Cholecystectomy

INDICATION:
  • Chronic Cholecystitis. 
  • Cholelethiasis 
  • Acute on Chronic Cholecystitis. 
  • Acute Cholecystitis with complications. 
  • Empyema Gallbladder. 
  • Gangrenous Gallbladder. 
  • Perforated Gallbladder. 
  • Trauma to Gallbladder. 
  • Mucocele 
  • Choledocholesthiasis. 
  • As a part of other procedure like Whipple Procedure. 
  • Carcinoma Gallbladder. 
  • Direct Invasion of Hepato-cellular carcinoma. 
  • Metastasis to gall bladder 
  • Prophylactic Cholecystectomy in high risk patients 
  • Parasitic Infestation of Gallbladder like in Ascariasis 
CONTRAINDICATION:
  • Contraindications to laparoscopic cholecystectomy include 
  • Coagulopathy 
  • Severe chronic obstructive pulmonary disease 
  • End-stage liver disease 
  • Congestive heart failure 
  • Currently, the major contraindication to completing a laparoscopic cholecystectomy is inability to clearly identify all of the anatomic structures 
OPEN PROCEDURE:
  • Right Sub-costal Incision. 
  • Right Transverse upper abdominal Incision. 
  • Upper Midline Incision. 
  • Muscle Cutting variety of incision 
  • Hemostasis 
  • Division of Right Rectus Abdomenis Muscle versus retraction 
  • Ligation of Right Superior Epigastric Artery 
  • Placement of Retractors and abdominal Sponges.
  • Dissection in Calot’s Triangle : 
  1. Use of Sponge Holder to hold fundus of gall bladder. 
  2. Dissection of Cystic Duct & Cyst Artery by gentle pull on gallbladder after division of Peritoneal reflection. 
  3. Ligation and Division of Cystic Artery & Cystic Duct with Lahey Forceps (Right Angle Forceps). 
  4. Dissection of gallbladder from liver bed. 
  5. Hemostasis. 
  6. Drain Versus no Drain. 
  • Closure of the Wound 
  1. After adequate Hemostasis & removal of abdominal packs closure of posterior rectus sheath with absorbable sutures. 
  2. Anterior Rectus Sheath is closed in continuous fashion by Non-Absorbable sutures. 
  3. Skin Closure by Interrupted Sutures. 
  4. Sterile Dressing Techniques. 
  5. Connecting Drain if placed with gravity drainage container. 
  • Postoperative Management 
  1. Nill by mouth till bowl sounds are present. 
  2. Continue Intravenous fluids till patient is oral free 
  3. Adequate Analgesia 
  4. Continue Intravenous Antibiotics for 72 hours and then change to oral for one week 
  5. Change of dressing if soaked early otherwise after 72 hours 
  6. Removal of drain when drainage is minimal 
  7. Removal of Sutures when wound is healed 
  8. Anti-ulcer therapy if needed. 
  9. DVT Prophylaxis 
  10. Send specimen for Histopathology and stones for chemical Analysis if present. 
LAPROSCOPIC APPROACH:
  • The technique of laproscopic cholecystectomy was first described by Erich Muhe 
  • Anaesthetic of choice in laparoscopic cholecystectomy is Propofol 
  • Acute Cholecystitis with medically controled symptoms is further treated with Laparoscopy cholecystectomy immediately 
  1. Traditional approach is 4 port but SILS has become available as well now a days. 
  2. Has become a gold standard approach for gallbladder removal. 
  3. If fails then convert to Open Procedure. 
  4. Difficult to perform in Patients with Previous open Abdominal Surgeries. 
  5. Carries some increased risk of extra-hepatic duct injuries. 
  6. Recovery is better and early than open surgery. 
  7. Needs specialized equipment & training of personnel. 
  8. Usually avoided in cases of suspected malignant Disease. 
Comparison Open Approach
  • Easy. 
  • Can be done in peripheral centers. 
  • Cost effective. 
  • Less extra hepatic injuries. 
  • May have more post operative respiratory complications. 
  • Cosmetically not good. 
  • Hospital Stay is longer. 
  • Usually Reserved for failed laparoscopic cases & malignant Disease. 
  • Laparoscopic Approach 
  1. Needs special equipment & training of personnel. 
  2. Learning Curve & Good Hand eye coordination needed. 
  3. Cost is higher. 
  4. Extra-hepatic duct injuries are more than open approach. 
  5. Hospital stay is shorter. 
  6. Lesser post operative complications. 
  7. Avoided in Malignant Disease. 
  8. If fails then have to proceed towards open approach. 
  9. Has become Gold standard treatment for Gall bladder Surgery. 
Exam Question
  • Contraindication for laparoscopic Cholecystectomy is Coagulopathy,Obstructive pulmonary disease, End-stage liver disease 
  • Asymptomatic gall stone of 1.5cm can be treated with Cholecystectomy only, if she develops biliary colic 
  • The technique of laproscopic cholecystectomy was first described by Erich Muhe 
  • Anaesthetic of choice in laparoscopic cholecystectomy is Propofol 
  • Open cholecystectomy for cholelithiasis is considered a clean contaminated wound 
  • Acute Cholecystitis with medically controled symptoms is further treated with Laparoscopy cholecystectomy immediately 
  • The treatment of choice for mucocele of gallbladder is Cholecystectomy 
  • Howel-Jolly bodies may be seen after Cholecystectomy 
  • Treatment of chronic cholecystitis is Cholecystectomy

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