03 / General Surgery · laparoscopic
Laparoscopic cholecystectomy
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.
Read the imaging first
Practice before you scrub
Read the gallbladder
Fatty-food pain for months, now constant for 18 hours with fever. RUQ ultrasound. (Fictional educational case.)
- Stones plus an inflamed wall plus a tender probe is cholecystitis: the operation is laparoscopic cholecystectomy on this admission, not a deferred clinic date.
- The duct's calibre on the same scan sequences the pathway: dilated means the duct is interrogated before the gallbladder leaves.
On the tray for this operation
Test yourself on the tray
Trocar
Access channel through the abdominal wall for laparoscopic instruments.
Maryland dissector
Fine laparoscopic dissection, the curved-tip workhorse of the critical view.
Clip applier
Applying metal or polymer clips to close small ducts and vessels.
Electrosurgical pencil
Cutting and coagulating with high-frequency current.
Needle driver
Holding the curved needle while suturing.
Stage
1 / 6
Access & insufflation
Pneumoperitoneum established (commonly at the umbilicus), then ports placed under vision.
Watch for: Vascular or bowel injury during first entry · CO2 embolism (rare)
Why are we operating?
Cholecystectomy removes the organ that makes the stones rather than chasing the stones themselves: for symptomatic gallstone disease it ends the biliary colic, cholecystitis and pancreatitis the gallbladder keeps producing. Done laparoscopically it turned a week's admission into a day case, which is why it became the commonest elective abdominal operation.
Pulls toward surgery
Gives the team pause
Shared foundations
What the surgeon is thinking
Access & insufflation
Why insufflate the abdomen at all?
The pneumoperitoneum is the operation's exposure: carbon dioxide lifts the wall off the viscera and creates the working dome the camera and instruments need. Its physiology is not free, raised airway pressures and reduced venous return, which is why the pressure is a set number and the anaesthetist is told before the gas goes on.
Critical View of Safety
What is the Critical View of Safety actually for?
It is an identity check, not a milestone: two structures and only two entering the gallbladder, seen through a cleared triangle with the cystic plate exposed. The injury it prevents is the classic one, the common bile duct mistaken for the cystic duct, and the view exists so that nothing is clipped on assumption.
Clip & divide
Why do the clips wait for the view?
Because a clip is a decision that cannot be un-made cheaply. Everything before the Critical View is reversible dissection; the moment metal closes on a duct, the operation has committed to an anatomy. The discipline is that commitment follows proof, never momentum.
Gallbladder off the liver bed
Why is the plane on the gallbladder wall, not the liver?
The cystic plate is the fence between gallbladder and liver: stray liver-side and it bleeds and leaks bile from the bed; stray gallbladder-side and the specimen opens, spilling stones. Hugging the gallbladder keeps both neighbours honest.
Decision points
The triangle is fused and fibrotic, and the Critical View will not come. What now?
Bail out: subtotal cholecystectomy
Remove what is safe, leave the fused portion, drain: trades an elegant specimen for an intact bile duct.
Convert to open
A bigger incision buys tactile dissection, but does not itself make dangerous anatomy safe: conversion is a tool, not a rescue.
Press on laparoscopically
The wrong answer when the view is unobtainable: most major duct injuries are committed by persistence, not incompetence.
The safest cholecystectomy is sometimes an incomplete one: bail-out options exist precisely because no gallbladder is worth a common bile duct. Saying 'the view is not achievable' out loud is an operative skill.
The cholangiogram (or the pre-op MRCP) shows a stone in the common bile duct. How does it come out?
ERCP, before or after surgery
The commonest pathway: endoscopic clearance, with the cholecystectomy on the same admission.
Laparoscopic duct exploration
One anaesthetic, one admission, where the kit and the expertise exist.
Duct stones are a plumbing problem with two doors: which door depends on local expertise and timing more than dogma. What is not optional is the plan: a known duct stone left unaddressed is a cholangitis appointment.
Leaving the OR
The handoff
- Procedure
- Laparoscopic cholecystectomy for acute cholecystitis
- Findings
- Distended, inflamed gallbladder; Critical View achieved; no spillage
- Drains
- None; local anaesthetic to port sites
- Watch for
- Shoulder-tip gas pain vs real pain; bile in any vomit; fever or tachycardia past hour 6
A fictional educational patient, handed over the way real ones are.
The postoperative course
- RecoveryAwake and drinking within hours; shoulder-tip pain from diaphragmatic gas irritation is expected and self-limiting.
- Same day / POD 1Home when eating, walking and passing urine; day-case is the norm for elective disease.
- POD 2-7Port sites settle; increasing pain, fever or jaundice in this window says bile leak or retained stone, not normal recovery.
- Week 2+Back to normal activity; a fatty meal no longer has a debt collector.
Watch it done
Bail-out strategies for the difficult laparoscopic cholecystectomy
What to do when the critical view will not come: subtotal, fundus-first, or stop.
Source: SAGES · Watch on YouTube