Cholecystectomy open versus laparoscopic surgery

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Cholecystectomy open versus laparoscopic surgery

  1. 1. Cholecystectomy: Open Versus Laparoscopic Surgery. Dr Imran Javed. Associate Professor Surgery. Fiji National University.
  2. 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. 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. 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. 5. Dissection in Calot’s 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. 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. 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. 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. 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. 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.

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