Laparoscopic Cholecystectomy

Indications & Contraindications - Snip or No Snip?

• Indications:
  • Symptomatic gallstones (biliary colic, cholecystitis)
  • Acalculous cholecystitis
  • Gallstone pancreatitis (post-resolution)
  • GB polyps (>1 cm / symptomatic)
  • Porcelain gallbladder (malignancy risk)
• Contraindications (Absolute):
  • Uncontrolled coagulopathy
  • Unfit for GA/pneumoperitoneum
  • Diffuse peritonitis
  • Suspected GB cancer (open preferred)
• Contraindications (Relative):
  • Severe cardiorespiratory disease
  • Cirrhosis & portal HTN (↑ bleeding)
  • Pregnancy (safest 2nd trimester)
  • Multiple prior upper abdominal surgeries

⭐ Symptomatic cholelithiasis remains the primary indication for laparoscopic cholecystectomy.

Pre-op Prep & Patient Positioning - Setting the Stage

• Pre-operative:
  • Informed consent obtained.
  • NPO: 6-8 hrs solids, 2 hrs clear fluids.
  • IV access, prophylactic antibiotics (e.g., Cefazolin 1-2g).
  • DVT prophylaxis (risk-stratified).
• Patient Positioning:
  • Supine initially.
  • Intra-op: Reverse Trendelenburg (15-20°), slight left lateral tilt.
  • Arms: Typically one abducted, one tucked. Secure patient well.

  ⭐ Reverse Trendelenburg position is crucial for optimal visualization by displacing bowel inferiorly.

Surgical Anatomy & Critical View - X Marks the Spot!

• Calot's Triangle (Hepatocystic):
  • Boundaries: Cystic duct (inf.), Common Hepatic Duct (med.), Liver edge (sup.).
  • Contents: Cystic artery (key!), Calot's node.
• Critical View of Safety (CVS): Prevents Bile Duct Injury (BDI).
  • Clear hepatocystic triangle.
  • Expose cystic plate (GB base off liver).
  • Only 2 structures enter GB: cystic duct & artery.
• Key Landmarks:
  • Rouviere's Sulcus: Plane of CBD.
  • Moynihan's Hump: Coiled RHA (⚠️ risk).

⭐ The cystic artery usually originates from the right hepatic artery within Calot's triangle.

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Lap Chole Steps & Ports - Keyhole Magic

• Ports (Usually 4):
  • Umbilical (10-12mm): Camera, CO2 insufflation (Veress/Hasson).
  • Epigastric (10mm): Main working port (dissectors, clippers).
  • Right Mid-Clavicular (5mm): Fundal retraction (superior-lateral).
  • Right Anterior Axillary (5mm): Infundibular retraction (lateral).
• Key Steps:
  • Pneumoperitoneum (CO2 to 12-15 mmHg).
  • Port insertion.
  • Gallbladder retraction.
  • Calot's triangle dissection.
  • Achieve Critical View of Safety (CVS).
  • Clip & divide cystic duct & artery.
  • Dissect gallbladder from liver bed.
  • Specimen retrieval.
  • Hemostasis & closure.

⭐ The Critical View of Safety (CVS) - ensuring only two structures (cystic duct, cystic artery) enter the gallbladder base - is paramount to prevent bile duct injury.

Complications & Conversions - Uh Oh Moments

• Intra-op Complications:

  • Bile Duct Injury (BDI): Most feared; Strasberg classification.
  • Bleeding: Cystic artery/vein, liver bed.
  • Bowel/Vascular injury.

• Post-op Complications:

  • Port-site hernia/infection.
  • Retained CBD stones; Bile leak.
  • Post-Cholecystectomy Syndrome (PCS).

• Conversion to Open Surgery Triggers (HALT-IF): 📌

  • Hemorrhage (uncontrolled).
  • Anatomy unclear (Calot's Δ obscured).
  • Large CBD stone (unexpected/unmanageable).
  • Tumor suspected (e.g., incidental Gallbladder Cancer).
  • Injury (BDI, bowel).
  • Failure to progress/Dense adhesions.

⭐ The "Critical View of Safety" (CVS) technique is paramount to prevent BDI. Failure to achieve CVS is a strong indication for conversion to open surgery.

Post-op Care & Advantages - Swift & Smooth

• Post-operative Care:
  • Early ambulation encouraged.
  • Diet: Clear liquids, advanced as tolerated.
  • Pain management: Multimodal (NSAIDs, minimal opioids).
  • Discharge: Typically same day or within 24 hours.
  • Wound care: Keep dressings clean, dry.
• Advantages (Laparoscopic vs. Open):
  • Reduced post-operative pain.
  • Shorter hospital stay (↓).
  • Faster return to activity (↑).
  • Improved cosmesis (smaller scars).
  • Lower risk of ileus & respiratory complications.

⭐ Most patients resume normal activities within 1 week post-laparoscopic cholecystectomy.

High‑Yield Points - ⚡ Biggest Takeaways

• Laparoscopic cholecystectomy is the gold standard for symptomatic gallstones.
• Critical View of Safety (CVS) is crucial to prevent bile duct injury (BDI).
• Key complications include BDI, vascular injury, and post-op bile leak.
• Pneumoperitoneum is usually established with CO2 at 12-15 mmHg.
• Calot's triangle (cystic duct, common hepatic duct, liver edge) is key anatomy.
• Conversion to open surgery is a safety measure, not a complication.
• Early cholecystectomy is preferred for acute cholecystitis within 72 hours.