Based on the history, physical examination, ultrasound examination and investigations.
Murphy’s sign
Tenderness in RHC that exacerbate on deep inspiration.
Mass may be palpable
Omentum
Mucocele
Empyema
Peritonitis
Courvoisier’s sign-
A palpable non tender gall bladder usually indicate a sinister diagnosis.
Treatment
Only treatment of gall stones is surgical removal of gall bladder whether symptomatic or asymptomatic.
Irrespective of time, early operation is better choice whether acute or chronic cholecystitis.
If the patient has serious co-morbid conditions, a percutaneous cholecystostomy can be performed under ultrasound control for speed-up recovery and than subsequent cholecystectomy.
Empyema of gall bladder is best treated with early cholecystectomy.
Acalculous cholecystitis (in the absence of stones cholecystitis) is treated on same lines as calculous cholecystitis.
One hole Cholecystectomy
The procedure of choice is one hole cholecystectomy as it is very simple, safe, and most economical, further patient is discharged with in 04 hours or even in 02 hours.
After routine preparing the abdomen, a 2 to 3 cm incision is given quite above in the epigastrum.
Anterior rectus sheath is cut transversely 3 cm or more.
Rectus abdominis muscle is split open and posterior rectus sheath is cut.
After opening the peritoneum, try to take a look of inside or explore the area with finger.
Identify the gall bladder and hold it from neck.
Use narrow neck retractors to facilitate vision.
If needed use ribbon sponge to safe the colon and duodenum.
The key to success is elevation of the Hartman’s pouch and neck vertically and separation of them from liver, so making a window in mesentery of gall bladder.
Pass ligature around the cystic duct and artery and ligate them together.
Cut the pedicel and gently take out the gall bladder.
Bleeding from gall bladder bed usually stop spontaneously and some time need ligation or cauterization.
After securing homeostasis, if needed put a drain from same wound and close the wound in layers after washing it with normal saline.
No need of dressing.
Allow fluid as soon as patient is out of anesthesia.
Patient should be out of bed with in one hours and give him a pain killer post operative.
After 02 hours do an ultrasound and take out the drain if put, and patient discharge simply on ponstan SOS.
Golden rule in case of difficulty is
Simply enlarge the wound 1 to 2 cm and other steps are same as you do in open cholecystectomy.
Choledochotomy can be done by just enlarging the wound 1 to 3 cm.
Indications of choledochotomy are, palpable stone in common bile duct, a dilated common bile duct, a history jaundice or cholangitis, abnormal liver function tests especially raised alkaline phosphatase.
