.

1. Surgical
Management
of Gall Stone
Diseases
Dr. Waqar Saeed
PGR GSU4

2. Anatomy of
the biliary tract
Valves of heister

3. Common bile duct: 10cm in length and 7mm
in diameter.

4. • CBD tunnels through
the groove behind the
head of pancreas and
ends obliquely through
posteromedial wall of 2nd
part of duodenum
(descending)

6. Indications of cholecystectomy

7. Contraindications of cholecystectomy

8. Incisions of open cholecystectomy
• Rooftop/ Bilateral subcostal incision
• Kocher’s subcostal incision
• Right upper quadrant transverse incision
• Uppermidline incision

9. • Mayo Robson incision/ hockey
stick incision: combination of
upper midline and a medial
subcostal incision

10. Cholecystectomy
Emergency
cholecystectomy
Golden <24
hours
Silver 24-72
hours
Interval/ elective
cholecystectomy

11. Indications of emergency cholecystectomy
• Empyema GB
• Emphysematous Cholecystitis
• GB perforation

12. Principle methods
of removing gall
bladder
Retrograde
method
Antegrade
method
Retrograde method/
Fundus first method:
During laparoscopic
retrograde
cholecystectomy, the
gallbladder is removed
from the fundus
downward, rather than
from the cystic duct.

13. Principle methods
of removing gall
bladder
Retrograde
method
Antegrade
method
Antegrade Cholecystectomy: Early
delineation of key structures. Ligature/
clamping of cystic duct and
cholecystectomy done.

14. Calot’s
Triangle
Calot’s triangle is orientated so that its apex is directed
at the liver. The borders are as follows:
• Medial – common hepatic duct.
• Inferior – cystic duct.
• Superior – inferior surface of the liver.
The contents of the Calot’s triangle include:
• Right hepatic artery – formed by the bifurcation of
the proper hepatic artery into right and left branches.
• Cystic artery – typically arises from the right hepatic
artery and traverses the triangle to supply the gall
bladder.
• Lymph node of Lund – the first lymph node of the
gallbladder.
• Lymphatics

15. • Rouviere's sulcus is a 2-5 cm fissure on the liver between the right
lobe and caudate process. The benefit of finding the Rouviere's sulcus
during laparoscopic cholecystectomy is supported by the fact that the
cystic duct and artery lay anterosuperior to the sulcus, and the common
bile duct (CBD) lays below the level of the Rouviere's sulcus
Rouviere’s
sulcus

16. Cholecystostomy
• The gallbladder can be punctured with a
trocar needle-catheter or by using a
Seldinger technique.
• Fundus and gall bladder are opened,
gallstones and biliary sludge are removed
• Tube is left insitu for several weeks and then
removed.
Indications of cholecystostomy
• Critically ill patients who cannot
undergo cholecystectomy
• Elderly patients
• History of severe CAD
Most clinicians prefer a transhepatic approach because a transperitoneal approach poses a risk
of bile peritonitis. However, a transperitoneal approach can be used if the gallbladder is greatly

17. Choledochotomy Indications
• Failure of endoscopic extraction of the stone, large or occluding.
• Perioperative imaging and preop cholangiography is not available
• Stone proximal to the junction of CBD and cystc duct.
• Severe inflammation of Calot’s triangle rendering difficult anatomy of
cystic duct

18. Peritoneum over the supra
duodenal portion of CBD is
incised, peritoneum is cleared
along with fatty tissue over a
distance of 1.5cm
Stay sutures are are applied
along the lateral borders of the
the duct and 1.5 to 2cm
incision is made between
them and bile is then
aspirated.

19. Fogarty catheter is
inserted downward
until the duodenum
has been reached.
And all stones are
retrieved.

20. Thank You