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.

1. OPEN
CHOLECYSTECTOMY
DR.B.Selvaraj MS; Mch; FICS;
“ Surgical Educator”
Malaysia
OPERATIVE SURGERY

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

9. THANK YOU