Lesson 1Managing dense inflammation and difficult dissection: subtotal (fenestrating/reeves) cholecystectomy techniques, intraoperative drainage, use of drainsCovers strategies for managing dense inflammation and difficult gallbladder dissection, including subtotal cholecystectomy variants, safe use of energy devices, intraoperative drainage, and indications for leaving drains in situ, using basic methods.
Identifying the difficult gallbladder earlyFundus-first and subtotal cholecystectomy optionsFenestrating versus reconstituting techniquesSafe use of energy in inflamed tissuesDrain placement in difficult dissectionsLesson 2Postoperative care and common complications: bile leak recognition, postoperative antibiotics, drain management, follow-up imaging indicationsCovers routine postoperative care after laparoscopic cholecystectomy, early recognition of bile leak and infection, rational antibiotic use, drain indications and management, and criteria for postoperative imaging and specialist referral in local clinics.
Standard recovery milestones and discharge criteriaRecognition of bile leak and biloma formationPostoperative antibiotics: when indicatedDrain placement, monitoring, and timely removalIndications for postoperative ultrasound or CTLesson 3Patient positioning and operating room layout: supine with reverse Trendelenburg and left tilt, surgeon/assistant/monitor positions for ergonomicsDescribes optimal patient positioning for laparoscopic cholecystectomy, including supine, reverse Trendelenburg, and left tilt, and details ergonomic placement of surgeon, assistant, scrub nurse, and monitors to optimize visualization and safety.
Supine and reverse Trendelenburg positioningLeft tilt and table adjustments for exposureSurgeon and assistant standing positionsMonitor height, distance, and alignmentInstrument table and scrub nurse placementLesson 4Control of cystic duct and artery with basic devices: selection and application of clips, adequate stump length, specimen extraction techniquesExplains safe control of the cystic duct and artery using clips and basic devices, including clip selection, spacing, and stump length, as well as safe division, retrieval, and extraction of the gallbladder specimen in routine cases.
Choosing clip size and material for cystic structuresNumber, spacing, and orientation of clipsEnsuring adequate cystic duct stump lengthSafe division of cystic duct and arterySpecimen bag use and extraction techniquesLesson 5Port placement and instrument choices: four-port technique (sizes and exact abdominal landmarks), use of traction sutures or retraction methods with basic toolsDetails standard four-port placement with precise landmarks, port sizes, and angles, and discusses instrument selection, including graspers, dissectors, energy devices, and optional traction sutures or alternative retraction methods with simple tools.
Umbilical camera port placement and sizeEpigastric working port positioningRight subcostal accessory port landmarksChoice of graspers, dissectors, and scissorsUse of traction sutures for gallbladder fundusLesson 6Exposure of Calot’s triangle and dissection strategies: fundus-first vs antegrade approaches, gentle gallbladder traction, use of blunt and sharp dissection with electrocauteryExplores techniques to expose Calot’s triangle safely, comparing antegrade and fundus-first approaches, optimizing traction vectors, and using blunt and sharp dissection with electrocautery while protecting adjacent structures.
Traction directions for optimal Calot’s exposureAntegrade versus fundus-first dissectionBlunt versus sharp dissection techniquesSafe use of monopolar electrocauteryAvoiding injury to CBD and hepatic arteryLesson 7Contraindications and relative considerations for laparoscopic cholecystectomy: severe cardiopulmonary disease, uncorrected coagulopathy, unclear anatomy, suspicion of gallbladder cancerOutlines absolute and relative contraindications to laparoscopic cholecystectomy, including severe cardiopulmonary disease, coagulopathy, unclear anatomy, and suspected malignancy, and discusses risk–benefit assessment and alternative strategies in Eritrea.
Absolute versus relative contraindicationsImpact of severe cardiopulmonary diseaseManagement of uncorrected coagulopathyHandling unclear anatomy or prior surgerySuspicion of gallbladder cancer and stagingLesson 8Typical clinical presentation of symptomatic cholelithiasis and chronic cholecystitis: pain pattern, Murphy’s sign, labs and imaging findingsReviews typical symptoms and signs of biliary colic and chronic cholecystitis, correlating pain patterns, Murphy’s sign, laboratory abnormalities, and key ultrasound and CT findings to guide diagnosis and surgical planning.
Typical biliary colic pain pattern and triggersMurphy’s sign and focused abdominal examinationLaboratory patterns in acute and chronic cholecystitisUltrasound features of stones and gallbladder wallCT and other imaging roles in equivocal casesLesson 9Critical view of safety: definition, stepwise steps to achieve it, documentation and criteria for stopping and convertingDefines the critical view of safety, details the stepwise dissection required to obtain it, emphasizes documentation with images or video, and clarifies criteria for aborting dissection, bailout procedures, or conversion to open surgery.
Formal definition of critical view of safetyStepwise dissection to expose Calot’s triangleConfirming and documenting the critical viewCommon pitfalls and misinterpretationsCriteria for bailout or conversion to openLesson 10Preoperative evaluation for biliary surgery: LFT interpretation, ultrasound assessment of gallbladder and ducts, indications for MRCP or ERCP, perioperative antibiotic choicesAddresses preoperative evaluation for biliary surgery, including interpretation of liver function tests, ultrasound assessment of gallbladder and ducts, indications for MRCP or ERCP, and evidence-based selection and timing of perioperative antibiotics.
Pattern recognition in liver function testsUltrasound assessment of gallbladder and CBDWhen to order MRCP versus ERCPRisk stratification for choledocholithiasisPerioperative antibiotic selection and timingLesson 11Immediate management of suspected bile duct injury: recognition signs, intraoperative cholangiography considerations, damage-limitation measures, when to call biliary surgery/transferFocuses on early recognition of suspected bile duct injury, intraoperative cholangiography options, immediate damage-control strategies, documentation, and criteria for urgent consultation or transfer to a hepatobiliary center.
Intraoperative signs suggesting bile duct injuryRole and technique of on-table cholangiographyDamage-limitation strategies and when to stopDocumentation and communication with the teamCriteria for referral to biliary surgery centersLesson 12Creating pneumoperitoneum and safe access: open (Hasson) vs Veress needle technique, insufflation pressures, trocar insertion safety checksExplains safe creation of pneumoperitoneum using open and Veress techniques, recommended insufflation pressures, trocar insertion angles, entry-related complication avoidance, and confirmation of adequate working space before proceeding.
Patient selection for open versus Veress entryVeress needle insertion tests and checksHasson open technique step by stepRecommended insufflation pressures and flowSafe primary trocar insertion and verification
