Both abdominal and laparoscopic cholecystectomies are performed under general anesthesia. An abdominal cholecystectomy begins with a right subcostal or paramedial incision. The surgeon then surveys the abdomen and uses laparotomy packs to isolate the gallbladder from the surrounding organs. After identifying biliary tract structures, he may use cholangiography or ultrasonography to help identify gallstones. Using a choledoscope, he directly visualizes the bile ducts and inserts a Fogarty balloon-tipped catheter to clear the ducts of stones.

The surgeon ligates and divides the cystic duct and artery and removes the entire gallbladder. Typically, he performs a choledochotomy: the insertion of a T tube into the common bile duct to decompress the biliary tree and prevent bile peritonitis during healing. He may also insert a Penrose drain into the ducts. After completion of the surgery and, if necessary, implantation of the T tube, the surgeon removes blood and debris from the abdomen, closes the incision, and applies a dressing.

For a laparoscopic cholecystectomy, the surgeon begins by making a small incision just above the umbilicus and injecting either carbon dioxide or nitrous oxide into the abdominal cavity. This inflates the abdomen and lifts the abdominal wall away from the abdominal organs, allowing the surgeon to identify the gallbladder readily. He then connects a trocar to an insufflator and inserts it through the incision. Next, he passes a thin, flexible optical instrument, called a laparoscope, through the trocar. The laparoscope allows the surgeon to view the intra-abdominal contents.

At this time, the patient is placed in Trendelenburg’s position. This causes the small intestines to fall out of the pelvis, making room for the initial needle and trocar insertion. Then, while looking through the laparoscope, the surgeon makes three incisions in the patient’s right upper quadrant: one 2″ (5 cm) below the xiphoid process in the midline; one 1″ (2.5 cm) below the right costal margin in the midclavicular line; and one in the anterior axillary line at the level of the umbilicus.

While continuing to look through the laparoscope, the surgeon passes instruments through the three incisions in the right upper quadrant. He uses these to clamp and then tie off the cystic duct and to excise the gallbladder. The gallbladder is then removed through the umbilical opening. After this, the surgeon sutures all four incisions and places a dressing over each one.