Laparoscopic Cholecystectomy — Skin to Skin Surgery | Step-by-Step Gallbladder Removal at WLH - video Dailymotion

Aaradhya Sharma

https://www.laparoscopyhospital.com/SERV01.HTM  Watch a complete skin-to-skin laparoscopic cholecystectomy performed by Dr. R.K. Mishra, a pioneer in minimal access surgery. This video demonstrates every crucial step in the safe removal of the gallbladder using a standard 4-port laparoscopic technique. Ideal for surgeons in training and medical professionals looking to enhance their skills.  🔍 Key Highlights:  • Patient positioning and port placement  • Dissection of Calot’s triangle  • Clipping and cutting of cystic duct and artery  • Gallbladder removal from liver bed  • Specimen retrieval and skin closure  🎓 Performed by: Dr. R.K. Mishra 🎥 Location: World Laparoscopy Hospital, Gurugram, India 🌍 www.laparoscopyhospital.com  Subscribe for more surgical videos and updates on laparoscopic and robotic surgery techniques.

Transcript

00:00Hello friends. So, for collisiectomy we are putting the varus needle over the inferior

00:07crease of umbilicus. One small stab wound is given by 11 number of knife and then we

00:14are putting the varus needle in the inferior crease of umbilicus and then pneumoperitonium

00:21started. So, for the long time I have not put the you know the video of the collisiectomy

00:31last video I have put may be 6 years ago. So, our student has asked that they want one

00:38a skin to a skin collisiectomy. So, now after pneumoperitonium we are enlarging the incision

00:46and 11 mm to put the optical port. So, this is cholelithiasis symptomatic and we will do

01:01laparoscopic collisiectomy with the four port. So, here optical port is introduced right side

01:09is the head of the present, left side is the leg part and this is a 26 year old female.

01:17This is the hissing sound is coming once the trocar is introduced. Now, white balancing and

01:26focusing of telescope is performed and then telescope will be introduced inside here we

01:32are giving the epigastic port just below the jiffy sternum and this is the right hand instrument

01:40of the surgeon will be taken in the epigastic port. So, here we are performing the collisiectomy

01:47in the American position where surgeon will stand left and after putting this is the third

01:54port that is mid clavicular line just below the costal margin or you can say just below the

02:01fundus of the fundus of the gall bedded. This you can allow your assistant to put or you

02:08can also introduce.

02:15And the fourth port is 7.5 centimeter lateral and below the third port in the NTA auxiliary

02:22line or at the level of umbilicus in the NTA auxiliary line. So, this will be used for

02:29the assistant to hold the fundus of the gallbladder and once all the port is introduced under vision

02:36of the telescope then head will be up and right will be up position. So, we can see all the

02:46four port is now in and then we will start the surgery. So, the first step is that one semi-traumatic

02:58grasper should be introduced and then we have to hold the fundus of the gallbladder and it

03:07has to be retracted towards the right shoulder. Better to hold the fundus horizontally so that

03:15your instrument will not touch the lever only gallbladder will touch. Now, with the left

03:22hand we can hold the horseman pouch and then we can give the anteromedial traction here we

03:29can see this is rovier sulcus is visible and rovier sulcus is at the level of porta hepatis.

03:36So, all your dissection should be above the rovier sulcus this is the porta hepatis and now

03:43first we will separate the posterior peritonium. And that should be we can use hook also we

03:51can use harmonic also and this is teflon jaw of the harmonic should be kept towards the gallbladder.

04:01So, that it will not puncture at least half mm that is 0.5 mm of the plutonium of the visceral

04:12plutonium should be left attached with the lever. So, that you will get a good areolar plane

04:18for dissection and at least one third of the gallbladder posterior plutonium should be separated.

04:29Remember that we will give anterolateral traction to open the anterior plutonium at the same level

04:39and only plutonium should be taken care should be taken that you should not push your harmonic

04:45deeper otherwise you can puncture the gallbladder or you can injure the artery.

04:59After that we have to do a skeletonization of the cystic pedicle for that you can give the

05:09anterior traction over the horseman and very thin film of the visceral plutonium over the

05:15cystic pedicle can be separated all around care should be taken the teflon jaw should be

05:23pears in the plutonium and only half mm you should hold because you should not hold a thick tissue

05:32otherwise you can accidentally puncture the artery or you can puncture the duct. So, this

05:40is done plutonium is separated. Now, once all the plutonium is cut now the job of the harmonic

05:48is over after that you can do the entire procedure with the simple Maryland. Here Maryland is introduced

05:58into the posterior window and this is the posterior window is formed, but to make it more conform

06:05you can just dissect little more to the cystic plate. So, that at least one third of the gallbladder

06:13should be separated from the liver and that means you can enlarge the posterior window that

06:21will be safer because in the calots of the laparoscopy posterior inferior this is of the

06:28liver should be visible. After that you can make a Maryland and just you can make the interior

06:37window for that initially tip of the Maryland should be kept towards the liver and open couple

06:45of time to make a plane between the artery and duct and then you can just rotate the Maryland

06:52to keep convexity towards the liver and then you can separate artery with the duct and this

06:59is the interior window. So, we can see critical view of safety and this is the ICG we will turn

07:05the ICG on and you can clearly see the CBD there this is CBD this is cystic duct and there is

07:13a common hepatic duct. If you will push the telescope inside then you can see entire common hepatic

07:19duct together with the right and left hepatic duct. So, it is over now we will clip the artery

07:26first and while you are clipping both the limb of the clip applicator should be visible. So, light

07:33will be turned at a 7 o clock position in the 30 degree telescope. So, you can see both the

07:40tip of the clip applicator. Here we are planning to cut the cystic artery with the harmonic.

07:48So, one clip is enough however, you can do the clipless also, but one clip is enough after

07:55that this is the clipping of the duct and we should take care that you should not go very

08:00near to the CBD. So, at least 3 mm you should go away from the CBD. So, that lateral clipping

08:08of the CBD should not happen accidentally. So, first clip is applied 3 millimeter away from

08:16the CBD. Now, we are applying third clip and you can sweep the cystic duct with the lower

08:21jaw of the clip applicator. So, that any stone will not come in that and then we will apply

08:28second clip that will be applied 3 millimeter away from the first clip. So, this is the second

08:36clip and clipping part is complete. After that you can cut the artery and duct. So, this is

08:47the harmonic which is cutting the artery and it will seal the artery also and after that

08:55you can cut the duct.

09:02And then you have to give anteromedial anterolateral traction and just keep on separating the peritoneum

09:09folds of the either side and automatically you will get a areolar tissue plane always remember

09:16that white is right. Once you will get a areolar tissue plane automatically it will look white

09:24and that area should be cut. You should not go very near to the lever and we should not

09:29go very near to the gallbladder also. If you are using hook also similarly hook, look and cook.

09:36If you are using harmonic then better to keep teflon jaw towards the lever towards the gallbladder

09:44so that gallbladder will not puncture accidentally. So, slowly, slowly gallbladder is getting separated.

09:55Once you have done your two third of the separation of the gallbladder then fundus grasper has to

10:01be better removed and you can optimize your traction with your left hand holding near the lever.

10:09And now this is the last part of the gallbladder has to be removed. This is the point where

10:14maximum perforation of the gallbladder happens. So, you have to be little slow and the traction

10:22should be optimized sometime blunt dissection also can separate the gallbladder. Now, before

10:28completely detaching the gallbladder from the lever you should have a final view. For that

10:34you may turn the ICG mode again on and you can inspect the entire bed and that will show

10:43you if there is any bleeding or any duct of Luska or systoleopathic duct. Before once you

10:50will totally cut liver will drop. So, this is the final inspection and again ICG mode is on

10:57and you can check the. So, there is no bleeding there is no any duct of Luska or systoleopathic

11:03duct and then you can do final cut. So, at the time of final cut you have to be careful

11:14that you should maintain the plane of areolar tissue and optimize the traction in the inferro

11:22anterior direction like it should be inferiorly and anteriorly pulled. So, it is over after

11:32that you can bring a claw forcep and you can catch the clip of the clip up clip in between

11:39the jaw of the claw forcep and then you can bring the neck in the cannula and then bring

11:44everything together. Outside you can cut the gallbladder and you can suck it. So, bile will

11:51be sucked with the suction and if there are multiple stone you have to put a ovum forcep and that

11:59will empty the gallbladder. Alternatively you can enlarge the incision, but better is to

12:05take little time and extract all the stone out so that you do not need to enlarge the incision.

12:14So, this is a very simple case of laparoscopic cholecystectomy and just I have put this video for just

12:24a repetition of the surgery. Thank you very much.

Laparoscopic Cholecystectomy — Skin to Skin Surgery | Step-by-Step Gallbladder Removal at WLH

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