENTIFY BLEEDER & CLIP PRECISELY
BIPOLAR DIATHERMY CAN BE SAFELY USED
AVOID BLIND CLIPPING AND PARTIAL CLIPPING
LAPAROTOMY IF CONTROL MEASURES FAIL

74. CONTROL OF LIVER BED BLEEDING
*COMPRESS THE BLEEDING WITH GUAZE

75. CONTROL OF LIVER BED BLEEDING
*REMOVE THE GUAZE AFTER FEW MINUTES
*SUCTION IRRIGATION CANNULA ON LEFT HAND
*SPATULA IN THE RIGHT HAND
*DIATHERMISE WHILE GENTLE SUCTION

76. CONTROL OF LIVER BED BLEEDING
CLIP APPLICATION IS A WASTE OF TIME
*MINOR TEAR
-APPLY SPONGSTAN- COMPRESS & WAIT
*MAJOR TEAR
-CONVERT TO MINI LAPAROTOMY

77. CONTROL OF LIVER BED BLEEDING
-APPLY SURGICEL / SPONGSTAN-

78. POST OP BILIARY LEAK CYSTIC DUCT LEAK C B D INJURY
RIGHT HEPATIC DUCT INJURY
ACCESSORY BILE DUCT INJURY

79. SAGES GUIDELINES
Principles of the technique for laparoscopic cholecystectomy ·    
The cystic duct should be identified at its junction with the gallbladder
·     Traction of the gallbladder infundibulum should be lateral rather than cephalad
·     Meticulous dissection of the cystic duct and cystic artery is essential
·     All energy sources may cause occult injury
·     Perforations of the gallbladder should be controlled to prevent loss of stones
·     Spilled stones should be retrieved if possible and irrigation is useful for small stones and bile
·     Biliary tract imaging should be applied liberally to identify surgically important anomalies, clarify difficult anatomy, and detect common bile duct stones(3)
The surgeon should convert to open operation for unresolvable technical difficulties or anatomic uncertainties or anomalies, especially in cases of acute cholecystitis

80. Principles of the technique for laparoscopic cholecystectomy ·
SAGES GUIDELINES
Principles of the technique for laparoscopic cholecystectomy ·    
The cystic duct should be identified at its junction with the gallbladder
·     Traction of the gallbladder infundibulum should be lateral rather than cephalad
·     Meticulous dissection of the cystic duct and cystic artery is essential
·     All energy sources may cause occult injury
·     Perforations of the gallbladder should be controlled to prevent loss of stones
·     Spilled stones should be retrieved if possible and irrigation is useful for small stones and bile
·     Biliary tract imaging should be applied liberally to identify surgically important anomalies, clarify difficult anatomy, and detect common bile duct stones(3)
The surgeon should convert to open operation for unresolvable technical difficulties or anatomic uncertainties or anomalies, especially in cases of acute cholecystitis

81. SAGES GUIDELINES
Principles of the technique for laparoscopic cholecystectomy ·    
The cystic duct should be identified at its junction with the gallbladder
·     Traction of the gallbladder infundibulum should be lateral rather than cephalad
·     Meticulous dissection of the cystic duct and cystic artery is essential
·     All energy sources may cause occult injury
·     Perforations of the gallbladder should be controlled to prevent loss of stones
·     Spilled stones should be retrieved if possible and irrigation is useful for small stones and bile
·     Biliary tract imaging should be applied liberally to identify surgically important anomalies, clarify difficult anatomy, and detect common bile duct stones(3)
The surgeon should convert to open operation for unresolvable technical difficulties or anatomic uncertainties or anomalies, especially in cases of acute cholecystitis

82. SAGES GUIDELINES
Principles of the technique for laparoscopic cholecystectomy ·    
The cystic duct should be identified at its junction with the gallbladder
·     Traction of the gallbladder infundibulum should be lateral rather than cephalad
·     Meticulous dissection of the cystic duct and cystic artery is essential
·     All energy sources may cause occult injury
·     Perforations of the gallbladder should be controlled to prevent loss of stones
·     Spilled stones should be retrieved if possible and irrigation is useful for small stones and bile
·     Biliary tract imaging should be applied liberally to identify surgically important anomalies, clarify difficult anatomy, and detect common bile duct stones(3)
The surgeon should convert to open operation for unresolvable technical difficulties or anatomic uncertainties or anomalies, especially in cases of acute cholecystitis

83. SAGES GUIDELINES
Principles of the technique for laparoscopic cholecystectomy ·    
The cystic duct should be identified at its junction with the gallbladder
·     Traction of the gallbladder infundibulum should be lateral rather than cephalad
·     Meticulous dissection of the cystic duct and cystic artery is essential
·     All energy sources may cause occult injury
·     Perforations of the gallbladder should be controlled to prevent loss of stones
·     Spilled stones should be retrieved if possible and irrigation is useful for small stones and bile
·     Biliary tract imaging should be applied liberally to identify surgically important anomalies, clarify difficult anatomy, and detect common bile duct stones(3)
The surgeon should convert to open operation for unresolvable technical difficulties or anatomic uncertainties or anomalies, especially in cases of acute cholecystitis

84. SAGES GUIDELINES
Principles of the technique for laparoscopic cholecystectomy ·    
The cystic duct should be identified at its junction with the gallbladder
·     Traction of the gallbladder infundibulum should be lateral rather than cephalad
·     Meticulous dissection of the cystic duct and cystic artery is essential
·     All energy sources may cause occult injury
·     Perforations of the gallbladder should be controlled to prevent loss of stones
·     Spilled stones should be retrieved if possible and irrigation is useful for small stones and bile
·     Biliary tract imaging should be applied liberally to identify surgically important anomalies, clarify difficult anatomy, and detect common bile duct stones(3)
The surgeon should convert to open operation for unresolvable technical difficulties or anatomic uncertainties or anomalies, especially in cases of acute cholecystitis

85. SAGES GUIDELINES
Principles of the technique for laparoscopic cholecystectomy ·    
The cystic duct should be identified at its junction with the gallbladder
·     Traction of the gallbladder infundibulum should be lateral rather than cephalad
·     Meticulous dissection of the cystic duct and cystic artery is essential
·     All energy sources may cause occult injury
·     Perforations of the gallbladder should be controlled to prevent loss of stones
·     Spilled stones should be retrieved if possible and irrigation is useful for small stones and bile
·     Biliary tract imaging should be applied liberally to identify surgically important anomalies, clarify difficult anatomy, and detect common bile duct stones
The surgeon should convert to open operation for unresolvable technical difficulties or anatomic uncertainties or anomalies, especially in cases of acute cholecystitis

86. Principles of the technique for laparoscopic cholecystectomy ·
SAGES GUIDELINES
Principles of the technique for laparoscopic cholecystectomy ·    
The cystic duct should be identified at its junction with the gallbladder
·     Traction of the gallbladder infundibulum should be lateral rather than cephalad
·     Meticulous dissection of the cystic duct and cystic artery is essential
·     All energy sources may cause occult injury
·     Perforations of the gallbladder should be controlled to prevent loss of stones
·     Spilled stones should be retrieved if possible and irrigation is useful for small stones and bile
·     Biliary tract imaging should be applied liberally to identify surgically important anomalies, clarify difficult anatomy, and detect common bile duct stones
The surgeon should convert to open operation for unresolvable technical difficulties or anatomic uncertainties or anomalies, especially in cases of acute cholecystitis

87. THANK YOU
THANK YOU
THANK YOU