Laparoscopic cholecystectomy: instrumentation and technique

Laparoscopic cholecystectomy is rapidly evolving as a therapeutic modality for the treatment of gallstone disease. The technical details of this procedure and the method by which the gallbladder is dissected and removed are critical to the safe, effective execution of the procedure. Our technique has been developed through extensive practice in porcine models and through experience with more than 250 patients. To perform laparoscopic cholecystectomy we employ a high-resolution video endoscopy system, two high-resolution color monitors, a high-flow CO2 insufflator, a 300 W Xenon light source, electrocautery and/or lasers, and an endoscopic suction-irrigation system. This equipment permits the surgeon to obtain a clear field of view within the abdomen. With these tools, appropriately designed for laparoscopic surgery, including a laparoscope, graspers, dissectors, cholangiography equipment, scissors, and clip appliers, the surgeon can remove the gallbladder without opening the abdomen. The procedure requires the induction of a CO2 pneumoperitoneum, insertion of four trocars, and placement of a grasping retractor to set the operative field. An additional retractor placed on Hartmann's pouch provides countertraction for dissection of the hilum. Careful dissection around the cystic duct and cystic artery with a combination of electrocautery and blunt dissection allows the surgeon to skeletonize the cystic duct and artery. After intraoperative cholangiography confirms the anatomy, the cystic artery and cystic duct are clipped and divided. Electrocautery or laser techniques can be used to perform retrograde dissection of the gallbladder from the liver bed and insure hemostasis. The gallbladder is detached and removed intact through the large trocars. This basic technique can be applied in a wide variety of patients with cholelithiasis. The surgeon proficient in this technique may apply it to a broad range of patients with gallbladder disease.