Laparoscopic cholecystectomy

Why are we operating?

Removal of the gallbladder through ports, built around one idea: never divide a structure until the Critical View of Safety proves what it is.

Indication: Symptomatic gallstones, cholecystitis, biliary dyskinesia, gallstone pancreatitis after recovery.

The operation in 6 steps

1. 01Access & insufflation

   Pneumoperitoneum established (commonly at the umbilicus), then ports placed under vision.

   Why: CO2 lifts the abdominal wall off the viscera to create working space; every later step depends on this room to see and move.

2. 02Exposure

   The fundus is pushed over the liver edge toward the shoulder; the infundibulum is pulled laterally.

   Why: Lateral traction on the infundibulum opens the hepatocystic triangle; pulling upward instead aligns the cystic duct with the common bile duct, the set-up for the classic injury.

3. 03Critical View of Safety

   The hepatocystic triangle is cleared of fat and fibrous tissue until only two structures enter the gallbladder, and the lower third of the gallbladder is separated from its liver bed.

   Why: The Critical View is an identification standard, not a dissection technique: if three structures are visible, or the view cannot be achieved, the answer is to stop and reassess, not to clip and hope.

4. 04Clip & divide

   Cystic duct and cystic artery are each clipped (typically two proximal, one distal) and divided.

   Why: Clips only go on structures the Critical View has proven; the proximal double clip is insurance on the side that stays with the patient.

5. 05Gallbladder off the liver bed

   Diathermy dissection separates the gallbladder from the cystic plate, fundus-ward.

   Why: Staying in the avascular plane between gallbladder and liver keeps the field dry; straying into liver causes ooze that obscures everything downstream.

6. 06Extraction & closure

   Gallbladder retrieved in a bag through a port site; ports removed under vision; fascia of larger ports closed.

   Why: The bag keeps bile and stones out of the wound; closing 10 mm+ port fascia prevents the port-site hernias that follow shortcuts here.

Danger zones

• Common bile duct

  Inflammation shortens and tents the cystic duct until the common duct can masquerade as it; the classic injury is clipping and dividing the wrong duct with complete confidence.

• Right hepatic artery

  Often loops close to the cystic artery; injury can devascularise the right liver.

• Duodenum

  Sits just below the porta, thermal injury from diathermy can present days later as a leak.

Anatomy you need

Trace the biliary tree from gallbladder to ampulla; the pancreas is kept on because the common duct disappears into its head.

What can go wrong

• Bile leak

  Right upper quadrant pain, fever, and bilious drain output, or a patient who is simply failing to thrive after cholecystectomy.

• Postoperative bleeding

  Tachycardia first, hypotension late; falling urine output; a distending abdomen or rising drain output.

• Surgical-site infection

  Wound erythema, warmth, discharge, and pain out of proportion, typically from postoperative day 4–7.