VIII.

SURGICAL MANAGEMENT

Open Cholecystectomy with Biliary Exploration

Choledochoduodenostomy

Definition:

A cholecystectomy is the surgical removal of the gallbladder

A choledochoduodenostomy is the surgigal creation of a passage uniting the common bile duct and
the duodenum.
Type of operation
Discussion:
Cholecystectomy may be performed to treat chronic or acut cholecystitis, with or without
cholelithiasis, or to resect a malignancy.

Choledochoduodenostomy may be performed for a biliary bypass operation are benign biliary
strictures and malignant obstruction of the biliary system caused by pancreatic or biliary ductal
carcinomas.Indicated mainly in patients with recurrent stones, giant stones, or concominant
common bile stricture and stones.

Note:

Cholecystectomy, perfomed laparospically, is the preferred treatment for symptomatic gallstones

unless the patient is extremely obese, there are excessive adhesions, or ductal or vascular anomalies
exist. If unexpected pathology is encountered, if acute inflammation distorts normal tissue planes,
or if there is excessive bleeding or surgical injury, the laparoscopic procedure is promptly
converted to “open” cholecystectomy.

Choledochoduodenostomy is also useful for preventing cholangitis caused by recurrent stones in

patients with chronic disease, such as chronic heart failure, chronic respiratory failure, and diabetes.
Main indication for biliary obstruction either benign or malignant.
 Type of Anesthesia

Spinal Anesthesia Block

- is induced by injecting small amounts of local anaesthetic into the cerebro-spinal fluid (CSF). The
injection is usually made in the lumbar spine below the level at which the spinal cord ends (L2).
Spinal anaesthesia is easy to perform and has the potential to provide excellent operating conditions
for surgery below the umbilicus.

Table 1 Equipment f
IInstrumentation/ Device Number Size Comments

Laparoscopic cart
High-intensity halogen light source
(150–300 watts)
High-flow electronic insufflator
(minimum flow rate of 106 L/min)
Laparoscopic camera box
Videocassette digital video and still image
recorder (optional)
Digital still image capture system (optional)
Laparoscope 1 3.5-10mm Available in 0° and angled views; we prefer to use a 30°
5 mm diameter laparoscope
Atraumatic grasping forceps 2-4 2-10mm Selection of graspers should allow surgeon choice
appropriate to thickness and consistency of gallbladder
wall; insulation is unnecessary
Large-tooth grasping forceps 1 10mm Used to extract gallbladder at end of procedure
Curved dissector 1 2-5mm Should have a rotatable shaft; insulation is required

Scissors 2-3 2-5mm One curved and one straight scissors with rotating shaft
and insulation; additional microscissors may be helpful
for incising cystic duct
Clip appliers 1-2 5-10mm Either disposable multiple clip applier or 2 manually
loaded reusable single clip appliers for small and
medium-to-large clips; 5 and 10 mm diameter
Dissecting electrocautery hook or spatula 1 5mm Available in various shapes according to surgeon’s
preference; instrument should have channel for suction
and irrigation controlled by trumpet valve(s); insulation
required
High-frequency electrical cord 1 Cord should be designed with appropriate connectors
for electrosurgical unit and instruments being used
Suction-irrigation probe 1 5-10mm Probe should have trumpet valve controls for suction
and irrigation; may be used with pump for
hydrodissection
10-to-5 mm reducers 2 Allow use of 5 mm instruments in 10 mm trocar
without loss of pneumoperitoneum; these are often
unncessary with newer disposable trocars and may be
built into some reusable trocars
5-to-3 mm reducer 1 Allows use of 2–3 mm instruments and ligating loops
in 5 mm trocars
Ligating loops

Endoscopic needle holders 1-2 5mm

Cholangiogram clamp with catheter 1 5mm Allow passage of catheter and clamping of catheter
in cystic duct
Veress needle 1 Used if initial trocar is inserted by percutaneous
technique
Allis or Babcock forceps 1-2 5mm Allow atraumatic grasping of bowel or gallbladder
 Long spinal needle 1 14gauge Useful for aspirating gallbladder percutaneously in
cases of acute cholecystitis or hydrops
Retrieval bag 1 Useful for preventing spillage of bile or stones in
removal of infl amed or friable gallbladder; facilitates
retrieval of spilled stones

A cholecystectomy with choledochoduodenostomy was performed with patient under Spinal Anesthesia Block in supine position, a
right subcostal incision was made; the adhesion was released, and the area of the hepatoduodenal ligament was dissected. The
cholecystectomy was performed in the usual manner.

A right subcostal incision is usually performed.The duodenum is widely mobilized by generous Kocher maneuver, so that it can be
approximated to the common bile duct without tension. A 2.0- 2.5 cm longitudinal incision is made in the distal common bile duct as
close as possible to the area of stenosis or obstruction in patients with benign disease. In patients with a stricture, the bile duct is
divided and the stricture excised. The duodenum and duct are joined by a posterior or row of interrupted 3-0 silk sutures. The
duodenum is opened longitudinally for a distance of 2.0- 2.5cm and a second row of interrupted 3-0 or 4-0 chromic catgut. Sutures is
placed to approximate the ductal and duodenal mucosa. A T-tube is used in patients with thin walled ducts or difficult anastomosies. A
final row of interrupted 3-0 silk sutures completes the anterior row of anastomosies.