1. The majority of patients with typical biliary pain undergoing surgery for documented gallstones may expect an excellent response to their operation in terms of symptom resolution and postoperative side-effects.

2. Asymptomatic gallstones are common and it is vital to obtain a careful corroborating history before ascribing vague upper abdominal symptoms to stones seen on imaging.

3. In patients where symptoms are not typical, there should be a warning that the operation may not provide complete relief and a thorough search for an alternative diagnosis should be undertaken prior to surgery.

4. The aim of the operation is to remove the gallbladder with division of the cystic duct, which connects the gallbladder to the main biliary tree and the cystic artery, which is the major blood supply to the gallbladder and usually a branch of the right hepatic artery.

5. Significant variation exists in both biliary and hepatic arterial anatomy and, although the majority of these variations will have little impact on a safely performed cholecystectomy, full advantage should be taken of any preoperative imaging that may be available and careful note made of any anatomical anomalies identified on ultrasound scans, magnetic resonance cholangiograms (MRCP) or ERCPs where available.

1. The majority of patients can be treated laparoscopically. Fitness for surgery should be considered on the basis that an open operation may be required. The cardiovascular effects of a pneumoperitoneum should be borne in mind.

2. Patients should be booked to appropriate lists based on any underlying medical co-morbidity and clues as to the likely severity of their disease process, such as a long history of severe and constant pain and ultrasound findings of a very thick-walled gallbladder with surrounding oedema or empyema.

3. Informed consent should be obtained with mention of specific risks such as bleeding, infection, injury to surrounding blood vessels, bowel or the main bile duct, to include bile leak. General complications of surgery such as venous thromboembolism (VTE), acute coronary events, pulmonary and cerebrovascular events and anaesthetic complications should also be discussed. In general terms’ any complications that occur relatively frequently (> 1 in 1000) should be outlined, along with other rarer, but very significant risks.

4. Ensure that a sample of blood has been obtained for group and save of serum and review the preoperative blood results – specifically, the liver function tests.

5. If it is planned to undertake the operation laparoscopically, the patient should be warned of the possibility of conversion to open surgery depending on intra-operative findings or events.

6. Instigate adequate VTE prophylaxis, according to local protocol, which may include the use of pre- or perioperative prophylactic heparin therapy, compression stockings or pneumatic compression devices.

7. A meta-analysis has shown no benefit to the routine use of antibiotic prophylaxis in the prevention of wound infection and septic complications, but they should be considered if the biliary tree is considered to be infected.

8. The operation is conducted under general anaesthesia and care should be taken to ensure that a radiolucent operating table is used, as regardless of whether an intra-operative cholangiogram is performed routinely or selectively, it may be essential in the case of intra-operative difficulties.

1. The patient is positioned supine, and following the application of a warming device, antiseptic skin preparation should be applied from an area extending from the nipples to the symphisis pubis, with the drapes positioned such that the full costal margin and the lower border of the sternum are within the sterile operative field.

2. The convention is for the operating surgeon to stand on the patient’s left hand side with an assistant to their left and the scrub nurse with instruments on the patient’s right. Some surgeons prefer to place the patient in a Lloyd-Davies position and to operate from between the legs and a few will stand on the right side of the table.

3. The monitor is placed at the surgeon’s eye level at the patient’s right shoulder (Fig. 15.1).

4. The pneumoperitoneum may be safely established by either an open cut-down or through the use of a Veress needle. Although numerous safe techniques exist for an open approach, the authors favour a 1-cm vertical supraumbilical incision with sharp scissor dissection down to the linea alba. A stay suture is then placed either side of the midline and the sheath and peritoneum incised to enter the peritoneal cavity whilst maintaining upward traction on the fascial stay stitches. A blunt trocar is then used to insert a 10- or 11-mm cannula to be used as the optical port. An operating pressure of 12 mmHg is favoured.

5. If a Veress needle technique is preferred, this is introduced through a similarly sited skin incision and gentle upward traction applied by grasping the surrounding skin of the abdominal wall until two distinct clicks of the needle are felt as it passes through first the abdominal wall fascia and then the peritoneum. Correct positioning can be confirmed by either placing a drop of saline at the injection port of the needle with the valve closed – the fluid should be ‘sucked’ into the needle when the valve is opened and the abdominal wall lifted – or, alternatively, the insufflation machine can be attached and should show a high flow rate and low intra-abdominal pressure. Following insufflation of at least 3 L of gas and with an intra-abdominal pressure of 12 mmHg, the needle is removed and an armed, sharp trocar used to introduce the first port, again whilst maintaining traction on the upper abdominal wall. You must be certain of correct positioning of the Veress needle and of an adequate peritoneum prior to the blind insertion of a sharp port and if in any doubt, should consider reverting to an open introduction technique.

6. Following insertion of the optical port, the laparoscope should be introduced and a full inspection of the abdominal contents performed to identify concomitant pathology outside of the vicinity of the gallbladder.

7. Tilt the operating table head-up and to the patient’s left in order to facilitate an optimal view.

8. A standard four-port laparoscopic cholecystectomy requires the introduction of three further ports which should be introduced under direct vision and usually consist of a further 11-mm port in the epigastrium, one 5-mm port in the right upper quadrant and a further 5-mm port in the right lower quadrant (Fig. 15.2). A three-port cholecystectomy has also been described whereby all retraction is supplied by the surgeon’s left hand instrument and there is no dedicated fundal retractor. There has been no evidence that the elimination of the fourth port alters outcome in terms of postoperative pain or complications – nor have there been any studies addressing safety of the three-port technique.

9. Divide any omental or visceral adhesions to expose the fundus of the gallbladder, which is then grasped with a suitably robust, ratcheted instrument inserted through the RLQ port and retracted cranially to expose Hartmann’s pouch and Calot’s triangle (the area between the cystic duct, common hepatic duct and liver).

10. If the view is obscured by distended duodenum or stomach then the anaesthetist should be asked to aspirate via a nasogastric tube.

11. Apply traction to Hartmann’s pouch using a suitable instrument (Johann or dolphin grasper) in your left hand and use an instrument for dissection in the right hand – usually a diathermy hook, scissors, curved dissecting forceps or a combination of the above.

12. Make a peritoneal incision at the medial aspect of the lower border of Hartmann’s pouch and continue to divide the peritoneum around the base of the gallbladder and extended a little way up each of the medial and lateral borders with the liver (Fig. 15.3). This will increase mobility and facilitate the dissection of Calot’s triangle.

13. Carefully dissect Calot’s triangle to expose the cystic duct and artery (with the artery usually, but not always, lying between the cystic duct and liver plate and usually related to a cystic lymph node). Following isolation of these structures, about 1/3 of the proximal gallbladder should be dissected from the liver in order to be sure of the correct identity of the cystic structures – the so-called critical view of safety (Fig. 15.4).

14. Only when you are absolutely satisfied that the structures are the cystic artery and duct may they be secured and divided. Mechanical clips are the commonest technique used (either metal or polypropylene) and usually the structures are clipped twice proximally and once distally before division with scissors, ensuring that a safe cuff of tissue is left beyond the proximal clips (at least 3 mm).

15. Now grasp Hartmann’s pouch with your left hand and retract it cranially to facilitate dissection of the gallbladder from the liver bed in the layer of the cystic plate.

16. Care should be taken not to stray too deeply towards the liver substance as the middle hepatic vein can lie quite superficially within the gallbladder bed and will be the source of significant and difficult-to-control haemorrhage if injured.

17. A small blood vessel or occasionally a bile duct (of Lushka) may be encountered during dissection of the cystic plate – these should be clipped proximally if they are to be divided.

18. The final dissection of the fundus of the gallbladder from the liver bed is facilitated by conversion to caudal traction with the fundal grasper. However, the cystic structures and the gallbladder bed should be checked for haemostasis and bile leaks prior to division of the final gallbladder attachments, as retraction is more difficult when the gallbladder has been completely detached.

19. Retrieve the gallbladder in an impermeable extraction bag to minimize the risk of port site infection and to protect the wound in the infrequent case of an incidental carcinoma. Extraction is best performed through the umbilical port, as this fascial incision is usually the largest and the simplest to extend and subsequently close.

20. Make a final inspection of the operative field to exclude bleeding and bile leaks and remove each port under direct vision, again to check haemostasis.

21. Close the 11-mm fascial defects using an 0 absorbable suture. The 5-mm ports are not often closed routinely, though some surgeons would advocate doing so to avoid the infrequent hernias encountered through these port sites.

22. Close the skin according to your own preference and instil local anaesthetic into each of the wounds, based on the safe maximum dose for the individual patient.

1. The majority of cholecystectomies are now performed laparoscopically, with the open procedure usually reserved for cases where laparoscopic progress is impossible or when the gallbladder is being removed in conjunction with another procedure that is being performed via an open technique.

2. The presence of previous upper abdominal incisions is not an absolute contraindication to laparoscopic surgery. It is usually possible to insert a laparoscope and take down adhesions (perhaps with a slight modification of the port positioning) in order to proceed to a laparoscopic cholecystectomy.

1. The same preoperative steps are required as for the laparoscopic procedure. In addition, antibiotic prophylaxis against wound infection is usually given in all cases.

1. The surgeon usually stands on the patient’s right side with the first assistant and scrub nurse opposite. A second assistant is very useful, if available, and should stand to the surgeon’s left.

2. Make a transverse subcostal incision on the right hand side and deepen this using monopolar diathermy through the fat layer, down to the fascia overlying the rectus and external oblique muscles. Usually a 6–10-cm incision will suffice, though this may need to be extended according to the patient’s build and the degree of inflammation of the gallbladder.

3. Incise the fascia in the same oblique line and stay at least 3–4 cm beneath the costal margin to allow closure of the wound without having to stray too close to the periosteum of the ribs.

4. Some surgeons will pass a swab or tape beneath the rectus muscle prior to division, but it is perfectly safe to simply divide the muscle using diathermy until the posterior fascial layer is reached. Any large vessels encountered within the muscle can be grasped with forceps and diathermized or ligated as required.

5. Grasp the posterior layer of fascia with two clips and incise between them, then extend the full length of the wound with a hand inside the abdominal cavity to protect any underlying bowel.

6. Following an inspection of the abdominal contents, place a folded swab above the right dome of the liver in order to bring the gallbladder and hilum into the operative field.

7. Divide any omental or visceral adhesions to allow the colon and small bowel to be retracted caudally beneath a further folded pack and use a deep retractor such as a ‘Kelly’ held in the assistant’s left hand to maintain a clear view of the gallbladder neck and the hepatic hilum.

8. A ‘Rampley’s’ sponge holding forceps on the fundus of the gallbladder and retracted towards the right shoulder by a second assistant is often useful to display Calot’s triangle.

9. Cholecystectomy may commence with either dissection of the structures in Calot’s triangle, as with the laparoscopic operation, or by a fundus-first dissection of the gallbladder from the liver bed. It is the authors’ preference to first identify and divide the cystic artery and duct and to divide the tissue within Calot’s triangle prior to detaching the gallbladder, as this helps guide the final stage of mobilization of the gallbladder from the liver.

10. Transfix the cystic duct and artery proximally and ligate them distally prior to division. An absorbable suture is adequate and the authors’ preference is for 3/0 vicryl.

11. Dissection should follow the same plane within the cystic plate as with the laparoscopic operation and as the cystic plate is continuous with the hilar plate it is necessary to direct dissection over the cystic structures on reaching Calot’s triangle, as continuing along the cystic plate will lead to the right hilar structures. Determining the correct plane to follow at this stage of the dissection is made very much easier if Calot’s triangle has been dissected in the first instance (Fig. 15.5).

12. Following removal of the gallbladder, check the cystic plate for bile leaks and bleeding by applying a clean white swab.

13. Unless the gallbladder was perforated during removal, routine lavage or drainage is not required. If bile or stones were spilt, then a careful wash should be performed and all stones retrieved.

14. A drain will not be necessary unless you have any doubts about the integrity of your closure of the cystic duct stump.

15. You may close the wound using either a heavy permanent or an absorbable suture, either in two layers or by mass closure, according to preference. A ‘fat stitch’ is not usually necessary and skin can be closed, again according to preference.

1. Insert a special SILS port, via an open incision through the umbilicus, which allows passage of a number of standard instruments and a 10-mm laparoscope (Fig. 15.6).

2. The technique for the operation is the same as for the laparoscopic procedure; however, manipulation angles for the instruments are restricted and high-quality camera work is essential.

3. Some lateral retraction of the gallbladder can be achieved by passing a suture on a straight needle through the anterior abdominal wall in the left upper quadrant, passing the suture through Hartmann’s pouch and out through the abdominal wall in the right upper quadrant. Ligaclips are then placed on the suture on either side of Hartmann’s pouch and external traction on either end of the suture will provide some lateral retraction of the gallbladder to facilitate dissection (Fig. 15.7).