Initially in laparoscopic cholecystectomy, grasping forceps passed through the 5 mm cannulae are used to retract the fundus of the gallbladder towards the right shoulder and to grasp Hartmann's pouch. Using a dissector such as a diathermy hook passed through the 10 mm epigastric trocar, the cystic artery and duct are exposed and cleaned.
The anatomy of the area or a suspected ductal stone may be confirmed at this stage by cholangiogram. The cystic duct is opened and a specialised catheter is introduced. Contrast is introduced and an image intensifier used for visualisation. Laparoscopic sonography is a sensitive and specific alternative.
The cystic duct is then ligated with metallic or plastic clips, and divided with scissors. This is followed by an equivalent procedure for the cystic artery: some prefer to diathermy branches of the artery rather than ligate the main trunk. The gallbladder is then dissected out of the hepatic fossa using diathermy. This requires a retraction of its neck superiorly. After checking for residual leaks of blood or bile, the gallbladder is detached and removed from the abdomen. This necessitates the transfer of laparoscope from infraumbilical to epigastric portal. The gallbladder is then removed via the former with the latter acting as the viewing channel. Removal may be facilitated by aspirating the contents of the still intrabdominal viscus or crushing stones with forceps or dedicated tools.
The umbilical defect is then closed, the abdomen irrigated and reinspected for leaks, and finally the other trocars are removed, gaseous escape permitted, and all abdominal entry sites are sutured.
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