Gallbladder and gallstone removal, open versus closed laparoscopy, and pneumoperitoneum.

Surgeons need to be aware of the various options available to remove enlarged gallbladders or gallstones lost during laparoscopic cholecystectomy. Every attempt should be made to recover stones that have escaped from a ruptured gallbladder during laparoscopic cholecystectomy, short of converting to laparotomy. Initial access to the peritoneal cavity can be safely accomplished using either a closed or an open technique. Ideally, surgeons should become facile with both procedures. Carbon dioxide (CO2) gas has emerged as the most practical agent for pneumoperitoneum during laparoscopic cholecystectomy. Surgeons should be knowledgeable about the physiologic and pathologic effects of CO2 gas.