Detailed Step-by-Step Guide to Laparoscopic Cholecystectomy by Dr. Madhuka Shahi MBBS, MS, M.MAS

1. Preoperative Preparation:

   • Ensure informed consent is obtained.
   • Perform a complete preoperative workup including liver function tests and ultrasound.
   • Instruct the patient to fast according to standard preoperative guidelines.

2. Anesthesia:

   • Administer general anesthesia.
   • Secure airway with intubation and ensure proper ventilation.

3. Patient Positioning:

   • Position the patient supine on the operating table.
   • The patient’s right arm is extended, and the left arm is tucked.
   • Position the table in a reverse Trendelenburg with a slight left tilt to improve the exposure of the gallbladder.

4. Team Positioning:

   • The surgeon stands on the left side of the patient.
   • The first assistant stands on the right side of the patient.
   • The scrub nurse or technician is positioned at the lower end of the table, adjacent to the patient's feet.
   • The monitor is placed near the patient’s right shoulder.

5. Establishment of Pneumoperitoneum:

   • Make a small incision at the umbilicus.
   • Insert a Veress needle or a trocar to insufflate the abdomen with CO2, creating a pneumoperitoneum.

6. Port Placement:

   • Insert the primary 10-mm camera port at the umbilicus.
   • Place a 10-12 mm port in the epigastrium, just below the xiphoid process for the insertion of the laparoscopic clip applier and other instruments.
   • Insert two more 5-mm ports: one in the right subcostal region at the midclavicular line and another at the anterior axillary line.

7. Exploration and Identification:

   • Insert the laparoscope through the umbilical port.
   • Inspect the abdominal cavity to confirm anatomy and ensure no contraindications for continuing.

8. Dissection of Calot's Triangle:

   • Carefully dissect Calot's triangle to identify the cystic duct and cystic artery.
   • Use laparoscopic graspers, scissors, and electrocautery as needed.

9. Clipping and Division of Cystic Duct and Artery:

   • Double clip the cystic duct and artery with 10-mm clips.
   • Divide the duct and artery between the clips using laparoscopic scissors.

10. Dissection of the Gallbladder:

    • Begin dissecting the gallbladder from the fundus downwards towards the neck using a combination of blunt and sharp dissection.
    • Carefully peel the gallbladder off the liver bed, using electrocautery for hemostasis.

11. Checking for Hemostasis:

    • Thoroughly inspect the gallbladder bed and the dissected area for any bleeding.
    • Achieve hemostasis using cautery or clips as necessary.

12. Gallbladder Extraction:

    • Place the detached gallbladder into a retrieval bag.
    • Extract the bag through the enlarged umbilical or epigastric port.

13. Closure:

    • Desufflate the abdomen and remove all trocars under direct vision.
    • Close the port sites, with particular attention to the larger port sites which may require fascial closure to prevent hernias.
    • Skin closure is typically done with absorbable sutures or skin adhesive.

14. Postoperative Management:

    • Monitor the patient in the recovery room for immediate postoperative complications.
    • Manage pain and provide instructions regarding activity, diet, and wound care.

15. Follow-Up:

    • Arrange a postoperative follow-up to evaluate recovery and address any concerns.