Laparoscopic Cholecystectomy with Possible IOC

Preop antibiotic (give 30 min before incision)

Cefazolin 2g IV (3g if weight ≥ 120 kg)

Local anesthetic

• —0.25% Bupivacaine with epinephrine — port sites at closure

Irrigation

• —Warm normal saline 1L bag on field

Labeling

Label all medications and syringes on the sterile field per facility policy

Core trays

• —Basic laparoscopic tray
• —Clip applier — medium-large clips

Specialty items

• —10mm trocar × 1 (umbilical)
• —5mm trocars × 3 (subxiphoid, RUQ × 2)
• —Maryland dissector
• —Hook cautery with long cord
• —Specimen retrieval bag

Energy devices

• —Monopolar hook cautery
• —Harmonic scalpel (backup for difficult dissections)

Scopes / robot

• —10mm 30° laparoscope

Primary position

Supine, 15–20° reverse Trendelenburg with left lateral tilt

Variations

• —Bean bag or lateral tilt attachment recommended

Pressure points

• —Heels
• —Sacrum
• —Occiput
• —Bilateral calves

Arm position

Left arm tucked, right arm on armboard

Pearls

• —Secure patient before table manipulation
• —Confirm patient secured after tilt — verify with surgeon before final position

Prep solution

• —Chlorhexidine gluconate (CHG) — apply wet over dry
• —DuraPrep if CHG allergy

Prep area

Right upper quadrant extending to mid-chest superiorly, bilateral flanks laterally, and pubis inferiorly — include umbilicus

Draping

Laparoscopic drape or 4-towel square + lap sheet; ensure umbilicus fully accessible

Pearls

• —Allow full drying time (3 min CHG, 3 min alcohol-based) before draping
• —Confirm sterile field boundaries with circulator before incision

Typical sutures

• —0-Vicryl — 10mm fascial port closure
• —4-0 Monocryl — subcuticular skin closure
• —3-0 Vicryl — subcutaneous if needed

Staplers

• —Endoscopic stapler for cystic duct if wide or inflamed (have available)

Energy

• —Monopolar hook cautery — liver bed dissection
• —Harmonic — complex or bleeding-prone dissections

Hemostatic agents

• —Surgicel Nu-Knit
• —FloSeal if oozing from liver bed

Wound dressings

• —Steri-strips × each port site
• —Tegaderm or Opsite occlusive over each site

Drains

• —JP drain only if bile leak concern or difficult/bloody dissection

Application notes

Cover umbilical port thoroughly — largest incision; confirm patient allergy to adhesives before applying

Typical specimens

• —Gallbladder — send fresh (do not formalin until path confirms)

Handling

Remove via specimen retrieval bag through umbilical port. Inspect bag integrity before removal to prevent bile/stone spill in abdomen.

Labeling notes

Label 'gallbladder' with site — right upper quadrant; document stone count if spill occurs

Common pitfalls

• —Misidentifying cystic duct vs. CBD — surgeon must confirm critical view of safety before any clipping
• —Bile or stone spill — irrigate copiously; document in chart; count any retrieved stones
• —Bleeding from cystic artery or trocar site — have open tray and vascular clamps immediately available

Conversion risks

• —Dense adhesions from prior surgery or severe cholecystitis
• —Mirizzi syndrome or unclear biliary anatomy
• —Uncontrolled bleeding
• —Have open cholecystectomy tray open and ready on back table

Vascular structures at risk

• —Cystic artery
• —Right hepatic artery (aberrant anatomy in ~25% of patients)
• —Hepatic portal vein

Reportable events

• —Bile duct injury
• —Retained stone post-op
• —Port site hernia
• —Retained foreign body — count discrepancy

Initial count

Sponges, sharps, instruments per facility policy; count laparoscopic port caps and trocars

Closing count

Full count × 2 before fascia closure; × 2 before skin closure; verify clip count with surgeon

Special items to count

• —Laparoscopic clips — document total used and remaining
• —Specimen retrieval bag
• —Suture needles

Step-by-step

• —Position and secure patient; apply grounding pad to thigh; confirm allergies and consent
• —Perform surgical time-out per facility policy — circulator documents
• —Abdominal prep and drape; confirm CO2 tank level and laparoscope white balance
• —Umbilical incision; Veress needle or Hasson open technique for access
• —Establish 12–15 mmHg pneumoperitoneum; insert 10mm umbilical trocar
• —Insert 5mm trocars under direct laparoscopic vision
• —Achieve and confirm critical view of safety — document on video if available
• —Clip (× 2 proximal, × 1 distal) and divide cystic artery and duct
• —Dissect gallbladder off liver bed with hook cautery
• —Place gallbladder in retrieval bag; remove through umbilical port
• —Irrigate abdomen; confirm hemostasis; remove trocars under direct vision
• —Close 10mm fascial port with 0-Vicryl; subcuticular skin closure × all ports
• —Apply dressings; count × 2 before leaving room

Circulator notes

• —Confirm CO2 tank and backup before patient arrives
• —Document time-out, clip count, and any intraoperative findings
• —Have IOC equipment (C-arm, cholangiogram catheter) immediately available if surgeon requests
• —Monitor insufflation pressure — alert surgeon if >15 mmHg sustained