Laparoscopic cholecystectomy is the current gold standard for surgical removal of the Gall bladder, particularly in benign pathologies. Hence, it is necessary to highlight some steps to accomplish this procedure successfully while avoiding pitfalls.

1. TIPS AND TRICKS IN
LAPAROSCOPIC
CHOLECYSTECTOMY
by
Dr Echebiri, P.
Department of Surgery, National Hospital, Abuja
24th May, 2018

2. OUTLINE
• Antibiotic prophylaxis
• Deep venous thrombosis prophylaxis
• Systemic anticoagulation
• Cirrhotic patients
• Acute cholecystitis
• Pregnancy
• Assistant surgeon
• Creation of adequate working space

3. OUTLINE
• Abdominal access
• Dissection
• Bile duct injury
• Conversion to open cholecystectomy
• Drains
• Post-operative management references

4. ANTIBIOTIC PROPHYLAXIS
• Reduces surgical site infection.
• Benefit convincingly demonstrated only in high risk patients:
Age > 60 years
Jaundice
Diabetic status
Acute colic within 30 days
Acute cholecystitis
Acute cholangitis

5. ANTIBIOTIC PROPHYLAXIS
• Administered prophylactically as a single dose, otherwise repeat if duration of
surgery exceeds 4 hours

6. DEEP VENOUS THROMBOSIS PROPHYLAXIS
• Procedure inherently thrombogenic:
Raised intra-abdominal pressure from pneumoperitoneum which impedes venous
return from lower limbs and pelvis.
Reverse trendelenburg position leading to gravitational pooling in lower limbs
General anesthesia with resultant systemic vasodilation
• Routine calf-length compression devices is sufficient for patients lacking additional
risk factors

7. DEEP VENOUS THROMBOSIS PROPHYLAXIS
• Addition of pharmacological prophylaxis by means of low molecular weight heparins
is indicated in patients with extra risk factors.
• Recognised extra risk factors include:
Age> 40 years
Previous DVT
Obesity
Cancer
Exogenous estrogens
Anticipated duration of procedure > 2 hours

8. SYSTEMIC ANTICOAGULATION
• Caution should be exercised in chronically anticoagulated patients on oral
anticoagulation, particularly in those requiring bridging with low molecular weight
heparin even in the presence of normal clotting profile (INR<1.5) due to
demonstrated unpredictable increased postoperative hemorrhage.

9. CIRRHOTIC PATIENTS
• Laparoscopic cholecystectomy is not recommended for Child’s C patients in the
setting of Cirrhosis

10. ACUTE CHOLECYSTITIS
• Early cholecystectomy performed within 24-72 hours of diagnosis is safe and planes
of dissection are aided by the edema of acute inflammation.
• Outcome of early cholecystectomy is better than delayed/interval procedures because
it precludes further recurrent episodes or progression with attendant complications

11. PREGNANCY
• Preferably delay laparoscopic Cholecystectomy until second trimester of pregnancy
and beyond

12. ASSISTANT SURGEON
• For anticipated difficult procedures, perform a laparoscopic cholecystectomy with a
skilled laparoscopic surgeon as your assistant.

13. CREATION OF ADEQUATE WORKING SPACE
• A distended stomach may encroach on the sites of trocar insertion at the
epigastrium, as well as, the right hypochondrial region thereby impairing
visualization during procedur and increasing risk of iatrogenic injuries.
• Decompression of the stomach by means of a nasogastric tube may significantly
contribute favorably to success of the procedure

14. ABDOMINAL ACCESS
• Numerous techniques of abdominal access with no clearly demonstrated
comparative benefit of any
• The sub-umbilical fold is routinely employed as entry point
• In patients with intra-abdominal adhesions from previous surgeries/diseases
additional entry points include:
Palmer’s point
Left lower intercostal space
Right iliac fossa

15. ABDOMINAL ACCESS
• Introduce all trocars under direct vision while noting and avoiding vessels on the
deep surfaces of the anterior abdominal wall

16. DISSECTION
• Watch out for sword-fighting and take necessary steps
• Sharp instruments must be manipulated and moved under direct vision always
• Preferably use blunt dissection devoid of energy sources in the hepatocystic triangle
until structures have been clearly delineated

17. DISSECTION
• Aim for safe ductal identification. Proven steps include:
Rouviere’s sulcus method
Strasberg’s critical view of safety
Infundibular technique (elephant trunk sign)
Intra-operative cholangiogram
• Retraction of gall bladder should be appropriate and not excessive as this would
predispose to misidentification of anatomy and bile duct injuries

18. DISSECTION
• It is suffient to dissect and skeletonize structures in the hepatocystic triangle to
without attempting to confirm their nature
• Angled laparoscopy may improve judgement of ductal and vascular anatomy
• Aspirate grossly distended gall bladder prior to retraction

19. DISSECTION
• Utilize stay sutures for traction on a Hartmann’s pouch when direct trocar
application fails. Do not struggle!
• Allow an intra-operative time-out each time, prior to dividing or clipping
ductal/vascular structures.
• Only structures traceable to the gall bladder should be divided/clipped
• If an injury occurs, do not panic! The magnified view during laparoscopy tends to blow
the extent of injury out of proportion.

20. DISSECTION
• Clip and divide cystic artery and cystic duct separately
• The top-bottom approach may be expedient when difficulties are encountered in
freeing the gall bladder from its fossa on the liver
• Complete a posterior dissection of the gall bladder from the fossa prior to continuing
anteriorly

21. BILE DUCT INJURY
• Inadvertent injuries mainly result from misidentification due to the surgeon’s
assumption. Hence, a high level of experience alone is not sufficient to prevent bile
duct injuries!
• Subtotal cholecystectomy is preferable to open conversion in cases of difficult gall
bladder such as fibrotic ones because open conversion does not eliminate the
underlying pathology, blood loss is increased and significant wound morbidity is
introduced. Another option is cholecystostomy tube placement.

22. BILE DUCT INJURY
• Do not attempt repair of a bile duct injury. Invite an expert hepatobiliary surgeon to
take over, otherwise, place a drain and refer to the specialist.
• Admit when you need help and do not hesitate to ask immediately for an expert
advise

23. CONVERSION TO OPEN
CHOLECYSTECTOMY
• Patients MUST always be counselled on the possibility of conversion while obtaining
consent for surgery.
• Conversion should not be considered a complication and should be resorted to in
order to prevent complications and for damage control when complications that are
not amenable to laparsoscopic correction develop.

24. DRAINS
• Use of drain in uncomplicated, straightforward laparoscopic cholecystectomy is
discouraged because their use may increase complication rates including pain and
surgical site infection
• Drains are nevertheless indicated in complicated cases especially when a
choledochotomy was performed.

25. POST-OPERATIVE MANAGEMENT
• Do not downplay post-operative complaints for example, pain, fever,nausea etc. They
deserve a thorough evaluation to exclude missed bile duct injuries

26. REFERENCES
• Sanjay P, Fulke JL, Exon DJ. Critical view of safety as an alternative to routine
intraoperative cholangiography during laparoscopic cholecystectomy for acute
biliary pathology. J Gastrointest Surg 2010;14:1280-84.
• Ludwig K, Bernhardt J, Steffen H, Lorenz D. Contribution of intraoperative
cholangiography to incidence and outcome of common bile duct injuries during
laparoscopic cholecystectomy. Surg Endosc 2002;16:1098-1104.
• Fletcher DR, Hobbs MS, Tan P, et al. Complications of cholecystectomy: Risks of the
laparoscopic approach and protective effects of operative cholangiography: A
population-based study. Ann Surg 1999;229:449-57.

27. REFERENCES
• Way LW, Stewart L, Gantert W, et al. Causes and prevention of laparoscopic bile
duct injuries: Analysis of 252 cases from a human factors and cognitive psychology
perspective. Ann Surg 2003;237:460-69.
• Ishizawa T, Bandai Y, Ijichi M, Kaneko J, Hasegawa K, Kokudo N. Fluorescent
cholangiography illuminating the biliary tree during laparoscopic cholecystectomy.
Br J Surg 2010;97: 1369-77.
• Sari YS, Tunali V, Tomaoglu K, Karagoz B, Guney A, Karago I. Can bile duct injuries
be prevented? A new technique in laparoscopic cholecystectomy. BMC Surgery
2005;5:14.

28. REFERENCES
• Hugh TB, Kelly MD, Mekisic A. Rouviere's sulcus: A useful landmark in laparoscopic
cholecystectomy. Br J Surg 1997;84: 1253-54.
• Beldi G, Glattli A. Laparoscopic subtotal cholecystectomy for severe cholecystitis.
Surg Endosc 2003;17:1437-39.
• Tian U, Wu SD, Yang S, et al. Laparoscopic subtotal cholecystectomy as an
alternative procedure designed to prevent bile duct injury: Experience of a hospital
in Northern China. Surg Today 2009;39:510-13.
• Reason J. Human error: Models and management. Br Med J 2000;320:768-70.

29. THANK YOU ALL
• THANK YOU ALL