Gallbladder removal surgery, known as a cholecystectomy, is one of the most common procedures performed worldwide. The modern standard of care is the laparoscopic approach, a minimally invasive technique that avoids the large incision required for traditional open surgery. This method offers patients significant benefits, including less post-operative discomfort, a quicker recovery, and a shorter hospital stay. The procedure uses small incisions to access the abdomen, allowing specialized instruments and a camera to operate internally.
The Standard Laparoscopic Approach
Laparoscopic cholecystectomy relies on creating a sealed working space within the abdomen by inflating it with carbon dioxide gas, a condition called pneumoperitoneum. This inflation lifts the abdominal wall away from the internal organs, creating the necessary room for the surgeon to see and work. The procedure is accomplished using three or four small entry points, known as ports.
These ports are strategically placed to give the surgical instruments optimal angles for dissection. One port is placed near the navel (umbilicus) to serve as the main access point for the camera. The remaining ports are usually positioned in the upper right side of the abdomen, corresponding to the location of the gallbladder and liver. While a three-port technique is sometimes used, most surgeons employ a four-port setup for a standard case.
Roles of the Primary Surgical Ports
Each incision site has a specific function necessary to complete the operation. The umbilical port is designated for the laparoscope, a small telescope connected to a high-definition camera. This camera provides the surgeon’s visual field, projecting internal images onto a monitor. This is the largest incision, as the removed gallbladder is often extracted through this site after being placed into a retrieval pouch.
A second port, frequently placed in the upper central abdomen, serves as the primary working channel for the surgeon’s dominant hand. Through this port, instruments like dissectors, clip appliers, and energy devices are introduced to separate the gallbladder from the liver and clip the cystic duct and artery. The remaining upper abdominal ports are used for grasping and retraction tools to hold the gallbladder and surrounding tissue steady. One grasper pulls the gallbladder upward and outward, providing the tension and clear view necessary to identify the duct and artery structures.
A fourth port is routinely used to provide additional leverage for gentle retraction, often specifically for the liver. This helps the surgeon hold the liver out of the way, ensuring the visual field remains unobstructed. The precise placement of these working ports is determined by the surgeon based on the patient’s anatomy and the need to establish optimal triangulation for the instruments. This arrangement provides the stable visual and manual access required for the completion of a routine cholecystectomy.
Reasons for Requiring a Fifth Incision
The need for a fifth port arises when the standard four-port setup does not provide the safety or visualization required to complete the procedure. Adding an additional port is an indication that the surgeon is adapting the technique to the complexity of the internal environment, rather than a sign of complication.
Difficult Anatomy
One common reason for an extra port is difficult anatomy, such as severe inflammation or scarring from acute cholecystitis. When tissues are swollen and stuck together, structures like the cystic duct and artery are difficult to identify. The fifth incision can introduce an extra retractor or grasper, allowing the surgeon to gently pull apart inflamed tissue and achieve the critical view of safety.
Body Habitus
A patient’s body habitus, particularly obesity, can push the organs deeper into the abdomen, making them harder to reach. The fifth port can be placed in a different location to improve the angle of attack or to provide specialized retraction for organs like the liver or nearby intestines. This extra tool helps clear the surgical field for better visibility and dissection.
Intraoperative Cholangiogram
The fifth port may also be used to facilitate an intraoperative cholangiogram, a specialized X-ray procedure used to check for stones in the bile ducts outside of the gallbladder. Although modern clamps and catheters often fit through the existing ports, a dedicated, optimally positioned port may be needed to introduce the imaging equipment. The addition of a fifth incision is a tactical decision made to ensure a safe, precise, and complete removal of the gallbladder when faced with a challenging surgical field.
Care and Healing of Laparoscopic Wounds
The small incisions from laparoscopic surgery require attentive care to ensure proper healing and minimize the risk of infection. Most laparoscopic wounds are closed using dissolvable sutures placed beneath the skin, surgical glue, or small adhesive strips.
It is safe to shower about 24 to 48 hours after the procedure, but patients must avoid soaking the wounds by taking baths or swimming until cleared by the surgeon. Patients should gently wash the area with mild soap and water, then pat the incision sites dry. Adhesive strips should be left in place until they naturally fall off, which usually occurs within 7 to 10 days.
While mild redness and tenderness around the incision are normal, patients must watch for signs of infection that require immediate medical attention:
- Increasing pain.
- Fever above 100.4°F.
- Thick, yellowish-green fluid draining from the wound site.
- Swelling or significant expansion of redness beyond the incision line.