21 Tips for Management of Abnormal Anatomy and Difficult Cases During Laparoscopic Cholecystectomy

Abstract Background Laparoscopic cholecystectomy is considered a routine procedure for general surgeons; however, it is not always straightforward. We present here the operative management of various complex gallbladder cases in our high-volume centre for gallbladder surgery. Method All cases were successfully completed laparoscopically. In patients with acute cholecystitis wherein Calot’s triangle dissection is unsafe, a subtotal cholecystectomy was performed. Results High BMI patients pose a lot of challenges intra-operatively including a thick abdominal wall, heavy liver, and a fatty Calot’s triangle. To overcome those challenges, we adopted useful manoeuvres such as achieving pneumoperitoneum via Palmer’s point, placing the camera port higher than the umbilicus to the right of midline, using bariatric trocars, releasing part of the falciform ligament, using a pledget for blunt dissection around Calot’s triangle, and releasing the fundus firstly to allow for better gallbladder retraction. Cases with previous midline or other scars, access can be achieved safely through the Palmer’s point as described earlier to avoid the adherent omentum and scar tissues. In case of encountering a vascular anomaly e.g. aberrant right hepatic artery intraoperatively careful dissection was performed up to the liver bed. In the rare case of an extraordinarily large gallbladder, stapled cholecystectomy was performed. We would recommend the use of a stapler, endo loop or suture ligation for a wide cystic duct when it is unsafe to control with regular clips or hem o lok. Conclusions Advanced laparoscopic skills, utilising available resources, and higher thinking contribute to completion of difficult laparoscopic gallbladder surgery without conversion to open.