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- 1. Laparoscopic Cholecystectomy Capt Umar Farooq House Surgeon Supervisor Lt Col Muhammad Saeed Akhtar Assistant Professor and HOD Surgery Consultant General and Laparoscopic Surgeon
- 2. Case History • Name : Razia • Age : 22 yrs • Gender : female • Occupation : housewife • Resident of : Layyah 2
- 3. Presenting Complaints 3 • Pain right upper abdomen • Nausea & Vomiting 2 days
- 4. History of Present Illness • Pain - Sudden, continuous, sharp, radiating to right shoulder • Vomiting - Non projectile , initially containing food particles then became greenish • Fever – Low grade, intermittent, not associated with rigors & chills 4
- 5. Case History • Past history • Family history • Personal history • Socioeconomic history 5
- 6. General Physical Examination 6 • Vital signs: Pulse :88/ min BP : 120/80 mmHg Temp : 98.6 F R/R : 20/min • Relevant Physical Exam
- 7. Systemic Examination • Abdomen • Flat, inverted umbilicus • Tenderness in RHC • Murphy’s Sign – present • Percussion - tympanatic 7
- 8. Systemic Examination • Cardiovascular system • Respiratory system NAD • Central nervous system 8
- 9. Investigations 9 • Blood CP ―TLC - 10 x 109 ―Neutrophils – 90% ―Hb - 11 gm/dl • Urine RE • RFTs WNL
- 10. Investigations 10 • LFTs • Serum Amylase WNL • CXR
- 11. Investigations • USG Abdomen ―Thick walled Gall bladder about 3.9mm ―Multiple calculi in the GB largest measuring 11mm ―Small amount of peri cholecystic fluid ―No intra or extra hepatic dilatation 11
- 12. Definitive Diagnosis • Acute calculus cholecystitis 12
- 13. Management • Hospitalize • NPO • I/V fluids • I/V antibiotics • Analgesics 13
- 14. Response • Patient responded well to conservative treatment • Pain relieved • Fever and vomiting settled • Started oral intake and tolerating 14
- 15. Plan • Discharged on the 3rd day of admission • Pre – Anesthesia Assessment • Follow up of the patient after 6 weeks • Laparoscopic cholecystectomy 15
- 32. Post op • Patient had an uneventful recovery • Started oral intake after 6 hrs • Mobilized out of bed after 6 hrs • Discharged on 1st post op day 32
- 34. Acute Cholecystitis • Acute inflammation of gall bladder • Calculus cholecystitis – “obstruction of cystic duct by gallstone” • Acalculus cholecystitis - Sepsis - Prolonged parentral nutrition - Diabetes - Cardiovascular disease 34
- 35. Cholelithiasis Prevalence • Fat • Fertile • Flatulent • Female • Forty Years of age Reference : Bailey and Love’s Short Practice Of Surgery 26th Edition 35
- 36. Clinical Presentation • Pain and tenderness right hypochondrium • Association of pain with large fatty meal • Radiating to right shoulder • Low grade fever • Nausea and vomiting 36
- 37. Investigations • Blood CP • LFTs • RFTs • S. Amylase • Ultrasonography 37
- 39. Investigations • CT- Scan abdomen • ERCP • MRCP 39
- 40. Treatment • Hospitalize • NPO • I/V fluids • I/V antibiotics • Analgesics • Surgery 40
- 41. Cholecystectomy • Surgical removal of GB • Asymptomatic/incidental gallstones do not require operation • Indications ―A single complication includes biliary colic, gall stone cholecystitis and pancreatitis ―Risk of recurrent complications is high 41
- 42. Cholecystectomy When To Perform? • After acute cholecystitis, cholecystectomy traditionally performed after 6 weeks • Arguments for 6 weeks later • Laparoscopic dissection more difficult when acutely inflammed GB • Surgery not optimal when patient septic/dehydrated 42
- 43. Laparoscopic Cholecystectomy 43 • Advantages: ― Less post-op pain ― Shorter hospital stay ― Quicker return to daily life activities • Limitations: ― Conversion to Open method
- 44. Post Op • Fluids – 6 hrs post op • Soft diet – evening / next day • Patients can be sent home the same day • Fatty meal - avoided in first 6 weeks post op 44
- 45. Take Home Message • Patient with recurrent, non remitting dyspepsia - ultrasound • Ultrasound abdomen - 12hrs empty stomach to visualize GB • Laparoscopic cholecystectomy is the gold standard treatment for cholelithiasis • Symptomatic Gallstones – should undergo surgery • Laparoscopic cholecystectomy is a day care surgery 45
Editor's Notes
- Worthy commandant respected offrs and dear colleagues aoa today i will be presenting a case of acute cholecystitis managed by laparoscopic cholecystectomy.
- My patient was in usual state of health 02 days back when he experienced sudden onset of pain in epigastrium and right hypochondrium , the pain was continuous, sharp in character, radiating to right shoulder and inter scapular region, not relieved by painkillers, and was associated with nausea and 2 episodes of vomiting, which was non projectile about half cup of tea in amount initially containing food particles later become greenish in color, no hx of hematemesis. There was low grade intermittent fever not associated with rigors or chills relieved by medicines.
- My Patients had no co morbids. she is non smoker and non addict. My patient is married with 3 son and 1 daughters all healhty and belongs to a middle socioeconomic background
- My patient was of avg build, lying on bed, conscious and well oriented in time, place and person. His Pulse was 88 per min, BP 120/80mm of Hg. He was afebrile and had a R/R of 20 breaths per min. There was no pallor, jaundice, edema, his lymph nodes & thyroid was not palpable, JVP was not raised.
- Abdominal examination showed a flat abdomen with inverted umbilicus. There were no scars marks or visible, dilated veins There was marked tenderness in RHC and epigastric region. MURPHY’s sign was present. Percussion note was tympanatic all over the abdomen. Fluid shift & thrill was absent. Hernial orifices were intact, bowel sounds were audible. On DRE there were soft stools in the rectum. CLICK!
- Rest of the systemic examination was unremarkable.
- Patient admitted in surgical ward and following investigations were carried out on urgent basis
- Patient admitted in surgical ward and following investigations were carried out on urgent basis
- Thick walled Gall bladder with wall thickness of 3.9mm, multiple calculi largest measuring 11mm and small amount of peri cholecystic fluid seen.
- Patient responded well to conservative treatment, she became pain free, fever and vomiting settled. she was started on oral fluid after 24hrs which he tolerated well.
- Patient was discharged on the 3rd day of admission after pre anesthesia assessment. sHe was booked for laparoscopic cholecystectomy after 6 weeks.
- On entering the abdominal cavity through laparoscope ports this is the gall bladder under the anterior border of liver CLICK
- Gall bladder was elevated to visualize the calot’s triangle.CLICK
- Calot’s triangle showing adhesions. CLICK
- Dissection was carried out in calot’s triangle with the help of maryland dissecter, CLICK
- This is the cystic duct dissected out & separated CLICK
- And clips were applied.,CLICK
- After applying the clips the cystic duct was cut with scissors, .
- Here the dissected cystic artery can be seen.
- Here the dissected cystic artery can be seen and dissection of the GB started from the liver bed.
- Here u can see the dissected part of GB from the liver bed.
- GB is separated from the attached part of the liver. CLICK
- This is the post dissection part of the liver showing no bleed and no discharge. CLICK
- GB is removed out of the abdomen through the epigastric port. CLICK
- GB is out of the abdomen. CLICK
- This is the opened GB showing gall stones. CLICK
- Patient had an uneventful recovery. He Started oral intake after 6 hrs Mobilized out of bed after 6 hrs And was Discharged on 2nd post op day.
- Now, I would talk about the literature review of the topic...CLICK
- Acute inflammation of gall bladder is called acute cholecystitis There are two types of acute cholecystitis , calculus and acalculus.
- Fat , fertile ,flatulent, female of forty suffer from cholelithiasis the most
- Pain and tenderness right hypochondrium Association of pain with large fatty meal Radiating to right shoulder Low grade fever Nausea and vomiting
- USG confirms diagnosis (gallstones, thickened gallbladder wall, peri-cholecystic fluid)
- Cholescintigraphy is scintigraphy of the hepato billiary tract including GB and bile ducts. It’s a nuclear medicine procedure to visulise the GB and CBD ERCP…endoscopic retrograde cholangio pancreatography therapeutic as well as diagnostic. MRCP magnetic rasonance cholangio pancreatography diagnostic.
- Surgical removal of GB is called cholecystectomy. Asymptomatic gallstones do not require operation A single complication of gallstones is an indication for cholecystectomy (this includes biliary colic, gall stone cholecystitis and pancreatitis) After a single complication risk of recurrent complications is high