Exposure, dissection, and laser versus electrosurgery in laparoscopic cholecystectomy.

The technical complications of laparoscopic cholecystectomy occur while creating the pneumoperitoneum, placing trocars, obtaining exposure, and performing the initial dissection of the cystic duct and artery. The errors most feared are intestinal injury, vascular injury, and common bile duct injury. Bile duct injury usually results from the misinterpretation of the extrahepatic biliary anatomy. Confusion is most likely if the gallbladder infundibulum is pushed superiorly and medially, pulling the common bile duct out from behind the duodenum and into line with the cystic duct and gallbladder. Other dissection errors resulting in bile duct injury include the failure to begin dissection on the gallbladder, routine dissection of the cystic duct all the way to the common bile duct, failure to identify anomalies of the cystic and hepatic ducts, failure to open all folds of the gallbladder infundibulum, and entrapment of a narrow common bile duct by a cystic duct clip "slid" too far proximally. Proper dissection strategy includes posterolateral traction on the gallbladder infundibulum and initiation of dissection at the most medial point where the gallbladder is clearly seen. Pedunculation of the gallbladder will reveal most ductal anomalies but should be supplemented with routine digital fluoroscopic cholangiography. The controversy over optimal sources for thermal dissection of the gallbladder has largely been resolved. Electrosurgical dissection is a more rapid, hemostatic, and economical dissection.