Cholecystectomy (Laparoscopic, Open)

Procedure Snapshot

• Indication/urgency: Symptomatic cholelithiasis, acute/chronic cholecystitis, biliary dyskinesia, gallstone pancreatitis (post-ERCP).
• Expected duration: ___
• Special instruments: 30° laparoscope, 4 ports, clip applier, cholangiogram setup, retrieval bag.

Step Workflow

1. Supine, reverse Trendelenburg, left tilt.
2. Place ports: umbilical (camera), epigastric (dissector), RUQ (grasper), lateral (retractor).
3. Retract fundus cephalad, infundibulum laterally.
4. Dissect Calot’s triangle to achieve Critical View of Safety (PMID 10482271).
5. Clip/divide cystic duct and artery.
6. Remove gallbladder from liver bed with cautery.
7. Bag specimen; irrigate; check hemostasis.
   (Open: right subcostal incision; Kocher maneuver if needed.)

Key Pimp Questions

• Q: What defines Critical View of Safety?
  A: (1) Clear hepatocystic triangle, (2) lower gallbladder separated from bed, (3) only two structures entering GB.
• Q: Rate of CBD injury? ___ (PMID 10482271).
• Q: Conversion indications? Inflammation, unclear anatomy, bleeding.

Critical Anatomy

• Landmarks: Calot’s triangle (cystic duct, common hepatic duct, cystic artery), Rouvière’s sulcus.
• Danger zones: Right hepatic artery, CBD, portal triad.

Informed Consent Highlights

• Risks:
  • Bleeding ___
  • CBD injury ___ (PMID 10482271)
  • Bile leak ___ (PMID 33548230)
  • Retained stones ___
  • Conversion to open ___

Post-op Considerations

• Discharge POD 0–1.
• Diet advance as tolerated.
• NSAIDs for pain; avoid fatty meals briefly.
• Watch for jaundice or bile leak.

References

• Chassin’s, Biliary chapter.
• Clinical Scenarios, Biliary section.
• Strasberg 1995 (PMID 10482271); de Reuver 2021 (PMID 33548230).