- Assess the risk of bile duct stones (by history, liver function tests and bile duct appearance on US) and plan treatment with an ERCP, if necessary.
- Informed consent includes a warning of the rare but possible risk of bile duct injury.
- An assistant places a grasping forceps via the lateral 5 mm port and pushes the fundus of the gallbladder and liver up towards the right shoulder. This allows the operating surgeon to see and grasp Hartmann’s pouch and retract it laterally and distally. Divide the peritoneum close to the gallbladder and using gentle dissection, with minimal and judicious use of diathermy, the cystic duct and artery are displayed. As in the open operation, no structures are divided until both the cystic duct and artery are clearly identified being cognisant of potential injury to the CBD.
- Metal clips are applied first to the cystic duct — an operative cholangiogram can be performed beforehand. It is then divided between clips, followed by the cystic artery.
- Next, dissect the gallbladder from the liver with diathermy dissection using a scissors or hook.
- Before detaching the fundus from the liver, ensure haemostasis.
- Irrigate and aspirate saline to lavage the right upper quadrant.
- The gallbladder is then removed via any of the 10 mm ports but if any spillage of bile or stones has occurred during the dissection then a bag is used for retrieval.
Main Postoperative Complications
Include injury or division of the CBD. Beware of a diathermy injury in a laparoscopic cholecystectomy.