CHOLECYSTECTOMY

With CBD EXPLORATION

Operative Technique

Patient supine under SAB/CLEA/GA

Asepsis and antisepsis technique

Sterile drapes placed

Incision made carried from skin through subcutaneous tissue

Midline – Fascia cut and opened through linea alba

Kocher’s (Right Subcostal) – Anterior rectus sheath cut and opened

Right belly of Rectus muscle cut

Posterior Rectus sheath cut and opened

Peritoneum cut and opened

Exploration of entire abdomen carried out

Intra-operative findings noted

Retractors applied accordingly

Gallbladder identified and clamped with a Kelly at the ampulla applying traction

Triangle of Calot dissected, cutting the peritoneum that covers the area; Cystic duct identified, isolated and a temporary silk 4-0 ligature applied.

Intra-operative cholangiogram done, findings noted

Cystic artery identified, isolated, ligated and divided

Gallbladder deperitonealization done and dissected from the liver bed using electrocautery

Cystic duct divided and doubly ligated

CBD Exploration:

Noted stones in IOC, palpate CBD

Kocher maneuver done by incising the lateral peritoneal attachments along the descending duodenum

Palpate distal CBD

Distal to entrance of cystic duct, incision made on the peritoneum overlying CBD

2 guide sutures placed silk 4-0 RB1 one opposite the other on the anterior wall of the CBD

Incision made, CBD opened

Calculi extracted

Bakes dilator passed

Intra-operative chlangiogram done, findings noted

T-tube placed

Choledochotomy incision closed using silk 4-0 interrupted sutures

Closure:

Peritoneal lavage

Hemostasis

Complete sponge and instrument count

Penrose drain placed area of choledochotomy and exteriorized on lateral part of abdomen

End of T-tube exteriorized in most direct manner

Closure layer by layer

Peritoneum and Fascia – Vicryl 0 continuous

Subcutaneous layer – chromic 2-0 inverted T-sutures

Skin – silk 3-0 interrupted sutures

T-tube anchored with silk 2-0 to the skin

Betadine paint

Dry sterile dressing placed