Then incise the posterior peritoneal attachment behind Hartmann144s pouch to separateHartmann144s pouch from the liver to further stretch out Calot144s triangle Laparoscopic Cholecystectomy ID: 940175
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Retraction and dissection of CalotÕs triangleOnce caudad retraction ofthe fundus is established,the crucial maneuver is lateral retrac-tion ofHartmanns pouch by the upper lateral 5-mm port.This places Calots t
riangle onthe stretch and will greatly reduce the chance ofinjury ofthe common bile duct. Then incise the posterior peritoneal attachment behind Hartmanns pouch to separateHartmanns pouch from the liver to furt
her stretch out Calots triangle. Laparoscopic Cholecystectomy,Open Cholecystectomy and Cholecystostomy529 Once these two maneuvers are instituted,hook dissection can be performed,stayingclose to the gallbladder to in
cise the anterior sheet ofperitoneum over Calots triangle.This will expose one or two cystic arteries and the cystic duct .Windows should bedeveloped between all these structures before anything is divided.Once the a
natomy is determined (see anatomical variations and tricks),the cysticarteries are divided between clips and a clip is placed below Hartmanns pouch to theproximal end ofthe cystic duct. SECTION4Biliary Tract and Gall
bladder Removal of gallbladderOnce cholangiography is completed,the ureteric catheter is removed and the cystic duct is clamped.The gallbladder is then removed from the liver bed using hookdiathermy.This is done through a
combination ofelevating the peritoneum,burningwith the hook and pushing so that the gallbladder is removed toward the fundus and“nally separated from the liver at the fundus.There is very little place for fundus-“
;rstlaparoscopic cholecystectomy. SECTION4Biliary Tract and Gallbladder Anatomical VariationsThe major anatomical variations are involved with the common bile duct and theright hepatic artery.A very small common bile duct
can be mistaken for the cystic duct and completelyexcised.Even more worrisome is the variant ofa low junction ofthe left and righthepatic ducts () or a low junction ofthe right anterior and right posterior hepaticducts ().
In these situations the cystic duct can enter the right hepatic duct or the right posterior hepatic duct.The right or right posterior ducts can therefore be mistaken for the cystic duct and divided.More rarely,but even mor
e dif“cult,particularly in the setting ofacute cholecystitis,is when there is no cystic duct and Hartmanns pouch opens directly underneath theright hepatic duct or the common duct. Laparoscopic Cholecystectomy,O
pen Cholecystectomy and Cholecystostomy533 The peritoneal cavity is elevated with the “ngers and the wound incised along its fulllength.Three packs are inserted … one behind the liver,one on the colon and one ove
rthe gastroduodenal area and retractors are placed over the gastroduodenal area and one over the liver to place Calots triangle on the stretch. Laparoscopic Cholecystectomy,Open Cholecystectomy and Cholecystostomy537