Cholecystectomy

Cholecystectomy is a common procedure in biliary surgery. The antegrade (starting from the cystic duct) is resected and retrograde (starting from the bottom of the gallbladder). Anterior cholecystectomy, less bleeding, easy surgery, should be preferred. However, in the case of severe inflammation, the gallbladder is closely adhered to the surrounding organs, and it is not easy to expose the cystic duct and the gallbladder artery. Sometimes it is necessary to combine the two. Indication 1. Acute suppurative, gangrenous, hemorrhagic or perforating cholecystitis. 2. Chronic cholecystitis recurrent, non-surgical treatment is invalid. 3. Gallstones, especially small stones, are prone to blockage. 4. Gallbladder has no function, such as hydronephrosis and chronic atrophic cholecystitis. 5. Gallbladder neck obstruction. 6. Gallbladder tumors. 7. For the Odd sphincter incision, or the common bile duct duodenal anastomosis, the gallbladder should be removed. 8. Gallbladder fistula, gallbladder trauma rupture and good general condition. Preoperative preparation 1. For preoperative preparation of emergency patients, see gallbladder ostomy. 2. Chronic cases should be properly prepared before surgery: correct anemia, improve nutritional status, use high sugar, high protein and high vitamins to protect the liver. Preoperative blood preparation 300 ~ 500ml. Surgical procedure 1. In the supine position, the upper abdomen is aligned with the lumbar bridge of the operating table. During the operation, because the biliary tract is deep, when the exposure is poor, the bridge can be shaken. Place a cushion under the knee to relax the abdominal muscles. 2. Incision: generally take the right upper transabdominal rectus incision; or right upper median incision; patients with wide obesity and rib arch can use the right inferior oblique incision. 3. Exploration: First explore the color and quality of the liver, whether there is swelling or atrophy, abnormal nodules, hard changes and abscesses, respectively, to explore the right lobe and the dirty surface, left lobe. Secondly, the shape, size, edema, necrosis, perforation, etc. of the gallbladder were explored. Can the gallbladder be evacuated, whether there are stones in the capsule, whether the gallbladder neck and the cystic duct are incarcerated, and the adhesion around the gallbladder. Homeopathic left hand, middle finger into the omentum hole, left thumb placed on the duodenal ligament, from the top down to the liver tube, common bile duct in the absence of stones or mites, lymph nodes are swollen, the head of the pancreas is hard, Swollen. If the gallbladder is swollen and can not be emptied, it should be probed at the end of the gallbladder. Sewing at the puncture site. Then, carefully check the stomach and duodenum for ulcers, tumors, etc. If necessary, explore the spleen, pancreas, transverse colon, ascending colon, appendix and right kidney. In short, under the conditions of the condition and the conditions required, it should be as detailed as possible to explore, and then determine the surgical methods and procedures. In the exploration, if the gallbladder lesion is only a part of the biliary lesion, it is not appropriate to administer the cholecystectomy, but the treatment should be determined according to other lesions found. 4. Exposing the gallbladder and cystic duct: Use the 3 deep-drawn hook pads to spread the liver, stomach, duodenum and transverse colon, so that the duodenal ligament is straightened, and the gallbladder and common bile duct can be revealed. Use saline gauze to block the pores of the omentum to prevent bile and blood from flowing into the small retina cavity. 5. Remove the gallbladder. An anterograde cholecystectomy (starting from the gallbladder neck) (1) Exposing and treating the cystic duct: Use the oval clamp or curved hemostat to clamp the neck of the gallbladder and pull it slightly to the upper right. The peritoneum on the left side of the gallbladder neck was cut with a knife along the outer edge of the hepatoduodenal ligament, and the cystic duct was carefully and bluntly separated. During the separation process, the forceps clamped on the neck of the gallbladder can be continuously pulled, so that the cystic duct is slightly tensioned for identification. After confirming the relationship between the gallbladder and the common bile duct, the traction of the gallbladder neck is relaxed, and the common bile duct is prevented from being pulled into an angle. Use two hemostats to clamp the cystic duct 0.5 cm from the common bile duct. Be careful not to clip the common bile duct, right hepatic duct and right hepatic artery to avoid accidental injury. The cystic duct was cut between the two clamps, the proximal end was ligated with a 4-0 silk thread, and the distal end was sutured with a 1-0 silk thread to avoid detachment. (2) Treatment of the gallbladder artery: The gallbladder artery is located in the deep tissue behind the cystic duct, and the distal end of the cystic duct is pulled upward. In the posterior upper triangular region, the gallbladder artery is found, and the relationship between it and the right hepatic artery is confirmed. After being distributed to the gallbladder, it is clamped, cut and ligated on the side close to the gallbladder, and then the proximal end is added as a filament. If the local anatomical relationship can be clearly identified, the cystic duct can be treated after the gallbladder artery is ligated and cut off in the gallbladder triangle. In this way, the surgical field is clean and has less bleeding. The cystic duct can be pulled with confidence, and the cystic tube that is twisted and spiraled is straightened, and the relationship with the common bile duct is easily recognized. If the gallbladder artery is not cut or ligated, when the gallbladder is pulled, it is likely to tear or break the gallbladder artery, causing massive bleeding. Whether to treat the gallbladder artery first, or to treat the gallbladder neck first, should be based on local anatomy. If the gallbladder artery is sometimes in a deep position, it is difficult to expose the artery without first ligation and cutting the cystic duct. The cystic duct should be treated first. (3) stripping the gallbladder: under the serosa at the junction of the gallbladder and the liver surface, 1 to 1.5 cm from the edge of the liver, the gallbladder serosa is cut, if there is acute inflammation recently, it can be cut with a finger or gauze ball. The subserosal loose gap is separated. If the gallbladder wall is thickened and the surrounding tissue is not easily peeled off, a small amount of sterile physiological saline or 0.25% procaine may be injected under the gallbladder serosa and then separated. When the gallbladder is separated, it can meet from the bottom of the gallbladder and the neck of the gallbladder to the middle. Remove the gallbladder. If there is a traffic vessel between the gallbladder and the liver and a small bile duct, it should be ligated and cut off to avoid postoperative bleeding or cholestasis. (4) Treatment of the liver: After the gallbladder is removed, a small amount of oozing from the gallbladder fossa can be stopped by a hot saline gauze pad for 3 to 5 minutes. Active bleeding points should be ligated or sutured to stop bleeding. After hemostasis, the serosa of both sides of the gallbladder fossa were sutured with silk to prevent bleeding or adhesion. However, if the gallbladder fossa is wide and the serosa is small, it is not necessarily sutured. Retrograde cholecystectomy (starting from the bottom of the gallbladder) (1) Incision of the serosa at the bottom of the gallbladder: use a hemostat or an oval clamp to clamp the bottom of the gallbladder for traction. Inject a small amount of normal saline under the serosa at 1 cm from the liver boundary to make the serosa edema float and cut there. Open the pulp film. (2) Separation of the gallbladder: The gallbladder is separated by a finger and a small gauze ball along the incision of the inferior serosal space, starting from the bottom of the gallbladder and gradually dividing downward to the body; if necessary, with sharp separation. Any separation, ligation, and cutting must be performed against the wall of the gallbladder. If the adhesion is tight and the separation is difficult, the gallbladder bottom can be cut open, and the left hand is used to extend into the gallbladder. The other four fingers hold the clamp of the gallbladder wall to guide the finger. The right hand is separated by scissors around the gallbladder wall. . (3) Exposure and ligation of the gallbladder artery: When the neck of the gallbladder is isolated, the gallbladder artery is found in the upper side of the gallbladder. The artery is clamped, cut, and ligated close to the gallbladder wall, and the proximal end is double ligated. (4) Separation and ligation of the cystic duct: the neck of the gallbladder is clamped to the outside, the covered serosa is separated, the cystic duct is found, and the junction is traced to the junction with the common bile duct. See the relationship between the two, cut the gallbladder after clamping and cutting at 0.5cm from the common bile duct. The stump of the cystic duct was ligated with a medium thread and then sewed. Hemorrhage on the liver bed is not stopped, sutured, or blocked with large omentum to stop bleeding. 6. Place the drainage and suture the abdominal wall: place a cigarette drainage at the retina hole, and make a small opening along the gallbladder fossa to the right upper abdominal wall. The abdominal wall is fixed with a safety needle to prevent slipping into the abdominal cavity. If the surgical field is clean, no bleeding and bile contamination, all kinds of ligation are reliable, and it is a clinically non-infectious elective surgery patient, and can also not discharge cigarettes. Place the omentum between the liver and gallbladder, and the stomach and duodenum to avoid adhesion between the liver and the gastrointestinal tract. If there is a need for biliary surgery again, it is beneficial to reveal. Put down the bridge that is rocking. Finally, the abdominal wall incision is sutured layer by layer.