principles of cholecystectomy
TRANSCRIPT
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DISCUSS OPERATIVEPRINCIPLES OF
CHOLECYSTECTOMY
DR. BASHIRU M. A
18THJANUARY, 2014
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OBJECTIVES
To know what cholecystectomy is all about
To know possible indications for
cholecystectomy
In details, to know the guiding surgical
principles of cholecystectomy
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OUTLINE
INTRODUCTION
INDICATIONS Cholecystectomy
Common bile duct exploration
PRE-OPERATIVE PREPARATIONS
PER-OPERATIVE PERIOD
Open procedure
Laparoscopic approach
POST-OPERATIVE MANAGEMENTCOMPLICATIONS
CONCLUSION
REFERENCES
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Introduction Cholecystectomy is the surgical removal of the
gall bladder and the cystic duct
Performed to treat inflammation or Obstruction
Can be performed: Approach
Open
Laparoscopic
Timing Urgent
Emergency
Elective
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HISTORY
1882Langenbuch: Performed the 1st successful
cholecystectomy
1896Hans Kehr made cholecystectomy a
routine procedure for gall stone
1989 - Eddie Joe Reddick, lap cholecystectomy
was developed and popularised in USA
Moynihan and Mayo
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Brief Surgical Anatomy
The gall bladder lies on the
underside of the liver
Pear-shaped structure, 7.512 cm
long, (capacity 3550 mls) Parts
Cystic duct is about 3 cmCHD usually < 2.5 cm long
CBD is about 7.5 cm long
Parts: Four parts
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INDICATIONS
CHOLECYSTECTOMY Acute acalculous cholecystitis
Acute calculous cholecystitis
Chronic obstructing cholecystitis Part of major resection of hepatobiliary or
pancreatic dx
Gall bladder tumour
Porcelain gall bladder
Gall bladder polyps
Prophylactic: Batriatic, TPN, immunosuppression
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Indications...
COMMON BILE DUCT EXPLORATION
Pre-op:
History of jaundice
Abnormal LFT Cholangitis(fever, jaundice and upper abd
pain)
Multiple stones with patent dilated cysticduct on oral cholangiogram.
Dilated common bile duct
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Indications...
INTRA
OP Dilated common bile duct > 10-12 mm
Palpable stone in CBD
Periductal fibrosis
Indurated pancreas
Thickened gall bladder, no stone or
single faceted stone
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PRE-OPERATIVE
Confirming diagnosis
Treatment of co-morbidity
Antibiotics
Pre-op drainage
Thromboprophylaxis
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Confirming diagnosis
Clinical features
Pain(continuous, colicky, intense)
Vomiting
Jaundice/Fever
Murphys sign
Investigations
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Ultrasonography
Hyperechoic with acoustic shadowing in GB,
CBD Thickening of G.B. wall
Distension of G.B. with serosal oedema
Pericystic collection of fluid
Polyps
Plain Abd X-rays
Radio-opaque ( central radiolucent) Gas seen in the gall bladder and biliary tree
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FBC
LFT-
Bilirubin(conj and unconj)
ALP, AST, ALT
Albumin
Clotting profile
U/E/CR
Renal failure (from hypovolaemia, biliary
sepsis, bile)
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Pre op prep cont.
GXM blood for surgery
For jaundice ptVit K 10mg/d x 5days
Avail FFP/fresh whole blood
Antibbiotics
Proper rehydration
Replenish glucose store
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Pre op Prep...
Low dose heparin(5000iu)
Broad Spectrum Antibiotics
Sign informed consent
Nil Per Oral
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INTRA-OPERATIVE
Anaesthesia
Position
Incision
Good instruments
Managing critical steps Dissection, Ligation, Resection
Intra-operative cholangiographyClosure
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PER OPERATIVE
OPEN(retrograde or fundus first)
Anaesthesia-GA
Op-table radio-lucent
Modifiable to positions
Position- supine: Trendelenbergs
Cleaning and draping
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INTRA-OPERATIVE...
Position of surgeon
Cholecystectomy -Rt
CBD exploration-Lt
Incisions
Rt sub costal( Kocher's) incision Rt paramedian incision
Upper mid line incision( surgeon on Lt)
Rt transverse incision
Bilateral sub costal/roof top/chevron incision
Mayo Robson/ hockey stick incision
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Instruments Kelly clamps
Deaversretractor
Kockersforceps
Right Angle clamps
Balfour retractor Good illuminator
Electrosurgical diathermy
Fogarty biliary catheter Desjardins forceps
Maingotsforceps
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Position of surgeon, assistants and peri-op during
Common bile duct exploration or upper mid line
approach
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INTRA-OPERATIVE...
Good access
State of neighbouring structures/Laparatomy
Retract surrounding structures/Packing
Retract GB at fundus and Hartmann's pouch
Blunt dissect d CD&CA around d calot triangle
Free, clamp divide and secure the vessel
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.
Dissect GB of its bed & secure haemostasis
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Common Bile Duct Exploration Supra duodenal approach
Kocherize duodenum & bring it 2 d incision
Open peritoneum in free border of lesser
omentum. Identify CBD
Stay sutures on the borders 4/0 PDS
1.5-2 cm incision closer to the duodenum
Take a swab for M/C/S Scoop apparent stones and bile
Gently milk other stones towards the opening
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Cont.
Choledochotomy Fogarty catheter in situ
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Use Fogarty biliary catheter, Dormia basket
Explore and remove stones in Rt, Lt & CBD
Irrigate with normal saline
Close with 4/0 PDS over a T-tube
Drain the sub hepatic area with a tube drain
Close incision in layers
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Cont.Instruments/Connection
Operation table- reverse trendelenbergsAnaesthesia - GA
Patients position- supine or lithotomy position
Cleaning and draping
Surgeon position-Lt
Camera operator Lt
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2ndassistant-Rt
Scrub nurse- Rt NG Tube and urethral catheter in situ
Ports-4 in number
10mm Infa-umbilical: for telescopic camera
10mm Epigastric: for dissection, clipping,
diathermy
5mm Rt sub costal MCL: grasping hartmanns
pouch
5mm RIF: Grasping fundus of GB
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Cont.
Port insertion
Open/ Hassons technique
Closed/ Veress needle
Creation of pneumoperitoneum
Warm CO2, to a pressure of 12mmHg
Laparoscopy is done
Other ports inserted under direct visionAdhesions divided
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Laparascopic Cholecystectomy...
GB retracted at fundus and Hartmann's pouch using
graspers, this opens the porta hepatis
Calots triangle dissected by cutting peritoneum ant
&post to cystic duct
On exposure of CD &CA, intra operativecholangiography may be done as in open
CD is clipped prox & dist to incision & then div
CA is clipped and divided
GB dissected off its bed and haemostasis secured
GB retrieved thru 10mm port, via an endopouch
C t
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Cont.CBD EXPLORATION
If indicated, done with:
Choledochoscope
Open
ERCP+ stone extraction
Closed over a T-tube & sub hepatic area
drained
Pneumoperitoneum released
Ports are removed
Wounds infiltrated with LA
Wound closed with absorbable suture
C t i di ti t l i
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Contra-indications to laparascopic
cholecystectomy
Unable to tolerate GA
Refractory coagulopathy
Suspicion of GB Cancer Previous upper abdominal
surgery
Cholangitis
Diffuse peritonitis
Empyematous cholecystits
Perforated cholecystitis
Cholecysto-enteric fistula
Cirrhosis
Portal hypertension
Morbid obesity
Pregnancy
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When to convert to open
Unclear anatomy
No tissue plane
Uncontrollable bleeding Accidental damage
Equipment failure
Lack of progress
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POST OP MANAGEMENT
Most pt can be discharge same day after lap
cholecystectomy
Post op analgesia
Antibiotics
Fluid therapy, subsequent oral feeding
Early ambulation
Wound care Management of T-tube
Management of drain( removed at day 5)
Post-op chlangiograpy
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KehrsT-tube management
Early accidental removalopen abd and
replace immediately
Clamp tube at day five
T-tube cholangiography at day ten
Remove if x-rays are satisfactorily
If not, leave for another 7-10 days and repeat Leave for 4wks b4 instrumental retrieval of
stone via T-tube
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COMPLICATIONS Haemorrhage
Iatrogenic bile duct injury
Bile leak/Peritonitis
Cholangitis/CBD Fibrosis
Acute Pancreatitis
Retained stone
Post cholecystectomy syndrome Inadvertent bowel injury
Subcutaneous emphysema
CONCLUSION
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CONCLUSION
Cholecystectomy stands as a part of routinesurgical options for numerous biliary system
pathology
Introduction of laparoscopy haverevolutionized the procedure
It is a common question during surgical
residents training/examination
Therefore, residents are expected to master the
procedure
REFERENCES
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REFERENCES
Margaret Farquharson, Brendon Moran. Gall bladder
and biliary surgery. Farquharsons textbook of operativegeneral surgery.
Al fallouji. Cholecystectomy and common bile ductexploration. Postgraduate surgery, the candidates guide.
E.A Badoe,E.Q Archampong,J.T da Rocha-Afodu.theumbilicus and anterior abdominal wall. Principles and
practice of surgery including pathology in the tropics
E.A Badoe, E.Q Archampong, J.T da Rocha-Afodu.
Gall bladder and extrabulbar system. Principles andpractice of surgery including pathology in the tropics
Steen W. Jensen. Post cholecystectomy syndrome.
e-medicine. 27thaugust 2009.
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