Open cholecystectomy

1.Supine position and square drape with Ioban.
2.Make a right subcostal incision through rectus (ninth nerve is divided).
3.When the liver and GB are high up under the costal arch add a Kehr hockey stick extension superiorly up to the xiphoid process.
4.Place a Balfour self-retaining retractor in the wound and use a Deaver retractor to lift the under surface of the liver.
5.Use moist gauze packs to pack away the SB and the colon/duodenum once any adhesions to the GB have been divided.
6.Place a Rampley forcep on Hartmanns pouch and begin dissection of Calots triangle by flag technique as described for lap cholecystectomy.
7.Identify and define the cystic duct, artery and clip but do not divide the artery. Make a transverse incision in the cystic duct for a cholangiogram then insert a 5F catheter (yellow) and secure with a wek clip.
8.Perform a cholangiogram.
9.Remove catheter and secure cystic duct stump with two clips. Divide the cystic artery.
10.Dissect the GB off its bed entirely or in the submucosal plane for a subtotal cholecystectomy.
11.Lavage, remove packs/retractors.
12.Close in layers.