Key steps for a safe cholecystectomy in a case of acute cholecystitis

This video is focused in the key points to achieve a laparoscopic cholecystectomy in a case of acute cholecystitis.

In this case a total of three trocars were used. Two of 12mm located at the umbilicus and the epigastrium and the other of 5mm in the right flank. First maneuver is to clear the surgical field suctioning all the free liquid or bilis when the gallbladder is perforated.

Surrounding structures like the epiplon, duodenum and the colon can be attached to the inflamed gallbladder, the hook is helpful to separate them and minimize the bleeding.

The gallbladder is distended with thickened walls, this can impair the traction during the surgery. Puncture with a veress needle and emptying the bilis is very useful, keeping in mind that it is possible to produce injuries of the liver with this maneuver.

To start dissecting the posterior aspect of the neck is a good approach because it will improve the visualization of the anatomical structures of the Calot's triangle as you will appreciate later. The hook can be used for both electric and blunt dissection.

Medial dissection is addressed to identify the cystic duct and the cystic artery. In this part of the procedure the surgeon must be focused, careful dissection must be done to avoid unexpected vascular or biliary injuries due to anatomical variations. In the normal disposition the cystic duct below and the artery above. The movements and traction must be dedicated, remember that the tissues can be easily torn.

Clips are placed before section, make sure that the ducts end in the gallbladder. Place two below, in parallel to avoid them to getting crossed to prevent bleeding and a biliary leak.

The posterior wall of the gallbladder is detached from the liver to complete the cholecystectomy. The correct plain can be difficult to identify, it is closer to the gallbladder than were it seems to be. Remember that a branch from the right portal vein can pass near this area, avoid going deep into the liver.

The specimen is placed in a bag for extraction. Final lavage and revision for hemostasis is made.  It is recommended to use a drain for postoperative surveillance of a leak, bleeding or collections.