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)

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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)

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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.

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Ileo-colostomy

Ileocolostomy

Indications

In cases of:

•   In poor risk patients with obstruction due to ileocecal tuberculosis

•   Unresectable growth of transverse of descending colon

•   Ileotransverse Colostomy to bypass the obstruction because of unresectable cancer of cecum or ascending colon.

Position

Supine.

Anesthesia

General.

Procedure

1.  An upper or lower paramedian or midline incision.

2.  Take a mobile loop of terminal ileum and bring it in apposition to transverse or sigmoid colon as the case may be.

3.  Incise ileum and colon between clamps.

4.  Carry out a two layer anastomosis using continuous or interrupted sutures making a 4 cm stoma.

Instruments

•   General set, 1

•   Gastrointestinal set, 1

•   Dennis anastomosis clamp (Fig. 9.21).

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Small Bowel Resection

8.  Small Bowel Resection and Entero-Enterostomy

Objective

In case of small bowel obstruction due to:

•   Inflammation

•   Tumor.

     Bypass the obstruction or remove the deceased segment and restore continuity of the bowel.

Position

Supine.

Anesthesia

General.

Procedure

1.  Open the abdomen gain entry to the peritoneal cavity.

2.  Identify area to be resected.

3.  Divide mesentery to this area in the line of a shallow V, serially between ligatures.

4.  The apex of the V is toward the root of the mesentery.

5.  Divide bowel to be removed obliquely, removing more of antimesenteric border between noncrushing clamps.

6.  Approximate noncrushing clamps to appose the two cut ends of bowel.

7.  Carry out end to end anastomosis—an inner continuous layer of catgut and an outer continuous layer of silk.

     Approximate cut end of mesentery with interrupted sutures.

Instruments

•   General set, 1

•   Gastrointestinal set, 1.

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