What is the technique for placing ports and instruments in laparoscopic cholecystectomy?

Updated: Apr 16, 2020
  • Author: Danny A Sherwinter, MD; Chief Editor: Kurt E Roberts, MD  more...
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Answer

A 1.5-cm longitudinal incision is made at the inferior aspect of the umbilicus, then deepened through the subcutaneous fat to the anterior rectus sheath. A Kocher clamp is used to grasp the reflection of the linea alba onto the umbilicus and elevate it cephalad.

A 1.2-cm longitudinal incision is made in the linea alba with a No. 15 blade. Two U stitches, one on either side of the fascial incision, are placed with 0 polyglactin suture on a curved needle (see the video below).

Laparoscopic cholecystectomy. Placement of fascial stay sutures.

The peritoneum is elevated between two straight clamps and incised so as to afford safe entry into the abdominal cavity. An 11-mm blunt Hasson trocar is placed into the abdominal cavity, and insufflation of carbon dioxide is initiated to a maximum pressure of 15 mm Hg.

The authors prefer a 30° laparoscope to a 0° laparoscope because they feel it gives better visualization of the cystic structures from multiple vantage points. A 30° scope requires a more skilled scope operator.

The laparoscope is white-balanced and advanced slowly into the abdominal cavity. A 1.2-cm incision is made three fingerbreadths below the xiphoid process and deepened into the subcutaneous fat. An 11-mm trocar is advanced into the abdominal cavity under direct vision (see the image below) in the direction of the gallbladder through the abdominal wall, with care taken to enter just to the right of the falciform ligament.

Laparoscopic cholecystectomy. Advancement of 11-mm Laparoscopic cholecystectomy. Advancement of 11-mm trocar under direct vision.

The table is then adjusted to place the patient in a reverse Trendelenburg position with the right side up to allow the small bowel and colon to fall away from the operative field (see the image below).

Laparoscopic cholecystectomy. Visualization of gal Laparoscopic cholecystectomy. Visualization of gallbladder after placement of table in reverse Trendelenburg position.

A 5-mm grasper is placed through the 11-mm subxiphoid port and applied to the fundus of the gallbladder. The gallbladder is then elevated cephalad over the dome of the liver to facilitate the surgeon’s choice of the optimal positions for the lateral 5-mm ports.

After appropriate port sites are chosen, the lateral skin incisions are made, and two 5-mm trocars are advanced into the peritoneal cavity under direct vision (see the first image below). A 5-mm grasper with locking mechanism is placed through each of these lateral ports (see the second image below).

Laparoscopic cholecystectomy. Placement of two lat Laparoscopic cholecystectomy. Placement of two lateral 5-mm ports under direct vision.
Laparoscopic cholecystectomy. External view after Laparoscopic cholecystectomy. External view after port placement.

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