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Treatment of One Hole Cholecystectomy

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.

 

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.