**5.2 Laparoscopic cholecystectomy**

Nowadays, the state-of-the-art surgical therapy for gallstones is laparoscopic cholecystectomy. Laparoscopy is associated with lower postoperative pain, shorter hospital stay, and shorter recovery period [12]. From the first laparoscopic cholecystectomy in the beginning of the 1990s, this technique has changed the therapy for many gallbladder pathologies. Laparoscopic cholecystectomy is indicated for the therapy of acute and chronic cholecystitis, symptomatic gallstone disease, biliary dyskinesis, acalculous cholecystitis, benign gallbladder tumors. According to a recently published meta-analysis, laparoscopic cholecystectomy is also a safe alternative to open cholecystectomy for early gallbladder cancer (stage Tis—T3) with comparable overall survival and the rate of complications [13].

### *5.2.1 Technique*

Initially, we start with the insufflation of the carbon dioxide into the abdominal cavity until we reach the pneumoperitoneum with the intra-abdominal pressure of 15 mmHg. In conventional laparoscopic cholecystectomy, we continue with the

placement of the multiple ports depending on the surgeon's experience and skills. Surgeon standardly chooses 3 or 4 ports localised supraumbilically (10 mm port), subxiphoidally (10 mm port), and 1–2 ports in the right subcostal region (5 mm port). The key step in the safe gallbladder removal is the achievement of the critical view of safety (more on the topic in part 6) through meticulous preparation and dissection if this can be achieved. Only in this case, the surgeon can continue with the certainty that he/she has identified the cystic artery and the cystic duct. Both structures are then ligated and interrupted. Later on, we continue with the separation of the gallbladder from the gallbladder bed with the use of electrocautery or the harmonic scalpel. To achieve complete haemostasis, some authors recommend lowering intra-abdominal pressure to 8 mmHg for 2 min to spot potential venous bleeding, which can be undetectable with the intra-abdominal pressure of 15 mmHg. The gallbladder is extracted in the retrieval bag. The drainage in the subhepatic region after uncomplicated cholecystectomy is not routinely recommended. In the end, the trocars should be extracted under direct visualisation, and to prevent incisional hernias, some authors recommend fascial sutures in case of ports larger than 5 mm.

#### *5.2.2 Single-incision laparoscopic cholecystectomy (SILC)*

Even though the benefits of the conventional multiple ports access laparoscopic cholecystectomy are undeniable, the efforts to further minimise the traumatisation of the abdominal wall continued with the effort to reduce the number of ports. It was shown that laparoscopic cholecystectomy with the use of only one incision is possible in the clinical setting [14]. The limitations of this technique are the difficulties with the triangulation while using linear laparoscopic tools, limited view, and the possibility of the tools' collisions. SILC can be indicated in patients with uncomplicated disease, with BMI <35 kg/m2 , in whom there is a low probability of conversion either to multiple ports access laparoscopy or open cholecystectomy [15]. However, the role of the SILC compared to conventional LC in day-to-day praxis is debatable based on non-existent clear benefits beyond lower postoperative pain and improved cosmetic effects with no option to clarify the impact on the quality of life [15]. On the other hand, among the disadvantages are the higher occurrence of adverse events with prolonged duration of the surgery and frequent demand for additional port [15].

#### *5.2.3 Common issues in laparoscopic cholecystectomy*

The first thing that may compromise our ability to perform safe laparoscopic cholecystectomy may be the problem with the port placement. When we place a supraumbilical port in obese or tall patients in the umbilicus, it can create too low of a view [16]. Another issue with the limitations of fine motor movements may arise when placing the subxiphoidal port too low or not perpendicular to the abdominal wall while creating a form of "port tension" [16]. Tool collisions may happen when we place the surgeon's left-hand port in line with the camera view or the lateral retraction port [16].

The dissection of the gallbladder should be done with the proper incision of the peritoneum, therefore releasing the gallbladder from the liver [16]. A common issue may be with insufficient retraction of the infundibulum inferiorly and laterally and endangering the common hepatic duct or common bile duct by the possibility of an alignment with the cystic duct in the same plane [16]. Important to remember is to use the clips, ligations, or electrosurgical energy on ductal structures only after the visualisation of the regional anatomy [16]. The critical view of safety cannot be achieved unless the bottom third of the cystic plate is fully exposed with adequate dissection of

the hepatocystic triangle and clear identification of the cystic duct and the cystic artery [16]. When the CVS is not achievable, the attempt to perform total cholecystectomy is a risk for the patient and we must utilise a bail-out manoeuver [16].
