Umbilical cholecystectomy
Gall bladder can be removed from umbilicus when cosmetic is more important. This is new approach, safe, practicable with different vision and new concept. First prerequisite is surgeon must be experience and routinely doing cholecystectomies. Second there should be no doubt regarding the diagnosis and all relevant investigations are done. Third start doing it in simple and straight forwarded cases preferably thin one with small abdomen. Fourth it is difficult to address common bile duct (CBD) pathology through this approach.
Instruments requirements
Narrow neck retractors, light retractor, ribbon abdominal sponges and general trolley instruments.
Investigations
Routine body tests, LFTs, hepatitis B & C, and ultrasonography.
Anesthesia
Umbilical cholecystectomy can be done under locoregional anesthesia with SSS, or general anesthesia and even spinal anesthesia.
Procedure
Under anesthesia after draping the patient give semicircle infra umbilical or c shape incision. Deepen the incision up to linea alba. Detach the umbilicus from linea alba for free movements of this entry point. Raised the upper abdominal flap, then open the linea alba in midline as your requirements may be 2 to 5 cm. On opening the peritoneum palpate the GB, identified its location separate the adhesions if any and mobilize it. Put inside ribbon abdominal sponge to retract the stomach and duodenum. Use the narrow neck retractors to isolate the GB. Use light retractor to visualize inside. Hold the GB and slowly approach the hartmann pouch which should be detach from liver after detaching the hepatocolic ligament. Rotate hartmann pouch from posterior to anterior side by gentle traction. By doing this cystic duct and artery become parallel and form a pedicle which can safely be separated from liver. Pull back any impacted stone in neck of GB or cystic duct if not open them and removed the stones. With the help of long curved artery forceps encircle the pedicle by two zero vicryl repeat. Ligate the GB pedicle en masse. Cut the GB pedicle and gently peal out GB. Bleeding from liver bed stop spontaneously except in cases of cirrhotic liver with portal hypertension having abnormal portocaval anastomosis and those are not candidates of umbilical cholecystectomy. Secure hemostasis put a drain; removed the abdominal sponge and close the wound in layers with vicryl 2/0 repeat and reattach the umbilicus. When patient is ambulatory which in our cases there and then remove the drain within 20 minutes.
Difficulties
If GB is not identified; further search extreme right and posterior side. Further pack the gut and retract toward down.
GB is badly adherent; slowly and gently dissection will help, finger dissection is very important.
Hemostasis; not big issue everything is under direct vision and easily manageable.
Difficult to do cholecystectomy just enlarge the linea alba incision, extreme cases either use the mid line incision or another incision on right side of abdomen at more appropriate site.
Apply SKL in wound for no post-operative pain at all.
Incisional hernia after this approach
If you know the reason of incisional hernias than you can reduce them.
The commonest cause of incisional hernia is prolene stitch itself which is use to close the wound to prevent hernia. It cause cheese wire effect which cause solely tissue cutting leading to micro hemorrhage where greater omentum stuck and with passage enter into multiple hole made by prolene stitch and one or more of them enlarge enough leading to incisional hernia.
If you don’t close the peritoneum properly; even smallest trocar site enter can lead to incisional hernia.
If wound is not close properly and especially greater omentum is trap in it than it definitely lead to incisional hernia.
Conclusion
For cosmetic purposes this is best approach, time tested, safe, practicable and at extreme end advantages over laparoscopic approach, as it is under direct vision with tactile sensations and normal sizes. There is lot of time saving and guaranteed operation. Gall bladder is safely removed with no chance of biliary injuries. Patient can go home from operation theater as well.