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A. CHOLECYSTECTOMY FROM FUNDUS DOWNWARD (“DOME-DOWN APPROACH”)

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INDICATIONS

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Cholecystectomy from the fundus downward is the desirable method in many cases of acute or gangrenous cholecystitis, where exposure of the cystic duct is difficult and hazardous. Extensive adhesions, a large, thick-walled, acutely inflamed gallbladder, or a large calculus impacted in the neck of the gallbladder makes this the safe and wiser procedure. Better definition of the cystic duct and cystic artery is ensured with far less chance of injury to the common duct. Some prefer this method of cholecystectomy as a routine procedure.

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PREOPERATIVE PREPARATION

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In the presence of acute cholecystitis, the preoperative treatment depends on the severity and duration of the attack. Early operation is indicated in patients seen within 48 hours after the onset, as soon as fluid balance and antibiotic coverage have been established. Frequent clinical and laboratory evaluation over a 24-hour period is necessary. Antibiotic therapy is given. Regardless of the duration of the acute manifestations, surgical intervention is indicated if there is recurrence of pain, a mounting white cell count, or an increase in the signs and symptoms suggesting a perforation. The gallbladder may show advanced acute inflammation despite a normal temperature and white count and negative physical findings. It is generally recommended that patients undergo surgery within 72 hours of the onset of symptoms as delays longer than this are associated with an increased risk of common bile duct injury. Percutaneous cholecystostomy may be considered for patients with a delayed presentation, or for those who are too ill to tolerate surgery. These patients may undergo interval cholecystectomy in 6 weeks.

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ANESTHESIA

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POSITION

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The patient is placed in the usual position for gallbladder surgery. If local anesthesia is used, the position may be modified slightly to make the patient more comfortable.

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OPERATIVE PREPARATION

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The skin is prepared in the usual manner.

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INCISION AND EXPOSURE

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Incision and exposure are carried out as shown in Chapter 70 The omentum must be separated carefully by either sharp or blunt dissection from the fundus of the gallbladder, care being taken to tie all bleeding points. An oblique incision below the costal margin is preferred, especially if the mass presents rather far laterally.

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DETAILS OF PROCEDURE

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Blunt dissection only is utilized to free the omentum and other structures from the gallbladder wall. It is safer to empty the contents of the gallbladder immediately to decrease the bulk and to give more exposure. A short incision is made through the serosa of the fundus, a trocar introduced, and the liquid contents are removed by suction. Cultures are taken. A fenestrated forceps is introduced deep into the gallbladder to remove any calculi in the ampulla. The ...

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