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1、This video shows detailed steps when performing laparoscopic cholecystectomy.Keywords: Laparoscopic, cholecystectomy, step by step, basic, procedure 0018 Introduction Here we have a typical case of a 60-year-old woman, who presented an acute pancreatitis three months ago. This was spontaneously heal
2、ed and we performed preoperatively an MRI that confirmed the lack of stones in the common bile duct. We have the policy in our unit not to perform any intraoperative cholangiography systematically if there are no more bile stones. That is the reason why we have performed an MRI.0051 Patient and troc
3、ar position The standard installation that you have here is the patient in a French position; the surgeon will stay between the legs. I have just placed the first port in order to have a very clear positioning of the anatomy. I have drawn on the skin the costal margin, the xiphoid appendix, the seco
4、nd costal margin, the iliac crest that you see here, so we have the landmarks. The umbilicus is just above the trocar and Ive placed the first 10mm trocar into the umbilicus by a direct approach. We dont use a Veress needle, we do systematically a direct approach. Positioning of the trocars: we want
5、 to create a triangulation for the operator to operate, I will place one 5mm trocar on the midline with a distance of 7cm between the optic and the trocar; the second 5mm trocar here, to have a good triangulation at the level of the gallbladder and I will add one retracting trocar, which is placed v
6、ery high. Usually we try to place it at the level of the xiphoid appendix, well place approximately here to have it also on the midline to have an esthetic scar and to have the possibility to retract the gallbladder from a place out of the operative field. I will make immediately the three little 5m
7、m incisions and I will place under direct control with a safety movement, you see, a protective movement. I will insert the trocar with a direct control under the view. Here you see the view. The trocar is inserted very easily thanks to its blade. It is a very effective single-use trocar. Under dire
8、ct vision, I will place a second trocar on the midline, and then I will place the third trocar at the level just below the xiphoid appendix, a little bit higher thanks to the insufflation, and I will insert it directly in the abdomen. It is at the level of the round ligament. Usually we start by pla
9、cing the trocar directly on the side of the gallbladder and we will see if we need or not to retract the round ligament. I will move, I will go between the legs of the patient, surgeon between the legs, one assistant on the left of the patient. We gently grasp the gallbladder approximately at the le
10、vel of the liver. We retract the gallbladder and we have a very nice exposure. In the left hand, I will place another retracting forceps, which will be a dissecting forceps. It should allow to control the dissection area. I work with a 0-degree optic. Here we see the duodenum. Here we see the dissec
11、tion area. There are very smooth adhesions related to the previous pancreatitis. The stomach is empty. There is no other abnormality seen in the operative field.0402 Dissection of adhesions Here you see the duodenum, the gallbladder neck. I will first free gently the adhesions below the gallbladder
12、neck and you see that even with 20 Watts there is absolutely no problem to cut these smooth adhesions. Advantage of this low voltage current is that there is very few diffusion of electricity and so, almost no risk of damage at the distance of the application of the cautery. Here we see that we iden
13、tify the position of the common bile duct.0438 Exposure of Calots triangle Here is the triangle of Calot. The objective will be to open first anteriorly, and then posteriorly the peritoneal sheet. I will grasp the peritoneal sheet and I will, only using the monopolar cautery, which is very useful in
14、 this type of surgery, open anteriorly and posteriorly the peritoneal reflection at the level of the triangle of Calot. Again, the objective is to free the peritoneal reflection over the triangle of Calot. The direction of dissection is always up and towards the liver and never down towards the comm
15、on bile duct. You see that the hook is always looking upwards. Second thing, I always have a view by transparency in order to avoid grasping any structure that should not be coagulated at this step. After having dissected upwards, I will do a posterior freeing of the reflection of the peritoneum, an
16、d this will have its advantages to free and to lengthen Calots triangle. I preserve a little distance of 2mm in order to avoid injury of the liver and dissection is done until here, you see a little vessel, and usually when you make this opening, you always identify a very short vessel going from the liver to the gallbladder.0616 Dissection of cystic duct and artery The next step will be the freeing of all the little surround
