Preparation and approach

Firstly, the patient is placed under a general anaesthetic. The surgeon then stands in one of two positions - either on the left side or between the patient's legs. A nasogastric tube is sited to decompress the stomach. A urinary catheter is passed to empty the bladder.

It is then necessary to lift the abdominal wall and distract tissue and structures. This can be achieved with mechanical retractors, but more commonly, carbon dioxide is insufflated. An infra-umbilical incision is made and 3-5 litres of gas is pumped in at a pressure of about 14 mmHg.

A 10 mm trocar is then inserted through the same incision and directed towards the right upper quadrant where it is used for exploratory laparoscopy. If cholecystectomy is then thought to be feasible, further trocars and cannulae are inserted into the abdominal wall:

• a second 10mm cannula:
  • sited between xiphoid process and umbilicus
  • used for dissecting instruments
    
    
• a 5mm cannula:
  • sited in the anterior axillary line beneath the costal margin
  • used for ratcheted grasping forceps
    
    
• a second 5mm cannula:
  • sited in the right midclavicular line beneath the costal margin
  • for grasping forceps