Watch this detailed video of a Laparoscopic Cholecystectomy performed for acute cholecystitis. This surgical video demonstrates step-by-step techniques, from port placement to gallbladder removal, highlighting key tips for safe and effective laparoscopic surgery. Ideal for surgeons, trainees, and medical students looking to enhance their laparoscopic skills.

CBD injury is one of the most common injuries during laparoscopic cholecystectomy. It is very important to minimize CBD injury for a laparoscopic surgeon. This video demonstrates Safe Way of Performing Laparoscopic Cholecystectomy. The incidence of biliary injury after laparoscopic cholecystectomy (LC) has shown a declining trend though it may still be twice that as with open cholecystectomy. A safe cholecystectomy is one that is “safe for both the patient no bile duct/hollow viscus/vascular injury and for the operating surgeon no or minimal scope for litigation. In addition, a surgeon should be able to anticipate the operative difficulty based on various preoperative predictors, should adhere to basic principles of surgery including safe use of energy devices and use of fluorescence cholangiography using ICG.

Laparoscopic cholecystectomy (LC) is the gold standard for treating symptomatic gallstones and other gallbladder diseases. While minimally invasive surgery offers quicker recovery, less postoperative pain, and smaller scars, it carries potential risks, including bile duct injury and bleeding. Ensuring patient safety requires adherence to meticulous surgical principles, thorough planning, and advanced technical skills.

1. Preoperative Assessment

Patient safety begins before the first incision:

• Detailed history and physical examination: Assess for previous abdominal surgeries, comorbidities, and biliary symptoms.

• Imaging studies: Abdominal ultrasound is mandatory to evaluate gallbladder anatomy, stones, wall thickness, and anomalies. MRCP (Magnetic Resonance Cholangiopancreatography) may be indicated in complex cases or suspected biliary variations.

• Risk stratification: Identify patients at higher risk for complications, such as those with acute cholecystitis, obesity, or liver disease.

2. Proper Patient Positioning

• Place the patient in the supine position with slight reverse Trendelenburg.

• Tilt the table slightly to the left to displace the bowel and improve exposure.

• Ensure the surgeon, assistant, and camera operator have ergonomic positions to reduce fatigue and maintain precision.

3. Safe Port Placement

• Four-port technique is standard: one umbilical (camera), one epigastric (working), and two lateral (retraction).

• Optical entry or Veress needle should be chosen based on surgeon preference and patient anatomy.

• Always inspect the abdominal cavity for adhesions or unexpected findings before proceeding.

4. Critical View of Safety (CVS)

Achieving the Critical View of Safety (CVS) is the cornerstone of preventing bile duct injuries:

1. Dissection of Calot’s triangle: Identify cystic duct and cystic artery clearly.

2. Separation from liver bed: Lower third of gallbladder is dissected off the liver.

3. Confirmation of only two structures entering the gallbladder: Never clip or cut until the anatomy is fully visualized.

Tip: Use gentle traction, avoid excessive force, and maintain a clear, bloodless field.

5. Intraoperative Safety Techniques

• Use of energy devices: Harmonic scalpel or bipolar cautery reduces bleeding but requires careful handling near ducts.

• Routine cholangiography: In difficult cases or suspected anatomical variations, intraoperative cholangiography helps prevent injury.

• Indocyanine green (ICG) fluorescence imaging: Emerging technology that enhances visualization of bile ducts, especially in complex cases.

• Conversion to open surgery: Never hesitate if visualization is poor or anatomy is unclear—patient safety is paramount.

6. Gallbladder Extraction

• Place the gallbladder in an endoscopic retrieval bag to prevent spillage of stones and bile.

• Remove through the umbilical port to minimize wound contamination.

7. Postoperative Care

• Monitor for signs of bile leak, bleeding, or infection.

• Early ambulation and diet advancement improve recovery.

• Provide clear discharge instructions regarding warning signs and follow-up.

8. Training and Experience

The safety of laparoscopic cholecystectomy is highly dependent on surgeon experience and training:

• Hands-on simulation, mentorship, and exposure to complex cases improve outcomes.

• Surgeons must stay updated on latest techniques, energy devices, and imaging tools.

Conclusion

A safe laparoscopic cholecystectomy requires meticulous planning, careful dissection, and strict adherence to the Critical View of Safety. Combining preoperative evaluation, advanced imaging, judicious use of energy devices, and readiness to convert to open surgery ensures minimal complications and excellent patient outcomes. By prioritizing safety over speed, surgeons can achieve the best results in laparoscopic gallbladder surgery.