Laparoscopic cholecystectomy

What it is

In laparoscopic cholecystectomy there are 4 incisions or ports: the umbilicus, the sub-xiphoid, the medial sub-costal and the lateral sub-xiphoid. The steps run in order: identify the gall bladder; identify the infundibulum and clear the omentum from it, so that the cystic artery and the cystic duct can be identified; and all of this is done in order to achieve the critical view of safety, by which only 2 tubular structures are seen going into the gallbladder. The structure that the whole operation turns on is Calot's triangle. Its borders are the inferior border of the liver, the cystic duct and the common hepatic duct, and the liver side is also given as the inferior surface of the liver. Its contents are the cystic artery, which is identified through the triangle, and a node, given as the node of Lund in one place and as the cystic node in another.

How it is treated

Symptomatic gallstones have to have laparoscopic cholecystectomy, while asymptomatic gallstones are managed conservatively with lifestyle changes and an appointment for elective surgery, and ERCP is indicated only when the patient presents with obstructive jaundice, to relieve the obstruction. In acute cholecystitis: admit the patient, keep NPO, hydrate the patient because of the vomiting, start analgesia and antibiotics such as ceftriaxone and metronidazole, and consent for the operation. Timing then depends on the presentation. If the patient presents within 72 hours, surgery. If the patient presents after 72 hours, treat with antibiotics, analgesia and fluids, then discharge the patient, who comes back after 6 to 8 weeks for the cholecystectomy.