This video demonstrate Laparoscopic Cholecystectomy for Stone impacted at Hartmann's pouch. Manipulating the gallbladder with the left-hand instrument is a key part of performing a laparoscopic cholecystectomy. In these case stone should be removed from hartmann pouch. If a stone is impacted in the Hartmann’s pouch, this manipulation can be difficult, and can cause cramp and exhaustion of the surgeon’s left hand or injury to the gallbladder if a toothed instrument is used to improve grip. For the experienced laparoscopic surgeon, this tip makes manoeuvrability of the thickened, impacted Hartmann’s pouch simpler. We have used it in the acute and elective setting to great effect. The tape provides gentle traction and can be resisted easily if there are any concerns about placement as dissection continues.

Laparoscopic cholecystectomy has become the gold standard for the treatment of symptomatic gallstones. However, when a gallstone is impacted at Hartmann’s pouch—the junction of the gallbladder neck and the cystic duct—it can pose significant technical challenges. Such impactions increase the risk of bile duct injury, make dissection difficult, and may complicate the extraction of the stone. Careful preoperative planning and meticulous surgical technique are crucial to ensure patient safety and successful outcomes.

Anatomical Considerations

Hartmann’s pouch is a small outpouching at the neck of the gallbladder that may harbor stones, especially large or recurrent ones. Stones impacted here can obscure the cystic duct and Calot’s triangle anatomy, increasing the risk of injury to the common bile duct (CBD) during dissection. Understanding the relationship between the gallbladder, cystic duct, CBD, and surrounding structures is essential for a safe laparoscopic procedure.

Preoperative Evaluation
Patients typically present with right upper quadrant pain, nausea, vomiting, or signs of biliary colic. Ultrasound is the first-line imaging modality to identify the location of stones and gallbladder wall thickness. Magnetic Resonance Cholangiopancreatography (MRCP) may be used in complex cases to delineate biliary anatomy and detect stones in the common bile duct.

Surgical Technique

1. Patient Positioning and Port Placement

   • The patient is placed in a supine position with slight reverse Trendelenburg.

   • Standard four-port laparoscopic access is used: umbilical port for camera, epigastric port for working instruments, and two lateral ports for retraction and assistance.

2. Exposure and Retraction

   • The gallbladder fundus is retracted superiorly and laterally to expose Calot’s triangle.

   • Adequate traction is critical to delineate the anatomy, especially when inflammation is present.

3. Dissection of Calot’s Triangle

   • Careful blunt and sharp dissection is performed to identify the cystic duct and cystic artery.

   • Impacted stones at Hartmann’s pouch may require careful separation from the cystic duct to prevent injury.

4. Stone Extraction Techniques

   • If the stone cannot be mobilized, the gallbladder neck may be partially opened to remove it.

   • Some surgeons prefer intraoperative decompression or milking the stone back into the gallbladder body for safer removal.

   • A retrieval bag is often used to extract the stone and prevent spillage into the peritoneal cavity.

5. Securing Cystic Duct and Artery

   • After stone removal, the cystic duct and artery are clipped or ligated.

   • Care must be taken to avoid injury to the common bile duct, especially in cases with distorted anatomy.

6. Gallbladder Removal

   • The gallbladder is dissected from the liver bed using electrocautery or energy devices.

   • Hemostasis is ensured, and the gallbladder is removed through the umbilical port.

Postoperative Care
Patients usually recover quickly after laparoscopic cholecystectomy. Early ambulation, pain control, and monitoring for signs of bile leak or infection are standard. Most patients can be discharged within 24–48 hours.

Complications

• Bile duct injury

• Bile leak

• Bleeding from the liver bed

• Retained stones

• Conversion to open surgery in difficult cases

Conclusion
Laparoscopic cholecystectomy for stones impacted at Hartmann’s pouch is challenging but feasible with careful technique and understanding of biliary anatomy. Preoperative imaging, meticulous dissection, and adherence to safety protocols reduce complications and improve patient outcomes. Surgeons should be prepared to adapt their approach, including using stone extraction maneuvers or conversion to open surgery if necessary.