What is the technique for mobilization and laparoscopic removal of the gallbladder?

Answer

Once the cystic structures have been clipped and divided, the infundibulum is retracted cephalad. A hook or spatula is used to develop a plane in the areolar tissue between gallbladder and liver with smooth sweeping movements from right to left and back again. As in any surgical procedure, the traction-countertraction rule is essential. As the dissection marches up the gallbladder bed, the assistant should reposition his or her graspers to ensure optimal tension on the areolar tissue between gallbladder and liver bed (see the images below).

Laparoscopic cholecystectomy. Use of hook to develop plane in areolar tissue between gallbladder and liver.

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Laparoscopic cholecystectomy. Use of traction and hook to remove gallbladder from gallbladder bed.

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Laparoscopic cholecystectomy. Side-to-side sweeping motion with electrocautery to remove gallbladder from gallbladder bed.

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It is important to be alert for any aberrant vessels and ducts that may arise from the liver bed and enter directly into the gallbladder. These should be clipped and not simply cauterized.

Before the last strands connecting the gallbladder to the liver are divided, a final inspection of the gallbladder fossa and the clipped cystic structures should be carried out. Any bleeding points in the gallbladder fossa should be controlled at this time, before the gallbladder is completely separated from the liver (see the image below). This is the surgeon’s last opportunity to visualize these areas well.

Laparoscopic cholecystectomy. Cauterization of any bleeding in gallbladder bed before complete division of gallbladder.

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Both 5-mm graspers are applied to the gallbladder and used to hold it over the right upper quadrant. The laparoscope is transferred to the subxiphoid port, and an endoscopic retrieval pouch is inserted through the umbilical trocar. The gallbladder is placed in the bag, which is then cinched closed. (See the images below.) The authors prefer to leave the bag suspended from the umbilical trocar while they replace the camera through the same port and perform the final inspection and washout.

Laparoscopic cholecystectomy. Placement of gallbladder into endoscopic retrieval pouch.

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Laparoscopic cholecystectomy. Placement of gallbladder into endoscopic retrieval pouch and removal of instrument from pouch.

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The table is returned to the neutral position. The gallbladder bed and the suprahepatic spaces are irrigated and suctioned to ensure adequate hemostasis and removal of any debris or bile that may have spilled (see the image below).

Laparoscopic cholecystectomy. Irrigation and suction of gallbladder bed.

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Media Gallery

Laparoscopic cholecystectomy. Placement of fascial stay sutures.
Laparoscopic cholecystectomy. Visualization of gallbladder after placement of table in reverse Trendelenburg position.
Laparoscopic cholecystectomy. Advancement of 11-mm trocar under direct vision.
Laparoscopic cholecystectomy. Placement of two lateral 5-mm ports under direct vision.
Laparoscopic cholecystectomy. External view after port placement.
Laparoscopic cholecystectomy. Lateral grasper is used to retract fundus cephalad and retract adhesions.
Laparoscopic cholecystectomy. Medial grasper is applied to infundibulum.
Laparoscopic cholecystectomy. Medial grasper is used to retract infundibulum in caudolateral direction.
Laparoscopic cholecystectomy. Critical view, with only cystic duct and cystic artery seen entering gallbladder.
Laparoscopic cholecystectomy. Use of L-hook electrocautery to score anterior peritoneum.
Laparoscopic cholecystectomy. Division of peritoneum along medial aspect.
Laparoscopic cholecystectomy. Use of Endo Peanut to identify cystic structures.
Laparoscopic cholecystectomy. Use of Maryland dissector to dissect cystic duct.
Laparoscopic cholecystectomy. Use of Maryland dissector to dissect cystic artery.
Laparoscopic cholecystectomy. Continued dissection of critical structures.
Laparoscopic cholecystectomy. Placement of clip at lower aspect of cystic artery.
Laparoscopic cholecystectomy. Placement of superior clips on cystic artery.
Laparoscopic cholecystectomy. Transection of cystic artery with Endo Shears.
Laparoscopic cholecystectomy. Placement of clips on distal cystic duct.
Laparoscopic cholecystectomy. Placement of proximal clip on cystic duct.
Laparoscopic cholecystectomy. View of clipped cystic duct before transection.
Laparoscopic cholecystectomy. Transection of cystic duct between clips with Endo Shears.
Laparoscopic cholecystectomy. Use of hook to develop plane in areolar tissue between gallbladder and liver.
Laparoscopic cholecystectomy. Use of traction and hook to remove gallbladder from gallbladder bed.
Laparoscopic cholecystectomy. Side-to-side sweeping motion with electrocautery to remove gallbladder from gallbladder bed.
Laparoscopic cholecystectomy. Cauterization of any bleeding in gallbladder bed before complete division of gallbladder.
Laparoscopic cholecystectomy. Placement of gallbladder into endoscopic retrieval pouch.
Laparoscopic cholecystectomy. Placement of gallbladder into endoscopic retrieval pouch and removal of instrument from pouch.
Laparoscopic cholecystectomy. Irrigation and suction of gallbladder bed.
Laparoscopic cholecystectomy. Removal of ports under direct vision.
Laparoscopic cholecystectomy. Abdomen after skin closure.
Laparoscopic cholecystectomy. CT scan illustrating biloma.
Laparoscopic cholecystectomy. Postcholecystectomy ERCP showing leak of contrast.
Laparoscopic cholecystectomy. Postcholecystectomy ERCP.
Laparoscopic cholecystectomy. ERCP-guided stent placement.
Laparoscopic cholecystectomy. HIDA scan showing postcholecystectomy leak.
Anatomy of biliary tree.

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Author

Danny A Sherwinter, MD Attending Surgeon, Department of Mimially Invasive Surgery and Bariatrics, Associate Program Director, Department of Surgery, Maimonides Medical Center; Director of Minimally Invasive and Bariatric Surgery, American Society for Metabolic and Bariatric Surgery (ASMBS) Center of Excellence

Danny A Sherwinter, MD is a member of the following medical societies: American College of Surgeons, American Society for Metabolic and Bariatric Surgery, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

Stalin Ramakrishnan Subramanian, MD Resident Physician, Department of Medicine, Brookdale University Hospital and Medical Center

Disclosure: Nothing to disclose.

Lee S Cummings, MD Transplant Fellow, Georgetown University Hospital

Lee S Cummings, MD is a member of the following medical societies: American College of Surgeons, American Medical Association

Disclosure: Nothing to disclose.

Michele F Malit, DO Resident Physician, Department of Surgery, Maimonides Medical Center

Michele F Malit, DO is a member of the following medical societies: American College of Surgeons, American Medical Student Association/Foundation, American Osteopathic Association, American College of Osteopathic Surgeons, Student Osteopathic Medical Association

Disclosure: Nothing to disclose.

Sunny Leah Fink, MD Multi-Organ Abdominal Transplant Fellow, Department of Transplant Surgery, University of Pittsburgh Medical Center

Sunny Leah Fink, MD is a member of the following medical societies: American College of Surgeons, American Medical Student Association/Foundation

Disclosure: Nothing to disclose.

Harry L Adler, MD Assistant Clinical Professor of Surgery, Mount Sinai Hospital; Assistant Director and Consulting Physician, Maimonides Medical Center

Harry L Adler, MD is a member of the following medical societies: American Association for Physician Leadership, American College of Surgeons, Association for Academic Surgery

Disclosure: Nothing to disclose.

Chief Editor

Kurt E Roberts, MD Assistant Professor, Section of Surgical Gastroenterology, Department of Surgery, Director, Surgical Endoscopy, Associate Director, Surgical Skills and Simulation Center and Surgical Clerkship, Yale University School of Medicine

Kurt E Roberts, MD is a member of the following medical societies: American College of Surgeons, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons

Disclosure: Nothing to disclose.

Acknowledgements

Jerzy M Macura, MD Chief of Advanced Laparoscopic Surgery, Director of Bariatric Surgery, Maimonides Medical Center

Jerzy M Macura, MD is a member of the following medical societies: American Society for Metabolic and Bariatric Surgery, American Society of Abdominal Surgeons, and Society of American Gastrointestinal and Endoscopic Surgeons

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

What is the technique for mobilization and laparoscopic removal of the gallbladder?

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