Surgical Procedures/Abdominal Surgery/Cholecystectomy/Open

Introduction:

 * Cholecystectomy performd by Open method.

Indication:

 * If laparoscopic cholecystectomy is contraindicated
 * Intra operative conversion during laparoscopic cholecystectomy
 * Gallbladder carcinoma
 * Cholecystitis
 * Cholelithiasis
 * ?Biliary dyskinesia.

Contraindication:

 * Contraindicated if laparascopic cholecystectomy is indicated and can be performed.

Advantages:

 * Better exposure during surgery
 * Less risk of wound infection
 * Less days off work

Disadvantages:

 * Larger incision is made and leaves large scar.
 * Longer hospital stay
 * &ge; 5 days.
 * Longer recovery time.
 * Post-operative pain.

PreOperative management:

 * Glucose Drink 150mg/Day x 3 days.
 * If NPO:
 * 5% Dextrose I.V.
 * PreOP. BroadSpectrum Antibiots.
 * Preop Investigations:
 * Oral Cholangiogram.
 * If Charcot's Triad present:
 * I.V cholangiography.

Anaesthesia
(Anaesthesia will not be mentioned here.)
 * Commonly:
 * Endotracheal Sedation.

Incision.
Types of Incision:
 * Upper Right SubCostal Incision.
 * Kocher's Incision.
 * Modified Kocher's Incision.
 * Transverse Incision.

Mop placement

 * 2 wet mops are placed.
 * One Wet Mop is placed to displace the duodenum, the transverse colon and coils of small intestine.
 * Second Wet Mop is placed slightly to the left of the Common Bile Duct (CBD) to displace the stomach to the left.

Step III
(After 2 wet mop placement.)

Exposure of GallBladder:
Exposure of GallBladder is done by:
 * Retraction of liver.
 * Inferior surface of the right lobe of the liver is retracted upwards by the most appropriate retractor available.
 * e.g Deaver's retractor or most commonly the harrington retractor (aka the sweetheart).

Removal of GallBladder.
2 common methods for removal of GB:

Duct first method:

 * Cystic Duct and Artery are dissected first and divided, after which GallBladder is removed.
 * Indication:
 * Indicated if no presence of adhesions or exudates in CBD, CHD, CD.
 * Contraindication:
 * Contraindicated in the presence of adhesions or exudates in CBD, CHD, CD.
 * Advantages:
 * Less chance to injure:
 * CBD.
 * Right Heptic Artery.
 * Disadvantages:

Fundus First method:

 * Dissection is started from Fundus of the GallBladder and gradually proceeded towards the Cystic Duct, which is divided last of all.
 * Indication:
 * Indicated in the presence of adhesions or exudates in CBD, CHD, CD.
 * Contraindication:
 * Contraindicated in no presence of adhesions or exudates in CBD, CHD, CD due to disadvantages.
 * Advantages:
 * Gallbladder can be removed in the presence of adhesions or exudates in CBD, CHD, CD.
 * Disadvantages:
 * More chance to injure:
 * CBD.
 * Right Heptic Artery.