After informed consent was obtained, the patient was taken to the Operating
Suite and placed supine on the operating table. General endotracheal
anesthesia was induced. Preoperative antibiotics were administered. The
patient's abdomen was prepped and draped in the usual sterile surgical
fashion. A time-out was performed with all team members present.
A 5 mm transverse supraumbilical incision was made and a Veress needle was
inserted. The abdomen was insufflated with carbon dioxide gas to a pressure of
15 mmHg. The Veress needle was withdrawn and a 5 mm port was inserted
and a laparoscope was then placed. A general survey of the abdomen was
conducted and no injuries from Veress needle or trocar insertion were noted.
Inspection of the right upper quadrant showed an acutely inflamed and
distended gallbladder. Under direct vision, additional ports were placed in the
following locations: A 10 mm subxiphoid port and two right subcostal lateral
ports. No injury from trocar placement was noted.
Using two blunt graspers, the gallbladder fundus was retracted cephalad and
the infundibulum retracted laterally. The cystic duct was then circumferentially
dissected bluntly. After appropriate dissection two surgical clips were applied
to the proximal portion of the duct and one clip was applied distally. The cystic
duct was then divided sharply using laparoscopic scissors. Dissection then
continued until the cystic artery was identified. Blunt dissection was used to
circumferentially dissect the cystic artery. Two surgical clips were placed
proximally and one clip was placed distally on the cystic artery. The artery was
then divided sharply using laparoscopic scissors.
The gallbladder was dissected off of the liver using bovie hook electrocautery.
Once the gallbladder was dissected off, it was placed in an endoscopic retrieval
bag and removed from the abdominal cavity as specimen via the 10 mm port.
After careful irrigation, there appeared to be good hemostasis at the gall
bladder fossa and cystic artery stump.
The ports were removed under direct vision and no bleeding was noted. The
abdomen was allowed to collapse. The fascia of the 10 mm port was closed
with an 0 Vicryl stitch and simple interrupted fashion and the skin of all ports
was closed with a 4-0 Monocryl in a subcuticular fashion. The wounds were
cleaned and dressed with Steri-Strips.
Patient tolerated the procedure well and there were no complications. All
needle, lap and sponge counts were reported as correct. Patient was
extubated in the Operating Room and taken to the recovery room in stable
DD Surgical LLC
Always perform a time out with the entire team present!
There is always time for briefing and debriefing !
This example utilizes the veress needle and 4 ports. Please
note there will be variations from surgeon to surgeon. Sone
surgeons place the 10 mm port either at the umbilucus of
the sub-xiphoid area. The manner in which the gallbladder
is dissected from the liver bed also varies ( cautery vs
ultrasonic scissors, dome down, etc.) Your role as the
junior resident is to pay close attention to the steps of the
procedure. If you have any doubts of portions of the
procedure either during or after you should talk to your