SPLENECTOMY

Splenectomy

Indications

In cases of:

•   Traumatic splenic rupture

•   Hematologic splenic disorders (ITP, Hereditary spherocytosis)

•   Removal of deceased spleen.

Position

Supine.

Anesthesia

General.

Procedure

Incision of midline for trauma and left subcostal for elective splenectomy:

1.  Incise posterior layer of spleno-renal ligament and deliver spleen to wound.

2.  Divide splenic artery and vein between double ligatures protecting the tail of the pancreas.

3.  Divide short gastric arteries between ligatures taking care not to injure the stomach wall.

4.  Remove spleen.

5.  In hematological diseases, look for accessory spleens.

6.  Close abdomen in layers without drainage.

Instruments

•   General set, 1

•   Gastrointestinal set, 1

•   Deep set, 1.

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Cholecystostomy

Cholecystostomy

Objective

In case of inflammation of gallbladder:

•   Remove the gallstones

•   To remove pus from gallbladder.

Position

Supine.

Anesthesia

General.

Procedure

1.  Vertical or right subcostal incision.

2.  Surround gallbladder with packs.

3.  Aspirate bile.

4.  Incise into gallbladder fundus - aspirate bile and remove all stones.

5.  Do not miss stone impacted in cystic duct.

6.  Insert a 24 F Foley’s catheter and close opening around the catheter using a purse string suture.

7.  Fix gallbladder to parietal peritoneum.

8.  Wash subhepatic area and close abdomen with subhepatic suction drainage.

Instruments

•   General set, 1

•   Biliary tract set, 1

•           Foley’s catheter (drain GB)

Any questions be sent to drmmkapur@gmail.com
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Common Bile Duct Exploration

Common Bile Duct Exploration

Objective

In case of:

•   To remove stone in secondary bile duct stones

•   To remove stone in primary bile duct stones.

Position

Supine.

Anesthesia

General.

Procedure

•   Incise peritoneum over common bile duct

•   Put 2 stay sutures on anterior wall

•   Aspirate bile from the duct and incise its anterior wall

•   Extract all stones using a Desjardin’s forceps or Fogarty’s catheter

•   Confirm patency of lower end of CBD by posing a red rubber catheter into the duodenum

•   Close the CBD over an appropriate size T-tube

•   Do a pre-op T-tube cholangiogram to rule out missed stones

•   Close wound in layers with sub-hepatic drainage. Bring T-tube out through a separate stab wound.

Instruments

•   General set

•   Biliary tract set

•   Gallstone probe (Fig. 9.22)

•   Desjardin’s gallstone forceps (Fig. 9.23)

•           Kehr T tube (Fig. 9.24)

Any questions be sent to drmmkapur@gmail.com
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Cholecystectomy

Cholecystectomy

Objective

In cases of:

•   Symptomatic gallstones

•   Traumatic or inflammatory perforation of gallbladder

•   To remove gallbladder.

Position

Supine.

Anesthesia

General.

Procedure

1.  Subcostal (right) or midline.

2.  Identify gallbladder, divide adhesions.

3.  Apply forceps to fundus and to infundibulum of gallbladder and draw to right and forward.

4.  Divide cystic artery between ligatures.

5.  Divide cystic duct between ligatures after identifying Junction with CBD.

6.  Remove gallbladder; cut open to rule out malignancy and send for histopathology.

7.  Close abdomen with suction drain in subhepatic pouch.

Instruments

•   General set, 1

•   Biliary tract set, 1.

Any questions be sent to drmmkapur@gmail.com

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Visitors that follow may post contributions to the site,please write address above.

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