Open cholecystectomy/ operative surgery

OPEN CHOLECYSTECTOMY- OPERATIVE SURGERY
#surgicaleducator #operativesurgery #opencholecystectomy #usmle #babysurgeon #surgicaltutor


Dear viewers,
• Greetings from “Surgical Educator”
• Because of the popular demand by viewers of the YouTube channel “Surgical Educator”, I have decided to create and upload videos on common surgeries.
• I have already uploaded videos on open and Laparoscopic Appendicectomy, Thyroidectomy and Modified Radical Mastectomy.
• In this video today, I have discussed Open Cholecystectomy.
• However, these videos are not real surgeries but the theoretical aspect of operative surgery like going through an atlas of operative surgery.
• Along with these videos, I recommend you to watch real operative surgery videos as well and I will give a link for each surgery in the end of the video as end-cards, which I think will be very useful.
• This will give a very good opportunity for the surgical trainees to mentally rehearse various surgical steps in a sequential manner prior to actual surgery. You can watch the video in the following links:
• surgicaleducator.blogspot.com
• youtube.com/c/surgicaleducator
• Thank you for watching the videos.

1. OPEN CHOLECYSTECTOMY DR.B.Selvaraj MS; Mch ; FICS; “ Surgical Educator” Malaysia OPERATIVE SURGERY

2. OPEN CHOLECYSTECTOMY INDICATIONS: Symptomatic Cholelithiasis Porcelain Gall bladder/ Ca GB Failed Laparoscopic Cholecystectomy ANESTHESIA: GA/ETT POSITION: Supine- consider Xray table Rolled towel or sandbag in the Rt lower chest to bring the GB forward Informed consent- risks of surgery: Bile leak- biliary fistula 0.5% Peritonitis 0.1% Missed stone 1% Injury to bile duct 0.3% Injury to liver, duodenum or colon Vascular injuries to portal vein or hepatic artery 0.1% Abscess 0.2%

3. OPEN CHOLECYSTECTOMY Incision: Access Rt upper transverse abdominal- cosmetically superior Rt subcostal- Kocher’s incision Exposure Two deaver’s retractors to retract liver Abdominal pack over duodenum, stomach and transverse colon and then retract them inferiorly

4. OPEN CHOLECYSTECTOMY Dissection of Calot’s triangle Incise the peritoneum covering cystic duct and cystic artery anteriorly and posteriorly Grasp fundus of GB with sponge holding forceps and retract cephalad This puts cystic duct on a stretch Exposure of cystic duct& cystic artery Skeletonise cystic duct & cystic artery Beware of variant anatomy of cystic duct & cystic artery Cystic duct is clearly defined only if you can make out the CHD above the confluence of Cystic duct with CBD

5. OPEN CHOLECYSTECTOMY Division of the cystic duct After conforming the cystic duct, it should be divided Distal part is suture ligated and the proximal part simple ligature with vicryl If suspicious anatomy or suspicious CBD stone  do IOC Intra-op cholangiogram Division of the cystic artery Cystic artery usually lies cephalad to cystic duct Beware of anatomical variations Ligate it as close to the GB as possible

6. OPEN CHOLECYSTECTOMY Retrograde Cholecystectomy Accomplished by cephalad traction of GB neck Fibrous connections with liver are divided by scissors and hemostasis is achieved by diathermy Antegrade Cholecystectomy- Fundus first When dissection in Calot’s triangle is difficult because of dense adhesions GB is dissected off the liver bed beginning at fundus first

7. OPEN CHOLECYSTECTOMY Hemostasis of GB bed Separationof GB from GB bed is done in piecemeal with scissors and diathermy Uncontrolled bleeding can be stopped with local compression, suturing or with surgicel . Drainage of GB bed After hemostasis of GB bed, inspect stumps of cystic duct & cystic artery Consider sub hepatic drain only in complicated case with lot of dissection for extensive adhesions

8. OPEN CHOLECYSTECTOMY Closure of Abdominal Incision Kocher’s incision or Rt upper transverse abdominal incion should be closed in layers Post operative care Remove NGT on day1 and drain on day2 or 3 Diet: Oral fluids after 4 hrs and then progress rapidly to semisolids and then solids Ambulate the patient immediately Incentive spirometry or chest physio in post op period Advise rest from work for 7 days

9. THANK YOU