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SURGICAL WEBSITES BREAST DISEASE LIVER ABSCESS Anatomy of liver 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
TREATMENT MODALITIES OF GALL STONES
TREATMENT MODALITIES FOR GALL STONES
Opinion still differ regarding the treatment of gallstones. After confirmation of the diagnosis the following conservative treatment could be offered according to the severity of the disease
i. Keep the patient nil per orally.
ii. I/V fluids.
iii. Nasogastric tube aspiration.
iv. Antibiotics –preferably second generation cephalosporins.
v. Analgesics.
vi. Anti-emetics.
After stabilising the patient one of the options given below can be offered according to the disease progression and general health of the patient.
a. Medical dissolution.
b. Contact dissolution.
c. Electroshock wave lithotripsy.
d. Cholecystostomy.
i. Mini-cholecystostomy of Burden and stoller.
ii. Ultrasound guided percutaneous transhepatic cholecystostomy.
iii. Endoscopic transpapillary drainage of gall bladder.
e. Percutaneous cholecystolitotomy.
f. Subtotal cholecystectomy.
g. Minicholecystectomy.
h. Open cholecystectomy.
i. Laser cholecystectomy.
j. Laser laparoscopic cholecystectomy
k. Laparoscopic cholecystectomy.
a. MEDICAL DISSOLUTION:
Through the years a number of pharmacologic agents have been introduced advocated as safe effective means of dissolving gall stones
INDICATIONS
- Severely ill patients who cannot tolerate surgery.
- Patients unwilling for surgery
- Benefit for Cholesterol stones only.
- Old age.
- Patients with non-operable malignancies.
DISADVANTAGES:
- Recurrence-50% of the patients within 5 years.
- No role on pigment stones
- Expensive
The first major agent to be described which has had some degree of success was chenodeoxycholic acid. This commercially available drug, a primary bile acids which is synthesised in human liver achieves cholesterol gallstones dissolution by inhibiting the rate limiting enzyme in hepatic cholesterol synthesis (HMG-CoA reductase), thereby decreasing the degree of cholesterol saturation of bile. Complete dissolution and disappearance occur in approximately 15% of the patients.
b. CONTACT DISSOLUTION:
The direct instillation into the gall bladder of the agents that are capable of dissolving cholesterol gallstones has become a reality largely as a result of advances in interventional radiology. Methy tert-butyl ether when administered by percutaneous transhepatic catheter dissolves cholesterol stones within minute to hours. The time required for dissolution is probably determined predominantly by the surface are of the stones, the percentage of cholesterol in its composition and the permeability of Methy tert-butyl ether of elements other than cholesterol such as calcium bilirubinate and calcium carbonate especially on the stone surface 109.
INDICATIONS:
- Patient not fit for general anaesthesia.
- Old age.
- Non-operable carcinomas
DISADVANTAGES:
- Recurrence 50% at 5 years.
- As the procedure is invasive therefore there are chances of
- haemorrhage
- catheter related problems
Experience is limited, infusion of a potent cholesterol solvent, methy-tert-butyl ether (MBTE), into the gall bladder via a percutaneously placed catheter has been shown to be effective in selected patients in achieving gall stone dissolution.
c. EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY [ESWL]:
When it was first introduced, biliary lithotripsy was hailed as the ideal way of treating gallstones.
INDICATIONS:
- Limited subsets of the patients.
- Selection depends upon the number size volume and composition of the stones.
DISADVANTAGES:
- Recurrence 50% in 5 years time.
- Use of adjuvant oral dissolution agents.
- Not for all careful patient selection.
- Time---90% of the patients require 18 months
Treatment is associated
- Biliary colic
- Occasional episode of pancreatitis
The rationale for its application was identical with its use for kidney stones, i.e. removal of stones by extracorporeal shock waves. A number of large studies were completed which attempt to define specific criteria for its application and anticipated outcome. In general these addressed the number, size, volume and composition of stones. Recommendations for increasing its efficacy included careful patient selection and use of adjuvant oral dissolution agent. The introduction of laparoscopic cholecystectomy has revolutionised the surgical treatment of gallstone disease. However, it has also raised doubts about the future role of extracorporeal shock wave lithotripsy (ESWL) in the treatment of gallstones 110.
d. CHOLECYSTOSTOMY:
Historically, the first operative procedure used for the treatment of gallstone disease was cholecystostomy with removal of stones.
INDICATIONS:
- Empyaema of gall bladder
- Patient not fit for anaesthesia
- Old age
- Patient unwilling for cholecystectomy.
DISADVANTAGES:
- Recurrence.
It can be performed in three ways
i. MINI-CHOLECYSTOSTOMY OF BURHENNE AND STROLLER:
This is an equally valid approach in poor risk patients with severe acute disease. After the position of the inflamed fundus of the gall bladder is located by ultrasound, a small incision is made over it. Two stay sutures are inserted on either side of the fundus to steady the organ, the fluid contents of which are aspirated. The fundus is opened and stones are removed from the interior by Desjardins’ forceps. Foley catheter is placed for drainage, which is removed seven to ten days later. If no obstruction exist removal of the catheter will be followed by closure of the biliary fistula with in a week.
ii. ULTRASOUND-GUIDED PERCUTANEOUS TRANSHEPATIC CHOLECYSTOSTOMY
iii. ENDOSCOPIC TRANS PAPILLARY DRAINAGE OF GALL BLADDER.
Available data suggest that good outcomes and minimal morbidity can perform these procedures relatively safely.
The time horoured alternative to cholecystectomy is cholecystostomy. Welch and Malt reported retained stones in gallbladder or in common bile duct in 27% of the patients who survived cholecystostomy with others reporting this condition in 75% of the patients 111. Winkler et al have reported a mortality rate of 5% with cholecystostomy but 70% of their surviving patients underwent cholecystectomy 6-8 weeks later 112. The mortality may be higher due to the fact that the patients presented with a complicated condition, difficult to manage surgically. Although this approach necessitates subsequent operation, cholecystectomy performed in the survivors resulted in no mortality and only minor morbidity. Therefore a second definitive operation should not be an argument against performing cholecystectomy as an initial procedure 113.
e. PERCUTANEOUS CHOLECYSTOLITHOTOMY:
INDICATIONS:
Previous vagotomy for ulcer disease.
DISADVANTAGE:
- Recurrence.
- Use of adjuvant oral bile salts.
PROCEDURE:
In this procedure, a puncture is made in the gall bladder under ultrasound control. The tract so created is dilated to 30 Fr and an Amplatz tube inserted. A nephroscope is passed into the gall bladder and stones are removed. This procedure is ideal for those who have a percutaneous cholecystostomy, those who are unsuitable for a cholecystectomy on account of illness and those who wish to retain their gall bladder 114.
OTHER OPTION:
Laparoscopic cholecystotithotomy
f. SUBTOTAL CHOLECYSTECTOMY:
INDICATIONS:
- An alternative approach to cholecystectomy
- In patients whom formal cholecystectomy is considered hazardous.
DISADVANTAGES:
Risk of Gram negative bacteraemia.
PROCEDURE:
The operation is carried through right subcostal or transverse incision. After division of the adhesions the area of Calot's triangle is inspected and decision can be taken to perform subtotal rather than total cholecystectomy 115. The posterior wall of the gall bladder is left in situ attached to the liver bed, and the cystic duct is secured from within the gall bladder lumen by a purse-string suture. The bile and pus are sent for the bacteriological culture. Pus is thoroughly evacuated and peritoneal lavage, preferably with an antibiotic solution, carried out when gross peritoneal sepsis is found. All patients require a full course of antibiotic therapy for a minimum of seven days.
g. MINI CHOLECYSTECTOMY:
A few surgeons still practice this surgery. The postoperative pain is less and operative scar is acceptable 116.
INDICATIONS:
Thin individuals and reduces the hospital stay and morbidity 117.
DISADVANTAGES:
Improper exposure therefore, if any complication occurs, it is difficult to handle.
Recovery is slower than that following laparoscopic cholecystectomy 118.
PROCEDURE:
It is performed through a 5.0 cm subcostal incision, with the introduction of a circular retractor leading to the sub hepatic space. The gall bladder is mobilised from the fundus downward to the cystic duct. Both the cystic artery and duct are clipped.
h. OPEN CHOLECYSTECTOMY:
This procedure is performed in most hospitals through out the world and is associated with minimal morbidity and mortality. The most significant morbidity, bile duct injury occurs in less than 0.2 percent of the patients and the mortality is less than 0.5 percent. By performing this operation for the appropriate indication, symptom relief is achieved in almost all cases.
INDICATIONS:
- Recurrent biliary colic.
- Acute cholecystitis.
- Empyaema, perforation, Mucocele etc of the gall bladder.
- Chronic cholecystitis.
- Carcinoma of the gall bladder.
DISADVANTAGES:
- Scarring.
- Prolonged hospitalisation.
- Delayed return to work.
- Incision hernia.
- Deep Vain Thrombosis.
- Basal lung Atelectasis.
ANAESTHESIA:
General inhalation anaesthesia.
POSITION:
Supine.
PROCEDURE:
Procedure is discussed in detail in the conversion to laparotomy section.
i. LASER CHOLECYSTECTOMY:
INDICATIONS:
Patients who have chronic cholecystitis and admitted for elective cholecystectomy.
DISADVANTAGES:
Not every hospital has this facility.
PROCEDURE:
The subcostal incision was marked with a scalpel and the remainder of all sharp dissection was performed utilising the Nd:YAG laser. Haemostasis for the majority of vessels encountered was performed utilising the heat of the side of one scalpel tip. The steps of operation are same as of open cholecystectomy. However the cystic artery was doubly clipped and divided when encountered 119.
j. LASER LAPAROSCOPIC CHOLECYSTECTOMY:
The procedure is the same as laparoscopic cholecystectomy except using the laser for dissection. The lasers are KTP/YAG, argon, Nd:YAG and CO2. Laparoscopic cholecystectomy is now an accepted part of general surgery. With the recent upsurge of interest in laparoscopic techniques, an optimum method of ensuring secure haemostasis is important particularly during dissection of the gall bladder from its mesenteric attachments 120.
k. LAPAROSCOPIC CHOLECYSTECTOMY:
Discussed in detail in section on laparoscopy.
MANAGEMENT PROTOCOLS AND GUIDELINES OF BILIARY STONE DISEASE
1. Classifying the Biliary Stone Disease Patient
A. Asymptomatic Cholelithiasis:
Incidental Finding on Sonogram
Acute Cholecystitis:
Cholelithiasis on Sonogram, clinical Cholecystitis diagnosis or Positive Pipida Scan
Symptomatic Cholelithiasis:
Positive Sonogram, normal Liver Function Tests
B. Cholelithiasis with suspected choledocholithiasis:
Abnormal Liver Function Tests (Serum Transaminases elevation or Bilirubin >3.0, gallstone pancreatitis)
D. Cholelithiasis with Choledocholithiasis:
CBD Stone on Sonogram, MRI Cholangiography or Jaundice
F. Cholelithiasis with Resolving Gallstone Pancreatitis:
Pancreatitis on Sonogram, CAT or MER, Cholangiography or clinically, documented. High Serum Amylase and Lipase with decreasing Serum Pancreatic Enzymes after initial attack
1. Choosing the Appropriate Routine Management Protocol
MANAGEMENT PROTOCOLS FOR UNCOMPLICATED BILIARY STONE DISEASES
PROPOSED MANAGEMENT
A. Asymptomatic Cholelithiasis
No Surgical Intervention
B. Asymptomatic Cholelithiasis in Diabetic Patients
No Surgical Intervention
C. Symptomatic Cholelithiasis or Acute Cholecystitis.
Laparoscopic cholecystectomy.
C. Symptomatic Cholelithiasis with Suspected Choledocholithiasis
C. Laparoscopic cholecystectomy with Insertion of Cystic Duct Cannula with Cholangiography, if Choledocholithiasis, post operative ERCP
E. Symptomatic Cholelithiasis with Choledocholithiasis
Laparoscopic cholecystectomy with Insertion of Cystic Duct Cannula with Cholangiography, if choledocholithiasis, post operative ERCP. Laparoscopic cholecystectomy and common bile duct exploration is a highly successful procedure for the management of common duct stones in an unselected group of patients. Choledochotomy with choledochoscopy is the preferred method of common bile duct exploration 121.
F. Cholelithiasis with Resolving Biliary Pancreatitis
Treatment of biliary pancreatitis with combined laparoscopic cholecystectomy and selective ERCP is safe and effective and is associated with a shorter hospitalisation and fewer common bile duct exploration than open cholecystectomy 122. Laparoscopic cholecystectomy can be done with insertion of cystic duct cannula with Cholangiography.
G. Cholelithiasis with Unresolved Biliary Pancreatitis
After acute phase subsides, MRI Cholangiography or ERCP, if Choledocholithiasis ERCP followed by laparoscopic cholecystectomy.
H. Asymptomatic Gallbladder Polyps.
No Surgical Intervention
I. Symptomatic Gallbladder Polyps
Laparoscopic cholecystectomy.
J. Acute Cholecystitis.
Laparoscopic cholecystectomy.
K. Severe, Gangrenous Cholecystitis with Subhepatic Phlegmon
Laparoscopic cholecystectomy, if not safely feasible, Anterior laparoscopic cholecystectomy.
L. Post Cholecystectomy (Lap or open) Suspected Choledocholithiasis
MRI Cholangiogram or ERC
M. Post Cholecystectomy (Lap or open) Choledocholithiasis
ERCP, if failure then Laparoscopic Common Bile Duct Exploration.
ANAESTHESIA IN LAPAROSCOPIC SURGERY
Washington, DC Registry
Last modified: Monday, 29-Nov-2004 07:35:56 EST |
