Retraction and dissection of Calot’s triangle Once caudad retraction of the fundus is established, the crucial maneuver is lateral retraction of Hartmann’s pouch by the upper lateral 5-mm port. This places Calot’s triangle on the stretch and will greatly reduce the chance of injury of the common bile duct.
Then incise the posterior peritoneal attachment behind Hartmann’s pouch to separate Hartmann’s pouch from the liver to further stretch out Calot’s triangle.
Once these two maneuvers are instituted, hook dissection can be performed, staying close to the gallbladder to incise the anterior sheet of peritoneum over Calot’s triangle. This will expose one or two cystic arteries and the cystic duct . Windows should be developed between all these structures before anything is divided. Once the anatomy is determined (see anatomical variations and tricks), the cystic arteries are divided between clips and a clip is placed below Hartmann’s pouch to the proximal end of the cystic duct. Cystic duct is divided.
Removal of gallbladder: The gallbladder is then removed from the liver bed using hook diathermy. This is done through a combination of elevating the peritoneum, burning with the hook and pushing so that the gallbladder is removed toward the fundus and finally separated from the liver at the fundus. There is very little place for fundus-first laparoscopic cholecystectomy.