（胆石症）标准腹腔镜胆囊切除术

                               
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Minimal invasive laparoscopic cholecystectomy is the typical surgical treatment for cholelithiasis (gallstones), where patients present with a history of upper abdominal pain and episodes of biliary colic. The classic technique for minimal invasive laparoscopic cholecystectomy involves four ports: one umbilical port, two subcostal ports, and a single epigastric port. The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) has instituted a six-step strategy to foster a universal culture of safety for cholecystectomy and minimize risk of bile duct injury. The technical steps are documented within the context of the surgical video for (1) achieving a critical view of safety for identification of the cystic duct and artery, (2) intraoperative time-out prior to management of the ductal structures, (3) recognizing the zone of significant risk of injury, and (4) routine intraoperative cholangiography for imaging of the biliary tree. In this case, the patient presented with symptomatic biliary colic due to a gallstone seen on the ultrasound in the gallbladder. The patient was managed with mini-laparoscopic cholecystectomy using 3mm ports for the epigastric and subcostal port sites with intraoperative fluoroscopic cholangiogram. Specifically, the senior author encountered a tight cystic duct preventing the insertion of the cholangiocatheter and the surgical video describes how the author managed the cystic duct for achieving a cholangiogram, in addition to the entire technical details of laparoscopic cholecystectomy.

Table of Contents
00:10 Introduction
00:30 Umbilical Port Incision and Exposure for Abdominal Access
01:29 Placement of 2-0 Vicryl Stay Sutures into Umbilical Fascia for Hasson Cannula
02:23 Insertion of Hasson Cannula into Abdominal Cavity
02:45 Insertion of Laparoscopic Camera and 360° Inspection of Abdominal Cavity
02:54 Surgical Finding of Indirect Inguinal Hernia
02:59 Placement of Lateral Subcostal Port and Insertion of 3mm Trocar
03:23 Grasping of Fundus of Gallbladder for Initial Inspection and Superior Elevation
03:29 Placement of Medial Subcostal Port and Insertion of 3mm Trocar
03:49 Placement of Epigastric Port and Insertion of 3mm Trocar
04:08 Inspection of Indirect Inguinal Hernia
04:22 Take Down of the Fatty Adhesions from Gallbladder
04:55 Take Down of the Duodenal Adhesion from Gallbladder
06:02 Identification of the Hepatocystic Triangle and the Cystic Duct and Artery
06:06 Clearing the Cystic Bundle of Fat and Fibrous Tissue
06:16 Identification of the Cystic Artery
06:31 Identification of the Cystic Duct
06:55 Developing the Interval between the Cystic Artery and Duct
07:35 Elevating the Lower 1/3 of Gallbladder from Cystic Plate for Critical View of Safety
08:33 Further Clearance of Fat and Fibrous Tissue from Cystic Duct and Artery
10:20 TIMEOUT – Confirm Attaining the Critical View of Safety with the 3-Point Strategy
10:32 Insertion of Camera into Epigastric Port for Clipping of the Cystic Duct and Artery
10:45 Clipping the Cystic Artery at the Neck of Gallbladder
11:14 Insertion of Camera into Umbilical Port for Incision over/into Cystic Duct
11:20 Incision over the Cystic Duct for Insertion of Cholangiocatheter for Cholangiogram
11:39 Insertion Attempt of Cholangiocather into a Tight Cystic Duct
12:18 Upsize of Medial Subcostal Port to 5mm Trocar for Cystic Duct Cholangiography
12:57 Division of the Cystic Artery
13:04 Further Clearance of Fat and Fibrous Tissue from the Proximal Cystic Duct
13:59 Successful Insertion of Cholangiocather for Cholangiogram
14:13 Fluoroscopic Cholangiogram and Imaging of the Biliary Tree
14:39 Insertion of Camera into Epigastric Port for Proximal Clipping of Cystic Duct
14:47 Clipping of Proximal Cystic Duct
14:59 Insertion of Camera into Umbilical Port for Division of Cystic Duct
15:05 Division of Cystic Duct
15:14 Elevating the Gallbladder from the Liver Bed
16:13 Irrigation of the Liver Bed and Inspection for Hemostasis
16:36 Insertion of Camera into Medial Subcostal Port for Extraction of Gallbladder
16:50 Extraction of Gallbladder with Entrapment Bag
17:27 Closure of Umbilical Fascia with Interrupted 2-0 Vicryl Sutures
18:20 Demonstration of Gallstone within Gallbladder and Taken to Histopathology
18:35 Credits