DESCRIPTION OF OPERATION: After adequate preoperative evaluation of the patient with medical team as well as with cardiologist, the patient was urgently taken to the operating room. After the cystoscopy and stent placement was completed, the patient was placed in supine position. The abdomen was washed, prepped, and draped in the usual sterile manner. Procedure was started by making a small 1 cm incision along the lower margin of the umbilicus. The skin incision was taken down all the way to the fascia, where the fascia was grasped using Kocher clamps. A small incision was made along the midline on the fascia and the parietal peritoneum was then opened up to enter into the peritoneal cavity. Two stay sutures were placed using 0-Vicryl on either side. A Hasson port was then inserted and pneumoperitoneum was achieved in the range of 15 mmHg. A laparoscopic camera was then placed inside the peritoneal cavity and the peritoneal cavity was visualized. The patient was found to have extensive adhesions involving the whole upper abdomen. A 5 mm right-sided abdominal port was then placed and adhesions were lysed in the right upper quadrant and epigastric region using Harmonic scalpel. Then, a 10 mm epigastric and another 5 mm right-sided port was placed. At this point, after the adhesions were taken down, the gallbladder was exposed. The gallbladder was extremely large and distended, thick, and necrotic. The gallbladder was initially decompressed using 60 mL syringe, and after decompression, gallbladder was retracted cephalad and laterally. Extensive adhesions were present around the gallbladder. These adhesions were taken down. The inflammation in the right upper quadrant was very extensive. The gallbladder was friable, necrotic, and hemorrhagic. The exposure in the region of the triangle of Calot was difficult because of the extensive edema, inflammation and thickening of the tissue in the right upper quadrant. Because of the inadequate exposure and difficulty in dissection in that region, that is the region of triangle of Calot, we decided to convert this patient to an open procedure. Pneumoperitoneum was released, instruments were withdrawn, ports were removed and open procedure was started. A subcostal incision was made in the right upper quadrant just below the subcostal margin. The skin incision was taken down all the way to the fascia, where the fascia had been opened, followed by transection of the muscles of the abdominal wall. The parietal peritoneum was then opened all the way to the full extent of the incision. Self-retaining retractor was then placed and the right upper quadrant area containing the gallbladder and the cystic duct were exposed. After adequate exposure, dissection was performed fundus down, that is from the fundus all the way towards the cystic duct. The gallbladder was gradually taken off from the gallbladder fossa. During this process, the cystic artery was identified, it was ligated using 2-0 Vicryl. The dissection was then continued. The junction of the common bile duct and the cystic duct was then identified. The region of the cystic duct was extremely thick, edematous, and necrotic. The decision was made to transect the gallbladder at the level of the cystic duct using GIA stapler. A GIA stapler was then fired across the cystic duct and the stump was reinforced with 2-0 Vicryl suture. The gallbladder was extremely large, necrotic, friable, and thick-walled. It was filled with numerous 3 to 5 mm sized stones. After the removal of the specimen, the right upper quadrant area was irrigated extensively. The stones were picked and removed from inside the peritoneal cavity. The area was checked for any bleeding or oozing. No bleeding or oozing was identified. A JP drain was then placed in the right upper quadrant area close to the cystic duct and stump. The abdominal wound was then closed in layers. The first layer of fascia was closed using double standard loop PDS followed by closure of the skin using staples. The umbilical wound was then closed using 0-Vicryl suture for fascia and the skin was closed again using the staples. The JP drain was secured in place using 3-0 nylon. Dry sterile dressing was then applied. The patient was extubated in the operating room and was taken to the recovery room in stable condition.
