Step by step operative procedure for laparoscopic cholecystectomy:

1) The skin is initially prepared with chlorhexidine from just below the nipple line to the inguinal ligaments and laterally to the anterior superior iliac spine.

2) The operative field is then draped with sterile drapes.

Placement of ports and instruments:

3) A 10 smiling incision is made at the inferior crease of the umbilicus, then depened through the subcutaneous fat to the anterior rectus sheath.

4) A Kocher clamp is used to grasp the reflection of the linea alba onto the umbilicus and elevate it cephalad.

5) A 1.2-cm longitudinal incision is made in the linea alba with a No. 15 blade. Two U stitches, one on either side of the fascial incision, are placed with 0 polyglactin suture on a curved needle.

6) The peritoneum is elevated between two straight clamps and incised so as to afford safe entry into the abdominal cavity.

7) An 11-mm blunt Hasson trocar is placed into the abdominal cavity, and insufflation of carbon dioxide is initiated to a maximum pressure of 15 mm Hg.

8) The authors prefer a 30° laparoscope to a 0° laparoscope because they feel it gives better visualization of the cystic structures from multiple vantage points.

9) A 30° scope requires a more skilled scope operator.

10) The laparoscope is white-balanced and advanced slowly into the abdominal cavity.

11) A 1.2-cm incision is made three finger breadths below the xiphoid process and deepened into the subcutaneous fat.

12) An 11-mm trocar is advanced into the abdominal cavity under direct vision in the direction of the gallbladder through the abdominal wall, with care taken to enter just to the right of the falciform ligament.

13) The table is then adjusted to place the patient in a reverse Trendelenburg position with the right side up to allow the small bowel and colon to fall away from the operative field.

14) A 5-mm grasper is placed through the 11-mm subxiphoid port and applied to the fundus of the gallbladder.

15) The gallbladder is then elevated cephalad over the dome of the liver to facilitate the surgeon’s choice of the optimal positions for the lateral 5-mm ports.

16) After appropriate port sites are chosen, the lateral skin incisions are made, and two 5-mm trocars are advanced into the peritoneal cavity under direct vision.

17) A 5-mm grasper with locking mechanism is placed through each of these lateral ports.

Exposure and dissection:

18) The lateral grasper is applied to the fundus and used to hold it cephalad over the dome of the liver.

19) The medial grasper is used to retract the infundibulum caudolaterally.

20) This maneuver straightens the cystic duct (ie, retracts it at 90° from the common bile duct [CBD]) and helps protect the CBD from inadvertent injury.

21) In contrast, cephalad retraction of the infundibulum tends to bring the cystic duct in line with the CBD, making the CBD more prone to injury.

22) Occasionally, adhesions are encountered between the gallbladder and the omentum or duodenum. These may be carefully lysed with a hook cautery.

23) The authors prefer to use an L-hook electrocautery, which allows a very clean and delicate dissection, but any electrosurgical device can be used for this purpose.

24) Once the area of the hilum of the gallbladder has been reached, the importance of exposure and delicate dissection cannot be overemphasized.

25) The cystic duct and artery must be carefully dissected and identified in the triangle of Calot to obtain the critical view. This critical view is achieved when the surgeon can see only two structures (the cystic duct and artery) entering directly into the gallbladder; it must be obtained before any structures are clipped or transected.

26) The key to obtaining the critical view is complete clearance of the areolar tissue in the subhepatic space. With the infundibulum held caudolaterally, the hook is used to score the anterior peritoneum overlying the infundibulum−cystic duct junction.

27) Next, the peritoneum is incised along the medial aspect all the way to within 1 cm of the liver, and the incision is continued cephalad toward the fundus of the gallbladder.

28) The gallbladder is then retracted caudomedially, and a similar dissection is carried out on the lateral surface. This technique is sometimes referred to as the flag technique.

29) An Endo Peanut or a Maryland dissector can be of great help in better defining these structures.

30) At this point, the surgeon should be able to identify the cystic duct and cystic artery entering directly into the gallbladder; this is the critical view.

31) Once the critical view has been achieved and the cystic structures clearly identified, the structures can be clipped and divided.

32) An endoscopic clip applier is used to place clips on the artery and duct (two proximally and one distally), which are then divided with endoscopic shears.

33) When the cystic duct is large, there are several options that may be considered, including an endoscopic stapler, Endoloops, and the overlapping clip technique.

34) If an Endoloop is used, it should be placed through the subxiphoid port. The grasper from the infundibulum is used to gently hold the cystic stump through the loop; the loop is then pulled taut.

Mobilization and removal of gallbladder:

35) Once the cystic structures have been clipped and divided, the infundibulum is retracted cephalad.

36) A hook or spatula is used to develop a plane in the areolar tissue between gallbladder and liver with smooth sweeping movements from right to left and back again.

37) As in any surgical procedure, the traction-counter traction rule is essential. As the dissection marches up the gallbladder bed, the assistant should reposition his or her graspers to ensure optimal tension on the areolar tissue between gallbladder and liver bed.

38) It is important to be alert for any aberrant vessels and ducts that may arise from the liver bed and enter directly into the gallbladder. These should be clipped and not simply cauterized.

39) Before the last strands connecting the gallbladder to the liver are divided, a final inspection of the gallbladder fossa and the clipped cystic structures should be carried out.

40) Any bleeding points in the gallbladder fossa should be controlled at this time, before the gallbladder is completely separated from the liver. This is the surgeon’s last opportunity to visualize these areas well.

41) Both 5-mm graspers are applied to the gallbladder and used to hold it over the right upper quadrant. The laparoscope is transferred to the subxiphoid port, and an endoscopic retrieval pouch is inserted through the umbilical trocar.

42) The gallbladder is placed in the bag, which is then cinched closed. The authors prefer to leave the bag suspended from the umbilical trocar while they replace the camera through the same port and perform the final inspection and washout.

43) The table is returned to the neutral position. The gallbladder bed and the suprahepatic spaces are irrigated and suctioned to ensure adequate hemostasis and removal of any debris or bile that may have spilled.

Port removal and closure

44) The subxiphoid port and the two 5-mm ports are removed under direct vision, followed by the Hasson trocar.

45) Overall, the incidence of port-site hernias is very low. Tonouchi et al reported an incidence of 0.65-2.8%; their recommendation was to close all port sites larger than 10 mm.

46) The authors, however, do not close the subxiphoid port. The fascia is closed at the umbilical port by using the two U stitches placed at the beginning of the procedure.

47) All of the skin incisions are closed with 4-0 absorbable monofilament suture, followed by cyanoacrylate tissue adhesive.

Special consideration in sickle cell patient:

1) Sickle cell disease (SCD) is an inherited disorder of the red blood cells, which is characterized by hemolysis and recurrent vasoocclusive episodes.

2) The incidence of gallstones in sickle cell disease patients varies from 10 to 37% and increases with age.

3) Cholecystectomy is the most common surgical procedure performed in sickle cell anemia (SCA) patients.

4) SCA patients undergoing Open cholecystectomy have a high perioperative morbidity.

5) Prior knowledge of the patients sickling history and the actual-s level indicated by electrophoresis, helps to estimate the individual perioperative risks and facilitate safer anesthesia and surgery.

6) Patients with SCA undergoing elective surgery are admitted 1-2 days earlier, and the predicted risk of post-operative calculation is calculated.

7) A decision on a preoperative transfusion regimen is based on the frequency and severity of sickling crises.

8) This is a key component of the comprehensive management of SCA patients undergoing major surgical procedures as it reduces the perioperative risks associated with the surgery and the anesthesia.

9) The incidence of sickle cell events may be higher in patients not preoperatively transfused.

10) Conservative preoperative transfusion regimen should be recommended.

11) The use of the laparoscopic technique for SCA patients undergoing elective cholecystectomy should be encouraged.

12) Cholelithiasis is very common in patients with sickle cell anemia (SCA), prevalence rates ranging from 30% to 70% depending on age and diagnostic criteria

Special consideration in morbid obese patient:

1) Overweight and obesity are the result of an energy imbalance over a long period of time

2) Assessment of obesity are Body mass index and Waist circumference.

3) Pre-operative considerations are Ergonomics, Diagnostic investigations, Pharmacologic considerations, Airway and respiratory system, Cardiovascular system and others.

4) Ergonomics: Patients may be too big or too wide for the surgical table or chair, Increased risk of injury to the patient and personnel during patient transportation.

5) IV access more difficult in obese patients.

6) Obesity affects each imaging modality differently – CT, MRI, fluoroscopy limited by patient size – Ultrasound, plain Xray, nuclear medicine limited by attenuation through excessive fat.

7) Difficulty in mask ventilation and intubation due to features such as a fat face and cheeks, short neck, large breasts, large tongue, excessive palatal and pharyngeal soft tissue, restricted mouth opening, limitation of motion of cervical spine.

8) The length of instrument used in the obese patient is 45 cm.

9) DVT Prophylaxis should be consider: Anticoagulation, TED stockings, SCD compression system

10) Pneumoperitoneum: ↑vascular resistance, ↓ cardiac index, ↑MAP transiently, Rare reflex bradycardia.

11) Surgeon Considerations: Surgeon Expertise, Hospital Facility Expertise.

12) Post-operative considerations: Post-surgical Monitoring, Thromboembolic Events, Analgesia, Wound Complications, Respiratory Complications.

13) Obese patients have reduced FRC due to reduced lung and chest compliance.

14) More predisposed to post-operative sputum retention, atelectasis, hypoxia, hypercapnia and bronchopulmonary infection.

Special consideration for cirrhosis of liver patient:

1) The prevalence and incidence of cholelithiasis in patients with liver cirrhosis is 2 times higher than that in noncirrhotic patients

2) Laparoscopic Cholecystectomy has gradually replaced open cholecystectomy as the standard of care of gallstone disease in cirrhotic patients.

3) The evaluation of any patient undergoing surgery should include thorough history taking and physical examination.

4) In Cirrhotic patient complete medication review including other-the-counter (OTC) and herbal agents should be performed.

5) Symptoms or physical signs suggestive of liver dysfunction (eg, hepatosplenomegaly, spider angiomata, jaundice, gynecomastia, palmar erythema, scleral icterus, asterixis, encephalopathy) should prompt further examination with liver function tests, coagulation studies, complete blood cell (CBC) counts and metabolic panels.

6) Open surgery is associated with increased morbidity and mortality, and results in more adhesions than a laparoscopic procedure.

7) The technical problems that were encountered intraoperatively resulted in conversion to an open procedure in 15.78% of cases, almost twice more often than in the Normal group.

8) Cirrhotic patients who underwent LC had significantly increased blood loss compared with noncirrhotic patients.

9) Bleeding disorders can be significantly avoided with routine administration of fresh frozen plasma or platelets preoperatively.

10) Needless to say, the laparoscopic technique produces less bleeding than a right subcostal incision.

11) Abdominal wall vessel injury can be avoided by wall transillumination, and venous bleeding can be controlled by decreasing the pressure of pneumoperitoneum as required.

12) laparoscopic cholecystectomy is permissible for patients with Child class A cirrhosis and selected patients with Child class B cirrhosis without portal hypertension.

13) The ability of cirrhotic patients to compensate for this ischemia is impaired, so hepatic dysfunction can develop postoperatively. 14) Ascitic fluid is an excellent growth medium for bacterial contaminants released in cholecystectomy.

15) Fortunately, infected as-cites is far less frequent in LC than in open surgery, because bacterial contamination of the peritoneal cavity through the 5-mm or 10-mm ports does not occur as easily as contamination through a wide right subcostal incision.

Special consideration for HIV patient:

1) The HIV status of the patients should be determined before the operation.

2) The theatre ( Infection Control Team) should be informed so that appropriate preparations can be made.

3) An adequate supply of hypochlorite and a new sharps disposal container should be ordered.

4) All disposable items used during the operation (administration sets, i.v. cannulae, etc.) should be disposed of in the sharps container.

5) The sharps container should be sealed and disposed of as soon as possible after the procedure.

6) All instruments should be sent to the CSSD after the procedure. They should be clearly labelled as high risk. No attempt should be made to wash the instruments after the procedure.

7) Non-disposable items should not be incinerated - they can be sterilized.

8) Linen should be sent to laundry marked as 'infected linen'; there is no need for incineration. Pre-packed, disposable, sterile packs may be used if available.

9) All staff should wear protective clothing.

10) Keep equipment and staff to a minimum.

11) Suction - disposable suction tubing is preferred. Where this is not available send for autoclaving after use.

12) Disposal of abdominal swabs: - there should be minimal handling; - the contaminated (blood-soaked) swabs should be discarded by the surgeon into individual plastic bags, this will facilitate weighing and counting. The swabs can then be discarded. Soaking in a disinfectant such as hypochlorite is not necessary.

13) Where possible avoid electrical and other delicate equipment, which is difficult to sterilize.

14) All disposable, incineratable waste should be removed in clearly labelled colour-coded bags.

15) Wash walls up to hand height with water and detergent.

16) Spot clean blood and body fluid spillage with hypochlorite.

17) Send heat-stable equipment for sterilization Label 'high risk'. Do not soak in bleach.