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Laparoscopic cholecystectomy, the minimally invasive surgery for gallbladder removal, has revolutionized the field of abdominal surgery. With the advent of high-definition video technology and advanced surgical instruments, this procedure has become safer, quicker, and more efficient. In our comprehensive video guide, we delve into the skin-to-skin laparoscopic cholecystectomy, offering an in-depth look at the techniques and best practices essential for surgeons.


Introduction to Laparoscopic Cholecystectomy
Laparoscopic cholecystectomy involves the removal of the gallbladder through small incisions in the abdomen, using a laparoscope – a thin tube with a camera and light at the end. This approach has numerous advantages over traditional open surgery, including reduced pain, shorter hospital stays, and quicker recovery times.


Preoperative Preparation and Patient Selection
Our guide begins with a detailed section on preoperative preparations and patient selection criteria. It emphasizes the importance of a thorough medical evaluation to identify any potential risks and contraindications. The video also covers patient education, where surgeons explain the procedure, potential risks, and postoperative care to the patients.


Step-by-Step Surgical Technique
The core of our guide is the step-by-step demonstration of the surgical procedure. The video meticulously covers:


Trocar Placement: It demonstrates optimal placement of trocars to ensure safe access and efficient maneuverability of instruments.


Calot's Triangle Dissection: The guide highlights techniques for the safe and precise dissection of Calot's triangle, a crucial step in preventing bile duct injuries.


Gallbladder Detachment: It showcases the techniques for careful dissection and detachment of the gallbladder from the liver bed, emphasizing the importance of maintaining a clear field of vision and hemostasis.


Specimen Retrieval: The video explains methods for the safe extraction of the gallbladder through one of the incisions.


Handling Complications
A vital section of the guide is dedicated to the identification and management of intraoperative complications, such as bile duct injury or bleeding. It offers insights into the decision-making process for converting to open surgery when necessary.


Postoperative Care and Best Practices
The guide concludes with postoperative care instructions, emphasizing pain management, wound care, and the monitoring for potential complications. Best practices for follow-up care and patient education on lifestyle changes post-surgery are also included.

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Learning
Transcript
00:01Hello friend.
00:02This is a case of laparoscopic cholecystectomy and we will show you the skin to skin how to
00:07perform it.
00:08Here is one small stab wound is given over the inferior crease of omblycus and very steady
00:14it is introduced by lifting the abdomen and then we will start the insufflation.
00:23The flow rate should be one liter per minute and gas is starting insufflation.
00:28You can see liver dullness is obliterated and there is a tympanic sound all over the abdomen.
00:37After that, you can enlarge the incision to elemonum.
00:48And then you can dilate the obliterated vitro-estational track.
00:59That is a Scandinavian technique.
01:02And then you can introduce the optical port.
01:07So optical port is introduced perpendicular to the abdominal wall and by screwing movement
01:13it is introduced inside.
01:16Hissing sound is there.
01:18Now crocar is introduced and cannula is further introduced.
01:26After that, this is the epigastric port.
01:28This is just below the GPS sternum and slightly towards the left.
01:35And then we will put the second port.
01:37Second port will be used for harmonic.
01:40Initially, it should go perpendicular.
01:43And as soon as the tip of the trocar is anchored, then it should be pointed towards the right.
01:49So that will pierce the membranous part of the falciform ligament.
01:54Now the third port is mid-clavicular line, just below the costal margin or just below the
02:01fundus of the gallbladder and you can ask your assistant to put this port.
02:06This is the third port and it is going perpendicular.
02:16And after that, fourth port will be introduced.
02:19That is NTA auxiliary line, 7.5 cm lateral and 7.5 cm below the third port.
02:33And this is for fundus grasper.
02:37And now all the port is introduced.
02:41Then after that, tables will be lifted up and right up, head up and the right up.
02:52Now this is a semi-traumatic grasper which will be introduced through the right NTA auxiliary
03:00line port.
03:03And now fundus will be held and will push towards the right shoulder.
03:07Now there is a minimum adhesion.
03:12So first strip is to remove these flimsy adhesions, to strip it down.
03:25After that anteromedial direction is started and this is the posterior peritoneum dissection.
03:32Then only peritoneum should be stripped at the junction of the body of the gallbladder with
03:38the cystic particle.
03:41Left hand grasper should give anteromedial traction and this peritoneum should be separated.
03:47After that this is anterolateral traction and at the same level anterior peritoneum is separated.
03:55And that will make your posterior window.
04:09After that peritoneum of the cystic particle should be stripped down.
04:15And a skeletonization of the cystic particle should be performed by stripping it down and
04:22only peritoneum should be touched nothing except.
04:28Now we can see here.
04:32This is the CVD here is the lymph node of Lund and this is cystic duct.
04:39After that you can go and you can open the tip of CVD which is visible and then you can
04:46bring a Maryland and by opening the jaw of the Maryland you can make an anterior window.
04:52This is the posterior window we can see.
04:55This Maryland is opening the jaw fully and this is the posterior window which is formed.
05:01And now this is the anterior window.
05:04Keeping the tip of the Maryland initially towards the liver and after that hooking it up.
05:09And this is cystic duct.
05:12So we can see here.
05:14The artery this is CVD this is cystic duct.
05:18These are fibrous trabeculis which you can break.
05:22And then you can turn the ICG mode on.
05:25Here we have injected the endosyanin grain.
05:29And we can see this ICG mode is on.
05:32And that will show you the CVD as well as cystic duct.
05:36Now this is clipping of the artery.
05:38This patient has little fatty liver.
05:41So both the tip of the clip applicator must be visible.
05:45And this one clip is applied over the artery.
05:50And after that you will apply the clip over the duct.
05:55And then the three clip is applied.
05:58One will be towards the CVD.
06:03And this should be little bit away from the CVD so that lateral clipping of the CVD should
06:07not happen.
06:09Press it half.
06:10Meet it like a ring.
06:11Move it up and down.
06:12And then press it near the CVD.
06:15So this is the one clip is applied over the cystic duct.
06:20After that another clip is applied approximately nine millimeter away from the first clip.
06:26And then the second clip is applied approximately three millimeter away from the first clip.
06:37So this way all the clip is applied.
06:42And after that you will bring the harmonic.
06:46And then you or scissors and you can cut the cystic duct as well as cystic artery.
06:51So here we are using harmonic scalpel and this is cystic artery is cut.
06:57Only one clip is applied and you should relax the artery before cutting because in relaxation
07:03sealing effect of harmonic is better.
07:07After that again you can catch the cystic duct.
07:11Again relax it and cut the cystic duct.
07:14This was a little dilated cystic duct but it is okay.
07:18After that you can separate the gall barrier from the liver by giving anteromedial and
07:23anterolateral traction.
07:26And first the shoulders that is the pitonium should be fold and after that automatically
07:32you will get a good areolar tissue plane.
07:35For this purpose you may use any instrument.
07:38Some people they prefer the hook.
07:40Some people they prefer the spatula.
07:43Some people even they prefer the scissors.
07:46So this is first pitonium should be cut.
07:49And at that time your left hand should give anteromedial and anterolateral traction.
07:56Once the half of the gall barrier is separated after that light cable should be turned down.
08:02So that once you will turn the light cable down it will show you up.
08:08And we can see it is a good areolar plane.
08:11And now you can separate the gall barrier from the liver.
08:15And the 30 degree telescope will show you the gall barrier focia much nicely.
08:21Little bit blunt dissection is also required.
08:24Once you reach to two third then fundus grasper should be removed.
08:28So that you can optimize your traction by your own hand with giving the pitonial dissection
08:34first.
08:36Once you have reached to the last part of the fundus of the gall better then you should
08:41be careful that traction should be towards the right iliac focia.
08:47And with the harmonic you can just strip it and slowly you can start dissecting it.
08:55As soon as you reach to the last part of the fundus you should try to inspect the gall
09:00barrier focia by turning the light cable up.
09:03And if it is required you can do fulguration to stop the oozing.
09:08This easy mode also can be switched on and final inspection should be done.
09:14Once everything is okay after that you will do the last cut that is a final cut.
09:20Before final cut final inspection is necessary because after cutting the final cut liver will
09:26drop and then inspection of the gall better bed will not be so easy.
09:31So this traction is given towards the right iliac focia and then this is the final cut of
09:37the gall better and final separation of the gall better from the liver.
09:43So laparoscopic cholecystectomy is a very easy procedure if it is performed with the proper
09:48technique.
09:49And now this is the claw forcep you will pull the neck of the gall better into the cannula
09:55and then pull it out.
09:56Clips should be catched in between the jaw of the claw forcep.
10:01Once it is taken in the cannula then it should be outside and then you can put a suction
10:07by cutting the neck and you can suck the bile and then gall better come out.
10:11So thank you very much for watching this video.
10:13This was just a simple case of laparoscopic cholecystectomy.

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