Surgical Procedures/Abdominal Surgery/Cholecystectomy/Open

Introduction:

• Cholecystectomy performd by Open method.

Indication:

• If laparoscopic cholecystectomy is contraindicated
• Intra operative conversion during laparoscopic cholecystectomy
• Gallbladder carcinoma
• Cholecystitis
• Cholelithiasis
• ?Biliary dyskinesia.

Contraindication:

• Contraindicated if laparascopic cholecystectomy is indicated and can be performed.

Advantages:

• Better exposure during surgery
• Less risk of wound infection
• Shorter hospital stay
• Less days off work

Disadvantages:

• Larger incision is made and leaves large scar.
• Longer hospital stay
  • ≥ 5 days.
• Longer recovery time.
• Post-operative pain.

PreOperative management:

• Glucose Drink 150mg/Day x 3 days.
  • If NPO:
    • 5% Dextrose I.V.
• PreOP. BroadSpectrum Antibiots.
• Preop Investigations:
  • Oral Cholangiogram.
  • If Charcot's Triad present:
    • I.V cholangiography.

Anaesthesia

• Commonly:
  • Endotracheal Sedation.

(Anaesthesia will not be mentioned here.)

Simplified steps:

Step I

Incision.

Types of Incision:

• Upper Right SubCostal Incision.
• Kocher's Incision.
• Modified Kocher's Incision.
• Transverse Incision.

Step II

Mop placement

• 2 wet mops are placed.
  1. One Wet Mop is placed to displace the duodenum, the transverse colon and coils of small intestine.
  2. Second Wet Mop is placed slightly to the left of the Common Bile Duct (CBD) to displace the stomach to the left.

Step III

(After 2 wet mop placement.)

Exposure of GallBladder:

Exposure of GallBladder is done by:

• Retraction of liver.
  • Inferior surface of the right lobe of the liver is retracted upwards by the most appropriate retractor available.
    • e.g Deaver's retractor or most commonly the harrington retractor (aka the sweetheart).

Step IV

Removal of GallBladder.

2 common methods for removal of GB:

Duct first method:

• Cystic Duct and Artery are dissected first and divided, after which GallBladder is removed.
  • Indication:
    • Indicated if no presence of adhesions or exudates in CBD, CHD, CD.
  • Contraindication:
    • Contraindicated in the presence of adhesions or exudates in CBD, CHD, CD.
  • Advantages:
    • Less chance to injure:
      • CBD.
      • Right Heptic Artery.
  • Disadvantages:

Fundus First method:

• Dissection is started from Fundus of the GallBladder and gradually proceeded towards the Cystic Duct, which is divided last of all.
  • Indication:
    • Indicated in the presence of adhesions or exudates in CBD, CHD, CD.
  • Contraindication:
    • Contraindicated in no presence of adhesions or exudates in CBD, CHD, CD due to disadvantges.
  • Advantages:
    • Gallbladder can be removed in the presence of adhesions or exudates in CBD, CHD, CD.
  • Disadvantages:
    • More chance to injure:
      • CBD.
      • Right Heptic Artery.