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Video 1 How I do it: laparoscopic cholecystectomy and intraoperative cholangiogram. In the United States, the calculated disease remains a prevalent condition affecting over 20-25 million Americans, representing 10 to 15% of the population (1,2). Although not every patient with gallstones will manifest symptoms or require surgery, laparoscopic cholecystectomy (LC), which accounts for 90% of all cholecystectomies, remains one of the most commonly performed procedures conservatively 750,000 per year (3). Since its introduction in the 1980s and subsequent adoption, LC has become the standard of care thanks to its benefits of reduced costs and length of hospital stay and increased patient satisfaction (4.5). Overall, LC is considered a safe procedure, as morbidity can occur in about 6 and about 8% of patients (6), including bleeding, abscess, bile loss, intestinal/vascular lesions, wound complication and bile duct wound (BDI) (6,7). bile duct has become less frequent over the years, occurring in about 0.2% [0.4% of cases, the frequency is still somewhat higher than in the age of open cholecystectomy (8.9). Therefore, performing the laparoscopic cholecystectomy safely and embracing the principles outlined below is crucial. BDI has been associated with other complications and the need for further procedures/interventions, higher mortality, lower quality of life and disability, increased medical and litigation aircraft (10,11). Studies have shown both increased and short-term and long-term mortality due to BDI (12). In order to improve the safety of cholecystectomy and reduce the rate of biliary injury, in 2014 the Society of Gastrointestinal and Endoscopic Surgeons (Sages) formed the Task Force on Safe Cholecystectomy with the aim of improving a culture of safety around this procedure (13). The authors report the surgical techniques that follow the principles espoused by sages during laparoscopic cholecystectomy in order to guarantee a safe procedure. Surgery technique The patient is placed in a supine position with the left arm hidden to facilitate intraoperative cholangiography. With the surgeon standing to the left of the patient and the first assistant standing on the right side of the patient, abdominal access is obtained and the pneumoperitoneum is established. In our practice, we generally perform an open stitching technique and a positioning of Hasson's cannula at the navel (position T1) (Figure 1). In patients with periumbilic incisions after median incisions, an alternative access site is used, closed with a Verres needle in the upper right quadrant of the mid-clavic quadrant at the end of the diaphragm. below the quadrant of the liver or upper left quadrant (Palmer's point) or An open epigastric incision. In the obese patient, you get an AGO verres access closed, it is obtained right to the right of the median line 15 cm below the Xiphoid as the navel is unmanned below these patients; This allows you to position the camera door for the adequate display of the dissection site. dissection. creation of the pneumoperiitone, 5 mm doors are placed in the right side subcostal position (T2) and in the middle-clavicular right sub-costal line (T3), along with an epigastric port of 5 mm (T4), which is inserted just at the right edge of the phenyform bond. A socket introduced by T2 is used to apply the cephalic traction on the bottom to elevate the gallbladder and a socket through the middle-clavicular door portrays the infundibole laterally and lower. The working trocars used by the surgeon are T3 and T4. Figure 1 Positioning of the laparoscopic colecistectomy door. Phase 1: dissemination of the hepatocistic triangle The gallbladder is retracted over the liver with cephalic traction, while the lower side traction on the gallbladder neck is applied through the midclavicular door site. The assistant can usually maintain a constant voltage on this rewinder, unless adjustments are required for display changes. Using T3, the surgeon can manipulate the gallbladder neck to expose the front (medial) and rear (lateral) aspects as necessary. If the gallbladder is spread out, it is recommended to decompress it with a needle suction device to avoid bile leakage and gallstones. If there are adhesions, these are removed abruptly or with monopolar energy paying attention to avoiding energy consumption near the duodenum that can adhere to the gallbladder. The dissection begins with the incision of the peritonee along the edge of the gallbladder on both sides to open the hepatocistic triangle. This can be transported posteriorly along the gallbladder wall to its interface with the liver. A combination of contingent dissection and oculated use of cauterization is necessary to eliminate the triangle of adipose and fibrous tissue. Step 2: Establish critical vision of security Critical vision of security requires three criteria to be met: (I) the hepatocistic triangle (defined as the triangle formed by the cystic duct, the common liver duct and the lower edge of the liver) is eliminated from all adipose and fibrous tissues. The common bile duct and the common hepatic duct are sought but not exposed for dissection; (II) the lower third of the gallbladder is separated from the liver to expose the cystic plaque. The cystic plaque is defined as the hepatic bed of the gallbladder and represents the cystifellea pit; and (III) two and only two structures should be seen entering the gallbladder, which represent the cystic duct and the cystic artery. Once this vision is established, we recommend a pause and a confirmation between the surgeon and the assistant before proceeding to cut or cut any structure. At this point, the identification of aberrant anatomy is fundamental. Changes in positionCystic duct and entrance in the common bile duct are common, as well as the variants of arterial anatomy. An understanding and an in-depth appreciation of aberrant anatomy is important to minimize the risk of a lesion. A common consideration is to ensure the correct liver liver It is not mistaken for cystic artery or accessory branch at the rear in the cystic plaque area. Step 3: Cystic artery is cut and divided into our institution to minimize costs, a reusable clip applicator with 8 mm clips is used to hook the cystic artery, two clips on the proximal side and a clip On the distal side (sample) with an adequate space between them to allow division. The hook scissors are used to divide the artery. During this process, be careful not to disconnect proximal clips. It is advisable to leave a small tissue cuff over the edge of the clips to avoid accidental movement during or after the case. A clip is placed on the neck of the gallbladder at the top end of the Cystic GB duct junction. The division to the right of the clip can prepare the distal sample clip to break away. Step 4: Operating colangiography and division of the cistico duct and 'our practices regularly carry out colangiography. Colangiography is most commonly performed selectively, but convincing indications are the suspicion of CBD calculations (history of abnormal hepatic functionality or biliary pancreatitis), a common bile duct, anatomical uncertainty or concern for bile injury, and a story of ROUX Y gastric bypass which precludes the next ERCP. If you do not perform a colangiogram, similar to cystic artery, the cystic duct can be cut with three titanium clips, two on the stop side and one on the gall bladder side. In the event of a dilation or thickening of the cystic duct or presence of bile calculations, use a pre-tied endoloop suture to fix the duct on the proximal side. If an intraoperative colangiogram must be performed, it is positioned a single clip at the crossroads of the Cystic Duct and the infidal of the gall bladder. The cystic duct is partially engraved with hook scissors. Cystic ductotics is then dilated with a microsphorbice to interrupt any valves in the cystic duct. A 4 French ureteral catheter is then inserted into the cystic duct using an Olson colangioclamp to fix it. Single spot films are used to adjust the position of the arm C so that it is the entire biliary shaft and the duodenum can be displayed in the center of the frame. We use two 20 ml syringes, a containing saline solution and the other a 50-50 mixture of saline and iodotic contrast means connected via a three-way injection faucet. The duct is initially washed with saline solution and then contrasted with fluoroscopy. You should see the retrograde filling in the common hepatic duct as well as Right and Left Branches in the liver and the contrast should flow freely into the duodenum, ensuring a patented biliary tree. In the absence of contrast in the duodenum, administer 1 mg of intravenous glucagon for the sphincter of Oddi and repeat the injection within 2-3 minutes. In case of difficulty with the retrograde filling of the duct, place the patient in Trendelenburg, gently compressing the distal ductA ATRAUMIC RENTAL, or an intravenous intravenous morphine injection can be given to facilitate the contracture of the sphincter. If a stone is displayed in the bile duct, the decision should be carried out whether to try an exploration of the trans-cystic bile duct, laparoscopic choledocotomy or postponement for the ERCP polyperative, according to the skills and preferences of the surgeon. Once a satisfying colangiogram has been obtained, the colangiogram catheter is removed and the cystic conduit is doubly rebelled and divided. As indicated above, if there is concern about clips security on the cystic duct, you need to use a pre-linked cycle suture to fix the duct. Step 5: Separation of the gall bladder from the liver bed The following division of the cystic conduit is performed the retrograde dissection of the gall bladder from the liver bed. In our institution, we use a monopolar monopolar energy device to dissect the gallbladder from the liver. The care should be taken to stay in the plane between the gall bladder and the liver bed. The entrance to the liver bed can cause bleeding and / or losses of bile from a superficial submerchimal duct. The entrance to the gall bladder with bile leakage and stones make the later dissection more difficult, but should not have negative consequences until all the bile and the stones are removed from the field. Maintaining an appropriate retraction by moving the neck of the gallbladder back and forth to optimize the visualization and maintenance of the voltage on the dissection line facilitates this passage in the operation. For the difficult gallbladder in the setting of acute cholecystitis, an advanced energy device as an ultrasonic coagulator can keep the hemostasis base and produce less smoke plum, which makes the dissection easier and more efficient. Before completing the distribution of the gall bladder from its bed, the last attachment should be left in place to allow the retraction of the Epasto and the clear display of the cystic plate to allow any necessary hemostasis. The liver bed is irrigated and any blood or bile or aspirated from the field. The gall bladder is then placed in a trapping bag and removed at the 10 mm 10 mm port website. Step 6: Specimen and door removal Once the sample is in the bag, it can be removed in the 10 mm port website either to the navel or the epigastric region. These steps are summarized in our video (video 1). Some expansion of the skin and the fascial opening can be needed, especially if there are multiple or larger stones or a thickened gallbladder. Once the sample is removed, all ports are downloaded to eliminate any residual CO2 gas. The band of the site of the The extraction should be closed with 0-vicryl or similar suture and the skin closed with a sublemable absorbable monofilament suture. Recognition no one. Conflicts of interest: Authors have no conflicts of interest to declare. Ethical Statement: Authors are responsible for all aspects of the work to ensure that questions relating to the or the integrity of any part of the work are properly investigated and resolved. The written informed consent was obtained by the patient for the publication of this manuscript and any accompanying image. References Everhart JE, Ruhl CE. Burden of digestive diseases in the United States Part III: Liver, Tratto Biliario and Pancreas. Gastroenterology 2009;136:1134-44. [Crossref] Shaffer EA. Epidemiology and risk factors for biliary calculus disease: Has the paradigm changed in the 21st century? Curriculum Gastroenterol Rep. 2005;7:132-40. Russian MW, Wei JT, Thiny MT, et al. Statistics of digestive diseases and liver, 2004. Gastroenterology 2004;126:1448-53. [Crossref] [PubMed] Shea JA, Berlin JA, Bachwich DR, et al. Indications and results of choecistitectomy: A comparison of pre- and postlaparoscopic eras. Ann Surg 1998;227:343-50. Calland JF, Tanaka K, Foley E, et al. Cholecystectomia laparoscopic ambulante: Patient results after the implementation of a clinical path. Ann Surg 2001;233:704-15. Murphy MM, Ng SC, Simons JP, et al. Predators of major complications after Laparoscopic colectomy: Surgery, Hospital or Patient? J Am Coll Surg 2010;211:73-80. Giger UF, Michel JM, Opitz I, et al. Risk factors for perioperative complications in patients who submit laparoscopic colectomy: analysis of 22.953 Consecutive cases of the Swiss Association of Laparoscopic and Thoracoscopic Surgery Database. J Am Coll Surg 2006;203:723-8. Flum DR, Dellinger EP, Cheadle A, et al. Intraoperative cholangiography and the risk of joint injury of the body during choleecistitectomy. JAMA 2003;289:1639-44. [Crossref] Pucher PH, Brunt LM, Davies N, et al. Income trends and safety measures after 30 years of laparoscopicity choleecists: a systematic review and analysis of the data in pool. Surg Endosc 2018;32:2175-83. Kern KA. Malpractical dispute involving cholecystectomy laparoscopic: Cost, cause and consequences. Arch Surg 1997; 132:392-7; discussion 397-8. Carroll BJ, Birth M, Phillips EH. The lesions of the common bile duct during laparoscopic colecististectomy which results in litigation. Surg Endosc 1998; 12:310-3; discussion 314. Booij KAC, De Reuver PR, Van Dieren S, et al. Bile Duct's long-term lesion impact on Morbidity, Mortality, Quality of Life and Correct Limitations of Work. Ann Surg 2018;268:143-50. The SAGES Safe Cholecystectomy program. Available online: 10.21037/ales.2020.02.06 Cites this article as: Majumder A, Altieri MS, Brunt LM. How do I do: laparoscopic colectomy. Ann Laparosc Endosc Surg 2020;5:15. 2020;5:15.

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