Arrange the following steps of surgery in order:

A. Creating pneumoperitoneum

B. Dissection of hepatocystic triangle

C. Ligation of cystic duct and artery

D. Separation of gallbladder from liver bed

1. A

   A-B-C-D

2. B

   A-C-B-D

3. C

   B-A-C-D

4. D

   D-A-B-C

Appeared in: INI-CET EXAM -2025

Explanation

• The correct sequence for a laparoscopic cholecystectomy is creating pneumoperitoneum, dissecting the hepatocystic triangle, ligating the cystic duct and artery, and finally separating the gallbladder from the liver bed.
• This sequence follows the fundamental surgical principles of access, exposure, identification, control, and removal.
• Creating pneumoperitoneum (A) is always the first step to establish a working space for laparoscopic surgery.
• Dissection of the hepatocystic triangle (B) to achieve the 'critical view of safety' must precede ligation (C) to prevent bile duct injury.
• Separation from the liver bed (D) is the final step of removal after the gallbladder's connections have been safely divided.

Why Other Options Were Wrong

• Option B: This sequence (A-C-B-D) is incorrect because it involves ligating the cystic duct and artery (C) before fully dissecting the hepatocystic triangle (B).
• Option C: This sequence (B-A-C-D) is incorrect because it suggests dissecting the hepatocystic triangle (B) before creating the pneumoperitoneum (A).
• Option D: This sequence (D-A-B-C) is incorrect because it places the separation of the gallbladder from the liver bed (D) as the first step.

Related Visual

• Visual 1: Flowchart - A flowchart illustrating the four main steps of a laparoscopic cholecystectomy in the correct A -> B -> C -> D sequence.
• Visual 2: Diagram - An anatomical illustration of the hepatocystic triangle (Calot's triangle), clearly labeling the cystic duct, cystic artery, and common hepatic duct to emphasize the importance of the 'critical view of safety'.

Clinical Relevance

• Nursing practice connection: This is primarily an exam-oriented knowledge point with limited direct bedside application, so retain Surgical procedure steps for laparoscopic cholecystectomy as background academic context rather than a clinical decision trigger.
• Understanding the correct sequence of a laparoscopic cholecystectomy is crucial for perioperative nurses to anticipate the surgeon's needs for instruments and supplies.
• Knowledge of the steps helps the nurse identify any deviation from standard procedure, which could indicate a complication or a change in the surgical plan (e.g., conversion to open surgery).
• The 'critical view of safety' (Step B before Step C) is the single most important concept for preventing bile duct injury. Nurses should be aware of its significance in patient safety.

How to Approach the Question

• First, identify the core subject of the question, which is the correct order of steps for a specific surgical procedure (laparoscopic cholecystectomy).
• Think logically about the principles of surgery: first, you need access and visibility; second, you identify what you need to cut; third, you safely control and cut it; and finally, you remove the target organ.
• Apply this logic to the given options. Step A (creating pneumoperitoneum) must be first to provide access and visibility.
• Next, evaluate the safety-critical steps. Step B (dissection to identify) must come before Step C (ligation and cutting) to prevent injury to vital structures like the common bile duct.
• Step D (detaching the organ) is the final removal step after its main connections are severed.
• Based on this logical and safety-oriented flow, determine the only possible sequence: A -> B -> C -> D. Match this sequence to the given options.

Concept Tested & Keywords

• Concept Tested: Surgical procedure steps for laparoscopic cholecystectomy.
• Stem keywords: surgery, order, pneumoperitoneum, hepatocystic triangle, ligation, cystic duct, cystic artery, gallbladder
• Lead-in keywords: Arrange
• Negative lead-in flag: false

Question ID

Q3RaZtODM3k7sDjt0RvCOX

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