Page 4 - Journal of Laparoscopic Surgery - WALS Journal

Aswini K Misro, Prakash Sapkota

Fig. 1: A schematic diagram depicting the epigastric port assembly.
Port 3 must be inserted through the existing epigastric wound but
through a separate stab with a different angle, pointing toward
Hartmann’s pouch

10 mm port is inserted through the later incision vertically
till it pierces the rectus sheath. (This will be referred Fig. 2: Epigastric port assembly (top view)
henceforth as port 2.) Afterward, a slight right side
angling of the port is done to bring it through the angle ment (preferably a Maryland introduced through
between falciform ligament and the anterior peritoneum. port 2), Calot’s triangle dissection is done. The traction
A 5 mm grasper (with reducer) is introduced through and dissection instruments are used interchangeably
port 2 and the fundus of the gallbladder is grasped and through ports 2 and 3 as per requirement. The rotational
traction is applied toward the right shoulder. This step freedom of port 3 around port 2 helps in traction and
displays the gallbladder anatomy in its entirety. Now an dissection to be done at various points and depth
intraoperative assessment is done to determine if two- (however, the rotation of the port should never be
port laparoscopic cholecystectomy can be done safely attempted with the instrument inside the port) (Figs 4
(patient suitability has been described in discussion). and 5). The cystic artery and duct are circumferentially
If conditions are found to be favorable, with the trac- skeletonized. With double clips placed on the body side
tion maintained as described earlier, a 5 mm port is and a single clip on the specimen side, both the structures
inserted through the existing epigastric skin incision are divided. This step is completed by traction through
(but through a separate stab traversing a different port 3 instrument and clip application through port 2.
path to the peritoneal cavity) little away from port 2 With continued traction applied to Hartmann’s pouch in
pointing toward Hartmann’s pouch of the gallbladder the upward and right direction (this open up the interface

(This will be referred henceforth as port 3.) (Figs 1 to 3). between the gallbladder and the gallbladder fossa of the
Prior to this step, the skin incision may be extended liver), the gallbladder is separated from the gallbladder
3 to 5 mm or more as required. fossa by electro-dissection with an appropriate instrument
Now appropriate traction is applied to the Hartmann’s (a monopolar hook, Maryland or scissor). Before the final
pouch in lateral direction by the port 3 instrument, and detachment of gallbladder from the liver, hemostasis of
this widens up the Calot’s triangle. With a suitable instru- the gallbladder bed is achieved and the cystic pedicle

Fig. 3: Epigastric port assembly (side view) Fig. 4: Intraoperative photograph demonstrating the right- and
left-hand instruments
2