Diagnosis
- 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.
- Murphy’s sign
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.
