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The epigastric cannula is positioned over the liver
away from the omentum, CO2 insufflation stopped,
and residual CO2 allowed to escape from the
abdomen through the cannula. The cannula is
removed, and the incisions are closed with a
subcuticular stitch and sterile strips. Dressings are
placed over the incisions, and the nasogastric tube
and Foley catheter are removed. The patient may
be discharged after observation. Most patients can
be discharged within a few hours.
Open Cholecystectomy Procedure
A. After induction of anesthesia place a nasogastric
tube to decompress the stomach. The most
commonly used incision is Kocher's right
subcostal. Place incision 4 cm below and parallel
to the costal margin, and extend it from the midline
to the anterior axillary line. Open the anterior
rectus sheath with a knife in the line of the incision.
Divide the rectus muscle with cautery, and open
the peritoneum between forceps.
B. Systematically explore the peritoneal cavity and
note the appearance of the hiatus, stomach,
duodenum, liver, pancreas, intestines, and
kidneys. Palpate the gallbladder from the ampulla
towards the fundus, then palpate the common
duct, noting any dilation or foreign bodies.
Carefully palpate the colon for neoplasms.
C. Grasp the gallbladder with a Rochester-Pean
clamp near the fundus. Hold forceps in one hand,
and introduce the right hand over the right lobe of
the liver, permitting the liver to descend. Divide
any adhesions to the omentum, colon or
duodenum, and place a pack over these
structures. Retract the structures inferiorly with a
broad-bladed Deaver's retractor.
D. Inspect the anatomy of the biliary tree by carefully
dividing the peritoneum covering the anterior
aspect of the cystic duct, and continue dissecting
into the anterior layer of the lesser omentum
overlying the common bile duct. Bluntly dissect
with a dissector (Kitner), exposing Charcot s
triangle bounded by the cystic duct, common bile
duct and inferior border of the liver. The cystic
artery should be seen in this triangle. Carefully
observe the arrangement of the duct system and
arterial supply. Do not divide any structure until the
anatomy has been identified, including the cystic
duct and common bile duct.
E. Pass a ligature around the cystic duct with a right
angle clamp, and make a loose knot near the
common duct. Partially divide the cystic duct below
the infundibulum, and place a small polyethylene
catheter attached to a syringe filled with saline into
the cystic duct for 1-2 cm. Tighten the ligature
holding the catheter in position.
F. Attach a second syringe containing contrast
material to the catheter, and remove all
instruments. Place a sterile sheet, and slowly
inject 10-15 cc of diluted dye into the common
duct. An operative cholangiogram should be
performed to detect stones and evaluate the duct
system.
G. Palpate the lower end of common bile duct,
pancreas, and the foramen of Winslow. Palpate
the ampulla, checking for stones or tumor. Hold
the forceps on the gallbladder in the left hand, and
clear the cystic artery of soft tissue with a pledget
held in forceps. Follow the artery to the
gallbladder, and clamp it with a right angle clamp.
Divide and ligate the artery close to the edge of
the gallbladder, using clips or 000 silk.
H. Reaffirm the junction of the cystic duct with the
common bile, then completely divide the exposed
cystic duct, leaving a stump of 5 mm.
I. Incise the peritoneum anteriorly over the
gallbladder with a scalpel. Elevate the peritoneum
from the gallbladder, and separate the gallbladder
gently with sharp and blunt dissection. Tissue
strands containing vessels should be cauterized
before division.
J. Inspect the gallbladder bed for bleeding and
cauterize and/or ligate any bleeding areas. Control
any persistent oozing from the bed with a small
pack of hemostatic gauze.
K. Irrigate the site with saline. If there is excessive
fluid present, place a soft rubber Penrose drain or
closed suction drain in the area of the dissection,
and bring it out through a separate stab wound in
the right upper quadrant. Inspect the operative
field, including the ligatures on the arteries and the
cystic duct. Approximate the peritoneum with
continuous nonabsorbable suture.
L. Irrigate the wound with saline and approximate the
rectus fascia and fascia of the oblique muscles
with interrupted, nonabsorbable sutures. Irrigate
the subcutaneous space with saline, and close the
skin with staples, or absorbable subcuticular
sutures.
Choledocholithiasis
Choledocholithiasis results when gallstones pass from
the gallbladder through the cystic duct into the common
duct.
I. Clinical evaluation
A. Patients with choledocholithiasis generally present
with jaundice . The patient may have pain or [ Pobierz całość w formacie PDF ]
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The epigastric cannula is positioned over the liver
away from the omentum, CO2 insufflation stopped,
and residual CO2 allowed to escape from the
abdomen through the cannula. The cannula is
removed, and the incisions are closed with a
subcuticular stitch and sterile strips. Dressings are
placed over the incisions, and the nasogastric tube
and Foley catheter are removed. The patient may
be discharged after observation. Most patients can
be discharged within a few hours.
Open Cholecystectomy Procedure
A. After induction of anesthesia place a nasogastric
tube to decompress the stomach. The most
commonly used incision is Kocher's right
subcostal. Place incision 4 cm below and parallel
to the costal margin, and extend it from the midline
to the anterior axillary line. Open the anterior
rectus sheath with a knife in the line of the incision.
Divide the rectus muscle with cautery, and open
the peritoneum between forceps.
B. Systematically explore the peritoneal cavity and
note the appearance of the hiatus, stomach,
duodenum, liver, pancreas, intestines, and
kidneys. Palpate the gallbladder from the ampulla
towards the fundus, then palpate the common
duct, noting any dilation or foreign bodies.
Carefully palpate the colon for neoplasms.
C. Grasp the gallbladder with a Rochester-Pean
clamp near the fundus. Hold forceps in one hand,
and introduce the right hand over the right lobe of
the liver, permitting the liver to descend. Divide
any adhesions to the omentum, colon or
duodenum, and place a pack over these
structures. Retract the structures inferiorly with a
broad-bladed Deaver's retractor.
D. Inspect the anatomy of the biliary tree by carefully
dividing the peritoneum covering the anterior
aspect of the cystic duct, and continue dissecting
into the anterior layer of the lesser omentum
overlying the common bile duct. Bluntly dissect
with a dissector (Kitner), exposing Charcot s
triangle bounded by the cystic duct, common bile
duct and inferior border of the liver. The cystic
artery should be seen in this triangle. Carefully
observe the arrangement of the duct system and
arterial supply. Do not divide any structure until the
anatomy has been identified, including the cystic
duct and common bile duct.
E. Pass a ligature around the cystic duct with a right
angle clamp, and make a loose knot near the
common duct. Partially divide the cystic duct below
the infundibulum, and place a small polyethylene
catheter attached to a syringe filled with saline into
the cystic duct for 1-2 cm. Tighten the ligature
holding the catheter in position.
F. Attach a second syringe containing contrast
material to the catheter, and remove all
instruments. Place a sterile sheet, and slowly
inject 10-15 cc of diluted dye into the common
duct. An operative cholangiogram should be
performed to detect stones and evaluate the duct
system.
G. Palpate the lower end of common bile duct,
pancreas, and the foramen of Winslow. Palpate
the ampulla, checking for stones or tumor. Hold
the forceps on the gallbladder in the left hand, and
clear the cystic artery of soft tissue with a pledget
held in forceps. Follow the artery to the
gallbladder, and clamp it with a right angle clamp.
Divide and ligate the artery close to the edge of
the gallbladder, using clips or 000 silk.
H. Reaffirm the junction of the cystic duct with the
common bile, then completely divide the exposed
cystic duct, leaving a stump of 5 mm.
I. Incise the peritoneum anteriorly over the
gallbladder with a scalpel. Elevate the peritoneum
from the gallbladder, and separate the gallbladder
gently with sharp and blunt dissection. Tissue
strands containing vessels should be cauterized
before division.
J. Inspect the gallbladder bed for bleeding and
cauterize and/or ligate any bleeding areas. Control
any persistent oozing from the bed with a small
pack of hemostatic gauze.
K. Irrigate the site with saline. If there is excessive
fluid present, place a soft rubber Penrose drain or
closed suction drain in the area of the dissection,
and bring it out through a separate stab wound in
the right upper quadrant. Inspect the operative
field, including the ligatures on the arteries and the
cystic duct. Approximate the peritoneum with
continuous nonabsorbable suture.
L. Irrigate the wound with saline and approximate the
rectus fascia and fascia of the oblique muscles
with interrupted, nonabsorbable sutures. Irrigate
the subcutaneous space with saline, and close the
skin with staples, or absorbable subcuticular
sutures.
Choledocholithiasis
Choledocholithiasis results when gallstones pass from
the gallbladder through the cystic duct into the common
duct.
I. Clinical evaluation
A. Patients with choledocholithiasis generally present
with jaundice . The patient may have pain or [ Pobierz całość w formacie PDF ]