Operating Room Setup & Nursing Guide
A practical guide written from the perspective of an Operating Room Nurse.
The workflows, surgeon preferences, and nursing tips presented in this article are based on the author’s real clinical experience. Surgical techniques and operating room practices may vary depending on the surgeon, hospital, and institutional protocols.
📌 Quick Facts
| Item | Details |
|---|---|
| Procedure | Laparoscopic Cholecystectomy |
| Specialty | General Surgery |
| Approach | Laparoscopic |
| Anesthesia | General Anesthesia |
| Patient Position | Supine → Reverse Trendelenburg + Left Tilt |
| Retrieval Bag | Medium Lap Bag |
| Routine Drain | Hemovac 200 |
🕒 Procedure Timeline
- Patient Position
- Trocar Placement
- Position Change
- Calot’s Triangle Dissection
- Cystic Duct & Artery Control
- Gallbladder Dissection
- Specimen Retrieval
- Hemostasis
- Drain Placement
- Closure
Patient Position
The patient is initially placed in the supine position.
After pneumoperitoneum and trocar placement, the operating table is adjusted to:
- Reverse Trendelenburg (Head Up)
- Left Tilt
This position improves visualization of the gallbladder and Calot’s triangle by allowing the bowel to fall away from the operative field.
Trocar Placement
Standard Four-Port Technique
| Location | Size |
|---|---|
| Umbilicus | 10 mm |
| Epigastric | 12 mm |
| Right Upper Quadrant | 5 mm |
| Right Flank | 5 mm |
Camera System
| Surgeon | Camera |
|---|---|
| Surgeon A | Olympus 2D Flexible Laparoscope |
| Surgeon B | 10 mm 0° Rigid Laparoscope |
Energy Device
| Surgeon | Energy Device |
|---|---|
| Surgeon A | Harmonic Scalpel + Monopolar Hook |
| Surgeon B | Maryland Bipolar + Monopolar Hook |
Surgical Workflow (Standard)
- Establish pneumoperitoneum.
- Insert the trocars.
- Change the patient to Reverse Trendelenburg with Left Tilt.
- Expose Calot’s triangle.
- Identify the cystic duct and cystic artery.
- Secure and divide the cystic duct and artery.
- Dissect the gallbladder from the liver bed.
- Retrieve the specimen using a laparoscopic retrieval bag.
- Confirm hemostasis.
- Insert a drain if indicated.
- Close the port sites.
👨⚕️ Surgeon A Workflow
Olympus Flexible Camera + Harmonic-Based Technique
Surgical Workflow
- Insert the Olympus 2D flexible laparoscope.
- Dissect Calot’s triangle using the Harmonic Scalpel and Monopolar Hook.
- Apply Purple or Gold Weck Clips to the cystic duct according to duct size.
- Secure the cystic artery with either a Metal Clip or a Green Weck Clip.
- Divide the cystic duct and artery.
- Dissect the gallbladder from the liver bed using the Harmonic Scalpel.
- Place the gallbladder into a Medium Lap Bag.
- Remove the specimen through the umbilical port.
- Inspect the liver bed carefully.
- Control minor bleeding using the Hook Bovie (Spray Mode).
- If bleeding persists, apply Surgicel or Surgicel Snow.
- Insert a Hemovac 200 drain.
- Perform port closure.
OR Nurse Key Points
- Prepare the Olympus flexible laparoscope.
- Check Harmonic functionality before the procedure.
- Prepare Purple, Gold, and Green Weck Clips.
- Open the Lap Bag before specimen retrieval.
- Switch the electrocautery to Spray Mode before liver bed inspection.
- Prepare Hemovac 200 before drain insertion.
👨⚕️ Surgeon B Workflow
10 mm 0° Rigid Camera + Bipolar-Based Technique
Surgical Workflow
- Insert the 10 mm 0° rigid laparoscope.
- Dissect Calot’s triangle using the Maryland Bipolar and Monopolar Hook.
- Apply a Metal Clip to the cystic duct.
- Seal the cystic artery using the Maryland Bipolar without applying a clip.
- Divide the artery using the Monopolar Hook.
- Continue gallbladder dissection from the liver bed using the Maryland Bipolar and Hook.
- Place the specimen into a Medium Lap Bag.
- Remove the gallbladder through the umbilical port.
- Inspect the liver bed for bleeding.
- Control bleeding using the Hook Bovie (Spray Mode) when required.
- Insert a Hemovac 200 drain.
- Complete port closure.
OR Nurse Key Points
- Prepare the 10 mm 0° rigid laparoscope.
- Check Maryland Bipolar function.
- Prepare Metal Clips.
- Open the Lap Bag before specimen retrieval.
- Change to open suction before gallbladder extraction in case of gallbladder perforation.
- Switch to Spray Mode before liver bed hemostasis.
- Prepare Hemovac 200 before drain insertion.
Drain Placement
Our routine practice is to insert a Hemovac 200 drain after confirming hemostasis.
Closure
Fascial Closure
Umbilical Port
- Kocher ×2
- J Needle
- Vicryl 3-0
Tagging Suture
- Nylon 3-0
12 mm Port
- Vicryl 4-0
Skin Closure
- Nylon 3-0
Dressing
10 mm Port
- Steri-Strip
Remaining Port Sites
- Neo Dressing
Mayo Stand Setup
Initial Setup
- Senn Retractor
- Kelly
- Metzenbaum Scissors
- Adson Forceps (Toothed)
- Mosquito ×2–3
After Trocar Placement
- Laparoscopic Dissector
- Laparoscopic Grasper
- Laparoscopic Metzenbaum
- Laparoscopic Scissors
- Harmonic Scalpel (Surgeon A) or Maryland Bipolar (Surgeon B)
- Suction / Irrigation
Back Table Setup
- Medium Lap Bag
- Weck Clips
- Metal Clips
- Open Instrument Set
- Surgicel
- Surgicel Snow
✅ 30-Second OR Checklist
- □ Camera checked
- □ Energy device tested
- □ Clip applier tested
- □ Lap Bag opened
- □ Hemovac 200 prepared
- □ Open suction available
- □ Hook Bovie ready for Spray Mode
- □ Surgicel and Surgicel Snow available
- □ Final instrument, needle, and sponge counts completed
⚠️ Common Pitfalls
- Failure to obtain the Critical View of Safety
- Inadequate exposure of Calot’s triangle
- Incorrect clip size selection
- Gallbladder perforation during specimen retrieval
- Bleeding from the liver bed
- Inadequate hemostasis before drain placement or closure
💎 Pearls from Experience
- Always prepare and test the clip applier before cystic duct dissection.
- Open the retrieval bag before specimen extraction to avoid unnecessary delays.
- Switch to open suction before removing the gallbladder through the umbilical port in anticipation of gallbladder perforation or bile spillage.
- Change the electrocautery to Spray Mode immediately after specimen removal to prepare for liver bed hemostasis.
- For Single-Port Laparoscopic Cholecystectomy, prepare a 10 mm rigid laparoscope, position the patient in the lithotomy position, and cover both legs with Mayo stand covers before draping.
Frequently Asked Questions
Why is the patient placed in Reverse Trendelenburg with Left Tilt?
This position improves exposure of the gallbladder and Calot’s triangle by allowing the abdominal organs to fall away from the surgical field.
Why are different clip sizes used?
The diameter of the cystic duct varies between patients. Selecting the appropriate clip size provides a more secure ligation.
When is Spray Mode used?
Spray coagulation is commonly used to control diffuse oozing from the liver bed after gallbladder removal.
Conclusion
Laparoscopic cholecystectomy is one of the most commonly performed procedures in general surgery. Understanding both the standard operative sequence and surgeon-specific workflows allows the operating room nurse to anticipate each step, prepare the appropriate instruments in advance, and provide efficient intraoperative support. The practical differences between surgeons—such as camera systems, energy devices, and methods of vascular control—are equally important in ensuring a smooth and safe operation.