Dr. Sergio Antonio Acevedo Solera 

IN THE OFFICE PRIOR TO SUREGRY

1. Perform interview aboout History and Physical Exam on patient to wonder and consider preoperatrative risk factors
a. Find about history of hypertension, inmunosupression (Diabetes, Oncologic diseases, HIV, Tuberculosis, Hematologic diseases, Pulmonary diseases especially COPD, tobacco use, asthma): Concernig the surgical act, one should include: previous surgeries about the reasons to perform them, surgical time in the OR, trans and postop complications as well the necesity to do postop surveillance and monitoring in the ICU, postop functional capacity and reserve of physiology and also psychological aspects such as fears, uncertantities and elective versus emergency performance of a procedure given to decide wether to do or not.
b. On physical exam discover the field of work) explore abdominal wall to delimitate target pathology, port position according to baseball diamond concept, previous surgery scars, and bulging or belching parts of abdominal wall (hernias)
c. Discuss with the patient benefits and risks of disease about to interveen and get informed consent (specially in regards towards to possibility of conversion)

2. Before starting the surgery, review the lab work up and preop risk assesment (ASA, Goldmann) and informed consent

IN THE OPERATION THEATER

1. Room setled and OR conditions prestablished as to perform the surgery (with materials and isntruments as well as laparoscopy troly checked even with supply of gas and gasless instruments just in case of shortage of supply.
 
2. Review anatomy of the patient to take into cosideration the challenging aspects according to dificul antropometry, length of instruments and supply of other auxiliary methods to perform the surgery (C arc for cholagyogram), setting of the base ball diamond concept.

PROCEDURE ASPECTS OF THE SURGERY

1. Following scrubing, draping and placing instruments as all personel get starting for the procedure as for anesthesiologist to administer the general anesthesia, be aware of the possible pitfall at this stage (reactions or side effects of the patient to anesthesia and other enviroment elements)

2. Set the working spots for the principal surgeon (patients left side), assistant (patient’s right side), instrumental scrub nurse (foot side of the patient), anesthesiologist and aptient monitoring patient's head and optical axis of the monitor (surgeon, patient, target pathology, monitor). Two monitors, one of them positioned on opposite side of the surgeon and assistant. At the left corner of the OR should be for the placing of the parked mobile C.arm fluroscope and beside it also with a double TV monitor and control unito of the fluroscope. The scrub nurse has got to have on the intrument table with three trays (CBD instruments and choledocospe and conventional open surgery tray).

3. Set the baseball diamond principle in the patient and select appropaite instruments to develop the space window of your target pathology. 
a. Use 4 ports (canula and trocar) whether they are metal (pyramid shaped trocars) or plastic (flat two edge balde): 
i. One 10 mm port at the umbilical region to set the Teescope or optical axis, (port A)
ii. One 10 mm at the epigastrium 4 cm below xyphoid process to place the right handed instrument (port B)
iii. One 5mm port on the right hipocondrium (2 cm below costal margin) for the placement of the left handed instrument of the principal surgeon (port C)
iv. One 5 mm port in the left flanc at the paraumbilical level for assistant placement of traumatic grasper to handle lifting and mobilization of the gallbladder by way of gripping by the fundus (port D)

4. Select the type of telescope and adjust its setups
a. 30 degree angle telescope of 10 mm diameter entrance for the optical port and  35 cm rod
b. Perform white balancin using a white gauze, adjust the setp up by choosing the preselection variables. Also do the focusing within the range of 10 cm form the closest object.

5. Perform a 2 mm incision at the superior curs of the umbilicus.

6. Selection of pneumoperitoneum technique (in this case I’ll select Closed Technique with Veress Needle)
a. Check for patency (connect a 5 to 10 cc syringe filed with saline and irrigate to the inside)  and spring action of the needle (retract the body of the needle form the shaft and see it making a noise when its coming back to its normal position).
b. Insert a closed technique pneumoperitoneum with Veress Needle by grabbing it from the shaft part in a dart way fashion and orient its introduction to intraperitoneal space, having in mind the angles between the abdominal wall and the crus of the umbilicus. By this manner, introduce and advance the needle towars the contact of the abdominal wall in a 90 degree angle in relation to the flap being grabbed by your assistant’s hand and a 45 degree angle concernig that decribed from the nedle in relation to the abdominal.
c. Hear and feel the two clicks (one from the rectus fued fascia and one form peritoneum)
d. Do the instilation and aspiration test, hang drop test, and insulfation test.
e. Beware of quadromanometrum values of laparosufflator (Preset pressure, flow rate, actual pressure and amount of gas used). Use Flow rate 2 liter per minute and presete  pressure of 12 mm of Hg.
f. Once obtained the compartemnt distention be aware of actual presure and amount of gas ued as well as Non invasive patient monitoring (Blood pressure, Heart rate, ETCO2 capnography, pulse oximetry, temperature and curves of Mechanical Ventialtion such as PEEP, Tidal Volume)
g. Under direct vision introduce the ports by insinuating method to the peritoneum (inside view); as for the outside handling of the port, grab them in a pistol fashion (head of the trocar rested on the thenar eminence of the surgeons hand, middle finger placed over the gas inlet and index finger pointed towards the sharp end of the trocar by resting on the shaft) just to have a precaution control about the length for the depth and precision towards the invasion of the peritoneal space just by having your index finger as a sudden stop point as the delimitation of no more pushing the trocar deeper than that limit.
h. Remebre to keep in mind the depht of the canula being inserted in order to perform a type 1 Lever and avoiding type 2 (diminshed range of motion of the operator with appplied energy to little unpurposed movements and maneuvers) and 3 lever (mismatch control of overshooting and coordinated maneuvers with wide range of motion).

7. Make a diagnostic laparoscopy by making a clockwise rotation starting form right lower quadrant and ending up at the left lower quadrant.

8. Focus on the right upper qudrant and locate the liver to try to establish the optimal view of surgery
a. Identify rib margin
b. Check for the smoothness of liver surface to be homogenous
c. Extension of the fundus of the gallbladder

9. Position the patien in Reverse Tremdelemburgs and rotate the patient to the left side to display more of the inferior surface of the gallbladder and displace bowel viscera toward the pelvic rim.

EXECUTIONAL ASPECTS OF THE SURGERY

1. Capture and traction of the gallbladder by grabbing it by the fundus through the port D with a locked traumatic grasper

2. Key point of second grasping area of the gallbladder by holding it from the Hartmann’s pouch through port C with an atraumatic grasper in order to perform antero lateral and anteromedial traction to display a better exposure of the Calot Triangle.

3. Identify anatomical landmarks of Hepatocistic Triangle and thaen try to delimitate boundaries of Calot’s Triangle. (Critical view of safety)

4. Make a posterior window on the peritoneum through the port B with right angle disection instrument on the surgeons right hand. The movements should be smooth, clean and progresive towards to seek out to tip of the the instrument to meet with anterior window of the triangle.

5. Make an anterior window thorugh the same port redirectin the gallbladder to an anterolateral traction to expose the anterior view of the Calot’s triangle. Pass the tip of Maryland’s disection through the peritoneum across the anterior window and try to be as close as posible to the gallbladder.

6. Get an insinuation of the tip passing it form the anterior window to meet with posterior window intially made until it passes through and reach the hole passage through the peritoneum.

7. Perform a nipple sign to see how much deflected o retracted is the CBD. Also perform the bow sign.

8. Strip up the preperitoneal fat of the pericystic duct and gallbladder away form the CBD towards the gallbladder, to try to separate as much as possible the gallbladder form the CBD. Try to se if the CBD get its normal physiologic position after having the distal cystic duct mostly skeletonized or stripped down the peritoneum.

9. Visualize and set up the anatomical discontinuance of the structure form the major bile duct system and according to that, select and prepare the clamping and cutting instruments and technique as well as to see the challenge of the operative field in order to perform the procedure.
a. In it’s by ligating the cystic duct, perform an extracorporeal knot having in hand a 120-150 cm length (90 cm of preformed loop or 25 cm intracorporeal knot) 3.0 Vicryl by which your going to pass the cystic duct and proximal to CBD leaving a margin less than 1o mm you’ll be performing a Mishra’s knot and take it down to the site where the knot it should be located with the Bakhar Knot pusher, and give three long pushes once you’ve already positioned it on the proximal cystic duct.
b. Give three long medium press pushing movement towrds the knot to tighted to kont against the structure in order to secure it.
c. Perform another distal knot from the proximal kont havin in between a distance of 6 mm in order to have a residual dumbell configuration of the structured being secured by the knot.
d. If performing the section of the tubular structure by the way of clipping method, one should grab the cystic duct and clip it proximal to the CBD by leavin a 10 mm margin to locate the first clip which is needed to be held by a long medium forced press form three to five seconds of duration. Then, add another distal clip to the previous proximal one leaving in between a margin of 3 mm. Finally leave a 6 mm margin by the placing of this tird clip form the second one by having a 6 mm margin between the second and the las clip. All clips should be secured by forced long medium press of 3 to 5 second duration.
e. Cut in between the second and third clip by cold scissors fashion observing the passage of the two arm of the instrument at the distal end with the scope.
f. Stripo out the peritoneum in directoion towrds the gallbladder an make a some what large window to locate the cystic arterie, which you can control repeatin the previous manouvers to sketelonize the structure. One should place to control the proximal part of the srtucture about to be sectioned with a clip. The distal part can be clipped as well or can be electro coagulated with bipolar instrument until melting colagen - elastin complex develops which can be recognized by whitening color an flattening of the structure.

10. Grab the gallbaldder form the liver bed and give anterolateral traction to disect it usin monopolar energy or harmonic scalpel.

11. Perform at the same time of galbladder disection from the liver bed, hepatic bed hemostasis with spray mode monopolar energy.

12. Perform a preterminal visualization of the surgical field in order to validate the procedure, surrounding structures as well as reomte structures as what should be called Review Diagnositc Laparoscopy.

13. Put the gallbladder above the liver in the hepatic dome.

14. Clean up the surgical field with irrigation of lactate ringer plus heparanized solution (or normal saline with or without heparin) just to clear of any debris of tissue as well as to dilute any content form the biliary anatomy spilled during the procedure, by this way adding a benefit in recovery to the postoperative period diminishing chemically localized peritonitis.

15. In case of having any any suspicion of a lesion, repair in the same time laparoscopically or convert in case of inexperienced maneuvers in complex situations. It’s a valid decision to discert in the further treatment of patients with complex anatomical lesions without any experience and minimu amount of instruments and materials, for what it should be best to do is refer the patient to a hepatico -bilio-pancreatic unit for better results and prognostic outcomes.

16. Retrieve all spilled gallstones that coul be spilled with gallstone scoop retriever.

17. Develop endobag by havin to cut a glove (previously cleansed and washed out of talc) in order to avoid foreign boy reactions and futures strong adhesions.

18. Put the gallbladder inside the bag and close it with surgette like efect to insinuate it towards the port B or A.

19. Prepare to irrigate and aspirate further tissue and bile content on morrisons pouch and suprahepatic bed by tilting patients position to lateral left side and Trendelemburg position.

20. Prepare for 10 mm port closure by glancing and passing a 3.0 vycryl through a suture passer or a 10 mm Veress needle at 6 and 12 oclock of the port entrance, pull the limbs of every thread but don’t tie the knot yet. Change port position to visualize other 10 mm port to stablish the passage ok the extracorporeal knot.

21. Perform the subcutaneous knot on one the ports and drop a few saline drops in the port to wathc for the leakage effect of the ports )sealing effect or Flat tire sign)

22. Tilt the patient to Trendelembrug’s position in order to have a 10 to 15 degree head down in order to aspirate all the pneumoperitoneum by aspiration. At the same time stop insufflator form delivering more CO2. Beware of abdominal wall desuflation and colapse. As you are deflating the cavity from the pneumoperitoneum, leave the canula with a filled blunt trocar in order to prevent port herniation by way of flushing outstream effect of decompressing towards a minimum presure cavity (outside).

23. Finally retrieve the hole port form this last port site and close by the thread being previously placed.