1. LAPAROSCOPIC CHOLECYSTECTOMY CARA LAWRENCE UNIVERSITY OF KENTUCKY COLLEGE OF MEDICINE

2. Symptoms pain located URQ to upper middle of the abdomen.
Pain occurs within minutes of a meal
clay colored stools
Jaundice (obstructive/conjugated)
Nausea
Vomiting
Mild fever

3. Work up
Blood tests:
Amylase and Lipase- digestive enzymes made by the pancreas
Bilirubin- jaundice (typically measures both BC/BU)
CBC
Liver function
Abdominal Ultrasound
Abdominal CT scan
Abdominal X-ray
Oral cholecystogram -Eat high fat meal at noon, low fat meal at night, take tablets and then NPO until the x-ray the next day
Gallbladder radionuclide scan- 1-2 hr scan that takes pictures to detect inflammation or gallstones
Useful for detecting gallstones and location

4. Abdominal Ultrasound Example
From St. Luke’s Health System Resource Library

5. Diagnosis1 Acute/Chronic cholecystitis:
Cholelithiasis -90% of cases & often obstruction of the cystic duct, in chronic it is not understood if gall stones are what first initiate symptoms
Rarely tumors: cholangiocarcinoma freq: 0.6/100,000 malignancy of the biliary tree
Biliary dyskinesia: (chronic acalculous gallbladder disease)

6. Diagnosis1 Cholelithiasis (gallstones)- 10-20% of the population
Pigment stones and Cholesterol stones
Women 2x more likely to have, aging also plays a role
Choledocholithiasis- if gallstone(s) located in the common bile duct
From Telepathology.com

7. Laparoscopic Cholecystectomy
Advantages
Contraindications2
Gall Bladder or Bile duct tumors
Portal Hypertension
Acute pancreatitis
Biliary fistula
Mirizzi’s Syndrome
Pregnancy in the final trimester
Cardiopulmonary or Coagulation disorders
Low mortality
Shorter hospital stay
Quicker recovery
Decreased cost

8. Instrumentation 2 or 3 5mm trocars 1 or 2 10mm trocars 10mm 30° scope
liver retractor/
grasper(s)
straight dissectors
clip applier
Scalpel and Suture
Metzenbaum Scissors
L-hook electrocautery
5 mm/10mm, irrigation & suction
Cholangiogram depending on location of stones
extraction bag

9. Structures to avoid Duodenum and colon on trocar placement
Common bile duct (2-7% chance of injury)
Common Hepatic Duct (can be mistaken for cystic artery in anatomical variations)
Liver and other instruments with L-Hook
Also note any variations such as an accessory hepatic ducts

10. Anatomy in the Operating Room
Falciform Ligament
Fundus of Gallbladder
Infindibulum of Gall bladder
Calot’s Triangle
Cystic Duct (connecting from Common Bile Duct)
Common Hepatic Duct
Liver
Cystic Artery (often arises from the right hepatic artery, but note that there are variations
Calot’s (Lund’s) Node

11. Operating Room Setup
Placed in a reverse Trendelenburg and tilted slightly to the left after insertion of optic trocar

12. Retrograde Laparoscopic Cholecystectomy Steps
Prep the patient
Placement of first trocar (midline navel)
Creation of Pneumoperitinium
Final Diagnosis (2 min 47 sec)
Place patient in Reverse Trendelenburg position slightly rotated to the left
Apply local anesthetics and 2-3 other trocars under visualization of scope (4 min 50 sec)

13. Trocar placement Surgical Trocar (both are often 5mm) Optical Trocar
Retraction of gall bladder/liver

14. Retrograde Laparoscopic Cholecystectomy Steps
Assistant grasps fundus of gallbladder and retract superiorly
Grasp infundibulum of the gallbladder (may need some dissecting)
Create tension by pulling slightly superior and laterally on the infundibulum of the gall bladder
Dissect Calot’s Triangle starting towards the infundibulum of the gall bladder and working your way to the common bile duct (12 min 51 sec)

15. Infundibulum of Gall Bladder
Cystic Artery
Cystic Duct

16. Retrograde Laparoscopic Cholecystectomy Steps
Using the gallbladder as point of reference, place 2 distal clips and 1 proximal clip along the cystic duct. (30 min 3 sec)
Divide making sure both jaws are visible to prevent vascular injury

17. Retrograde Laparoscopic Cholecystectomy Steps
Using the gallbladder as point of reference, place 2 distal clips and 1 proximal clip along the cystic artery. (39 min 21 sec)
Divide and cauterize/clip any necessary collateral arteries

18. Retrograde Laparoscopic Cholecystectomy Steps
Dissect away the posterior wall of the gall bladder using an L-Hook. Make sure L- hook does not come in contact with other instrumentation to prevent tissue damage
(45 min 9 sec)

19. Retrograde Laparoscopic Cholecystectomy Steps
Remove gallbladder via bag or trocar
Irrigate and Suction
Final visualization check
Deroofing of ovarian cyst (55 min 28 sec)
Irrigate and suction
Release of CO2 and steri-strip or suture trocar incisions

20. Post-operative care Transfer to PACU
Discharge typically within 24 hours
Post-operative pain can typically be relieved with OTC pain medications
Patient can resume normal daily activities in roughly 24 hours
Heavy lifting should be avoided for a few weeks
Watch for drainage, bleeding, swelling around incision sites, and for mild fever, as this could indicate complication

21. References
1. Kumar , V., Abbas, A., & Fausto, N. (7th Ed.). (2005). Robbins and Cotran: Pathologic basis of disease. Philidelphia, PA: Elsevier Saunders.
2. Kremer, K., Platzer, W., Schreiber, H., Steichen, F.M. (2001). Minimally Invasive Abdominal Surgery. New York, NY: Theime.
3. Berci, G., Nobuto, T., Phillips, E.H. (2008). A pocket atlas of laparoscopic surgery. Tuttlingen, Germany: Endo:Press.
4. Longstreth, G.F. (2009, July 6). Acute cholecystitis. Retrieved from
5. Swierzerski, III, S.J. (2001, November 1). Cholecystectomy: preoperative procedures, postoperative procedures, complications. Retrieved from