Open cholecystectomy

Open cholecystectomy

For patients in whom a laparoscopic approach is not indicated or in whom conversion from a laparoscopic approach is required, open cholecystectomy is performed. /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF An upper midline, short subcostal (Kocher) or right upper transverse incision is made, centred over the lateral border of the rectus muscle. The gallbladder is appropriately exposed and packs are placed on the hepatic flexure of the colon, the duodenum and the lesser omentum to ensure a clear view of the anatomy of the porta hepatis. These packs may be retracted by the assistant’s hand (‘It is the left hand of the assistant that does all the work’ – Moynihan). An artery or Duval forceps is placed on the infundibulum of the gallbladder and the peritoneum overlying Calot’s tri angle is placed on a stretch. The peritoneum is then divided close to the wall of the gallbladder and the fat in the triangle of Calot car efully dissected away to expose the cystic artery and the cystic duct. The cystic duct is cleaned down to the CBD, whose position is clearly ascertained. The cystic artery is tied and divided. The w hole of the triangle of Calot is displayed to ensure that the anatomy of the ducts is clear and the cystic duct is then divided between ligatures ( Figure 71.32 ). The gall bladder is then dissected away from its bed. Emil Theodor Kocher , 1841–1917, Professor of Surgery , Bern, Switzerland, first surgeon to win the Nobel Prize in Physiology or Medicine (1909) for his work on the physiology and surgery of the thyroid gland. Pierre Alfred Duval , 1874–1941, Professor of Surgery , Paris, France -

cholecystectomy. Operative steps Purpose Retraction ( Figure 71.31a ) Opens the hepatocystic triangle Proper retraction in the Increases the angle between correct direction: the fundus the cystic duct and the CBD is retracted towards the Limits the dissection above patient’s right shoulder and Rouvière’s sulcus the infundibulum is retracted Mental and spatial orientation inferolaterally towards the of the anatomy, variation and patient’s right side landmarks Look out for red /f_l ag signs Time out The surgeon should recognise Failure of timely progression these clues, stop dissection and of the dissection decide on the strategy for safe Anatomical disorientation operation before proceeding Dif /f_i culty in visualisation of Do not hesitate to seek a the operative /f_i eld second opinion Dif /f_i culty achieving CVS is a Achieve CVS ( Figure 71.31b ) warning Clearance of the hepatocystic Further dissection may be triangle of all /f_i brofatty and hazardous, with an increased soft areolar tissue to see risk of biliary and/or vascular only 2 structures enter the injury gallbladder (cystic artery and Stop and recon /f_i rm (with the duct) team/second surgeon) that CVS has been achieved Exposure of the cystic plate May be documented by ( Figure 71.31c ) photographs and/or video This is done by separating the recordings gallbladder from its liver bed to expose at least the medial third of the cystic plate To avoid bleeding from the liver Separate the gallbladder from sinuses and bile leak the fossa This is done by leaving the cystic plate attached to liver CBD, common bile duct; CVS, critical view of safety. (b) (c) Figure 71.31 (a–c) Operative images of laparoscopic cholecys

tectomy. See Table 71.5 for the important steps during operation (courtesy of Dr Sameer Rege, Mumbai, India).