Acute cholecystitis and management

How to manage the cases of Acute chlecystitis

1. Acute Cholecystitis and M anagement Dr . K. Sendhil Kumar MS, FICS , FCLS, FACS(USA), DNB (SGE ) Dr. Piyush Patwa DNB, FMAS, FIAGES, FIAS Gateway Clinics , Coimbatore , India

2. Acute Cholecystitis Introduction An acute inflammation of the gallbladder, which is often, but not always, attributable to gallstones

3. Etiology Calculous Acalculous Cholesterosis Polyposis of GB Cholecystitis glandularis proliferans Diverticulosis of GB Typhoid of GB 3 . Emphysamatous

4. Classification according to Morphology Catarhal Phlegmonous Gangrenous Gangrenous Perforation

5. Red Flags in Cholecystitis Acute Gall stone Pancreatitis Acute Cholangitis Fulminant Gangrenous Cholecystitis Gall bladder perforation with peritonitis Associated with Choledocholithiasis & Obstructive jaundice

6. Pathogenesis Stone leads to obstruction → Stasis → Edema of wall → Bacterial infection → Aute Calculous Cholecystitis Impacted stone → Mucosal erosion → Toxic bile salt act on submucosal tissue → Leads to infection, necrosis & perforation

7. Acalculous ICU Patients - TPN Post op patients Burns Sepsis Cholecystoses Gall bladder distension with release of factor 7

8. Clinical Symptoms Abdominal Pain : Rt HC, Epigastric , colicky, sudden onset, radiating ttoback & right shoulder Fever GI Symptoms : Nausea, Bilious vomiting, Belching, Flatulence, abdominal distension Toxic symptoms may be present in elderly and Diabetic pts.

9. Signs Tenderness in Right HC & Epigastrium Rigidity Murphy’s Sign Boas Sign Kera sign Shotkin Blumber sign Palpable tender mass

10. Investigation Labs : Elevated Leukocyte count, Bilirubin, Amylase, SGOT/PT X-ray abdomen – Radio-opaque stones USG Abdomen ERCP, MRCP, HIDA

11. Complications Empyema Perforation Peritonitis Abscess Fistula Mucocele Acute Pancreatitis Mirizzi Synd Gall stone Ileus Obstructive Jaundice Vascular Complications – Cystic Artery Pseudoaneurysm , PVT

12. Pre-Op Mx Broad spectrum Antibiotics IV Fluids NG tube – SOS Resuscitation

13. Surgery Open or Laparoscopic Cholecystectomy Total or Subtotal Cholecystectomy Cholecystostomy Duct first and Fundus first Method

14. SUB-TOTAL CHOLECYSTECTOMY Leave Hartmann’s pouch (To avoid Biliary Inflammation Zone) If unable to identify the cystic duct Frozen Calot’s triangle Portal Hypertension Leave posterior wall of gallbladder (To avoid GB bed Bleeding) In cirrhosis and/ or portal hypertension Thickened and Fibrosed GB wall

15. Opening infundibulum in Acute Cholecstitis with Liver Cirrhosis

16. Impacted stone seen during Subtotal Chole

17. SUB-TOTAL CHOLECYSTECTOMY Two types – 1) Reconstituting 2) Fenestrating Indications – Severe inflammation Gangrenous / Perforated GB Cirrhosis/ Portal HTN/ Coagulopathy

18. ‘‘Virtual’’ cholangiography using ICG dye at the very start of the procedure, to identify the normal anatomy or possible anatomic variations specially in potentially dangerous situations

19. Cholecystitis with Large Collaterals in Cirrhotic Liver Dangerous Entry & more chances of intraopeative bleed

20. Abnormal Varices in Abdominal Wall

21. GB Mass

22. Mirizzi Syndrome

23. Surgical pearls while tackling Acute Cholecystitis Identify the anatomy – Liver border, GB, Duodenum, Colon, CBD Decompress the gallbladder Displace the impacted stone Stay on the GB Adequate retraction of gallbladder – Toothed graspers Control of bleeding Identification of Cystic lymph node, Rouviere’s sulcus, Posterior dissection

24. Summary with Few Tips Good OT setup Safe access Proper exposure and orientation Adequate traction and retraction Stay away from CBD Harmonic scalpel or advanced Bipolar diathermy Perfect haemostasis and proper dissection technique

25. Summary with Few Tips Use of gauze piece & suction cannula for the blunt dissection in acute and friable cases Option of Subtotal Cholecystectomy or Tube cholecystostomy Subtotal to Completion Cholecystectomy( once anatomy is clear) Antegrade or fundus first techniques Peroperative cholangiogram / New safety Technology Conversion to Open/ Referral to higher centres are safe & effective & NOT failure

26. Video

27. Thank You