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1Contraindications	
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4Prior to entering into a discussion of contraindications to surgery, one must first understand the distinction between absolute and relative contraindications.  Absolute contraindications forbid the performance of a procedure under any circumstances.  Relative contraindications leave room for interpretation given individual patient and surgeon circumstances, and charge the surgeon with the final decision.  Due to progress in the application of laparoscopic techniques, very few absolute contraindications remain in the performance of laparoscopic cholecystectomy.  Relative contraindications include bowel obstruction, disorders of coagulation, hepatic cirrhosis, choledocholithiasis, and acute cholecystitis.  Essentially, all patients except those who are incapable of tolerating general anesthesia, are offered an initial attempt at laparoscopic cholecystectomy.  With proper precautions, laparoscopic cholecystectomy can be performed safely in patients who have had previous abdominal surgery, who are obese, and even those who are pregnant.  A further discussion of these three patient groups follows.
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6Previous surgery
7Approximately 30-50% of patients presenting for cholecystectomy have undergone previous abdominal surgery.  Intraabdominal adhesions or scarring from the prior procedure may interfere with entry into the abdomen and the performance of the cholecystectomy.  Laparoscopic adhesiolysis is often necessary to allow adequate access to the operative field.  Certain procedures, especially those in the upper abdomen may disturb anatomic relationships and make structure identification and exposure difficult in subsequent surgery.  Surgeons may need to employ an ‘open technique’ (Hasson procedure) to gain entry into the abdomen especially in proximity to previous incisions.  The open technique, which requires opening of the layers of the abdomen under direct vision, may protect against injury to blood vessels, but has not been shown to protect against bowel injuries incurred on entry into the abdomen.  The alternative to open access, commonly used for routine laparoscopy, is induction of pneumoperitoneum using a needle inserted into the abdomen carefully but blindly.  Variations from standard technique such as modifications on trocar positioning, establishment of pneumoperitoneum, or the implementation of additional or optical trocars may further limit complications resulting from laparoscopic surgery in this group of patients.
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9Obesity
10Approximately 26-40% of the US population are obese.  A recent increase in public awareness has catapulted this problem into the national spotlight.  This patient population is at risk for a number of health-related concerns including the development of gallstones.  In addition, obese patients often carry multiple other diagnoses or comorbidities, putting them at increased risk for perioperative complications.  Technical concerns include the presence of a thick abdominal wall making trocar placement difficult and risky, and ample intraabdominal fat that may impair visualization.  Experienced surgeons modify their standard technique to minimize intraoperative and postoperative complications.  Such modifications include the utilization of specially designed trocars and instruments, and the angling of ports toward the operative field to improve instrument mobility.
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12Pregnancy
13The pregnant patient represents a true surgical dilemma.  Approximately 0.2% of pregnant patients require intraabdominal surgery during their pregnancies.  The surgeon must consider the gestational age of the fetus, and the mother’s specific pathology in determining the need for, and timing of, surgery.  A common error is to pursue ‘conservative’ management in these patients at the expense of basic surgical tenants.  A policy of thoughtful yet assertive management is paramount to avoid undue injury to mother or fetus.  Invasive techniques should be avoided during the first trimester due to the risk of teratogenicity and spontaneous abortion.  The third trimester is also perilous because of preterm labor, premature delivery, limited exposure offered by the gravid uterus, and potential injury to the enlarged uterus upon entering the abdomen.  For these reasons, most surgeons advocate delaying surgery until the second trimester or until the termination of gestation with delivery of the baby.  Pneumoperitoneum, which is necessary for laparoscopic surgery, may cause fetal tachycardia, fetal hypertension, or maternal and/or fetal acidosis.  Despite these observations, the overall risk to mother and fetus in the second trimester is relatively low.  Certain precautions including fetal and uterine monitoring, deep venous thrombosis prophylaxis, low pneumoperitoneum pressures, and a lead shield during intraoperative cholangiography are recommended from a safety standpoint.  Several attempts at conservative management may be necessary in order to delay surgery until the second trimester in cases of recurrent attacks of cholecystitis.  ERCP with papillotomy has been shown to be safe and effective in pregnant patients with common bile duct stones.  Common bile duct stenting is another bridge to laparoscopic cholecystectomy that may become necessary if obstruction of the duct is evident. 
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15Preoperative Evaluation	
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18All patients presenting for laparoscopic cholecystectomy should have a thorough preoperative evaluation including a physical exam, laboratory tests and radiographic studies to document the presence or absence of gallstones.  The physical examination should be thorough with a primary focus on the abdominal exam.  The examiner should look for evidence of jaundice, cholecystitis, previous abdominal surgery or prohibitive pulmonary, liver, or cardiac disease.  Common laboratory tests include routine blood counts, serum chemistries, pancreatic enzymes, liver function tests, and tests of the coagulation system.  Gallstones are most commonly identified on diagnostic or screening abdominal ultrasonography.  Sonography can provide information about the gallbladder wall thickness (acute/chronic cholecystitis), pericholecystic fluid (acute cholecystitis), and the size of the common bile duct (CBD).  The study is limited in its ability to assess gallbladder function or the presence of stones in other portions of the biliary system, including the CBD (choledocholithiasis).  A technetium-99-iminodiacetic acid (HIDA) scan may be useful in confirming acute cholecystitis.  Gallbladder dysfunction (biliary dyskinesis) can be assessed through measurement of cholecystokinin-stimulated emptying of the HIDA tracer.  If choledocholithiasis or pancreatic pathology is suspected on physical exam or ultrasound, the provider may opt for a magnetic resonance cholangiopancreatography or MRCP, which has a high sensitivity in documenting obstruction of the common bile duct by stones or pathology within the pancreas.  This study is non-invasive and provides high quality images of the entire pancreaticobiliary system.  If the diagnosis is still in doubt, or if gallstones are documented within the common bile duct, patients are often referred for endoscopic retrograde cholangiopancreatography or ERCP.  Under sedation in an ambulatory setting, the operator places a small endoscope into the first portion of the small intestine, or duodenum via the mouth.  The operator, who may be a gastroenterologist or surgeon, then passes a small catheter into the common bile duct.  Dilute dye is injected into the duct, which clarifies the presence of the gallstones or any other pathology within the pancreaticobiliary system.  Although this procedure is more invasive than MRCP, it affords the operator the ability to perform therapeutic as well as diagnostic maneuvers.  Devices can be inserted into the ducts to clear obstructing stones, or alternatively, stents can be placed to bypass the area of concern, allowing free flow of bile past the obstruction.
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20The complexity of the preoperative evaluation is a function of patient age, comorbidities, and suspected pathology.  The appropriate course of diagnostic tests should be determined on an individual basis after discussion between the patient and his/her physician.  Preoperative education is essential in reducing preoperative anxiety and guiding postoperative expectations.
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24Operative Considerations	
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27Hardware and Instrumentation
28Proper hardware and instrumentation are essential for performing a safe laparoscopic cholecystectomy. Most surgeons utilize an operating table capable of frequent changes of position to enhance exposure and visualization during the operation. The laparoscopic system itself is made up of two high-resolution monitors, a camera and video signal enhancer, a fiberoptic light source (usually xenon) and obligatory power cords. The light source produces considerable heat, and the end of the endoscope or fiber-optic light cable must be handled with caution. In addition to standard laparoscopic instruments, mandatory accessories consist of an insufflator for establishing CO2 pneumoperitoneum as well as suction and irrigation devices. Optional equipment includes a printer and/or video recorder.
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30Access for Pneumoperitoneum
31Pneumoperitoneum may be induced using an open or closed technique. The abdominal wall should be prepped from mid thigh to nipple line and as lateral as possible. Preparations must be made for insertion of unanticipated trocars away from the original operating site should the necessity arise. All patients, without exception, should be properly grounded to guard against electrocution and cautery burns.
32Pneumoperitoneum consists of carbon dioxide instilled into the abdominal cavity at a set pressure with safeguards to prevent pressures above 15-20 mmHg. A definite correlation exists between high insufflation pressures and the degree of postoperative discomfort after laparoscopic procedures. Studies in animals have indicated that insufflation pressures above 20mmHg cause alterations in blood flow to key organs such as liver and intestine. The increased pressure exerted on the diaphragm may also make ventilation difficult. After studying many different insufflation gases, most US surgeons agree that carbon dioxide is both safest and least expensive. The inert gas is widely available and rapidly absorbed into tissues minimizing the disastrous complication of air embolus syndrome, sometimes called the ‘bends’. 
33When using a closed or Veress needle technique, the safest access into the intraabdominal cavity is via the infraumbilical area. The anterior abdominal wall is thinnest at this level and the fascial layers are fused into a single plane. Thus, the surgeon always attempts to insert the Veress needle at this site in a virgin abdomen. The first step involves elevating the anterior abdominal wall in order to raise it above the intraabdominal contents. This is usually accomplished by grabbing the abdominal wall directly with a gloved-hand or towel clip. A 1-mm incision is made with a scalpel below the umbilicus. The needle is then slowly inserted into the incision and angled toward the pelvis to minimize the risk of visceral and/or vascular injury. The operator should sense the needle passing through two distinct planes; the anterior and posterior rectus sheaths. Once placed, the position of the needle is confirmed using a water-drop technique and the needle is connected to the CO2 insufflator. Insufflation is initiated at a low flow rate until low opening intraabdominal pressures (<8mmHg) are confirmed. If initial pressures exceed this threshold, the Veress needle is malpositioned and needs to be adjusted or removed and reinserted. Once the surgeon is confident of proper placement, the insufflator is switched to high flow for the remainder of the case. 
34A blunt trocar (Hasson-type) is used to safely create a pneumoperitoneum in the previously operated abdomen. Insertion begins by making an initial skin and a fascial incision. The fascial incision is made under direct vision to a length of 1 to 1.5 cm. A stay suture is then placed on either fascial edge and finger dissection is used to develop a pathway into the abdomen. Care must be taken to avoid injuring any adherent intestine during this technique. The blunt trocar is then inserted under direct vision. The cannula is seated and secured with the previously placed stay sutures. The stopcock is then connected to the insufflation tubing and the pneumoperitoneum is created.
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36A third option for initial trocar placement is the use of an optical trocar. This device is a simple modification of a standard trocar, which incorporates a transparent inner cannula and cutting tip, allowing continuous visualization of all layers of the abdominal wall as they are compromised by the trocar. The abdomen is typically first insufflated using a Veress technique, although some experienced surgeons insert the trocar using an abdominal wall lift technique without insufflating. A small skin incision is then made and a surgical telescope is inserted into the optical trocar. The trocar is advanced slowly through the different planes of the abdominal wall until the abdominal cavity is reached. Pneumoperitoneum is then created in the standard fashion.
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38Room Setup
39The surgeon stands on the patient’s left side and the assistant is on the right. An additional assistant to control camera movements is helpful but not necessary. Two laparoscopic towers are placed on each side of the patient's head.
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41Patient Positioning
42The patient is placed supine on the operating table. One or both arms may be tucked at the patient’s side to allow for monitor placement in proximity to the operating table. Patient’s extremities should be well padded and placed in the position of function. A foot support allows for safe placement of the patient in a head up (reverse Trendelenburg) position to facilitate exposure of the upper abdomen. A safety strap placed across the hips minimizes unwanted patient movement during tilting of the table and emergence from anesthesia. 
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44Trocar Positioning
45Trocar size and positioning are open to individual variation. Access is most commonly obtained through the infraumbilical route utilizing a 10mm trocar, although some surgeons advocate placement of a 5mm trocar in this position. The laparoscopic camera is placed through this port. A second 10mm trocar is placed in a subxiphoid position under direct vision. This port allows for dissection of the gallbladder and associated structures. Two accessory trocars are placed in a right subcostal position to permit retraction of the gallbladder fundus and neck in an anterolateral direction during dissection.
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47Click for details on surgical technique
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49Variations of Technique: DOME-DOWN AND MINILAPAROSCOPY	
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52The general trend in all of surgery has been toward less invasive, safer procedures. To satisfy this end, several variations in the traditional laparoscopic cholecystectomy have been recommended. One of the criticisms of laparoscopic cholecystectomy since its inception has been a higher incidence of CBD injuries as compared to an open technique. A popular explanation for this is that open cholecystectomy is performed using a dome-down or retrograde approach to the dissection. That is, the dome or fundus of the gallbladder is mobilized first, acting as a guide to the cystic duct as the dissection proceeds toward the infundibulum. As is evident in the preceding description, laparoscopic cholecystectomy commences in essentially the opposite direction. The cystic duct is identified first, and without the gallbladder as a guide, may be confused with the CBD or even the right hepatic duct. Misidentification can lead to injury or division of the CBD or hepatic duct, resulting in significant postoperative morbidity. In order to remedy this divergence, some surgeons perform a laparoscopic dome-down cholecystectomy.
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54Although the laparoscopic techniques employed in this procedure are similar to standard laparoscopic cholecystectomy, a few differences deserve mention. Unlike the standard dissection, the dome-down dissection is commonly performed with an ultrasonic dissector such as the Harmonic Scalpel. Due to an intact cystic artery, significant bleeding can be encountered during this procedure that may be managed more easily with ultrasonic dissection versus electrocautery. As indicated, a plane between the liver bed and posterior wall of the gallbladder is identified first. Often a short mesentery exists between the liver bed and gallbladder fundus. Small bites of tissue are grasped and divided with the ultrasonic blade in a controlled fashion in the direction of the gallbladder neck. The first ductal structure in continuity with the gallbladder neck is by definition the cystic duct. No anatomic confusion exists at this stage of the procedure as it may in standard laparoscopic cholecystectomy. Once the cystic duct is identified, the duct and artery are divided as in standard laparoscopic cholecystectomy and the gallbladder is extracted.
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56Outcomes	
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59SECTION NOT ON DISK 
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61Recovery	
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64SECTION NOT ON DISK