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Figure 14-1 Percutaneous insertion of the insufflation needle caudad to the bifurcation of the aorta and vena cava.

Figure 14-2 Following establishment of the pneumoperitoneum, a laparoscopic trocar is inserted in a caudad direction.

Figure 14-3 An open method of establishing the pneumoperitoneum and introducing the first cannula.

Umbilicus

Figure 14-4 The distal lens piece of most contemporary laparoscopes may be directed straight ahead or angled (30 to 50 degrees). The angled devices offer greater versatility in visualizing the peritoneal cavity.

Figure 14-5 Four cannulas are usually used when performing laparoscopic biliary tract surgery; however, a fifth or even sixth sheath may be inserted if necessary.

Figure 14-6 One popular method of obtaining an intraoperative cholangiogramuses a specialized clamp with a central lumen for introduction of the small catheter. Atraumatic ring forceps at the end of the clamp are then used to secure the catheter in place.

Figure 14-7 Stones may be gently "milked'

Figure 14-7 Stones may be gently "milked'

out of the cystic duct with atraumatic forceps.

Figure 14-8 The cephalad distortion of the gallbladder and cystic duct may "tent" the juncture of the cystic and common bile ducts out of their normal anatomic location.
Figure 14-9 An inflamed or edematous cystic duct remnant should be secured with a pretied laparoscopic loop ligature.
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