with Dr. Ludovica Baldari
Laparoscopic cholecystectomy is the most common elective procedure in abdominal surgery and it is usually performed by surgeons in training. There are two different approaches to performing this procedure: the French position and the American one. These approaches differ in operative room setup, patient and surgeon position and port placement. There are no significant differences regarding operative time and intraoperative and postoperative outcomes, so the position is defined according to the surgeon’s choice. The steps of the surgery are the same in both the French and the American approaches.
Before starting the dissection, the anatomy should be assessed according to anatomical landmarks, like the Rouviere sulcus and the base of segment IV of the liver, that are the most important. Intraoperative imaging with indocyanine green fluorescence cholangiography allows the definition of the biliary anatomy and has been demonstrated to be associated with a higher rate of identification of the biliary structures.
The dissection begins by incising the peritoneum along the edge of the gallbladder on both sides to open up the hepatocystic triangle and carries on with the dissection of the triangle itself to identify the cystic duct and artery. Critical exposure and proper use of monopolar electrocautery are fundamental to avoid any damage to biliary structures. The critical view of safety (CVS) should be achieved whenever possible. However, in case of anatomical variation or acute inflammation, the dissection required to achieve the CVS can represent a risk itself and should be avoided. Cystic duct and arteries are divided between clips and the gallbladder is then dissected from the liver bed avoiding bleeding and /or bile leakage from the liver bed. The gallbladder is removed at the umbilical port through an endobag.
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