OPEN CHOLECYSTECTOMY- OPERATIVE SURGERY
#surgicaleducator #operativesurgery #opencholecystectomy #usmle #babysurgeon #surgicaltutor
Dear viewers,
• Greetings from “Surgical Educator”
• Because of the popular demand by viewers of the YouTube channel “Surgical Educator”, I have decided to create and upload videos on common surgeries.
• I have already uploaded videos on open and Laparoscopic Appendicectomy, Thyroidectomy and Modified Radical Mastectomy.
• In this video today, I have discussed Open Cholecystectomy.
• However, these videos are not real surgeries but the theoretical aspect of operative surgery like going through an atlas of operative surgery.
• Along with these videos, I recommend you to watch real operative surgery videos as well and I will give a link for each surgery in the end of the video as end-cards, which I think will be very useful.
• This will give a very good opportunity for the surgical trainees to mentally rehearse various surgical steps in a sequential manner prior to actual surgery. You can watch the video in the following links:
• surgicaleducator.blogspot.com
• youtube.com/c/surgicaleducator
• Thank you for watching the videos.
2. OPEN CHOLECYSTECTOMY
• INDICATIONS:
Symptomatic Cholelithiasis
Porcelain Gall bladder/ Ca GB
Failed Laparoscopic Cholecystectomy
• ANESTHESIA:
GA/ETT
• POSITION:
Supine- consider Xray table
Rolled towel or sandbag in the
Rt lower chest to bring the GB
forward
• Informed consent- risks of surgery:
Bile leak- biliary fistula 0.5%
Peritonitis 0.1%
Missed stone 1%
Injury to bile duct 0.3%
Injury to liver, duodenum or colon
Vascular injuries to portal vein or hepatic
artery 0.1%
Abscess 0.2%
3. OPEN CHOLECYSTECTOMY
• Incision: Access
Rt upper transverse abdominal-
cosmetically superior
Rt subcostal- Kocher’s incision
• Exposure
Two deaver’s retractors to retract liver
Abdominal pack over duodenum,
stomach and transverse colon and then
retract them inferiorly
4. OPEN CHOLECYSTECTOMY
• Dissection of Calot’s triangle
Incise the peritoneum covering
cystic duct and cystic artery
anteriorly and posteriorly
Grasp fundus of GB with sponge
holding forceps and retract
cephalad
This puts cystic duct on a stretch
• Exposure of cystic duct& cystic artery
Skeletonise cystic duct & cystic artery
Beware of variant anatomy of cystic
duct & cystic artery
Cystic duct is clearly defined only if
you can make out the CHD above the
confluence of Cystic duct with CBD
5. OPEN CHOLECYSTECTOMY
• Division of the cystic duct
After conforming the cystic duct, it
should be divided
Distal part is suture ligated and
the proximal part simple ligature
with vicryl
If suspicious anatomy or suspicious
CBD stone do IOC Intra-op
cholangiogram
• Division of the cystic artery
Cystic artery usually lies cephalad to
cystic duct
Beware of anatomical variations
Ligate it as close to the GB as possible
6. OPEN CHOLECYSTECTOMY
• Retrograde Cholecystectomy
Accomplished by cephalad traction
of GB neck
Fibrous connections with liver are
divided by scissors and hemostasis
is achieved by diathermy
• Antegrade Cholecystectomy- Fundus first
When dissection in Calot’s triangle is
difficult because of dense adhesions
GB is dissected off the liver bed
beginning at fundus first
7. OPEN CHOLECYSTECTOMY
• Hemostasis of GB bed
Separationof GB from GB bed is
done in piecemeal with scissors and
diathermy
Uncontrolled bleeding can be
stopped with local compression,
suturing or with surgicel.
• Drainage of GB bed
After hemostasis of GB bed, inspect
stumps of cystic duct & cystic artery
Consider sub hepatic drain only in
complicated case with lot of dissection for
extensive adhesions
8. OPEN CHOLECYSTECTOMY
• Closure of Abdominal Incision
Kocher’s incision or Rt upper
transverse abdominal incion should
be closed in layers
• Post operative care
Remove NGT on day1 and drain on day2
or 3
Diet: Oral fluids after 4 hrs and then
progress rapidly to semisolids and then
solids
Ambulate the patient immediately
Incentive spirometry or chest physio in
post op period
Advise rest from work for 7 days