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SURGERY

Surgery Text Book by Dr Taj Uddin

SURGICAL WEBSITES             KIDNEY SURGERY         POSTGRADUATE SURGERY LINKS 

BREAST DISEASE     Breast cancer Breast lump Breast awareness Breast calcifications  Breast cysts Breast pain Duct ectasia Fat necrosis Fibroadenoma Hyperplasia Intraductal papilloma Phyllodes tumour Sclerosing adenosis                                                                                                                                                 

LIVER ABSCESS      Anatomy of liver Physiology of liver Method of examination of liver Haematology of liver disease. Amoebic liver abscess .Pyogenic liver abscess. Percutaneous needle aspiration of liver abscess. Case study.  Result Result continued  Discussion                                                                 

CHOLECYSTECTOMY    Introduction   Historical Review  Anatomy of Gallbladder Physiology of Gallbladder Physiologic effects of pneumoperitoneum Pathology  of Gallbladder Investigations Pre- operative preparation of laparoscopic cholecystectomy Contraindications  Treatment modalities for gallstones.  Anaesthesia                                                                                                                       

INGUINAL HERNIA    HOW SURGICAL OPERATION IS DONE     THYROID EXAMINATION MANAGEMENT OF SEVERELY INJURED PATIENT      SEPSIS AND MULTIPLE ORGAN FAILURE CHEST TRAUMA     BRONCHOGENIC CARCINOMA     TETANUS AND ANAEROBIC INFECTIONS 

SITE HOSTED BY

DR TAJ UDDIN

MBBS FCPS FRCS

ASSISTANT PROFESSOR OF SURGERY

BAQAI MEDICAL UNIVERSITY

KARACHI PAKISTAN

CONTACT DR TAJUDDIN PH NO 0300 2467670 OR EMAIL shmsqadr@cyber.net.pk

SURGERY WEB PAGE BY DR TAJ UDDIN  SURGICAL WEBSITES BREAST DISEASE LIVERABSCESS  INGUINAL HERNIA CHOLECYSTECTOMY KIDNEY SURGERY  HOW SURGICAL OPERATION IS DONE  THYROID EXAMINATION MANAGEMENT OF SEVERELY INJURED PATIENT  SEPSIS AND MULTIPLE ORGAN FAILURE CHEST TRAUMA  BRONCHOGENIC CARCINOMA  TETANUS AND ANAEROBIC INFECTIONS POSTGRADUATE SURGERY BLOOD TRANSFUSION  BREAST CANCER

 

Laparoscopic cholecystectomy 

SECTION 1                                                                                       

I           Summary                                                                                             

II          Introduction                                                                                         

III        Review of literature                                                                              

IV        Historical Review                                                                                 

V         Anatomy of Gallbladder                                                                      

VI        Physiology of Gallbladder                                                                   

      a    Physiologic effects of pneumoperitoneum                                            

VII       Pathology  of Gallbladder.     

             Investigations 

            Pre- operative preparation of laparoscopic cholecystectomy                                         

            Contraindications

        Treatment modalities for gallstones. .                                                      

IX         Anaesthesia

Steps of Laparoscopic cholecystectomy                                   

X   Conversion of laparoscopic cholecystectomy to open

          Cholecystectomy                                                                    

XI      Complications of laparoscopic cholecystectomy leading

            to open cholecystectomy (laparotomy).                                  

XII    Post-operative care.                                                                             

            SECTION 2                                                                              

            CASE STUDY

XXI     Introduction                                                                                       

 

XXII    Material and Methods                                                               

XXIII   Results                                                                                      

XXIV   Discussion                                                                                 

XXV    Conclusion                                                                                

XXVI   References                                                                                 

 

SUMMARY

      Laparoscopic cholecystectomy has become the accepted method for treatment of symptomatic gallstones Despite good results patient undergoing planned laparoscopic cholecystectomy are informed that there is a possibility that they will require conversion to open cholecystectomy. This study was designed to evaluate the causes of conversion, to analyse that can they are predicted preoperatively, and to define the preoperative indicators if any. From February 1997 to December 1998, 211 patients who were undergoing elective laparoscopic cholecystectomy form the basis of this analysis. 27 patients required conversion. The important factors that could lead intra-operative complications are recorded. The most common reason of conversion was inability to define the anatomy leading to failure of dissection and 6 patients lie in this group. Significant predictors of conversion to open cholecystectomy increasing age, obesity, thickened gall bladder wall found on preoperative ultrasound scan and acute cholecystitis.

      Both patients and surgeons would like to have a clear idea of the risk of conversion prior to surgery. Patients would like to have an idea of the probable risk of conversion in order to make appropriate plans. From the surgeon’s perspective by understanding factors that are associated with increased likelihood of conversion, surgeons may select their patients more objectively. Conversion of laparoscopic cholecystectomy into an open procedure is meant to ensure the safety of the procedure. As surgeons gain great confidence with laparoscopic cholecystectomy there is a tendency to persist with a difficult dissection to avoid opening. Thus conversion has become a marker for a truly difficult.

 

Key words

Laparoscopic; Cholecystectomy; laparoscopy; laparotomy.

 

CHOLECYSTECTOMY SITE BY DR TAJ

 

 

Cholecystectomy is a common surgical operation performed for gall bladder

PRINCIPLES OF CHOLECYSTECTOMY

by    Dr. Tajuddin

Assistant Professor of Surgery

Baqai Medical University

 

Indications

1 Calculous cholecystitis

2. (Typhoid carrier)

3 (Carcinoma of the gall bladder - rarely, an early cancer is found incidentally within a gallbladder removed for cholelithiasis)

Preoperative management

1 Investigations

a. Ultrasound of gallbladder and bile ducts

b. Cholecystogram

c. If previously jaundiced

• Liver function tests

• HBS Ag status

• Clotting screen

d. History of allergic reaction to X-ray contrast media
e. PTC/ERCP if jaundiced

2 The mortality of cholecystectomy in cirrhosis/portal
hypertension is up to 10%

3. Vitamin K if recently jaundiced

4. Antibiotics

a. Broad spectrum now generally accepted as one dose or three dose prophylaxis
b. Risk groups for infection in bilary surgery

• >70 years old

• Diabetic

• On steroids

• Jaundiced or recently jaundiced

• Common bile duct exploration

• Malignancy involving the biliary tree

• Common bile duct stones or stricture
5 IVI (with prehydration or 10% mannitol infusion if jaundiced)
6. Nasogastric tube to deflate the stomach peroperatively

 

 

Pre-incision

1. General anaesthetic (avoiding hepatotoxic agents such as
halothane) and endotracheal intubation

2. Position - supine on an X-ray operating table

3. Skin preparation for an upper abdominal incision

4. Empty bladder prior to laparoscopic procedure

Incision

1. Kochers right subcostal

2. Right paramedian               All equally acceptable

3. Right upper transverse

4. Laparoscopic with port sites at the umbilicus, midline
epigastrium and right subcostal in the mid-clavicular line

 

 

Procedure

1. Full laparotomy/laparoscopy with particular attention to a. 'Saints Triad'

• Gallstones

• Hiatus hernia

• Sigmoid diverticular disease
b. Other causes of upper abdominal pain

• Peptic ulcer

• Carcinoma of the stomach

• Pancreatic carcinoma

• Chronic pancreatitis

 

                              

 

2. Open cholecystectomy

a. Display the gall bladder

• Pack off the small bowel

• Retract the stomach and duodenum downwards

• Retract the liver upwards

b. Retract the gall bladder laterally, held in a sponge holder or Moynihan gall bladder clamp and incise the peritoneum over the right free border of the lesser omentum
3. Laparoscopic cholecystectomy

Grasp and retract the gallbladder fundus in a lateral direction
4. Dissect out Calot's triangle bordered by

a. Cystic duct inferiorly
b. Cystic artery superiorly

c. Common hepatic and right hepatic duct on the left
Before any structure is divided it is absolutely essential to identify the cystic duct and artery, and be absolutely certain of the position of the structures of the right free border of the lesser omentum common bile duct and common hepatic duct,hepatic artery and portal vein)
5. Ligate/clip and divide the cystic artery in continuity
6. Cannulate the cystic duct and aspirate bile for microbiological examination

7. Perform the operative cholangiogram
a. Remove all instruments and radio-opaque swabs
b. Tilt the operating table 10° to the right (so the bile ducts do not overlie the spine)

    c. Stop the ventilator during X-ray exposure
d. Take at least two films, after the injection of 2 and 10 ml of contrast

8. Points to establish on the operative cholangiogram

a. Clear visualisation of all the common bile and hepatic ducts with delineation of the anatomy
b. No filling defects or strictures
c. Free flow into the duodenum in all films
d. Common bile duct not dilated greater than 11 mm
e. Minimal retrograde flow of contrast into the pancreatic ducts

9. If all these are established then withdraw the catheter and proceed

10. Problems with peroperative cholangiography

a. Introduction of air bubbles, mimicking radiolucent stones
b. Spasm of the sphincter of Oddi

 c. Contrast in the duodenum obscuring the terminal common bile duct and ampulla

11. Complete the cholecystectomy

a. Transfix and ligate/clip the cystic duct within 1 cm of the common bile duct with an absorbable suture or metal clip
b. Divide the peritoneal reflection between the gallbladder and the liver and dissect the gallbladder out of its hepatic bed. Remove the gallbladder at this stage in an open procedure

c. Use diathermy coagulation to control bleeding from the liver bed
d. Remove the gallbladder via the umbilical port site if undertaking a laparoscopic procedure

12. Examine the gallbladder and gallstones. Send the gallbladder for histological examination to exclude co-existing
malignancy. Swab the gallbladder mucosa and send for microbiological culture and sensitivity. Any postoperative wound infection will be due to bile contamination.

 

 

13. Closure

a. Absolute haemostasis

• Cystic artery

• Gallbladder bed
b. Suction drain to gallbladder bed
c. If an open cholecystectomy leads to exploration of the common bile duct then bring the T-tube out by a separate stab incision
d. Close in layers

Postoperative management

1. Accurate measurements of drainage essential; suspect a significant leak if >300 ml of bile is drained daily from the suction drain to the gallbladder bed during the first 24 postoperative hours

2. Investigations

a. Histology of gallbladder

b. If T-tube present - T-tube cholangiogram to establish normal biliary flow and exclude retained stones prior to its removal

Complications

1. Early

a. Biliary leak

b. Ileus

c. Wound infection

d. Persistent jaundice with a retained stone

e. Septicaemia

f. Pancreatitis

2. Late

a. Cholangitis - retained stone
b. Biliary stricture

 

EXPLORATION OF THE COMMON BILE DUCT
Indications for choledochotomy/choledochoscopy

Abnormality noted on a preoperative or preoperative cholangiogram

Obstructive jaundice not due to pancreatic or ampullary disease

Palpable stones in the bile ducts

 

Factors in considering methods of choledochotomy

Mortality (%]

Cholecystectomy                                                                                                                                                    <1

Supraduodenal choledochotomy                                                                                                                            <2

Transduodenal choledochotomy                                                                                                                             <4

 

Supraduodenal choledochotomy

a. Place two stay sutures either side of the proposed 2 cm longitudinal incision in the common bile duct in the right free border of the lesser omentum
b. Kocherise the duodenum to expose the full length of the common bile duct

c. Incise the common bile duct longitudinally
d. Close the choledochotomy with an absorbable suture over a latex T-tube brought out through a tunnel of greater

omentum

Closure and postoperative management

As for cholecystectomy

 

 

 

 

       

LIVER ABSCESS

BREAST CANCER

INGUINAL HERNIA

FEED BACK OF CHOLECYSTECTOMY

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