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This will hopefully allow visualization of bile indicating the duct is ready for cannulation. At this point, the Maryland forceps are placed in the 10 mm operating port to retract Hartmann’s pouch laterally. The assistant now holds these forceps to free the surgeon’s two hands allowing him to focus on the introduction of the cholangiogram clamp. This description is based on the use of the Olsen cholangiogram clamp with a smooth ureteral catheter no. 4, which must be checked before insertion. This catheter should be introduced from the left lateral grasper port into the cystic duct.

If a flexible choledochoscope is unavailable or stone removal by this method proves difficult, a traditional rigid choledochoscope can be introduced into the subxyphoid skin incision after removal of the 10 mm trocar. A suture can be tightened around the choledochoscope to keep the abdomen airtight. This can also be done directly through a separate skin incision. 1). This T-tube is introduced through a separate small skin incision, and adequate tube length should be left in the abdomen in order to avoid its inadvertent dislodgement if an ileus is encountered postoperatively.

If used, it should be added at an early stage, permitting the insertion of an irrigation/suction device, which can be used as a retractor to push down the duodenum and the greater omentum. It will also serve for hydrodissection. This extra trocar should be used for all obese patients, and also when the duodenum is stuck to the gallbladder and the surgeon requires extra duodenal retraction. The Basic Laparoscopic Cholecys­tectomy  a b Fig. 2 Ideal port placement for laparoscopic cholecystectomy.

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18 Trading Champions Share Their Keys To Top Trading Profits by docchantw

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