Principles of Cholecystectomy

8/10/2019 Principles of Cholecystectomy

1/40

DISCUSS OPERATIVEPRINCIPLES OF

CHOLECYSTECTOMY

DR. BASHIRU M. A

18THJANUARY, 2014


2/40

OBJECTIVES

To know what cholecystectomy is all about

To know possible indications for

cholecystectomy

In details, to know the guiding surgical

principles of cholecystectomy


3/40

OUTLINE

INTRODUCTION

INDICATIONS Cholecystectomy

Common bile duct exploration

PRE-OPERATIVE PREPARATIONS

PER-OPERATIVE PERIOD

Open procedure

Laparoscopic approach

POST-OPERATIVE MANAGEMENTCOMPLICATIONS

CONCLUSION

REFERENCES


4/40

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


5/40

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


6/40

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


7/40

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


8/40

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


9/40

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


10/40

PRE-OPERATIVE

Confirming diagnosis

Treatment of co-morbidity

Antibiotics

Pre-op drainage

Thromboprophylaxis


11/40

Confirming diagnosis

Clinical features

Pain(continuous, colicky, intense)

Vomiting

Jaundice/Fever

Murphys sign

Investigations


12/40

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


13/40

FBC

LFT-

Bilirubin(conj and unconj)

ALP, AST, ALT

Albumin

Clotting profile

U/E/CR

Renal failure (from hypovolaemia, biliary

sepsis, bile)


14/40

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


15/40

Pre op Prep...

Low dose heparin(5000iu)

Broad Spectrum Antibiotics

Sign informed consent

Nil Per Oral


16/40

INTRA-OPERATIVE

Anaesthesia

Position

Incision

Good instruments

Managing critical steps Dissection, Ligation, Resection

Intra-operative cholangiographyClosure


17/40

PER OPERATIVE

OPEN(retrograde or fundus first)

Anaesthesia-GA

Op-table radio-lucent

Modifiable to positions

Position- supine: Trendelenbergs

Cleaning and draping


18/40

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


19/40

Instruments Kelly clamps

Deaversretractor

Kockersforceps

Right Angle clamps

Balfour retractor Good illuminator

Electrosurgical diathermy

Fogarty biliary catheter Desjardins forceps

Maingotsforceps


20/40

Position of surgeon, assistants and peri-op during

Common bile duct exploration or upper mid line

approach


21/40

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


22/40


23/40

.

Dissect GB of its bed & secure haemostasis


24/40

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


25/40

Cont.

Choledochotomy Fogarty catheter in situ


26/40

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


27/40

Cont.Instruments/Connection

Operation table- reverse trendelenbergsAnaesthesia - GA

Patients position- supine or lithotomy position

Cleaning and draping

Surgeon position-Lt

Camera operator Lt


28/40

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


29/40


30/40

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


31/40

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


32/40

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


33/40

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


34/40

When to convert to open

Unclear anatomy

No tissue plane

Uncontrollable bleeding Accidental damage

Equipment failure

Lack of progress


35/40

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


36/40

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


37/40

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


38/40

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


39/40

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.


40/40

THANK YOU

FOR LISTENING.

Documents

Principles of Cholecystectomy