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Technique

Placement of the patient
The patient is put under general anesthesia and is intubated. A double lumen nasogastric tube is introduced. The patient is put in the lithotomy position, the thighs being only slightly flexed. The operating table is put in reverse Trendelenburg 30°. The surgeon is positioned between the patient’s legs, the first assistant is to the left of the patient and the second assistant to the right. The surgeon, optical system, operative field and monitor have to be approximately on one straight line.

  

Initiation of the pneumoperitoneum
A Verres’ needle is introduced at the level of the umbilicus. A maximum 14 mm Hg intraperitoneal pressure is established, and maintained thanks to a high volume insufflator.

  

Placement of trocars and surgical tools
Four trocars are introduced :

1. a 10 mm trocar through the umbilicus ;
2. a 5 mm trocar high in the epigastrium, just to the right of the falciform ligament of the liver ;
3. a 5 mm trocar under the right costal margin, at the level of the anterior axillary line ;
4. a 10 mm trocar half way between trocar 1 and 2, 2 cm to the left of the midline.

The optical system with a 30° angled scope is introduced through trocar 1, a probe is introduced in trocar 2 in order to retract the liver, a grasping forceps (fenestrated and atraumatic) is introduced in trocar 3 and the coagulating hook is introduced in trocar 4.

  

Exposure and dissection of Callot’s triangle
The right lobe of the liver is retracted by the probe while the grasping forceps grasps the fundus of the gallbladder and pushes this to the right of the patient so as to keep the peritoneum of Callot’s triangle under traction.
This forceps will subsequently pull the neck of the gallbladder anteriorly, which will expose the posterior aspect of Callot’s triangle. Dissection is initiated by incising the posterior peritoneal sheath with the coagulating hook. The next step is to incise the entire peritoneal sheath of Callot’s triangle while the gallbladder is forcefully pulled posteriorly.

Skeletonization of cystic artery and cystic duct
Dissection of the cystic pedicle is performed with the coagulating hook. In order to dissect artery and cystic duct safely, the gallbladder will be successively pulled anteriorly and posteriorly so that the ventral and dorsal aspect of the structures can be identified. Elective ligation of artery and cystic duct with clips can only be performed after perfect skeletonization of those structures. The common bile duct has to be visualized on all occasions, and so does the right branch of the hepatic artery.
Two clips are placed proximally and 1 clip is placed distally. Transsection of artery and cystic duct is performed with scissors.

  

Retrograde cholecystectomy
The neck of the gallbladder is pulled to the right of the patient so as to put the cholecysto-hepatic adhesions under tension. Severance of adhesions is performed under direct view with the coagulating hook. Traction, and counter traction usually allow for easy dissection of the gallbladder bed. This dissection is usually bloodless.

Extraction of the gallbladder
Once freed, the gallbladder is left on the anterior side of the liver. The cystic stump is checked for perfect closure.
All accumulated blood can now be safely suctioned by the suction pump, care being taken not to dislodge any clips. The optical system is subsequently introduced in trocar 4. An alligator clamp is introduced in trocar 1. The gallbladder neck is grasped and pulled inside trocar 1 under direct vision. Trocars, alligator clamp and gallbladder neck are then pulled back under tension through the abdominal wall. The gallbladder neck is grasped with two kelly clamps and incised. Bile is aspirated with the suctioning device. A forceps can now be introduced through the incision in the gallbladder neck and the larger stones can be fragmented. The gallbladder is subsequently extracted without problems. The pneumoperitoneum is released and the umbilical wound is cleaned with an antiseptic solution. The skin is closed with staples. No drains are left except in case of acute cholecystitis.