DISCUSS OPERATIVE

PRINCIPLES OF
CHOLECYSTECTOMY
DR. BASHIRU M. A
18TH JANUARY, 2014

OBJECTIVES
To know what cholecystectomy is all about
To know possible indications for
cholecystectomy
In details, to know the guiding surgical
principles of cholecystectomy

OUTLINE
INTRODUCTION
INDICATIONS
Cholecystectomy
Common bile duct exploration

PRE-OPERATIVE PREPARATIONS
PER-OPERATIVE PERIOD
Open procedure
Laparoscopic approach

POST-OPERATIVE MANAGEMENT
COMPLICATIONS
CONCLUSION
REFERENCES

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

HISTORY
1882 Langenbuch: Performed the 1st successful
cholecystectomy
1896 Hans Kehr made cholecystectomy a
routine procedure for gall stone
1989 - Eddie Joe Reddick, lap cholecystectomy
was developed and popularised in USA
Moynihan and Mayo

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 cm
CHD usually < 2.5 cm long
CBD is about 7.5 cm long
Parts: Four parts

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

Indications...
COMMON BILE DUCT EXPLORATION
Pre-op:
History of jaundice
Abnormal LFT
Cholangitis(fever, jaundice and upper abd
pain)
Multiple stones with patent dilated cystic
duct on oral cholangiogram.
Dilated common bile duct

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

PRE-OPERATIVE
Confirming diagnosis
Treatment of co-morbidity
Antibiotics
Pre-op drainage
Thromboprophylaxis

Confirming diagnosis
Clinical features
Pain(continuous, colicky, intense)
Vomiting
Jaundice/Fever
Murphys sign

Investigations

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

 FBC
LFT Bilirubin(conj and unconj)
ALP, AST, ALT
Albumin
Clotting profile
U/E/CR
Renal failure (from hypovolaemia, biliary
sepsis, bile)

Pre op prep cont.

GXM blood for surgery
For jaundice pt
Vit K 10mg/d x 5days
Avail FFP/fresh whole blood
Antibbiotics
Proper rehydration
Replenish glucose store

Pre op Prep...
Low dose heparin(5000iu)
Broad Spectrum Antibiotics
Sign informed consent
Nil Per Oral

INTRA-OPERATIVE
Anaesthesia
Position
Incision
Good instruments
Managing critical steps
Dissection, Ligation, Resection

Intra-operative cholangiography
Closure

PER OPERATIVE
OPEN(retrograde or fundus first)
Anaesthesia-GA
Op-table
radio-lucent
Modifiable to positions

Position- supine: Trendelenbergs

Cleaning and draping

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

Instruments
Kelly clamps
Deavers retractor
Kockers forceps
Right Angle clamps
Balfour retractor
Good illuminator
Electrosurgical diathermy
Fogarty biliary catheter
Desjardins forceps
Maingots forceps

Position of surgeon, assistants and peri-op during

Common bile duct exploration or upper mid line
approach

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

Intra-operative Cholangiography
Ligate proximal tight and distal
loose,
Longitudinal incision btw then,
pass a catheter for intra op
cholangiography using hypaque
(5&10 mls)
Radiography may show....
Remove catheter and ligate the
duct 3mm away from the CBD

Dissect GB of its bed & secure haemostasis

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

Cont.
Choledochotomy

Fogarty catheter in situ

 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

Cont.

Instruments/Connection
Operation table- reverse trendelenbergs
Anaesthesia - GA
Patients position- supine or lithotomy position
Cleaning and draping
Surgeon position-Lt
Camera operator Lt

2nd assistant-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

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 vision
Adhesions divided

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 operative
cholangiography 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

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

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

When to convert to open

Unclear anatomy
No tissue plane
Uncontrollable bleeding
Accidental damage
Equipment failure
Lack of progress

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

Kehrs T-tube management

Early accidental removal open 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

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
Cholecystectomy stands as a part of routine
surgical options for numerous biliary system
pathology
Introduction of laparoscopy have
revolutionized the procedure
It is a common question during surgical
residents training/examination
Therefore, residents are expected to master the
procedure

REFERENCES
Margaret Farquharson, Brendon Moran. Gall bladder
and biliary surgery. Farquharsons textbook of operative
general surgery.
Al fallouji. Cholecystectomy and common bile duct
exploration. Postgraduate surgery, the candidates guide.
E.A Badoe,E.Q Archampong,J.T da Rocha-Afodu.the
umbilicus 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 and
practice of surgery including pathology in the tropics
Steen W. Jensen. Post cholecystectomy syndrome.
e-medicine. 27th august 2009.

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