A 300 laperoscope
One 12mm & three 5mm trocars
One 5mm dissecting Hook
One fenestrated atraumatic 5mm forceps
- A strong 5mm grasping forceps
- A 5mm clip applicator
5mm suction irrigation device
A specimen retrieval bag
Having tried operating from the patients left hand side and between the patients legs we moved over to standing on the patients right in 1994; the Brisbane approach of George Fielding. It feels strange at first but you do get used to it very quickly. It has lots of advantages if you are right handed. It also avoids the cameraman getting in your way and makes it easier to perform CBD exploration. The monitor is placed at the patients head on the right hand side. Try it!
We use a cut down to create a pneumoperitoneum (see methods of access). 5mm trocars are placed below the xiphoid process in the midline, one lateral right upper quadrant (operating) just above the level of the umbilicus with a more lateral one (gallbladder grasping) just below the level of the umbilicus.
We use a hook, introduced via the midliine port for all the dissection. All the dissection is carried out close to the gallblader.
Retract the gallblader medialy (holding Hartmann's pouch). Add some anterior traction. Incise the lateral peritoneal attachment of the body of the gallbladder and work towards the cystic duct. Then exert lateral traction to expose Calot's triangle. Incise the medial peritoneum close to the gallblader and work your way towards the cystic duct dividing the peritoneum above the lymph node. If the tissues are supple and not too chronicaly inflamed, push them medialy with the back of the hook to expose the cystic artery and duct.
Clear the duct with the hook. Complete the dissection of the cystic artery. If the branches are taken close to the gallblader you will not damage the right hepatic artery or need clips. If you take the main trunk use three clips.
Clip the cystic duct below hartmman's pouch. Introduce a fenestrated forceps from the midline and hold the gallbladder. Incise the cystic duct with a scissors introduced from the right jand side operating port close to the clip. Introduce a cholangiogram catheter into thr duct using the same lateral port. If a CBD exploration is not required, clip the duct distaly x2 and then divide.
Retract the gallbladder laterally/medialy to divide the peritoneum and the hepatic attachments. Maintain haemostasis as you go.
Check for bleeding and levage the operative site. Place thick walled gallbladers and large srones in a retrieval bag. Re-site the laparoscope in the medial port and remove the Gb or bag via the umbilical port. Open and drain the GB before crushing the stones.
If the procedure was difficult [place a suction drain in the sub hepatic space.
Mobility is the key to safe cholecystectomy. Empty thick walled gallbladders. Use an endo-loop on a large cystic duct.