Protocol for laparoscopic cholecystectomy: Is it rocket science?

Figure 2 Tips and pitfalls of laparoscopic cholecystectomy. A: Countertraction by grasping tissue (red arrow) is a useful dissection, and a dissectable/cuttable layer (dotted circle) is made under coordinated retraction (blue arrow); B: Blunt dissection in the overhead view is useful around Calot’s triangle (red arrows); C: Blunt dissection by suction in the overhead view is also useful under adequate retraction (blue arrow); D: A dissectible/cuttable layer is created and should be intentionally traced as close to the GB as possible. The width of the dissectable/cuttable layer is confirmed with a reciprocating L-hook (red arrow); E: A safe field is routinely made to the foreground. Tension is created with an L-hook (red arrow), and the tissue is then cut by energization. Adequate traction is performed (blue arrow); F: Hartmann’s pouch should be pulled laterally and inferiorly (blue arrow) to open the anterior left side of Calot’s triangle and create a wider angle between the CD and CHD (dotted line). A parallel junction of the CD with the CHD should be avoided. Nerves around the GB neck and CD are cut nearly at the GB (red lines); G: Hartmann’s pouch should be pulled laterally and inferiorly (blue arrow). The GB should be followed down to the presumed point of the IC junction, as close to the GB side as possible (red arrow). Nerves around the GB neck and the CD are cut (red lines). A partial penetration window is made to confirm the dorsal side (green arrow). The anterior left side of Calot’s triangle is adequately exposed in the overhead view; H: The posterior right side of Calot’s triangle is exposed and dissected while applying superior and medial traction of the GB infundibulum or Hartmann’s pouch (red arrow). The GB should never be pushed directly to the liver side. Supportive tractions are performed (blue arrows). CD: Cystic duct; CHD: Common hepatic duct; CVS: Critical view of safety; GB: Gallbladder; IC: Infundibulum-cystic duct; LB: Liver bed; LC: Laparoscopic cholecystectomy.