viii.surgical management

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VIII. SURGICAL MANAGEMENT

Type of operation

Open Cholecystectomy with Biliary ExplorationCholedochoduodenostomy

Definition:

A cholecystectomy is the surgical removal of the gallbladder

A choledochoduodenostomy is the surgigal creation of a passage uniting the common bile duct and

the duodenum.

Discussion:Cholecystectomy may be performed to treat chronic or acut cholecystitis, with or without

cholelithiasis, or to resect a malignancy.

Choledochoduodenostomy may be performed for a biliary bypass operation are benign biliarystrictures and malignant obstruction of the biliary system caused by pancreatic or biliary ductal

carcinomas.Indicated mainly in patients with recurrent stones, giant stones, or concominantcommon bile stricture and stones.

Note:

Cholecystectomy, perfomed laparospically, is the preferred treatment for symptomatic gallstones

unless the patient is extremely obese, there are excessive adhesions, or ductal or vascular anomaliesexist. If unexpected pathology is encountered, if acute inflammation distorts normal tissue planes,

or if there is excessive bleeding or surgical injury, the laparoscopic procedure is promptlyconverted to open cholecystectomy.

Choledochoduodenostomy is also useful for preventing cholangitis caused by recurrent stones in

patients with chronic disease, such as chronic heart failure, chronic respiratory failure, and diabetes.Main indication for biliary obstruction either benign or malignant.


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Type of Anesthesia

Spinal Anesthesia Block- is induced by injecting small amounts of local anaesthetic into the cerebro-spinal fluid (CSF). Theinjection is usually made in the lumbar spine below the level at which the spinal cord ends (L2).

Spinal anaesthesia is easy to perform and has the potential to provide excellent operating conditionsfor surgery below the umbilicus.

Table 1 Equipment f

IInstrumentation/ Device Number Size Comments

Laparoscopic cartHigh-intensity halogen light source(150300 watts)

High-flow electronic insufflator(minimum flow rate of 106 L/min)

Laparoscopic camera boxVideocassette digital video and still image

recorder (optional)

Digital still image capture system (optional)Laparoscope 1 3.5-10mm Available in 0 and angled views; we prefer to use a 30

5 mm diameter laparoscope

Atraumatic grasping forceps 2-4 2-10mm Selection of graspers should allow surgeon choiceappropriate to thickness and consistency of gallbladder

wall; insulation is unnecessary

Large-tooth grasping forceps 1 10mm Used to extract gallbladder at end of procedure


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Curved dissector 1 2-5mm Should have a rotatable shaft; insulation is required

Scissors 2-3 2-5mm One curved and one straight scissors with rotating shaftand insulation; additional microscissors may be helpfulfor incising cystic duct

Clip appliers 1-2 5-10mm Either disposable multiple clip applier or 2 manuallyloaded reusable single clip appliers for small and

medium-to-large clips; 5 and 10 mm diameter

Dissecting electrocautery hook or spatula 1 5mm Available in various shapes according to surgeons

preference; instrument should have channel for suction

and irrigation controlled by trumpet valve(s); insulationrequired

High-frequency electrical cord 1 Cord should be designed with appropriate connectors

for electrosurgical unit and instruments being used

Suction-irrigation probe 1 5-10mm Probe should have trumpet valve controls for suction

and irrigation; may be used with pump forhydrodissection

10-to-5 mm reducers 2 Allow use of 5 mm instruments in 10 mm trocarwithout loss of pneumoperitoneum; these are often

unncessary with newer disposable trocars and may bebuilt into some reusable trocars

5-to-3 mm reducer 1 Allows use of 23 mm instruments and ligating loops

in 5 mm trocars

Ligating loops

Endoscopic needle holders 1-2 5mm

Cholangiogram clamp with catheter 1 5mm Allow passage of catheter and clamping of catheter

in cystic duct

Veress needle 1 Used if initial trocar is inserted by percutaneous

technique

Allis or Babcock forceps 1-2 5mm Allow atraumatic grasping of bowel or gallbladder


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Long spinal needle 1 14gauge Useful for aspirating gallbladder percutaneously in

cases of acute cholecystitis or hydrops

Retrieval bag 1 Useful for preventing spillage of bile or stones inremoval of infl amed or friable gallbladder; facilitatesretrieval of spilled stones

A cholecystectomy with choledochoduodenostomy was performed with patient under Spinal Anesthesia Block in supine position, a

right subcostal incision was made; the adhesion was released, and the area of the hepatoduodenal ligament was dissected. The

cholecystectomy was performed in the usual manner.

A right subcostal incision is usually performed.The duodenum is widely mobilized by generous Kocher maneuver, so that it can be

approximated to the common bile duct without tension. A 2.0- 2.5 cm longitudinal incision is made in the distal common bile duct as

close as possible to the area of stenosis or obstruction in patients with benign disease. In patients with a stricture, the bile duct is

divided and the stricture excised. The duodenum and duct are joined by a posterior or row of interrupted 3-0 silk sutures. Theduodenum is opened longitudinally for a distance of 2.0- 2.5cm and a second row of interrupted 3-0 or 4-0 chromic catgut. Sutures is

placed to approximate the ductal and duodenal mucosa. A T-tube is used in patients with thin walled ducts or difficult anastomosies. A

final row of interrupted 3-0 silk sutures completes the anterior row of anastomosies.

viii.surgical management

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