Description

Explore the technique of three-port laparoscopic subserosal cholecystectomy demonstrated by Prof. Dr. R. K. Mishra at World Laparoscopy Hospital. This educational surgical video focuses on minimally invasive gallbladder removal, careful dissection in the subserosal plane, precise tissue handling, and the importance of maintaining a clear operative field throughout the procedure. Laparoscopic cholecystectomy is widely used to treat symptomatic gallstones and selected gallbladder conditions. The three-port approach uses strategically positioned laparoscopic instruments and a camera to provide visualization, traction, and working access. In selected patients, this approach can facilitate effective gallbladder removal while limiting the number of abdominal incisions. The appropriate technique depends on the patient's anatomy, gallbladder pathology, and the operating surgeon's assessment. Understanding Subserosal Dissection The subserosal approach involves carefully separating the gallbladder from its surrounding attachments while maintaining awareness of the underlying liver bed and nearby anatomical structures. Controlled dissection and appropriate traction are important for identifying the correct tissue plane and avoiding unnecessary tissue trauma. A bloodless operative field is a desirable surgical objective because bleeding can obscure the anatomy and make dissection more challenging. Achieving this objective requires meticulous technique, appropriate instrument use, careful energy application when indicated, and prompt management of any bleeding. However, no technique can guarantee a completely bloodless operation in every patient. Step-by-Step Surgical Learning Points 1. Preoperative assessment and preparation Patient selection begins with clinical assessment, relevant imaging, evaluation of gallbladder disease, and anesthetic review. The surgeon considers factors such as inflammation, previous abdominal surgery, anatomical variation, and the possibility of a difficult dissection. 2. Patient positioning and laparoscopic access After appropriate anesthesia and preparation, the patient is positioned to provide access to the upper abdomen. Pneumoperitoneum is established using an appropriate technique, and the laparoscope and working instruments are introduced through three planned ports. Port positioning should provide effective visualization, safe instrument movement, and suitable traction. 3. Exposure of the gallbladder The gallbladder is retracted to expose the operative field. Appropriate traction and countertraction help reveal the gallbladder neck, hepatocystic triangle, and liver attachment. Maintaining orientation is essential because inflammation and anatomical variation can distort the usual landmarks. 4. Careful subserosal plane dissection The gallbladder is dissected from its surrounding attachments using controlled movements and an appropriate operative plane. The surgeon aims to minimize unnecessary bleeding and tissue injury while maintaining clear visualization. Energy devices, when used, must be applied judiciously to reduce the risk of thermal injury to nearby structures. 5. Identification of the cystic duct and artery An essential safety principle is accurate identification of the biliary and vascular anatomy before dividing any structure. The critical view of safety should be pursued whenever feasible. This includes clearing the hepatocystic triangle, separating the lower portion of the gallbladder from the liver bed to expose the cystic plate, and confirming that only two structures enter the gallbladder. These principles help reduce the risk of misidentification. If the anatomy remains unclear, the surgeon should pause and consider additional imaging, an alternative operative strategy, or an appropriate bailout procedure rather than proceeding with uncertain anatomy. 6. Controlled division and gallbladder removal Once the relevant structures have been clearly identified and the required safety criteria are met, the cystic duct and artery are secured and divided using the selected technique. The remaining gallbladder attachments are released under direct vision, with attention to bleeding, bile leakage, and the condition of the liver bed. 7. Final inspection and specimen retrieval The operative field is inspected for bleeding, bile leakage, and other concerns. The gallbladder is retrieved using an appropriate method, and the ports are removed under suitable visualization. Closure and postoperative management are determined by the clinical circumstances.