Laparoscopic Cholecystectomy:

Laparoscopic cholecystectomy has now replaced open cholecystectomy as the first-choice of treatment for gallstones and inflammation of the gallbladder unless there are contraindications to the laparoscopic approach. This is because open surgery leaves the patient more prone to infection. Sometimes, a laparoscopic cholecystectomy will be converted to an open cholecystectomy for technical reasons or safety.

Laparoscopic cholecystectomy requires several (usually 4) small incisions in the abdomen to allow the insertion of operating ports, small cylindrical tubes approximately 5 to 10 mm in diameter, through which surgical instruments and a video camera are placed into the abdominal cavity. The camera illuminates the surgical field and sends a magnified image from inside the body to a video monitor, giving the surgeon a close-up view of the organs and tissues. The surgeon watches the monitor and performs the operation by manipulating the surgical instruments through the operating ports.

To begin the operation, the patient is placed in the supine position on the operating table and anesthetized. A scalpel is used to make a small incision at the umbilicus. Using a Veress needle or Hasson technique, the abdominal cavity is entered. The surgeon inflates the abdominal cavity with carbon dioxide to create a working space. The camera is placed through the umbilical port and the abdominal cavity is inspected. Additional ports are opened inferior to the ribs at the epigastria, midclavicular, and anterior maxillary positions. The gallbladder fundus is identified, grasped, and retracted superiorly. With a second grasper, the gallbladder infundibulum is retracted laterally to expose and open Calot's Triangle (cystic artery, cystic duct, and common hepatic duct). The triangle is gently dissected to clear the peritoneal covering and obtain a view of the underlying structures. The cystic duct and the cystic artery are identified, clipped with tiny titanium clips and cut. Then the gallbladder is dissected away from the liver bed and removed through one of the ports. This type of surgery requires meticulous surgical skill, but in straightforward cases, it can be done in about an hour.

Recently, new techniques have been developed to perform this surgery through a single incision in the patient's umbilicus. This advanced technique is called Laparoendoscopic Single Site Surgery or "LESS" or Single Incision Laparoscopic Surgery or "SILS". In this procedure, instead of making 3-4 four small different cuts (incisions), a single cut (incision) is made through the navel (umbilicus). Through this cut, specialized reticulating instruments (straight instruments which can be bent once inside the abdomen) are inserted to do the operation. The advantage of LESS / SILS operation is that the number of cuts is further reduced to one and this cut is also not visible after the operation is done as it is hidden inside the navel. A significantly higher incidence of wound complications, specifically development of hernia, has been noted with SILSSILS has also been associated with a higher risk for bile duct injury .

Laparoscopic bile duct exploration (LBDE) is recommended in current treatment guidelines for the management of choledocholithiasis with gallbladder in situ. Failure of this technique is common as a consequence of large or impacted common bile duct (CBD) stones. A new technique, LABEL (Laser-Assisted Bile duct Exploration by Laparoendoscopic) has been developed to enhance LBDE in cases of impacted or large stones using holmium-laser increasing the feasibility of the transcystic stone retrieval and reducing overall operative time in the treatment of choledocholithiasis.


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