Indications for cholecystectomy

• Symptomatic cholelithiasis
• Acute/chronic cholecystitis
• Choledocolithiasis (after ERCP to resolve choledoco; within same admission)
• Gallstone pancreatitis (after pancreatitis resolved; within same admission)

Operative dictation

1. Port sites: camera infraumbilical, additional in epigastrium, R mid-clavicular line, R anterior axillary line
2. Grasp fundus of gallbladder and elevate; dissect adhesions to expose triangle of Calot (hepatocystic triangle) bounded by:
1. cystic duct
2. common hepatic duct
3. inf. border of liver
3. Achieve Critical view of safety - Two and only two structures should be seen entering the gallbladder
1. Cystic duct (lateral)
2. Cystic artery (medial)
3. Do not have to expose common bile duct/common hepatic arter
4. Optional steps: intraoperative cholangiography if choledoco is suspected (elevated LFTs, dilated CBD, pancreatitis) and was not evaluated pre-operatively with ERCP
1. Clip cystic duct close to gallbladder; nick cystic duct and insert catheter to conduct fluoroscopy and visualize any filling defects; should drain into duodenum)
5. Doubly clip/divide cystic duct and artery
6. Dissect gallbladder from liver; hemostase and remove gallbladder
7. JP drain placement is optional

• CBC/WBC
• LFTs: T bili
• Lipase (gallstone pancreatitis)
• US - stones? pericholecystic fluid? common bile duct dilated? Murphy's sign (sonographic?)
• Normal wall thickness ~ 2 mm
• Normal gallbladder size max 5x10 cm
• Normal CBD diameter ~ 6 mm, may add on 1 mm for every decade older than 60 yo
• Sonographic Murphy's sign is more accurate than clinical Murphy's

Pre-op antibiotics - usually ancef, but if no risk factors can go without abx

Post-op care