Lateral to medial dissection: a surgical technique for safe management of adhesions encountered in laparoscopic cholecystectomy

Introduction

Background

In the United States, 300,000 laparoscopic cholecystectomies are performed for indications including but not limited to gallstone pancreatitis, symptomatic cholelithiasis, and acute cholecystitis (1). Acute or chronic inflammation of the gallbladder introduces opportunity for scarring of the hepatocystic triangle, making the cystic artery and duct difficult to define (2). In fact, acute cholecystitis is a risk factor associated with bile duct injury (3). Prior literature has shown that stones in Hartmann’s pouch significantly increase the technical difficulty of laparoscopic cholecystectomy, in part due to adhesiolysis to the duodenum and hepatic flexure (4). The conventional approach to laparoscopic cholecystectomy starts the dissection at the infundibulum (2). However, in the presence of adhesions, we suggest a posterolateral and top down approach. The three key structures to safeguard during dissection are: the transverse colon, the duodenum, and the porta hepatis. The following novel operative technique can be added to any surgeon’s repertoire and be used whenever a difficult cholecystectomy is encountered, particularly for Parkland grade IV and V cholecystitis.

Rationale

Adhesions encountered during laparoscopic cholecystectomy significantly increase technical difficulty and risk injury to critical structures, like the transverse colon, the duodenum, and the porta hepatis.

Objective

The manuscript presents a reproducible, laparoscopic surgical technique designed to isolate the gallbladder in the setting of adhesions, while preserving key anatomical landmarks and minimizing intraoperative complications. We present this article in accordance with the SUPER reporting checklist (available at https://ales.amegroups.com/article/view/10.21037/ales-25-28/rc).

Preoperative preparations and requirements

This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This research paper was exempt from NYU Langone Health Institutional Review Board (IRB) approval. This project did not involve human subjects and did not require IRB review. Informed consent was not required. All figures in this paper are original and printed with permission of the artist. The procedure must be performed in an operating suite and requires standard laparoscopic surgical equipment, including a dissector, grasper, suction and irrigation cannula, and a laparoscope. The described technique can be used for any cholecystectomy in which adhesions are present, such as adhesions between the gallbladder and the colon, duodenum or omentum. We use hook cautery to dissect, but choice of dissector is up to the surgeon. A complete team is needed with a primary surgeon, a surgical resident, an anesthesiologist, a scrub technician, and circulating nurse. Anesthesia and intraoperative monitoring are vital throughout the procedure to ensure hemodynamic and respiratory stability. The patient is positioned supine and kept flat throughout the case.

Step-by-step description

Step 0: positioning

Port positioning can be approximated by placing the surgeon’s right palm over the expected gallbladder location, allowing the fingers to point to the trocar locations. After insufflation through the Veress needle, a 5-mm port is introduced under Optiview visualization one-third to halfway between the xiphoid and umbilicus and 2.5–3 cm to the right of midline (Figure 1). In cases when the 5-mm camera does not provide enough resolution, it can be upsized to an 11-mm port to accommodate the 10-mm camera. The 11 mm port is placed at the subxiphoid position. Following the curve of the right costal margin, a 5-mm port is placed along the midclavicular line and another along the anterior axillary line (5). Once the abdomen has been entered, the gallbladder is retracted cephalad to expose the underlying adhesions (Figure 2).

Figure 1 Port positioning. This figure is published with artist Anne Erickson’s permission. GB, gallbladder.

Figure 2 Initial appearance of operative field with adhesions intact. This figure is published with artist Anne Erickson’s permission.

The two instruments performing the adhesiolysis must remain visible at all times during the dissection. The lysis of adhesions must be carried out in a multidirectional fashion—gingerly, prudently, and carefully. The distance between the grasper and dissector must not exceed 1 cm at any time. Anatomical landmarks must be respected, and only gentle tissue traction can be exerted. Suction and irrigation cannula must be available to help intermittently with blunt dissection and clearing the field. Cautery and clips can be used to stop bleeding when encountered.

Step 1: starting the dissection

In cases of severe inflammation and overlying adhesions, the infundibulum may not be visible. Furthermore, the plane between the infundibulum and the duodenum will be impossible to discern. Attempting to start the surgery by dissecting the infundibulum risks injury to both the duodenum and the porta hepatis. Therefore, dissection should begin along the inferior lateral edge of the right lobe of the liver (Figure 3). We start here because there is unlikely to be any critical anatomic structures between the right lateral edge of the liver and the lateral aspect of the gallbladder fundus (between the two black arrows in the diagram). The hepatic flexure and transverse colon are retracted caudad to further expose the lateral plane.

Figure 3 Initial dissection along inferior lateral edge of right liver. This figure is published with artist Anne Erickson’s permission.

Step 2: protecting the colon

Once the fundus of the gallbladder is reached, dissection then proceeds top down along the posterior and lateral aspects of the gallbladder (Figure 4). During this time, the transverse colon is retracted caudal out of the dissection field as in Step 1. Dissection stops once the hepatorenal recess (Morrison’s pouch) is reached as any deeper dissection would incur risk of injury to retroperitoneal structures. At this point, the posterolateral aspect of the infundibulum should be well visualized and the colon falling away from the gallbladder.

Figure 4 Top down dissection towards Morrison’s pouch. This figure is published with artist Anne Erickson’s permission.

Step 3: protecting the duodenum

Starting at the fundus of the gallbladder again, dissection marches along the gallbladder wall towards Hartmann’s pouch (Figure 5). When gallstones are lodged within Hartmann’s pouch, the pouch can become significantly dilated and adherent to the duodenum. The presence of stones also makes grasping the infundibulum especially difficult (4). Sharp and blunt dissection is used to separate the duodenum from the gallbladder at this junction. Cautery should be avoided to prevent thermal injury to the bowel.

Figure 5 Separating the duodenum from the gallbladder. This figure is published with artist Anne Erickson’s permission.

Step 4: protecting the porta hepatis

The lateral dissection from Steps 1–3 has now made the medial aspect of the gallbladder visible. Thus, the final step in dissection starts once again at the fundus in a top down fashion, this time hugging the medial aspect of the gallbladder (Figure 6). The gallbladder infundibulum is retracted laterally to expose adhesions to the porta hepatis. Once the medial aspect of the gallbladder infundibulum is isolated, the cystic duct and cystic artery are further skeletonized, clipped, and divided. The shield of McElmoyle covering the hepatocystic triangle is not violated, and the node of Lund overlying the proximal cystic artery is preserved.

Figure 6 Medial dissection towards the porta hepatis. This figure is published with artist Anne Erickson’s permission.

Postoperative considerations and tasks

Criteria for technical success are defined as safe identification and isolation of the gallbladder, without injury to the transverse colon, duodenum, or porta hepatis. Clinical success includes completion of the procedure laparoscopically, without need for conversion to open, and absence of postoperative complications, like bile leak or infection. Criteria for failure include intraoperative injury to key anatomical structures, an inability to dissect safely, or need for reoperation. Clinical effectiveness can be seen in shortened operative time since the approach is standardized and systematic, through reduced complication rates, and low conversion rates to open surgery.

Postoperative monitoring following adhesiolysis focuses on identification of organ injury, bleeding, and in cases involving subtotal cholecystectomy, the presence of a bile leak. Key indicators include stable vital signs, abdominal exams, liver function tests, and drain output. Drain removal occurs once output is minimal, non-bilious, and clinical signs of complications are absent.

Patients who undergo fenestrated subtotal cholecystectomy with JP drain will typically stay overnight for monitoring, while all others are discharged and followed in the outpatient setting, usually within 1–2 weeks.

Tips and pearls

• The three key structures to safeguard during dissection are: the transverse colon, the duodenum, and the porta hepatis.
• Dissection preserves the shield of McElmoyle and the lymph node of Lund as anatomical boundaries.
• Lysis of adhesions was encountered in 47.2% of laparoscopic cholecystectomies, as per Table 1, underscoring how commonly distorted anatomy presents in surgical practice.

  Table 1

  Summary of laparoscopic cholecystectomies between 2016–2024

  
  

  Year	Female, n	Male, n	Total, n	Lysis of adhesion, n	Fenestrated subtotal with JP drain, n	Total cholecystectomy with JP drain, n	Notable repairs
  2016	80	51	131	67	2	1	–
  2017	97	60	157	81	1	3	–
  2018	121	60	181	87	2	–	Conversion (liver bed bleed): 1
  2019	118	58	176	73	5	–	–
  2020	84	41	125	71	6	–	Transverse colon (serosal tear repair): 1
  2021	108	55	163	79	5	–	–
  2022	88	53	141	66	1	–	Duodenal (serosal tear repair): 1
  2023	89	53	142	66	4	3	–
  2024	113	60	173	66	4	1	–
  Total	898	491	1,389	656	30	8	3

  The table presents all laparoscopic cholecystectomy cases performed by the senior author (G.S.F.) between 2016 and 2024 at NYU Langone Health. The data serve as the basis for evaluating the described surgical technique of adhesiolysis when encountering difficult gallbladders.

Discussion

Surgical highlights

Pericholecystic adhesions involving the omentum can significantly obscure the operative field at the start of a laparoscopic cholecystectomy. These adhesions not only disorient the surgeon but also impede the safe identification of key anatomical landmarks and risk injury to the transverse colon, duodenum, and porta hepatis. Without a preplanned dissection strategy, attempts to proceed with the procedure can lead to compounding insults, such as excessive bleeding or bile and stone spillage, that further decrease laparoscopic visibility and increase the difficulty of the procedure. These factors frequently contribute to having to resort to a bailout strategy, like subtotal cholecystectomy, or conversion to an open cholecystectomy (6). The reported incidence of emergency conversion to open cholecystectomy ranges from 5% to 10% (7-9).

Strengths and limitations

The described technique in this paper requires proficiency in laparoscopy. Injury during difficult adhesiolysis in laparoscopic cholecystectomy often stems from poor visualization and the loss of clear tissue planes, especially in the context of inflamed or dense pericholecystic adhesions. The omentum and surrounding structures may be adherent to an inflamed gallbladder, especially in the setting of prior infections or repeated episodes of cholecystitis. As the surgeon attempts to separate these adhesions there is the added risk of injuring adjacent organs. The transverse colon can be accidentally entered, and the colotomy can go unrecognized intraoperatively, only to manifest postoperatively with peritonitis or feculent drainage. A review of general laparoscopic procedures found an incidence of gastrointestinal injury of 0.13% (430 of 329,935 cases) and of bowel perforation 0.22% (66 of 29,532 cases), with about 38% of cases involving the large bowel (10).

The duodenum is also vulnerable during a difficult adhesiolysis, where forceful or blind dissection can result in duodenal injury. Inflammation and the presence of impacted stones can cause the infundibulum to become adherent to the duodenum, increasing the likelihood of traction or thermal injury, and resulting in perforation. In a systematic review by Machado, duodenal injury occurred in approximately 0.04% of laparoscopic cholecystectomy cases (11).

Injury to the porta hepatis, is among the most feared complications of laparoscopic cholecystectomy. The most common injury being misidentification of the common bile duct for the cystic duct. Injury to the common bile duct is more frequently reported in laparoscopic procedures, compared to open procedures, with an incidence ranging from 0.3% to 0.5% versus 0.1% to 0.2% in open surgeries (12).

Comparison with other surgical techniques and researches

Several techniques have been described in the literature for when standard dissection of the gallbladder is not feasible. The fundus-first approach is utilized to approach the CVS from above, but in many cases this strategy becomes impractical due to inflammation or anatomic distortion. In such scenarios, subtotal cholecystectomy then becomes another possible surgical approach when it is necessary to avoid dissecting in these dangerous planes. Lastly, emergency conversion to open surgery remains a necessary option which is associated with increased morbidity and healthcare costs (6,13).

When dissection in Calot’s triangle is not feasible due to inflammation, subtotal cholecystectomy is employed as a bailout procedure. This approach removes the anterior wall of the gallbladder while leaving the posterior wall attached to the liver bed. In the reconstituting variant, the remaining gallbladder stump is closed, restoring a pouch-like structure and decreasing the risk of bile leak. In contrast, the fenestrating technique leaves the gallbladder stump open, along with the placement of a closed drainage system to avoid a bile leak (14).

Artificial intelligence has been used as a tool for better defining the critical view of safety in cholecystectomy. However when anatomy is distorted, such as in cases with extensive adhesions, artificial intelligence cannot recognize important landmarks (15).

Implications and actions recommended

The posterior infundibular approach was used in all cases by the senior author, GF, deliberately avoiding dissection near critical structures and preserving the shield of McElmoyle and the lymph node of Lund (or Mascagni) (16). The shield of McElmoyle, a peritoneal covering of the cystic duct and a portion of the gallbladder neck, body, and infundibulum, and the lymph node of Lund, the sentinel node of the gallbladder, serve as consistent anatomical landmarks. Preserving these structures reduces the risk of injuring the bile duct or surrounding vasculature (17).

The approach also has educational value in that it provides residents and attending physicians with a reproducible list of instructions to manage the difficult gallbladder dissection, before relying on improvisation or a bailout strategy. In the long run, patients are able to avoid the added expenditure of prolonged hospital stays from complications of a difficult gallbladder surgery.

Conclusions

When approached deliberately and early in the case, lateral to medial adhesiolysis can improve intraoperative visibility, reduce dissection-related complications, and potentially lower the likelihood of open conversion or bailout procedures. Additional studies would be needed to further confirm the efficacy of this approach. The described technique fills a common gap in difficult laparoscopic cholecystectomy, with operative teachings that are also transferable to robotic cholecystectomy.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the SUPER reporting checklist. Available at https://ales.amegroups.com/article/view/10.21037/ales-25-28/rc

Peer Review File: Available at https://ales.amegroups.com/article/view/10.21037/ales-25-28/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://ales.amegroups.com/article/view/10.21037/ales-25-28/coif). G.S.F. serves as an unpaid editorial board member of Annals of Laparoscopic and Endoscopic Surgery from April 2025 to March 2027. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This research paper was exempt from NYU Langone Health institutional review board (IRB) approval as this project did not involve human subjects and did not require IRB review. Informed consent was not required.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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