Protocol for laparoscopic cholecystectomy: Is it rocket science?

Figure 4 Tips and pitfalls of laparoscopic cholecystectomy. A: Adequate compression using gauze (blue arrows) works well to stop bleeding at the LB; B: Hemostasis by thermal spread should be never used, nearly at the LB of the GB neck, Rouviere’s sulcus, and CD stump; C: The GB neck and Hartmann’s pouch often extend into the dorsal space due to inflammatory change and/or healing contracture, and unexpected excursions of important ducts and vessels may occur (dotted area). The dissectable/cuttable layer is cut under adequate retraction (blue arrow) as close to the GB as possible using the L-hook electrocautery technique (red arrows); D: Surgeons should not hesitate to perform preoperative detailed imaging studies in complicated cases. The CD (yellow arrow) and CA (red arrow) can be clearly detected on the 3D image; E: The GB is decompressed at the fundus by a dissector with energization; F: Under GB fixation (blue arrows), aspiration is surely performed (red arrow); G: A couple of sutures are placed to close an aspiration hole (dotted arrow); H: The aspiration hole is promptly closed by an extracorporeal ligation (red 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.