Cholecystectomy open versus laparoscopic surgery

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Cholecystectomy: Open Versus Laparoscopic Surgery. Dr Imran Javed. Associate Professor Surgery. Fiji National University.

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Transcript of Cholecystectomy open versus laparoscopic surgery

  • 1. Cholecystectomy: Open Versus Laparoscopic Surgery. Dr Imran Javed. Associate Professor Surgery. Fiji National University.

2. Indications Chronic Cholecystitis. Cholelethiasis. Acute on Chronic Cholecystitis. Acute Cholecystitis with complications. Empyema Gallbladder. Gangrenous Gallbladder. Perforated Gallbladder. Trauma to Gallbladder. Choledocholesthiasis. As a part of other procedure like Whipple Procedure. Carcinoma Gallbladder. Direct Invasion of Hepato-cellular carcinoma. Metastasis to gall bladder. Prophylactic Cholecystectomy in high risk patients. Parasitic Infestation of Gallbladder like in Ascariasis. 3. Open Procedure Preoperative Considerations: Consent Nill by mouth for 6 hrs. Intravenous Fluids. Prophylactic Broad Spectrum Antibiotics. Anesthesia fitness for General Anesthesia especially with related to respiratory function. Control of Hypertension & DM in affected patients. Arrangement of 1-2 pints of cross-matched blood. Correction of Any bleeding or clotting disorder. 4. Operative Method Right Sub-costal Incision. Right Transverse upper abdominal Incision. Upper Midline Incision. Muscle Cutting variety of incision. Hemostasis. Division of Right Rectus Abdomenis Muscle versus retraction. Ligation of Right Superior Epigastric Artery. Placement of Retractors and abdominal Sponges. 5. Dissection in Calots Triangle Use of Sponge Holder to hold fundus of gall bladder. Dissection of Cystic Duct & Cyst Artery by gentle pull on gallbladder after division of Peritoneal reflection. Ligation and Division of Cystic Artery & Cystic Duct with Lahey Forceps (Right Angle Forceps). Dissection of gallbladder from liver bed. Hemostasis. Drain Versus no Drain. 6. Closure of the Wound After adequate Hemostasis & removal of abdominal packs closure of posterior rectus sheath with absorbable sutures. Anterior Rectus Sheath is closed in continuous fashion by Non-Absorbable sutures. Skin Closure by Interrupted Sutures. Sterile Dressing Techniques. Connecting Drain if placed with gravity drainage container. 7. Postoperative Management Nill by mouth till bowl sounds are present. Continue Intravenous fluids till patient is oral free. Adequate Analgesia. Continue Intravenous Antibiotics for 72 hours and then change to oral for one week. Change of dressing if soaked early otherwise after 72 hours. Removal of drain when drainage is minimal. Removal of Sutures when wound is healed. Anti-ulcer therapy if needed. DVT Prophylaxis. Send specimen for Histopathology and stones for chemical Analysis if present. 8. Laparoscopic Approach Traditional approach is 4 port but SILS has become available as well now a days. Has become a gold standard approach for gallbladder removal. If fails then convert to Open Procedure. Difficult to perform in Patients with Previous open Abdominal Surgeries. Carries some increased risk of extra-hepatic duct injuries. Recovery is better and early than open surgery. Needs specialized equipment & training of personnel. Usually avoided in cases of suspected malignant Disease. 9. Technical Considerations 4 ports (Umbilical, Epigastric & 2 subcostal). Umbilical is used for Camera. Subcostal (upper to hold gall bladder from neck & Lower from fundus) Epigastric port is for Dissector, Cautery, Sucker, Clip Placement & removal of Gall bladder. Varus Needle for Insufflation of CO2 into the peritoneal cavity. Lower Subcostal port may be used for Drain if needed. After surgery Epigastric & Umbilical Port may need one stich for closure other ports may be closed by sterri-strips or simple dressing. Post Operative Course is early recovery with shorter hospital stay. 10. Comparison Open Approach Easy. Can be done in peripheral centers. Cost effective. Less extra hepatic injuries. May have more post operative respiratory complications. Cosmetically not good. Hospital Stay is longer. Usually Reserved for failed laparoscopic cases & malignant Disease. Laparoscopic Approach Needs special equipment & training of personnel. Learning Curve & Good Hand eye coordination needed. Cost is higher. Extra-hepatic duct injuries are more than open approach. Hospital stay is shorter. Lesser post operative complications. Avoided in Malignant Disease. If fails then have to proceed towards open approach. Has become Gold standard treatment for Gall bladder Surgery.