Laparoscopic Cholecystectom Hamed Rashad Gall Bladder The gall

Laparoscopic Cholecystectom Hamed Rashad

Gall Bladder The gall bladder is the organ in the body responsible fore concentrating and storing bile

Relations of GB to surroundings

Usually G stones look like this

Two large gall stones : Notice how they reflect back shadows

Thick sludge in the gall bladder

Gall stones seen in ordinary x-ray

Laparoscopic Cholecystectomy(LC) Indication: Symptomatic gallstones l Other biliary tract disease l Difficult technical challenges Acute cholecystitis l Obesity l Previous intra-abdominal surgery l Pregnancy l

Benefit of LC Shorter hospital stays More rapid return to normal activities Small, limited incisions Less pain Less postoperative ileus

LC vs OC Treatment of Acute Cholecystitis Conversion rate: 15% l Operationg time: 88 vs 77 mins l Complication: 14% vs 23% l Hospital stay: 3. 3 vs 8. 1 days l Laparoscopic cholecystectomy vs Open cholecystectomy in the treatment of acute cholecystitis(ARCH SURG volume 133)

Anesthetic management Anesthetic technique l Regional anesthesia l l Thoracic epidural anesthesia(T 2) Advantage: l l Awake Protective airway reflex Shorter recovery Disadvantage: l l l Diaphragm irritation Significant nausea and vomiting Referred pain : neck and shoulder

Anesthetic management Anesthetic technique General anesthesia l Cuffed endotracheal tube placement l Controlled ventilation l Urinary catheter and nasogastric tube l

Open cholecystectomy : 5 -15 inches

Laparoscopic cholecystectomy : 1/4 -1/2 three or four incisions

LC-surgical technique Reverse Trendelenburg position Intraperitoneal CO 2 insufflation

Laparoscopic Cholecystectomy

Complications in Laparoscopy How to stay out -of-trouble Gandsas

Complications in Laparoscopy How to stay out -of-trouble • Trendelenburg Gandsas

Complications in Laparoscopy How to stay out -of-trouble • Trendelenburg • Elevate abd. wall Gandsas

Complications in Laparoscopy How to stay out -of-trouble • Trendelenburg • Elevate abd. wall • 45 degrees Gandsas

Complications in Laparoscopy How to stay out -of-trouble • Trendelenburg • Elevate abd. wall • 45 degrees • Stay in midline Gandsas

Complications in Laparoscopy How to stay out -of-trouble • Trendelenburg • Elevate abd. wall • 45 degrees • Stay in midline • 15 mm Hg 15 mm. Hg Gandsas

Complications in Laparoscopy How to stay out -of-trouble • Trendelenburg • Elevate abd. wall • 45 degrees • Stay in midline • 15 mm Hg • Inspection Gandsas

LC-surgical technique

Laparoscopic Cholecystectomy

Complications in Laparoscopy Hasson Closed (n=12, 444) (n=489, 335) Vascular Injuries (%) 0 0. 08 Intestinal Injuries (%) 0. 05 0. 08 Bonjer HJ. Br J Surg. 1997; 84: 599 -602 Gandsas

Laparoscopic Cholecystectomy

Laparoscopic Cholecystectomy Away from The CBD Lateral Retraction

Anesthetic management Post operative pain relief Wound infiltration with local anesthesia and NSAID - for peripheral pain l Opioids - for central pain l Ondansetron – for nausea and vomiting l

Lap CBD stone extraction : x-ray showing stone—flexible scope and basket used fore extraction

Missed CBD stone

ERCP : Balloon stone extraction

ERCP with sphincterotomy and stone extraction

Opening of BD---Widely open after sphincterotomy stones coming out

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