Merseyside laparoscopic cholecystectomy course, Royal Liverpool Academy.

1. TOTAL LAPAROSCOPIC CHOLECYSTECTOMY:
HOW I DO ITATAINTREE
Raimundas Lunevicius
Consultant Surgeon & Honorary Senior Lecturer
Emergency, Trauma, Biliary, Hernia Surgery
Aintree University Hospital NHS Foundation Trust, Liverpool, England
13th July 2018
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2. Provide PIL obtaining a consent
I always inspect umbilicus: as….
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3. Total laparoscopic cholecystectomy: How I do it
Never grab umbilicus with Littlewoods
tissue forceps (graspers) Incise skin
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4. Total laparoscopic cholecystectomy: How I do it
Littlewood tissue forceps
Langenbeck’s retractors and
scissors
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5. Linea alba to expose and lift up
with another Littlewoods forceps
Incise & gently perforate abdo wall
using Spencer Wells forceps
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6. 45 degree for 11 mm trocar Inspect all abdominal cavity
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7. 5 mm trocar above the anterior
margin of the normal liver Three trocars of 5 mm diameter
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I do not use 11 mm trocar routinely

8. I do not use Veress needle since
2011
I do not divide a superior midline
into three thirds / uncomfortable to
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9. 9
I do not puncture abdominal wall
Complications to aorta, IVC, mesenteric vessels, iliac vessels: sporadic
(historic figure, copied)

10. Blunt detachment of tissues from Aspiration via nearest 5 mm port
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11. Kindly require instruments you need:
Do not use sharp graspers routinely:
Increase risk of perforation, bile and gallstone spillage
• Two Johan forceps to
use
• Disposable
• Metallic
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12. Use Johan grasper & further blunt
detachment Expose proximal portion – Gn
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Never sharp grasper as too sharp
Gb
Gn

13. Medial dissection: in sub-s layer
(or vice versa)
Lateral dissection: in sub-s layer
(or vice versa)
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Medial serosa
Lateral serosa

14. Medial wall: for CWS behind CA Lateral wall: for CWS behind CA
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Lateral sub-serosa
Gn
Zone of arteries, lymphnode

15. Callot triangle: blunt manipulations
Window behind CA and between
CA and CD (in Callot triangle)
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Inside Callot triangle
Cystic duct
Cystic artery
Lateral branch of CA
Medial branch of CA

16. NB! Hepatocystic triangle:
Callot triangleAND Hepatocystic triangle: NOT SYNONYMS
sometimes it is very difficult to achieve minimal 30% window
It is sufficient window:
Structures of cystic pedicle left to identify
No structures behind CA and CD
(figure copied)
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17. CWS achieved: hem-o-lock CA Hem-o-lock in 2+1 fashion, divide
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18. CA divided CA divided, inspection again
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19. Large hem-o-locks on CD Division of CD
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CA above its division
Hartmann’s pouch
Transection of CD

20. Window of satefy and detachment of
gallbladder from cystic plate (sub-s layer)
Clip additional vessel/duct like structures:
prevalence of sub-vesical duct 4%
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Stump of CD
Stump of CA
Area of cystic plate behind CA

21. Insertion of a large bag:
Always through umbilical port
Make a basket
Insert Robinson drain if needed
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22. Gentle extraction
Incise linea alba, if needed
(NOT rectus muscle)
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23. 21 metallic clips on LC wounds (once found, happily)
Subcuticular 3-0 or 4-0 monocril
sutures: less pain, nicer scars
Never metallic skin clips around
umbilicus
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Subcuticular monocril 3-0 or 4-0

24. Never forget about esthetics in surgery
(figure copied)
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25. ‘YES’ summary points: for standard LC
(figure from Nagoya University, Japan; Dr Kamiya)
• Blade for skin
• Spencer Wells to enter
• Full inspection
• Internal hallmark (liver)
• All 5mm ports (three)
• Change when needed
• Avoid sharp graspers
• Large CWS
• Use polymeric clips: CD
• Monocril subcuticular
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26. ‘NO’ summary points: for standard LC
(figure from Nagoya University, Japan; Dr Kamiya)
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• No skin graspers
• No fingers to abd-cavity
• Do not limit yourself with
inspection of perihepatic
space
• No external hallmarks
• No 11 mm epi-port
• No sharp graspers
• Stop when in doubt
• Don’t use metallic clips
• No metallic skin clips,
please