Laparoscopic Cholecystectomy (Lap Chole) mayo stand and back table surgery setup

Laparoscopic cholecystectomy stands at the forefront of gallstone disease treatment, offering a minimally invasive solution. It involves making a few small incisions in the abdomen and using specialized instruments to remove the gallbladder. This surgery is commonly performed to treat gallstones or other gallbladder-related problems.

Extra Equipment
Camera, light cord, CO2 tubing, suction tubing, Endopouch, bovie, poss. port closure device, poss. Verres needle, trocars, poss. Cholangiogram device, telescopes, poss aspirating needle

Drapes
Four folded towels and laparotomy drape

Step 1: Incision and Trocar Insertion
The first step in a laparoscopic cholecystectomy is to make approximately 3-4 small incisions. The scalpel is used to create these incisions, which are then used to insert trocars. The S retractors or Army-Navys may be used to retract the incision area while inserting the trocars.

Step 2: Verres Needle Insertion
A Verres needle may be introduced into the umbilical incision to introduce CO2 into the abdomen. To insert the Verres needle, a Kelley and two towel clips should be available. Once the needle is inserted, a syringe of saline may be needed to check for proper placement.

Step 3: Pneumoperitoneum
Another method for creating pneumoperitoneum is to insert a trocar and then attach the CO2 tubing. This method can be used if the Verres needle is not used.

Step 4: Gallbladder Dissection
Once the pneumoperitoneum is established, a locking grasper is used to grasp the gallbladder and retract it. Fat or adhesions can be dissected with graspers, hook cautery, and Maryland. When properly dissected, the gallbladder hilum is visualized along with the cystic duct and artery.

Step 5: Cystic Artery Clip Applier
The clip applier is then used on the cystic artery two times. This is when a cholangiogram may be performed. The laparoscopic scissors will be used to incise the cystic duct. The cholangiogram catheter will be inserted into the duct’s incision, and the clip applier will be used again to hold it in place. Saline and radiopaque dye should be available and drawn up into syringes. X-ray will be used for visualization. The cholangiogram catheter will then be removed, and the clip applier will be used again on the duct.

Step 6: Gallbladder Removal
The rest of the gallbladder will then be dissected from the liver, most likely using the hook cautery and wave graspers. The suction/irrigator should then be used to visualize any bleeding on the liver. An endopouch will then be inserted, and the gallbladder will be removed from the port. If there are stones in the gallbladder preventing it from fitting through the port site, the gallbladder may be aspirated, and the stones may need to be removed.

Step 7: Suturing and Closure
Before skin closure, the doctor may use the suction irrigator one last time. The trocars will then be removed, and the port sites will be closed. A needle driver and an adson pick-up will be needed for suturing, and the straight mayo scissors should be available for cutting sutures.

The Surgery Sparknotes

1. Make incisions using scalpel and insert trocars.
2. Introduce CO2 into abdomen with Verres needle and insert Kelley and two towel clips.
3. Retract with S retractors or Army-Navys or insert trocar and attach CO2 tubing for pneumoperitoneum.
4. Dissect fat or adhesions with graspers, hook cautery, and Maryland.
5. Use clip applier on cystic artery twice and perform cholangiogram.
6. Incise cystic duct with laparoscopic scissors and insert cholangiogram catheter.
7. Remove catheter, use clip applier on duct, and dissect gallbladder from liver.
8. Use suction/irrigator to visualize bleeding and remove gallbladder with endopouch.
9. If necessary, aspirate gallbladder and remove stones.
10. Use needle driver and adson pick-up for suturing and mayo scissors for cutting sutures.