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Laparoscopic cholecystectomy has become the standard since its introduction in 1989. Variation is common in hepatic hilar structures. Careful dissection of the hilum to identify the cystic duct and cystic artery (“critical view”) in the hepatocystic triangle is key to safe execution. Staying close to the junction of the cystic duct with the infundibulum is the operative principle. The deep and superficial branches of the cystic artery may arise from a common trunk or independently, and must be positively identified and differentiated from a major hepatic vessel or bile duct before division.
Cystic duct cholangiogram is indicated if there is a suspicion of common duct stone (history of jaundice or pancreatitis) or if the anatomy is unclear. Dilute (25%) contrast helps visualization. Absence of filling defects with visualization of biliary radicals, distal common duct tapering, and free flow of contrast into the duodenum constitute a normal cholangiogram.
The spleen is tucked far posterior and cephalad under the left hemidiaphragm. The splenic flexure of the colon is very variable in location and may extend high up between spleen and stomach. Dividing the splenocolic ligament without tearing the capsule of the spleen can be tricky. Trauma to the left lower rib cage should raise the suspicion of splenic injury.