Preoperative evaluation should include verification of gallstones and assessment of common duct size by ultrasound, as, well as liver function tests. An electrocardiogram (or even specialized cardiac tests) may be prudent to exclude the rare patient in whom cardiac ischemia masquerades as biliary colic. Serum   amylase and lipase to exclude acute pancreatitis are ordered selectively. The operating table should be compatible with any radiographic equipment used for cholangiography, even if the routine use of this modality is not planned. Position the patient supine on the operating table. the arms may be extended, or may be tucked at the side. tucking the right arm facilitates intraoperative   cholangiography, since there is less impediment to positioning the c-arm. The surgeon stands at the left side of the patient. Some surgeons, especially in Europe, place the patient in the low lithotomy position and operate from between the patient’s legs. Two monitors are used, placed in the left and right of the patient near the head. An orogastric tube is placed after induction of anesthesia. Most surgeons place sequential compression stockings to avoid venous stasis (it is important to note that there are insufficient data in the literature to support this). some surgeons place a  foley  catheter  in the bladder.

 

Laparoscopic cholecystectomy usually is performed with four trocars; two 10-mm trocars (in the midepigastrium and umbilicus) and two 5-mm trocars along the right coastal margin some surgeons use a 5-mm camera and trocar in the epigastria two-or three port techniques have been described are not the norm. Place the first 10-mm trocar at the umbilicus, insert the laparoscope, and perform a general exploration of the abdomen. Although a 0-degree laparoscope can be used, a 30-degreelaproscope allows more flexibility in obtaining a complete view of all structures in the portal area and deceases the risk of injury to the ducts. Place the patient in reverse Trendelenburg position and rotate the operating table with the left side down.
 

Under laparoscopic visual control, place two 5-mmtrocarsalong the right costal margin. the usual location is tow fingerbreadths below the costal margin at the midclavicular and anterior axillary lines. these trocars should be approximately 8 to 10 cm apart. Exact position may need to be modified depending upon patient habitus and the location of the liver relative to the costal margin. The fourth trocar will be the main operating trocar; so good placement is crucial. Some surgeons place graspers into the two lateral ports and manipulate the liver to estimate where calot”s triangle will be during dissection. the most usual location for the fourth trocar is epigastric, at least 10 cm from the laparoscope. the trocar is placed under laparoscopic visual control and should be directed to the right of the falciform ligament as it enters the abdominal cavity.
 

It is often possible to place the epigastric and two subcostal incisions along the line of an incision suitable for conversion to open procedure. Modify these trocar positions slightly if the lithotomy position is used. move the 10/11-mm epigastric trocar to the left upper quadrant, and place one of the 5-mm trocars to the right of the umbilicus this facilitate two-handed operation from the lithotomy position.

 

Pass two atraumatic graspers through the right subcostal trocars and gently elevate the liver by passing these gaspers beneath the visible surrounded by omental adhesions. Adhesions to the underside of the liver and gallbladder may contain omentum, colon, stomach, or duodenum, and hence must be dissected with care. it is prudent to use cautery as little as possible to avoid transmission of   energy to the attached structures (which might result in delayed perforation of a viscus). If the gallbladder is acutely inflamed and tense, decompress it before attempting to grasp it. If the gallbladder is acutely and tense, decompress it before attempting grasp it. Pass a veress needle through the abdominal wall under laparoscopic visual control. Use the graspers, to lift the liver and elevate the gallbladder.
 

After the of the gallbladder is exposed, the first assistant grasps the fundus with an atraumatic locking grasper passed through the most medial of the right subcostal ports. The   assistant pushes the gallbladder over the liver towards the right shoulder, opening the sub hepatic space and exposing the infundibulum of the gallbladder.
 

The surgeon or assistant then places a second atraumatic grasper on the gallbladder at its base. This grasper is generally also a locking grasper, although some surgeons will prefer anon locking grasper. Throughout dissection, the direction of traction by this infundibular gasper is critical to prevent errors in identification of the ductal structures I this area.
 

In the two handed technique, the surgeon retracts the infundibulum with the left hand and dissects through the epigastric port with the right hand. alternatively, the assistant may control both graspers the surgeon maneuvers the camera with the left hand.
 

Begin dissection directly adjacent to the gallbladder sharply. Identify the cystic duct where it enters the gallbladder. The gallbladder should be seen to funnel down and terminate in the cystic duct. The fundus of the gallbladder towards the right axilla and the infundibulum laterally to expose calot’s triangle and increase the triangle. Move the infundibular grasper backward and forward from side to side, so that the gallbladder-cystic duct junction may be carefully delineated. Some surgeons incise the peritoneum extensively along the edge of the gallbladder and elevate the gallbladder and delineate the entire space medial to the gallbladder, leaving the cystic duct and artery intact until the gallbladder is almost completely separated from the liver bed. Dissect the cystic duct free over an adequate length for cholangiography, if desired generally at least 1 cm of length is necessary.
 

A useful alternative technique is the “fundus-first” or” top-down” technique, useful for a severely inflamed gallbladder. After dissecting Omental adhesions away from the gallbladder, the fundus is separated from the liver with a diathermy hooks or dissecting forceps leaving a peritoneal rim with which to grasp and retract the liver cranially. Alternatively, a malleable retractor can be placed through the lateral port to retract the liver cephalad.
 

The gallbladder is dissected away from the liver edge with a blunt dissecting forceps or cautery hook or spatula. If a stone is impacted in Hartmann’s pouch, it may be dislodged into the body of the gallbladder or removed by incising the pouch on the side way from the duct and removing the stone so that the entire circumference of the cystic duct-gallbladder junction can be viewed.
 

Cholangiogram should be performed before division of the cystic artery and cystic duct.  Place a clip as close to the gallbladder as possible and two similar clips on the cystic duct. Leave enough space between the set of clips to make it possible to divide the duct with scissors. Take care not to retract the duct so forcefully that the clips impinge on the cystic duct-common duct junction. Reposition the infundibular grasper to grasp the gallblf1adder adjacent to the cystic duct. Use the grasper to retract the gallbladder anteriorly and laterally so that the surgeon can expose the cystic triangle.
 

By gentle spreading and dissecting with a Maryland dissector or laparoscopic right -angle clamp. The cystic artery will be noted to terminated by running onto the gallbladder, and visible pulsation may be observed, generally, 1cm of length is necessary for safe division. Divide the cystic artery with clamps, leaving a minimum of two clips on the cystic artery stump. division of the cystic artery will generally permit the gallbladder to the pulled father away from the porta hepatic by traction on the infundibular grasper.
 

If the “fundus-first” technique has not been used, the remainder of the operation consists of dissection of the gallbladder from its bed, tacking care to say away from the porta hepatis and liver bed and to avoid perforating the gallbladder .the infundibular  grasper is used to elevate the gallbladder and at certain point it will become possible to use this grasper to push the gallbladder over the liver edge .generally better exposure will be obtained if this maneuver is postponed until late in the dissection.
 

Most surgeons use a hook cautery for this phase of the operation. The blunt edge of the hook can be used cold, without cautery, as a dissector. Band of connective tissue are hooked, placed on traction, and divided with cautery. Traction and counter traction facilitate the dissection. Some surgeons prefer cautery scissors or a spatula. Other energy sources such as laser or harmonic scalpel may be used, but are generally unnecessary, less versatile, and more expensive than simple electrocautery. When the gallbladder is dissected virtually free from the liver bed but a few second remain, inspect the gallbladder bed and ducts for evidence of bleeding. Exposure of this region is more difficult often the gallbladder has been removed.
 

Irrigate with saline, but take care not to suction directly on the cystic duct or artery stumps to prevent clip dislodgment. After achieving hemostasis, divide the remaining attachment of the gallbladder to the liver. Place a gallbladder grasper through one of the 10-mm trocars and grasp the gallbladder near the cystic duct. Consider using a specimen bag if the gallbladder is thick-walled (consider gallbladder carcinoma) or infected.
 

Once the gallbladder has been removed, replace the epigastric trocar and inspect the surgical site for bleeding. Irrigate the surgical field, and aspirate the irrigate from the sub phrenic space and other areas. Remove the Trocars and close the wounds in the usual fashion. Many surgeons inject the trocar sites with a long –acting local anesthetic to minimize pain and facilitate early discharge from hospital.