Laparoscopic Cholecystectomy

The gallbladder is removed through 3–4 small abdominal ports under CO2 pneumoperitoneum. Standard setup is an umbilical camera port, an epigastric working port, and 1–2 right subcostal ports. The surgeon retracts the fundus over the liver and dissects Calot's triangle until the critical view of safety is achieved. The cystic duct and artery are clipped and divided, and the gallbladder is taken off the liver bed with hook cautery. It comes out in a retrieval bag, usually through the umbilical or epigastric port. Cases usually run 45–90 minutes, and most patients go home the same day.

• Verify with surgeon preference cardverify
• !Common bile duct injury: surgeon confirms critical view before clipping
• !Open conversion tray in room, not opened — Conversion rate ~2–10%, higher in acute cholecystitis
• !Cystic artery or hepatic artery bleed: suction-irrigator ready
• Spilled stones: retrieve all, surgeon documents — Retained stones can cause abscess
• Watch insufflation pressure and CO2 flow — Typically 12–15 mmHg
• Cholangiogram possible: C-arm and contrast on standbyverify
• Trocar or Veress injury to bowel or vessels at entry

• Laparoscopic chole tray
• Minor/basic laparotomy tray for access and closure
• Tower: 30° 5 or 10 mm scope, light, camera — White balance, anti-fog
• Insufflator, CO2 tank checked full
• Trocars: 1x 10–12 mm, 3x 5 mm — Veress or Hasson per surgeonverify
• Hook cautery, Bovie, grounding pad — Check pad site and skin contact
• Suction-irrigator
• !Open chole tray available in room

• Clip applier, 5 or 10 mm, medium-large clips — Hem-o-lok or endoloop per surgeonverify
• 0 Vicryl UR-6 for fascia at 10–12 mm site
• 4-0 Monocryl PS-2 subcuticular
• Endoloop for wide cystic ductverify
• Hemostatic agent (Surgicel, Floseal) availableverify
• Skin glue (Dermabond)verify

• !Cefazolin 2 g IV — Within 60 min of incision; 3 g if ≥120 kg
• !Check allergies; alternative antibiotic if beta-lactam allergy
• 0.25% bupivacaine or 0.5% plain for port sites — Label syringe on fieldverify
• Warm NS irrigation for suction-irrigator
• Contrast for cholangiogram, diluted per surgeonverify
• !Label every med and solution on the field

• !Supine, safety strap across thighs — Secure strap; table tilts steeply
• !Arms out on padded armboards, less than 90°
• Left arm tucked per surgeonverify
• Pad heels, elbows, and occiput
• SCDs on and running before induction
• Reverse Trendelenburg, left side down during dissection
• Monitors at head of bed, right side up

• ChloraPrep (CHG/alcohol) prep — Povidone-iodine if CHG allergy
• Borders: nipples to pubis, table edge to table edge
• Clean umbilicus thoroughly
• !Let dry fully before draping, 3 min minimum — Fire risk with alcohol pooling
• Four towels, then laparotomy drape
• Clip hair only if needed; no razors

1. 1

   Umbilical access

   • ›Makes umbilical incision, Veress or open Hasson entry
   • ›Insufflates to 12–15 mmHg

   Have ready

   • #11 or #15 blade, 2 towel clips or Kochers
   • Veress needle + saline drop test syringeverify
   • Hasson trocar, S-retractors, 0 Vicryl stay suturesverify
   • Insufflator tubing connected, CO2 on
2. 2

   Port placement

   • ›Places scope, inspects abdomen
   • ›Places epigastric and right subcostal ports under vision

   Have ready

   • Scope white-balanced, anti-fogged
   • Local in syringe for port sitesverify
   • Remaining trocars open, #11 blade
3. 3

   Retraction and exposure

   • ›Grasps fundus, retracts cephalad over liver
   • ›Retracts infundibulum laterally; takes down adhesions

   Have ready

   • Two ratcheted graspers
   • Maryland dissector
   • Needle decompression of distended GBverify
4. 4

   Calot's triangle dissection

   • ›Dissects peritoneum with hook and Maryland
   • ›Achieves critical view of safety

   Have ready

   • Hook cautery connected, settings confirmed
   • Suction-irrigator primed
5. 5

   Cystic duct and artery

   • ›Clips and divides cystic artery and duct
   • ›May do cholangiogram before dividing duct

   Have ready

   • Clip applier loaded — Typically 3 clips each structure
   • Laparoscopic scissors
   • Cholangiogram catheter, contrast, C-armverify
6. 6

   Gallbladder off liver bed

   • ›Dissects GB from liver bed with hook
   • ›Checks hemostasis and clips before final detachment

   Have ready

   • Hook cautery
   • Hemostatic agent availableverify
7. 7

   Extraction

   • ›Places GB in retrieval bag
   • ›Removes through umbilical or epigastric site

   Have ready

   • Retrieval bag (Endocatch)
   • Kelly or Kocher to extend fascia
   • Specimen cup ready
8. 8

   Irrigation and closure

   • ›Irrigates, inspects, removes ports under vision
   • ›Closes fascia at 10–12 mm site, then skin

   Have ready

   • 0 Vicryl UR-6, fascia closure device if needed
   • 4-0 Monocryl, skin glue or Steri-Strips
   • !Closing count started

• Gallbladder, routine surgical pathology
• Formalin — Unless stones sent separately fresh
• Bile culture if cholecystitis or pusverify
• !Label: name, ID, site, specimen, date
• Confirm specimen verbally with surgeon before sending

• !Initial count: sponges, sharps, instruments
• !Closing count before fascia closure
• !Final count at skin closure
• Count trocar parts, seals, and reducers
• Count Veress needle and suture needles
• Account for retrieval bag and any Raytecs inside

• No drain typical
• JP drain if gangrenous GB or oozing liver bedverify
• Skin glue or Steri-Strips
• Small Tegaderm/gauze dressing over port sitesverify