Table of Contents
Gallstone disease is one of the leading causes of gastrointestinal hospital admissions in the United States. Cholelithiasis affects 10–15% of the Western adult population, with 20% of those patients experiencing symptoms at some point in their life. Biliary colic is the most common gallstone pathology, characterized by temporary acute right upper quadrant abdominal pain due to intermittent obstruction of the cystic duct by gallstones. Patients with biliary colic require surgical removal of their gallbladder (cholecystectomy) to alleviate their recurring symptoms. Here we present the case of a young woman with recurrent episodes of biliary colic who undergoes a laparoscopic cholecystectomy. This article and associated video describe the natural history, preoperative evaluation, and operative steps.
Cholelithiasis is the presence of gallstones within the gallbladder. Approximately 10–15% of the Western adult population has gallstones, yet 80% of these people will remain asymptomatic throughout their lifetimes.1 Between 1% and 4% of patients with gallstones will have an episode of biliary colic each year.2 Biliary colic is often a harbinger of future gallstone complications, with 15% eventually developing cholecystitis or inflammation of the gallbladder.3 Females are twice as likely to develop gallstones as males. Additional risk factors include family history, obesity, rapid weight loss, and increasing age.4
Our patient is a 32-year-old female with a prior medical history significant only for irritable bowel syndrome. She had recently delivered a child one year prior and had been in good health until six months postpartum when she began to notice symptoms of biliary colic. She had experienced intermittent, nonradiating pain in her midepigastric region for the last six months. The pain would most frequently occur a few hours after eating a fatty or greasy meal. The duration of this pain would last on average for two hours. Nausea and vomiting were associated with these episodes of colic. The pain would occasionally wake her from sleep. Her symptoms improved somewhat upon changing to a low-fat diet. Prior to her referral, she underwent an abdominal ultrasound that revealed multiple gallstones within her gallbladder. Our patient then presented for surgical evaluation for gallbladder removal.
She had no prior abdominal surgical history other than a cesarean section one year prior. She takes no medications at this time and has an allergy to latex. She is a former smoker who previously smoked a quarter of a pack a day for ten years but quit five years prior to this evaluation. She has no relevant family history.
Physical exam revealed a healthy-appearing young lady with a pulse of 72 bpm and blood pressure of 122/84 mmHg. Her BMI is 25.8 kg/m2. She had no scleral icterus, and neither cervical nor supraclavicular lymphadenopathy. Her lungs were clear to auscultation bilaterally, and her heart had a regular rate and rhythm without murmur. Her abdomen was soft, nontender, nondistended, and without any palpable masses, splenomegaly, hepatomegaly, or hernias. She had a negative Murphy’s exam. Her skin and extremities exams were without any focal abnormalities.
Our patient underwent an abdominal ultrasound that revealed numerous gallstones within the gallbladder. There was neither thickening of the gallbladder wall nor dilation of the cystic duct to suggest either acute cholecystitis or choledocholithiasis, respectively. No further imaging was necessary as these findings correlated with the patient’s clinical history and confirmed the diagnosis of biliary colic resulting from cholelithiasis.
Patients will often undergo imaging studies prior to their referral to a surgeon. The most common imaging modalities used are an abdominal ultrasound or an abdominal computed tomography (CT) scan. Both these modalities, when evaluated in context with the patient’s history and physical exam, provide useful adjuncts in surgical decision making. A right upper quadrant ultrasound, however, is often sufficient as it is the gold standard study diagnosing cholelithiasis.5 This modality is easy to interpret, inexpensive, and easily available.
More advanced imaging may be necessary if the ultrasound is inconclusive or if there is a concern for variant pathology. Both an abdominal CT scan or a hepatobiliary iminodiacetic acid (HIDA) scan are possibilities if the ultrasound is inconclusive. A CT scan would be able to demonstrate the gallstones within the gallbladder. A HIDA scan would only be beneficial if the gallstone were still impacting the cystic duct, meaning that the patient would likely still be symptomatic at the time of the exam.6 Magnetic resonance imaging (MRI) is typically reserved for patients with concern for choledocholithiasis, in which a magnetic resonance cholangiopancreatogram (MRCP) is performed to ascertain if there is obstruction of the common bile duct (CBD).7
Gallstones can be classified by their composition and are distinguished as either cholesterol stones or pigmented stones. Cholesterol stones are the predominant variant and develop as a result of the imbalance of concentrations of cholesterol and bile salts within the gallbladder. When the concentration of bile salts decreases, cholesterol can precipitate out of the bile salt-lecithin-cholesterol micelles to generate cholesterol stones.8 Pigmented stones can be further subdivided into black or brown pigment stones.9 Black pigment stones form in patients with increased concentrations of unconjugated bilirubin, most commonly due to hemolytic blood dyscrasias, or in patients with bile stasis from hypoactivity of the gallbladder, often seen in patients dependent on total parenteral nutrition.9, 10 Brown pigment stones typically form on account of infected bile that results in elevated calcium concentrations within the bile, ultimately precipitating and resulting in stone formation. Brown stones typically form within the intrahepatic or extrahepatic ducts rather than within the gallbladder.9, 11
The clinical manifestations of biliary colic occur when a gallstone temporarily obstructs the cystic duct of the gallbladder. This blockage results in colic or pain of the right upper quadrant.12 The pain is severe and will typically last at least 1–2 hours and can recur at unpredictable intervals. Contraction of the gallbladder to release bile typically occurs following a meal, and it is the contraction against an obstructed cystic duct, the outflow tract of the gallbladder, that results in visceral pain.13 This is why biliary colic most frequently occurs after ingesting a fatty or greasy meal.
Patients with biliary colic require surgical removal of their gallbladder to alleviate their recurring symptoms. Nevertheless, patients may require optimization prior to surgery. Nausea and vomiting associated with biliary colic can result in fluid imbalance or electrolyte abnormalities. These should be corrected prior to surgery. Pain should also be controlled, preferably with nonsteroidal anti-inflammatory drugs (NSAIDs) rather than opioids.14 Should patients have severe enough pain that results in a presentation to the emergency department, they should be admitted with a plan to operate within 72 hours. Recent studies have suggested that early gallbladder removal at the time of presentation is preferable to delayed removal in order to decrease the risk of recurrent attacks or representation with more advanced disease.15, 16
Our patient has had recurrent symptoms for the past six months; therefore, surgical removal of her gallbladder is the best option to relieve her recurrent pain and prevent future development of acute cholecystitis. The procedure of choice is a laparoscopic cholecystectomy given that she had no contraindications to laparoscopic surgery and her only prior operation was a cesarean section.
The above treatment recommendations are for biliary colic and apply in most situations for acute cholecystitis. Nevertheless, there are various gallbladder pathologies, many of which require adjustments to this workup. These include, but are not limited to, the following: biliary dyskinesia, choledocholithiasis, Mirizzi syndrome, gallstone pancreatitis, gallstone ileus, gallbladder polyps, hydrops, or emphysematous cholecystitis.
Please refer to an alternate reference if your patient has one of these other pathologies.
Here we present the case of a 32-year-old female with recurrent biliary colic. She underwent an uncomplicated laparoscopic cholecystectomy and recovered well without any additional complications. She has had no recurrent attacks of abdominal pain similar to what she had experienced prior. Final pathology revealed a normal gallbladder with numerous gallstones within it.
At the conclusion of this procedure, patients often return home the same day. Nevertheless, there is a low threshold to have the patient remain in the hospital for one night should they be experiencing notable pain or have significant nausea precluding them from ingesting adequate oral intake.
Patient diet should be slowly advanced as tolerated. Most begin with thin liquids but can usually tolerate solid food within 24 hours after surgery. This operation results in no postoperative dietary restrictions. In the absence of explicit complications, we usually provide routine restrictions after surgery including avoiding heavy lifting for 4 to 6 weeks after surgery. Patients will return to the clinic for follow-up either 2 or 3 weeks after surgery. No follow-up laboratory tests or imaging is required.
Since the 1990s, laparoscopic cholecystectomy has superseded the open cholecystectomy and become the standard operative procedure for gallstone disease.17 The principal advantages of a laparoscopic approach include decreased morbidity, shorter patient recovery, and shorter hospital length of stay. Among patients undergoing laparoscopic cholecystectomy, 5–10% are converted to open.18 The decision to convert the operation to open should not be judged as a complication but rather a demonstration of safe judgment in appropriate situations.
While the principles of an open cholecystectomy are the same, there are some fundamental differences inherent to the approach. The gallbladder is best accessed through a right subcostal incision. While the laparoscopic method used a “neck-to-fundus” removal of the gallbladder, the open exposure best allows for a “fundus-down” approach. By dissecting the fundus off of the liver first, this creates a new plane separate from the densest inflammation that allows for a reduced rate of inadvertent injury with the subsequent exposure of the cystic duct and artery.
The morbidity of an open cholecystectomy is 5–15%, yet the overall mortality is low at 0.1–0.5%.19 The most significant complication of either laparoscopic or open cholecystectomy is a bile duct injury. The incidence of bile duct injury is 0.2%–0.8% in laparoscopic cholecystectomy and 0.1%–0.2% in open cholecystectomy.19 Bile duct injury most commonly results from the misidentification of the hepatic duct or the common bile duct for the cystic duct, resulting in improper transection. Anatomic variations or extensive adhesions that are incompletely dissected are the most common reasons for this misidentification. Variations of the arterial anatomy can also be present and place the patient at risk for vascular injury. Injury to the right hepatic artery occurs when it is misidentified as the cystic artery.
The best way to reduce the risk of either a bile duct injury or vascular injury is to obtain the Critical View of Safety (CVS).20 These criteria should be obtained in every case, regardless of approach, prior to the clipping and transecting of the cystic duct and artery. The CVS, published by Strasberg in 1995, includes the following:
- The hepatocystic triangle is cleared of surrounding adhesions, fibrous tissue, and fat.
- The hepatocystic triangle is the triangle delineated by the cystic duct, the common hepatic duct, and the inferior edge of the liver. The common bile duct and common hepatic duct are not required to be exposed.
- The lower one third of the gallbladder is separated from the liver to expose the cystic plate.
- The cystic plate is also known as the liver bed of the gallbladder and lies in the gallbladder fossa.
- Only two structures should be visualized entering the gallbladder.
A common tool that was not indicated in the case presented but is nevertheless useful is an intraoperative cholangiogram (IOC). This technique is most helpful in cases where the ductal anatomy may be uncertain. The use of IOC can also elucidate unidentified gallstones within the biliary tree and provide a modality for their removal.21 Most surgeons use this tool selectively for difficult cases in which there is a concern for either a ductal injury or a retained stone within the duct.
There are additional approaches for the treatment of advanced gallbladder disease, including subtotal cholecystectomy and cholecystostomy tube. These techniques are suited for more complicated cases of acute cholecystitis rather than general biliary colic and, therefore, would not have been considered for the patient presented in this case. A subtotal cholecystectomy, as the name suggests, only removes a portion of the gallbladder.22 The anterior wall of the gallbladder is removed distal to the cystic duct. The posterior wall is left in contact with the liver; however, the mucosal layer is removed via electrocautery or curettage. The opening of the cystic duct is then stitched closed. This technique is only used in cases where Calot’s triangle cannot be safely identified or in emergent situations such as excessive bleeding or patient instability that require quick termination of the case. The placement of a cholecystostomy tube is an alternative to surgery, usually reserved for high-risk surgical patients.23 A cholecystostomy tube is placed percutaneously and results in immediate biliary decompression that can serve as either a temporizing measure or a definitive treatment.
Biliary colic is one of the most prevalent gastrointestinal pathologies. Laparoscopic cholecystectomy is a safe and effective procedure to alleviate symptoms.
No special equipment was used in this case.
Nothing to disclose.
The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.
- Stinton LM, Shaffer EA. Epidemiology of gallbladder disease: cholelithiasis and cancer. Gut Liver. 2012 Apr;6(2):172-87. https://doi.org/10.5009/gnl.2012.6.2.172
- Friedman GD. Natural history of asymptomatic and symptomatic gallstones. Am J Surg. 1993 Apr;165(4):399-404. https://doi.org/10.1016/s0002-9610(05)80930-4
- Strasberg SM. Clinical practice. Acute calculous cholecystitis. N Engl J Med. 2008 Jun 26;358(26):2804-11. https://doi.org/10.1056/NEJMcp0800929
- Stinton LM, Myers RP, Shaffer EA. Epidemiology of gallstones. Gastroenterol Clin North Am. 2010 Jun;39(2):157-69, vii. https://doi.org/10.1016/j.gtc.2010.02.003
- Vogt DP. Gallbladder disease: an update on diagnosis and treatment. Cleve Clin J Med. 2002 Dec;69(12):977-84. https://doi.org/10.3949/ccjm.69.12.977
- Eckenrode AH, Ewing JA, Kotrady J, et al. HIDA Scan with Ejection Fraction Is over Utilized in the Management of Biliary Dyskinesia. Am Surg. 2015 Jul;81(7):669-73. PMID: 26140885.
- Hjartarson JH, Hannesson P, Sverrisson I, et al. The value of magnetic resonance cholangiopancreatography for the exclusion of choledocholithiasis. Scand J Gastroenterol. 2016 Oct;51(10):1249-56. https://doi.org/10.1080/00365521.2016.1182584
- Carey MC. Pathogenesis of gallstones. Am J Surg. 1993 Apr;165(4):410-9. https://doi.org/10.1016/s0002-9610(05)80932-8
- Tazuma S. Gallstone disease: epidemiology, pathogenesis, and classification of biliary stones (common bile duct and intrahepatic). Best Pract Res Clin Gastroenterol. 2006;20:1075-1083. https://doi.org/10.1016/j.bpg.2006.05.009
- Trotman BW. Pigment gallstone disease. Gastroenterol Clin North Am. 1991 Mar;20(1):111-26. PMID: 2022417.
- Lammert F, Gurusamy K, Ko CW, et al. Gallstones. Nat Rev Dis Primers. 2016 Apr 28;2:16024. https://doi.org/10.1038/nrdp.2016.24
- Johnston DE, Kaplan MM. Pathogenesis and treatment of gallstones. N Engl J Med. 1993 Feb 11;328(6):412-21. https://doi.org/10.1056/NEJM199302113280608
- Diehl AK, Sugarek NJ, Todd KH. Clinical evaluation for gallstone disease: usefulness of symptoms and signs in diagnosis. Am J Med. 1990;89:29-33. https://doi.org/10.1016/0002-9343(90)90094-t
- Fraquelli M, Casazza G, Conte D, et al. Non-steroid anti-inflammatory drugs for biliary colic. Cochrane Database Syst Rev. 2016 Sep 9;9:CD006390. https://doi.org/10.1002/14651858.CD006390.pub2
- Lo CM, Liu CL, Fan ST, et al. Prospective randomized study of early versus delayed laparoscopic cholecystectomy for acute cholecystitis. Ann Surg. 1998 Apr;227(4):461-7. https://doi.org/10.1097/00000658-199804000-00001
- Rattner DW, Ferguson C, Warshaw AL. Factors associated with successful laparoscopic cholecystectomy for acute cholecystitis. Ann Surg. 1993 Mar;217(3):233-6. https://doi.org/10.1097/00000658-199303000-00003
- Duca S, Bãlã O, Al-Hajjar N, et al. Laparoscopic cholecystectomy: incidents and complications. A retrospective analysis of 9542 consecutive laparoscopic operations. HPB (Oxford). 2003;5(3):152-8. https://doi.org/10.1080/13651820310015293
- Livingston EH, Rege RV. A nationwide study of conversion from laparoscopic to open cholecystectomy. Am J Surg. 2004 Sep;188(3):205-11. https://doi.org/10.1016/j.amjsurg.2004.06.013
- Villegas L, Pappas T. “Operative Management of Cholecystitis and Cholelithiasis.” Shackelford’s Surgery of the Alimentary Tract – 7th Edition, edited by Charles J. Yeo. Elsevier, 2013, pp. 1315-1325.
- Strasberg SM, Brunt LM. Rationale and use of the critical view of safety in laparoscopic cholecystectomy. J Am Coll Surg. 2010 Jul;211(1):132-8. https://doi.org/10.1016/j.jamcollsurg.2010.02.053
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- Elshaer M, Gravante G, Thomas K, et al. Subtotal cholecystectomy for "difficult gallbladders": systematic review and meta-analysis. JAMA Surg. 2015 Feb;150(2):159-68. https://doi.org/10.1001/jamasurg.2014.1219
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Cite this article
Sell N, Gee DW. Laparoscopic cholecystectomy. J Med Insight. 2022;2022(251). doi:10.24296/jomi/251.
Table of Contents
- Placement of Trocars
- Retract Liver and Gallbladder Superolaterally
- Dissect into Peritoneum
- Examine Critical View
- Clip and Ligate Branches of Cystic Artery
- Clip and Ligate Cystic Duct
- Separate Gallbladder from Liver Bed
This is a young female patient who came in with a few months of abdominal pain after eating fatty foods, and the pain would last for hours, would sometimes radiate to her- was primarily in the right upper quadrant, sometimes radiate to her back. And imaging was consistent with either gallbladder sludge, or small stones, or potentially a polyp. And so, because she was having these symptoms that were really affecting her quality of life, we agreed to perform a laparoscopic cholecystectomy to remove the gallbladder. So, the positioning of the patient is generally supine. Once the case starts, we generally place the patient in reverse Trendelenburg with their head up, and rotate the patient to their left side, so that the gallbladder is at the highest point possible in the operative field, and everything else kind of falls away from it, and it's easier to access the gallbladder. We use, in general, four ports for these procedures. So there's usually one right around the umbilicus for the camera, and then three other ones along the right costal margin for dissection purposes. The key steps of operation are obtaining safe entry into the abdominal cavity, insufflating with carbon dioxide, and then gaining exposure to the gallbladder, and dissecting out the cystic duct and cystic artery safely, clipping and dividing them, and then taking the gallbladder off the liver, placing it in a bag, and removing it.
Make a little slit here. Veress needle, please. All right, gas on. So our opening pressure was about 4 mmHg. We're going to go up to 15.
So we're going to start by placing a 5-mm laparoscope at the umbilicus. And we'll use an optical viewing trocar for that. So I'll start with a knife, please. Thank you. So as we go in, I zoom out, so we can see. Slowly advance the trocar. There's the fascia. And then we're coming through the peritoneum. And then once we get in here, and we see the dark space, that's the pneumo. So I actually re-angle, so that we don't… We aren't at risk of going into any vital structures, and we're just advancing into the pneumo. And there we are. Take that cannula in. Okay, our needle is up here. Everything looks good. I pull the Veress needle out. So now let's see where we are. We could actually pull the OG tube back a little bit. Okay, pulling back. Great, okay. So… Is that better? A little more is fine. Yeah, more, more, more, more. You probably can- Yep, there you go, all right, you're good Okay, so I put a - my larger trocar up here. Can I have a knife, please? And this is an 11 mm. Thanks. Come in, and I skive a little bit, so that I come out just to the right of falci. Of the falciform ligament. There. Then my next two trocars… Let me switch sides. I put a 5 mm all the way out laterally, and then I kind of split the difference and I put another 5 mm right here, right above where the gallbladder is. This a good spot? Let's see. Yeah, probably right about there is good. Great.Knife back.The bed is all the way down. All right, great, so can we get a little bit of reverse Trendelenburg? And then rotate the bed towards the patient's left, towards me.
So we use this lateral retractor to retract up and over the gallbladder towards the patient's right shoulder. And then if you can hold the camera, I'll take a blunt and a pointy.
Okay. So I'm grabbing the infundibulum and I'm retracting laterally and a little bit towards the patient's feet. And come in a little bit with the camera. And down here, where we're not sure what we're looking at and what we're dissecting yet, I usually don't use a lot of energy, and I just carefully peel. So we have to open up the peritoneum on both sides. So, this appears to be - potentially the cystic duct. Remember, come in with your camera. Great. So… Yeah, all right. This might be a little- Come on in closer. This seems to be an artery right here. Do you have a hook on cautery, please? This must be the posterior branch. Yeah, right there. Cystic artery, there. Yep. This might be just a small branch of the artery. The patient has a long mesentery to the gallbladder, so that was pretty thin and opened up pretty easily. All right, so let's see here.
Come in a little bit more closely. Perfect. So in these choles, I always look for the critical view. And so, the critical view - is basically, you have the liver out here. You see the duct here. You see the liver here, and then here, the arteries - there's a branch of the artery here - it's small. Then there's a larger artery back here. I'd like to open this space all up, if possible. And to obtain the true critical view, you have to lift the gallbladder - almost a third of the way up the liver bed, to expose the cystic plate. Right up here. This back side - we'll open up the peritoneum here. Just a little bit less tension. Yep, perfect. Great, all right. So, let's see here. All right. So we've got the gallbladder hanging up over here. At this part, we've got a branch, a posterior branch here. And then this is all dissected up off the liver. I'd like to open up that a little bit more. I'm just dissecting out this posterior vessel a little bit. It looks like we're pretty open here, right? There we go. Can I have that hook again, please? All right, so now we've got gallbladder hung up over here. Liver is here, liver back here. A posterior branch of the cystic artery. Another branch of the cystic artery. And presumable duct here. And we don't see any common bile duct or anything kind of tenting behind here. You think we're safe to clip? I think so. All right, I'll just do this while I'm here. When it's easy, I always take this peritoneum and free up more of this because it just kind of saves you time on the back end. And it's, you have it anyways, and you can see it. If you're struggling, then I wait until after I clip. But that way, like, the more you lift this up, the surer you are that there's nothing traveling behind here. So this guy, I wonder if we could even just Bovie it. But I might just clip it. Just to be safe. All right. Actually, I'm going to take this one little lymphatic, that's right here if it's easy to take. Yeah, I think the duct's small enough that we can clip it all together. Okay. Clip, please. And there it goes, bleeding.
You want to take the branch first? Yeah, I'm going to take this branch first. Okay, let's get that back one. You can see the lumen's what we just divided. Right there. And then I always try to make sure I see the back… Back tongs of the clip. Free this up. I'm caught a little bit. Let's see here. Yep, now I can- Perfect. Great. This all looks good, so now we'll do the duct.
Clip, please. Yep. So, I put 1 clip on the bottom and 1 clip on the top for the vessels. But for the duct, I put 2 on the bottom and 2 on the top. Flip this around. Let's sneak under there. Can you see my back tong? Yep, I can see your back. There you go. All right, there's this. Scissors. Let go, great.
And now, we can, yep. Now I just use the hook to take the gallbladder off the liver bed. And I use a combination of hooking it versus backing - backing the Bovie in. Grab over here. Work on the lateral side? Yeah, I'm going to do the lateral side. Her gallbladder is a bit intrahepatic. There's a very thin layer between - gallbladder and liver. Okay. Now, let's look down for a second and make sure there's no active bleeding. I don't think there is. And look all the way down at the clips, make sure they look okay. Good. And then we take off the last little bit. Can you pull out a little bit? Yeah, perfect. And I'm just going to come around the back. Yep. Let's see. Great. Perfect.
So now - I'll let go. I have it. And I'll put the gallbladder into the bag that I put in through the 11-mm port. Push it in there. Great. Now I - give this back to you. You good? Mm hmm. All right, so once it's in… Scissors, please. Airflow out. SNaP. Kelly. All right, I'll take a - I actually won't need that. I'll take a blunt grasper. And is our irrigation hooked up, or no? So then, we'll just irrigate so we can look at the liver bed, or the gallbladder bed, which looks good and dry. Right? Locking grasper is fine. Just lift the liver up for you. Good. Yeah, I think we're good. Yeah, I think we are. Yeah, all right. So lay that down. Let's level the bed, please. Grasper back. Okay, so… The final step is to get the gallbladder out, which can sometimes be the most difficult part of the operation. Let's see, here. That to you. See if it comes out easily or not. Sometimes the fascia needs to be dilated here. Do you have a long Kelly? Yep. Stretch it open a little. And go. Here's the gallbladder. Okay, thank you. And then because the fascial defect is often buried within falci, I don't always close this port. Yeah, you want to just suction over there and just make sure that… Yeah, that was from that cystic artery that was bleeding earlier. And just lift up gently. Oh, that's the old clot. Let's suction some of this clot. Yeah, that looks good. That was just the bleeding from before. Yeah, from before. The old clot. All right, great. Okay.
So then we pull out all our ports. Here's the scope. Release the gas. And I'll take some local anesthetic. So we infiltrate each of these incisions with a little bit of local. More local. Some more? Did you do this one already? You can just split it between your two incisions, and then I'll inject through mine. Can I have some dry laps, please? Or dry sponges? Needle back. And here's the needle. And then we just closed with buried, subcuticular 4-0 Monocryl sutures. Thank you. Thank you. I'll take an Adson, please.
Today's procedure was pretty straightforward. And so, she did have a posterior cystic artery which is something to look out for when you perform the operation. Sometimes, the main cystic artery, when it looks smaller than you would expect, there's oftentimes another artery that's - that you need to look for posteriorly. Other than that, it was pretty straightforward. I think the same principles of identifying the critical view - the critical view of safety is very important regardless of whether the operation is straightforward or not in order to make sure that you don't damage any vital structures. Postoperatively, the patients can start on a PO diet, and go slowly in the beginning. They're able to move around as usual, and usually are able to perform their general activities of daily living. We ask them for no heavy lifting for approximately 4 to 6 weeks after the operation, but otherwise there are no real restrictions. In general, patients recover pretty quickly and quite well from this operation. They may have a little bit of pain in the beginning, but that generally is very manageable with medications and they recover probably within a week or two they're probably back to baseline. Patients should assume very normal quality of life and be back to their baseline. Some patients have a little bit of loose stools in the beginning, but usually that improves over time. So some of the complications that occur after this operation include a bile leak. And so, if the cystic duct is not clipped completely, or if there's a duct of Luschka that's leaking from the liver bed, patients can develop a bile leak or biloma. And in those cases, they would present with pain in the right upper quadrant. And - if they came into the hospital and an ultrasound would be performed, then you would notice a fluid collection. That would be concerning for a biloma. The other, more devastating complication would be injury to the common bile duct, And usually patients, hopefully most of the time, this is identified during the operation, and then it would be repaired at the same time. But otherwise, patients may come in with just pain and discomfort as well as elevated liver function tests, in which case, imaging can be performed to identify that problem. An MRCP can be obtained. And if that's what is found, then they would need to taken back to the operating room to have it repaired.