This video demonstrates Difficult Laparoscopic Cholecystectomy with Pledget and Mishra's Knot. Laparoscopic cholecystectomy is the treatment of choice for gall bladder stone disease. Difficult laparoscopic cholecystectomy is associated with serious complications and a high conversion rate. The aim of this video is to show the video of difficult laparoscopic cholecystectomy to give information about the current strategies to manage difficult cholecystectomy. No consensus is found among laparoscopic surgeons on how to manage difficult laparoscopic cholecystectomy. Iatrogenic injuries and conversion rate can be reduced depending on the surgeon's experience, special techniques, and intraoperative investigations, and using blunt dissection with the help of pledget and tying an extracorporeal knot. Subtotal cholecystectomy, antegrade or fundus first techniques and intra-operative cholangiogram using ICG can significantly reduce the complications and conversion rate of laparoscopic cholecystectomy.

Laparoscopic cholecystectomy is the gold standard treatment for symptomatic gallstone disease. However, a difficult laparoscopic cholecystectomy remains a significant surgical challenge, particularly in cases of acute or chronic cholecystitis, dense adhesions, contracted gallbladder, or distorted anatomy of Calot’s triangle. Safe dissection in such situations is crucial to prevent bile duct injury. Pledget dissection of Calot’s triangle has emerged as a valuable technique to facilitate safe and controlled laparoscopic cholecystectomy in difficult cases.

Challenges in Difficult Laparoscopic Cholecystectomy

Difficult cholecystectomy is commonly encountered in patients with:

• Acute inflammation or empyema of the gallbladder

• Dense fibrotic adhesions due to repeated attacks

• Frozen Calot’s triangle

• Short, thick cystic duct or aberrant anatomy

• Obesity or previous upper abdominal surgery

In these situations, conventional sharp or blunt dissection may increase the risk of bleeding or bile duct injury. Therefore, alternative dissection techniques are often required.

Concept of Pledget Dissection

Pledget dissection refers to the use of a small rolled gauze or cotton pledget introduced laparoscopically to perform atraumatic blunt dissection. Instead of using sharp instruments or excessive electrocautery, the pledget gently separates tissues along natural anatomical planes, allowing clearer visualization of structures within Calot’s triangle.

Technique of Pledget Dissection of Calot’s Triangle

After standard port placement and exposure of the gallbladder:

1. The fundus is retracted cephalad and the infundibulum laterally to open Calot’s triangle.

2. A small sterile gauze pledget is introduced through a 10 mm port using a grasper.

3. Gentle sweeping and rolling movements are applied to dissect inflammatory tissue and adhesions.

4. The pledget absorbs blood and bile, maintaining a clear operative field.

5. Progressive dissection helps identify the cystic duct and cystic artery safely.

6. The Critical View of Safety (CVS) is achieved before clipping and division of structures.

Advantages of Pledget Dissection

• Minimizes thermal injury to bile ducts

• Reduces bleeding by tamponade effect

• Enhances tactile feedback through laparoscopic instruments

• Improves visualization in inflamed Calot’s triangle

• Decreases risk of bile duct injury

• Useful in frozen or fibrotic anatomy

Indications for Use

Pledget dissection is particularly useful in:

• Acute cholecystitis

• Chronic cholecystitis with dense fibrosis

• Mirizzi syndrome (Type I)

• Difficult anatomy where sharp dissection is unsafe

Safety Considerations

While pledget dissection is a safe and effective technique, surgeons must:

• Use gentle movements to avoid avulsion injuries

• Always confirm anatomical structures visually

• Convert to subtotal cholecystectomy or open surgery if CVS cannot be achieved

• Avoid excessive force that may cause bleeding

Role in Preventing Bile Duct Injury

Bile duct injury is a feared complication of laparoscopic cholecystectomy. Pledget dissection allows gradual and controlled separation of tissues, facilitating accurate identification of biliary anatomy and significantly reducing the risk of misidentification injuries.

Conclusion

Pledget dissection of Calot’s triangle is a valuable adjunct in performing difficult laparoscopic cholecystectomy. By providing a gentle, atraumatic, and controlled method of dissection, it enhances surgical safety, especially in inflamed or distorted anatomy. Mastery of this technique adds an important tool to the armamentarium of laparoscopic surgeons and contributes to better patient outcomes.