Plate 102

Indications

Cholecystostomy, while not recognized as routine treatment for cholelithiasis, may be a lifesaving procedure. Today cholecystostomy is usually placed under image guidance by a percutaneous technique. Surgical cholecystostomy may be needed in some situations. It is the operation of choice in some elderly patients with acute cholecystitis, in poor surgical risks who present a well-defined mass, in seriously ill patients in whom minimum surgery is desirable when a large abscess surrounds the gallbladder, and when technical difficulties make cholecystectomy hazardous. If there is obstruction of the common duct with long-standing jaundice and a tendency toward hemorrhage that cannot be controlled by vitamin K and transfusions or percutaneous transhepatic biliary tube drainage, preliminary cholecystostomy for decompression may be the procedure of choice.

Preoperative Preparation

See Plate 95.

Anesthesia

See Plate 95.

Position

The position for a gallbladder operation, as described in Plate 95, is used. With local anesthesia this is modified if the patient is uncomfortable.

Operative Preparation

The skin is prepared in the routine manner.

Incision and Exposure

A small incision is made with its midportion directly over the maximum point of tenderness in the right upper quadrant. Occasionally, when unsuspected technical difficulties or inflammation more severe than anticipated are encountered, the procedure is carried out through the usual upper right rectus or infracostal incision. The adhesions are not dissected from the undersurface of the gallbladder unless it is thought that cholecystectomy might be feasible (Figure 1).

Details of Procedure

The fundus is walled off with gauze before the evacuation of its contents. An incision is made just through the serosa of the bulging fundus (Figure 2). A trocar is inserted to remove the liquid contents (Figure 3). Suction is maintained adjacent to the incision in the fundus as the trocar is withdrawn. A culture is taken routinely. The edematous wall is then grasped with Babcock forceps, and the opening is extended (Figure 4). A purse-string suture of fine absorbable material is placed about the opening in the fundus to control oozing and to close the fundus about the drainage tube. Any liquid or grumose material remaining in the lumen of the gallbladder is removed by suction. Since there is usually an impacted stone in the ampulla of the cystic duct, a determined effort is made to remove it to permit the escape of bile from the biliary ducts. A small, flexible scoop, such as a Cushing pituitary curet, is directed down to the ampulla (Figure 5). If the scoop cannot dislodge the stones, a fenestrated forceps is used. The lumen of the gallbladder is repeatedly flooded with saline. A small rubber catheter is inserted and anchored with an interrupted silk suture (Figures 6 and 7), or a Foley catheter may be used. The previously placed purse-string suture is tied snugly about the drainage tube (Figure 7). If the inflammation is severe, or if an abscess was encountered, or if there has been soiling about the wall, a rubber tissue drain is inserted along the wall of the gallbladder. The common duct must be decompressed if suppurative cholangitis is suspected.

Closure

Stitches are taken to anchor the fundus to the overlying peritoneum to prevent the soiling of the peritoneal cavity before the area is sealed off (Figure 8). A routine closure is made. After a sterile dressing has been applied, the drainage tube is anchored to the skin with a suture or adhesive tape and is connected to a drainage bottle.

Postoperative Care

See Plate 101. While the drainage tube is in place, a radiopaque substance may be injected and a cholangiogram taken for evidence of overlooked calculi. If the patient is in good condition, and the postoperative recovery is uncomplicated, a subsequent cholecystectomy may be performed through the original wound within several weeks. A secondary operation after cholecystostomy is not recommended in the extremely poor-risk patient. Antibiotics are given.

Indications

Plastic repair of the extrahepatic bile ducts is usually required as a result of stenosis or stricture following technical difficulties or errors, such as a faulty exposure or excessive bleeding that occurred during a previous cholecystectomy. The surgeon may hurriedly clamp and ligate blindly to control bleeding and include part or all of an extrahepatic bile duct. The ampulla of the gallbladder often lies parallel and adjacent to the common duct, so that the clamps applied roughly to the ampulla may also include a portion of the common duct. If extrahepatic ducts have been injured or divided accidentally during operation, they should be repaired immediately. Although common duct repair is preferred by many surgeons, consideration should be given to a Roux-en-Y bypass as shown in Plate 103.

Preoperative Preparation

See Plate 95. An ERCP procedure may be used to confirm the diagnosis, culture the bile, and provide prolonged decompression of the obstruction, especially if the bilirubin is 20 mg or above.

Anesthesia

See Plate 95.

Position

See Plate 95.

Operative Preparation

The skin is prepared in the routine manner.

Incision and Exposure

The incision may be made through the old scar and may be extended if necessary. If there is an external biliary fistula, a small probe is introduced to facilitate the dissection of the sinus down to its origin. Sharp dissection may be necessary to divide the adhesions between the anterior surface of the liver and the overlying peritoneum. Because of the previous cholecystectomy, the duodenum or hepatic flexure of the colon may be drawn up toward the hilus of the liver, and meticulous dissection is required to separate these structures from the old gallbladder bed until the region of the hepatoduodenal ligament is visualized. The dissection may be started far out laterally, progressing toward the midline until the foramen of Winslow can be identified. The remainder of the abdomen is packed off with warm moist gauze.

Details of Procedure

The lateral margin of the hepatoduodenal ligament should be searched carefully for the common duct. The hepatoduodenal ligament is incised along its lateral margin. Usually, it is easier if the dilated upper end of the common duct can be located. This may require searching well up toward the hilus of the liver. The second portion of the duodenum should be mobilized to permit visualization of the common duct by incising the peritoneal reflection along its lateral border (Figure 9). The duodenum is retracted medially by blunt dissection (Kocher maneuver) to expose the head of the pancreas and the lower portion of the common duct (Figure 10). Traction sutures are placed in either side of the isolated duct, and an opening is made either above or below the stricture, depending upon the space available (Figure 10). An attempt is made to pass a probe past the constriction, and an incision is made on the probe up and down along the constricted area (Figure 11). Additional traction sutures are placed in the cut edges of the duct. Saline is injected through a catheter that is directed downward through Vater's papilla to prove the patency of the lower end of the duct. A rubber T-tube, No. 14 French, is then passed through the opening that was made below the stricture (Figure 12). One arm is directed beyond the stricture and the other downward (Figures 13 and 14). Before the area of stricture is repaired, the duodenum is well mobilized to ensure that there will be no tension on the suture line. The distance gained must be more than the length of the vertical incision made through the strictured portion of the duct. The duodenum is pulled upward to the hilus of the liver, and its superior margin is anchored to the thickened hepatoduodenal ligament with interrupted sutures (Figures 14 and 15).

The vertical opening through the stricture is closed horizontally (Figure 13). The lateral traction sutures are gently manipulated so that the upper and lower lips of the opening approximate (Figure 13). Interrupted sutures are taken, including just the margin of the cut duct, and tied with the knot on the inside (Figure 13). A reinforcing layer of sutures is added if the tension is not too great and the tissue included does not encroach upon the lumen of the duct (Figure 14). The suture line is tested by injecting saline through the catheter, and a cholangiogram is made. If the ductal system is clear and contrast medium enters the duodenum freely, a final inspection to ensure that there is no tension on the suture line is made. The area is covered with omentum, and a Silastic closed-suction system is inserted past the common duct into Morison's pouch. Alternatively, a short structure may be resected and a primary end-to-end anastomosis created using a T-tube stent. See Plate 103.

Closure

Closure is routine.

Postoperative Care

Postoperative care is carried out as described in Plate 99. The common-duct catheter should not be removed for an indefinite period. The status of the extrahepatic biliary ducts should be determined by a cholangiogram before the catheter is removed. Bile losses must be measured accurately. Sodium deficits are corrected by the administration of sodium lactate or sodium bicarbonate, depending upon the extent of the loss. Long-term follow-up is needed as the stricture may recur and necessitate a Roux-en-Y bypass.