Page 62 - World Journal of Laparoscopic Surgery

HOW WE DO IT
Laparoscopic Cholecystectomy: Tricks Learned over

a Decade and How We Do It

1
3
2
Balram Goyal , Sanjay Sharma , Bhasavan Nair Remani Devi Sreejith , Vivek Agrawal 4
Received on: 22 April 2023; Accepted on: 04 June 2023; Published on: 05 September 2023
AbstrAct
Cholelithiasis is one of common health issues and about 10–20% population harboring the calculi without any clinical features. Only one-fifth
of these asymptomatic individuals progress to develop clinical symptoms at a rate of around 5% per year. Laparoscopic cholecystectomy is
indicated for symptomatic patients and considered to be a “Gold Standard’’ treatment for the last three decades. It is the commonest abdominal
procedure performed globally in an elective setting. Myriad techniques have been evaluated with increasing experience, skills, need, and
availability of laparoscopic instruments. We have witnessed lots of modifications in creating pneumoperitoneum, dissection of Calot’s triangle,
division and securing cystic duct and artery, dissection of gallbladder (GB) from liver bed, retrieval of specimen, and port closure.
Here we are presenting our experience and modifications used over the last one and a half decades.
Keywords: Bile duct injury, Cirrhosis, Fundus first Approach, Gallbladder extraction, Laparoscopic cholecystectomy, Pneumoperitoneum.
World Journal of Laparoscopic Surgery (2023): 10.5005/jp-journals-10033-1554

MAteriAls And Methods 1 Department of Gastrointestinal Surgery, Command Hospital
The surgical procedure was performed by an experienced surgeon (Southern Command) Associated with Armed Forces Medical College,
at various tertiary care teaching centers. We have retrieved patient’s Pune, Maharashtra, India
medical records including intra-operative pictures and videos. We 2 Department of Surgical Gastroenterology, Army Hospital R & R,
also search for any difficulties, complications, any modifications Delhi, India
used during the procedure, from available patient records in both 3 Department of Gastrointestinal Surgery, Command Hospital Kolkata
digital and manual forms. 1,2 (Eastern Command), Kolkata, West Bengal, India
4
Department of Vascular Surgery, Command Hospital Air Force,
Tricks Used during Laparoscopic Cholecystectomy Bengaluru, Karnataka, India
Patient Position and Perioperative Antibiotics: The Patient was Corresponding Author: Balram Goyal, Department of Gastrointestinal
placed in a supine position and a single dose of third-generation IV Surgery, Command Hospital (Southern Command) Associated with
cephalosporin was used selectively just prior to intubation. Another Armed Forces Medical College, Pune, Maharashtra, India, Phone:
position like Davis Lloyd was used when this procedure was done +91 9599386202, +91 9401562326, e-mail: balramneetu.goyal@gmail.
with other surgery like sleeve gastrectomy, cystogastrostomy, and com
splenectomy. How to cite this article: Goyal B, Sharma S, Sreejith BNRD, et al.
Creation of Pneumoperitoneum Laparoscopic Cholecystectomy: Tricks Learned over a Decade and
How We Do It. World J Lap Surg 2023;16(1):61–66.
Usually, pneumoperitoneum is created by the open method Source of support: Nil
through a horizontal incision just above the umbilicus. In patients
with mid-line scar from previous surgery may lead to bowel injury Conflict of interest: None
to avoid this we used optic trocar through the epigastric area
which is vergin.
By using this we could place port safely without any bowel Extra Ports Placement in Difficult Cholecystectomy
and vascular injury. Globally most of the modifications that have been invented are
related to the number of ports placed. A three-port modification
Vertical Incision on Linea Alba to Retrieve is common among these. We have used three port techniques
Large Calculus in which the port used for fundus retraction is not placed. In
In the case of large gallbladder calculus (>20 mm) retrieval of our experience, it is only feasible in selected patients in whom
calculus is difficult. adhesions at port are minimal or not present.
Anticipating this difficulty we make a vertical incision at the
umbilicus during the placement of the first port. At the time of Extra Port
retrieval, this incision enlarged cranially which facilitates retrieval. We have put an extra port in three cases where the left lobe of the
This incision is easily closed with Vicryl 2-0 suture material. liver was enlarged obscuring the Calot’s anatomy, precluding the

© The Author(s). 2023 Open Access. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.
org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and non-commercial reproduction in any medium, provided you give appropriate credit to
the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain
Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.