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If the cystic artery was not divided before the cystic duct, it is now carefully isolated by a right-angle clamp similar to those used in isolating the cystic duct (Figure 18). The cystic artery should be isolated as far away from the region of the hepatic duct as possible. A clamp is never applied blindly to this region, lest the hepatic artery lie in an anomalous location and be clamped and divided, resulting in a fatality (Figure 19). Anomalies of the blood supply in this region are so common that this possibility must be considered in every case. The cystic artery is divided between clamps similar to those utilized in the division of the cystic duct (Figure 20). The cystic artery should be tied as soon as it has been divided to avoid possible difficulties while the gallbladder is being removed (Figure 21). If desired, the ligation of the cystic duct can be delayed until after the cystic artery has been ligated. Some prefer to ligate the cystic artery routinely and leave the cystic duct intact until the gallbladder is completely freed from the liver bed. This approach minimizes possible injury to the ductal system as complete exposure is obtained before the cystic duct is divided. If the clamp or tie on the cystic artery slips off, resulting in vigorous bleeding, the hepatic artery may be compressed in the gastrohepatic ligament (Pringle maneuver) by the thumb and index finger of the left hand, temporarily controlling the bleeding (Figure 22). The field can be dried with suction by the assistant, and, as the surgeon releases compression of the hepatic artery, a hemostat may be applied safely and exactly to the bleeding point. The stumps of the cystic artery and cystic duct each are inspected thoroughly and, before the operation proceeds, the common duct is again visualized to make certain that it is not angulated or otherwise disturbed. Blind clamping in a bloody field is all too frequently responsible for injury to the ducts, producing the complication of stricture. Classic anatomic relationships in this area should never be taken for granted, since normal variations are more common in this critical zone than anywhere else in the body.
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After the cystic duct and artery have been tied, removal of the gallbladder is begun. The incision, initially made on the inferior surface of the gallbladder about 1 cm from the liver edge, is extended upward around the fundus (Figure 23). An edematous cleavage plane can be developed easily by injecting a few milliliters of saline between the serosa and the seromuscular layer, utilizing this cleavage plane for dissection. It is important that the serosa be divided with a scalpel or scissors along both the lateral and medial margins of the gallbladder so that the gallbladder is not torn from the liver bed by traction. If this occurs, raw liver surface results, and it may be impossible to peritonealize the liver bed. With the left hand, the surgeon holds the clamps that have been applied to the gallbladder and, by careful scissors dissection, divides the loose areolar tissue between the gallbladder and the liver. This allows the gallbladder to be dissected from its bed without dividing any sizable vessels. The final peritoneal attachment between gallbladder and liver is severed.
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When facilities permit, an operative cholangiogram (Figure 24) should be made routinely to ensure complete clearance of the ductal system. A syringe of saline as well as diluted contrast media should be connected by a two-way adapter in a closed system to avoid the introduction of air into the ducts. The cholangiogram catheter is filled with saline and it is introduced a short distance into the cystic duct. The tube is secured in the cystic duct by one tied suture utilizing a surgeon's knot. All gauze packs, clamps, and retractors are removed as the table is returned to a level position by the anesthesiologist. Five milliliters of contrast media, 20% to 25% concentration, are injected and the x-ray immediately taken. Limited amounts of a dilute solution prevent the obliteration of any small calculi within the ducts. A second injection of 15 to 20 mL is made to outline the ductal system completely and ensure patency of the ampula of Vater. The tube should be displaced laterally and the duodenum gently pushed to the right to ensure a clear roentgenogram without interference from the skeletal system or the tube filled with contrast media. Two roentgenograms are taken to provide a comparison in case doubtful shadows are noted, and another complete series of cholangiograms may be obtained if interpretation of the first two films is difficult. Alternatively, a fluoroscopic examination with continuous dye injection and periodic films may be performed. If no further studies are warranted, the tube is removed and the cystic duct ligated near the common duct. If the cystic duct cannot be used for the cholangiogram, a fine gauge needle, such as a butterfly, can be inserted into the common duct (Figure 25). The metal needle may be bent anteriorly as shown in the lateral view inset to facilitate its placement. Two or three dye injections are made and the needle is removed. The puncture site in the common duct is oversewn with a 0000 absorbable suture and some surgeons place a closed suction Silastic suction drain (Jackson-Pratt) in Morrison's pouch.
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The portal vessel area and the gallbladder bed are inspected for hemostasis and the omentum is tacked against the gallbladder bed. Culture of the gallbladder bile is performed routinely.
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The routine closure is performed. Most surgeons do not use a drain when the field is dry and there is no evidence of leakage from accessory ducts.
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The orogastric tube is removed in the operating room by the anesthesiologist, while a nasogastric tube may be beneficial for a day or two if significant infection, ileus, or debility is present. Perioperative antibiotics are administered unless significant infection, gangrenous gallbladder, or cholangitis require several days of coverage for resolution of sepsis. Coughing and ambulation are encouraged immediately. Oral intake of fluids is begun within a day, whereupon intravenous hydration and electrolyte replacement are discontinued. The diet is advanced to solid food as tolerated; however, foods that historically trigger the biliary attacks are resumed gradually.