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General Surgery
Cholecystitis and Cholelithiasis
Built from Maingot's Abdominal Operations
What’s inside
17 sections · 135 slides
Overview
- Topics covered
- Key terms in gallbladder surgery
Background and current practice
How gallbladder removal became a keyhole operation
- Cholecystectomy in current practice
- Development of cholecystectomy
- Documented advantages of the laparoscopic approach
- Effect of laparoscopy on operation rates
Indications for cholecystectomy
Who benefits from having the gallbladder removed
- Symptomatic cholelithiasis
- Biliary colic
- Natural history once symptoms begin
- Complications of gallstone obstruction
- Indications for laparoscopic cholecystectomy
- Asymptomatic gallstones
- Accepted grounds for prophylactic cholecystectomy
- Sickle cell disease
- Gallstones after bariatric surgery
- Gallstones in transplant recipients
- Other situations favouring prophylactic removal
- Biliary symptoms without gallstones
- Rome criteria for gallbladder dyskinesia
- Gallbladder polyps
- Porcelain gallbladder
Diagnostic studies
The tests that confirm biliary disease before operating
- Blood tests in suspected biliary disease
- Abdominal ultrasound
- Negative ultrasound with typical symptoms
- Atypical symptoms in a patient with gallstones
Contraindications and patient selection
When the keyhole route is unwise, and when no operation is
- Changes in the contraindication list
- Contraindications to laparoscopic cholecystectomy
- Absolute contraindications
- Diffuse peritonitis with hemodynamic compromise
- Suspected gallbladder malignancy
- Relative contraindications
- Laparoscopic cholecystectomy in pregnancy
- Technical precautions in the pregnant patient
- Acute cholecystitis and the laparoscopic approach
- Timing of surgery in acute cholecystitis
- Percutaneous cholecystostomy
- Continuing role of open cholecystectomy
Biliary anatomy and its variations
Why anomalies are the rule rather than the exception
- Frequency of classic biliary anatomy
- Variations of the cystic duct
- Variations of the cystic artery
- The common bile duct
- Hepatocystic triangle and Calot's triangle
- Aberrant right hepatic duct
- Cystic duct insertion patterns
- Accessory right hepatic duct variants
Preparation and operating room setup
Getting patient, team and working space ready
- Preparation before the operation
- Preparation in the operating room
- Operating room layout
- Pneumoperitoneum
- Closed and open entry into the abdomen
- Laparoscope choice and patient position
- Accessory port placement
- Instrument orientation and grasping the gallbladder
- Retraction of the gallbladder
- Difficult exposure and adhesions
Dissection and the critical view of safety
The step that prevents bile duct injury
- Principles of the dissection
- Opening the hepatocystic triangle
- Clearing the cystic duct and artery
- Critical view of safety
- Two structures crossing a window of liver
- Sequence of laparoscopic cholecystectomy
Imaging the bile duct during the operation
Cholangiography and laparoscopic ultrasound
- Indications for imaging the duct
- Performing intraoperative cholangiography
- Reading the operative cholangiogram
- Dividing the duct after cholangiography
- Laparoscopic ultrasound of the bile duct
- Comparison of ultrasound and cholangiography
Completing the cholecystectomy
Clipping, detaching, extracting and closing
- Dividing the cystic duct
- Dividing the cystic artery
- Checking the ligated stumps
- Separating the gallbladder from the liver
- Final checks before detaching
- Removing the gallbladder from the abdomen
- Choice of extraction site
- Extraction technique
- Closing the wounds
- Recovery and discharge
Advantages and disadvantages
What the keyhole route gains, and what it gives up
- Advantages over other treatments
- Advantages and disadvantages compared with open surgery
- Disadvantages of the laparoscopic approach
Conversion and the open operation
Switching route, and how open cholecystectomy is done
- Conversion to open operation
- Triggers for converting to an open operation
- Duct stones that force an open operation
- Incision and exposure in open cholecystectomy
- Identifying the structures in open surgery
- The fundus-first technique
- Ligation of the cystic duct and artery
- Pitfalls of the open operation
- Subtotal cholecystectomy and closure
Operating on acute cholecystitis
A harder operation, and the case for doing it early
- Findings in early acute cholecystitis
- Inflammation extending to the porta hepatis
- The subacute phase
- Early versus delayed surgery: hospital stay
- Randomized comparison of early and delayed surgery
- Predictors of a successful laparoscopic operation
- Laparoscopic versus open surgery in acute cholecystitis
- Conclusion on timing
Perforation and spilled stones
A common event, and what it actually costs the patient
- Intraoperative gallbladder perforation
- Outcome after bile spillage
- Management of perforation
- Risk from retained stones
- Practical recommendations on spilled stones
Complications and outcomes
What can go wrong, how often, and what it depends on
- Complications shared with open surgery
- Complications of laparoscopic cholecystectomy
- Complications caused by the pneumoperitoneum
- Trocar-related injuries
- Safe trocar insertion
- Management of suspected vascular injury
- Surgical experience and bile duct injury
- 0.2%
- Consequences and contributing causes of biliary injury
- Mechanism of the classic biliary injury
- Other causes of misidentification
- Management of a bile duct injury
- Mortality after open cholecystectomy
- Morbidity after open cholecystectomy
New and investigational techniques
Fewer incisions, and eventually none at all
- Aim of the newer approaches
- Single-port laparoscopic surgery
- Natural orifice translumenal endoscopic surgery
- Current status of NOTES
Summary
What to carry away from this topic
- Key points on indications and assessment
- Key points on technique and safety
- Key points on outcomes
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- References (continued)
- Maingot's Abdominal Operations, 12th Edition