Introduce the laparoscope through an umbilical portal. Place a 10-mm port in the epigastric region and two 5-mm ports in the right midclavicular line and right anterior axillary line (Fig. 73.2A). Explore the abdomen. Cautiously lyse any adhesions of gallbladder to colon, omentum, or duodenum (Fig. 73.2B). Pass a grasping forceps through the anterior axillary line port and grasp the fundus of the gallbladder, pulling it up and over the liver. This will expose the subhepatic space (Fig. 73.2C). If the stomach and duodenum are distended, have suction placed on an orogastric or nasogastric tube. Reverse Trendelenburg positioning and tilting the operating table right side up will help increase the working space by allowing the viscera to move caudad and to the left.

Place a second grasping forceps through the midclavicular line port and grasp Hartmann’s pouch. Pull out, away from the liver. This maneuver will open Calot’s triangle and create a safe working space (Fig. 73.2D).

Take a moment to orient yourself. Frequently, there is an obvious color difference between the pale blue or green of the gallbladder (unless severely diseased) and the yellow fat of the Calot’s triangle. This blue–yellow junction is a good place to begin dissection. A few filmy adhesions of omentum, transverse colon, or duodenum may need to be cautiously lysed to provide optimum visualization of the region. Calot’s node, often enlarged in acute or resolving acute cholecystitis, nestles in Calot’s triangle (Fig. 73.2E).

Another good landmark is the hepatic artery, which should be visible as a large pulsating vessel well to the left of the surgical field. This is a marker for the bile duct, which generally lies just to the right.

The cystic artery arises from the right hepatic artery in Calot’s triangle and ascends on the left side of the gallbladder in approximately 80% of individuals. A fatty stripe or slight tenting of the peritoneum overlying the gallbladder may serve as a clue to its probable location. In a significant minority of individuals, the cystic artery arises directly from the hepatic artery. Other anomalies of the cystic artery of laparoscopic significance are described in Figure 73.3.

Calot’s node is one of two fairly constant nodes in this region. The second node, termed the node of the anterior border of the epiploic foramen, lies along the upper part of the bile duct. Thus, simply noting the presence of a node in proximity to the bile duct does not guarantee a safe working distance from the bile duct.

Incise the peritoneum overlying the blue–yellow junction (Fig. 73.3A). The cystic duct should become evident as a tubular structure which runs into the gallbladder. It is generally

the closest structure to the laparoscope, and hence the first structure which is encountered. Develop a window behind the gallbladder by incising the gallbladder peritoneum on the left and right sides and blunt dissecting behind cystic duct and gallbladder (Fig. 73.3B). The cystic artery should be visible to the left of the cystic duct (Fig. 73.3C). With good traction outward on Hartmann’s pouch and an adequate peritoneal window, two tubular structures going to the gallbladder, the cystic duct and cystic artery, should be clearly seen (Fig. 73.3D).