The document outlines essential techniques and tips for performing a safe laparoscopic cholecystectomy, emphasizing patient positioning, trocar placement, and the importance of the critical view of safety (CVS) during the procedure. It also highlights the necessity of recognizing aberrant anatomy, utilizing intraoperative cholangiography, and making safe surgical decisions in challenging conditions. Additionally, the document suggests enlisting help from another surgeon when dissection becomes difficult or hazardous.

1. TIP & TECHNIQUE FOR SAFE
LAPAROSCOPIC CHOLECYSTECTOM
Y
Kamales Prasitvarakul ,MD. FRCS
T
Division of Minimally Invasive Surgery center
Department of Surgery
Hatyai Hospital
Songkla Thailand

2. Patient Position
1
.
Position the patient supine with both arms
tucked. Steep reverse Trendelenburg
position with right side up
.
2
.
The surgeon stands on the patient's left
and the assistant on the right. The camera
operator stands to the surgeon's left. The
primary video monitor should be placed
on the right at the level of the shoulder. A
second monitor can be placed on the
surgeon's right
.
3
.
Stomach is emptied with an orogastric
tube, and a Foley catheter may be placed,
based on the expected dif
fi
culties in the
case.

3. Abdominal assess and Trocar Placement
Abdominal Access
1. Veress needle
2. The open Hasson’s techniqu
e
3. Direct trocar placement without prior pneumoperitoneum
.
Trocar Placement
Typically, use four trocar
s
a
.
Umbilical 12-mm optical entry trocar
.
b
.
Epigastric 5-mm trocar is placed based on the liver edge
,just to the right of the falciform ligament.
c. Two additional 5-mm trocars laterally on the right side,
one in midclavicular line and another in anterior axillary
line.
**Three additional trocars are typically placed under
direct vision**

4. STEP
(A) Port placement
.
(B) Initial retraction of
gallbladder
.
(C) Critical view of safety
.
(D) Clipping and division of
cystic artery and duct
.
(E) Dissection of gallbladder
from liver bed
.
(F) Extraction of gallbladder
.

6. The SAGES Safe Cholecystectomy Program
1. Use the Critical View of Safety (CVS) method
Three criteria are required to
achieve the CVS:
A. The hepatocystic triangle
is cleared of fat and
fi
brous
tissue. The hepatocystic
triangle is de
fi
ned as the
triangle formed by the cystic
duct, the common hepatic
duct, and inferior edge of the
liver. The common bile duct
and common hepatic duct do
not have to be exposed.

7. The SAGES Safe Cholecystectomy Program
1. Use the Critical View of Safety (CVS) method
B. The lower one third of the
gallbladder is separated
from the liver to expose the
cystic plate. The cystic plate
is also known as liver bed of
the gallbladder and lies in the
gallbladder fossa.
C. Two and only two
structures should be seen
entering the gallbladder.
Visualization of the doublet view
(anterior)
Visualization of the doublet view
(posterior)

8. The SAGES Safe Cholecystectomy Program
2. Intraoperative Time Out CVS
• Consider an Intraoperative Time Out during
laparoscopic cholecystectomy prior to clipping, cutting
or transecting any ductal structures.
• The Intraoperative Time Out should consist of a stop
point in the operation to con
fi
rm that the CVS has been
achieved utilizing the Doublet View.

9. The SAGES Safe Cholecystectomy Program
3. Understand the potential for aberrant anatomy
in all cases.
• Aberrant anatomy may include
a short cystic duct, aberrant
hepatic ducts, or a right hepatic
artery that crosses anterior to the
common bile duct . These are
some but not all common
variants. •

11. The SAGES Safe Cholecystectomy Program
4. Make liberal use of cholangiography or other
methods to image the biliary tree intraoperatively.
▪ Cholangiography may be
especially important in di
ffi
cult
cases or unclear anatomy.
▪ Several studies have found
that cholangiography reduces the
incidence and extent of bile duct
injury but controversy remains on
this subject.

12. The SAGES Safe Cholecystectomy Program
5. Recognize when the dissection is approaching a zone of signi
fi
cant risk and halt
the dissection before entering the zone. Finish the operation by a safe method
other than cholecystectomy if conditions around the gallbladder are too
dangerous.
▪ Severe in
fl
ammation in the porta hepatis and neck of the gallbladder, the CVS can
be di
ffi
cult to achieve. The surgical judgment that a zone of signi
fi
cant risk is being
approached can be made when there is failure to obtain adequate exposure of the
anatomy of the hepatocystic triangle or when the dissection is not progressing due to
bleeding, in
fl
ammation or
fi
brosis.
▪ Consider laparoscopic subtotal cholecystectomy or Semi top-down technique
or cholecystostomy tube placement, and/or conversion to an open procedure based
on the judgment of the attending surgeon.
6. Get help from another surgeon when the dissection or conditions are di
ffi
cult.

13. THANK YOU