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SURGERY
obstructions from stricture formation. The gallbladder is
now sutured to the far side of the enterotomy as the surgeon looks at the site with a continuous monofilament
3-0 or 4-0 absorbable. An incision is now made in the
gallbladder to match the enterotomy. The near side of the
gallbladder incision and enterotomy are now sutured in
the same fashion. The area should be checked for leaks
and a liver biopsy taken. Any abnormal lesions in the area
of the bile duct, duodenal papilla should be biopsied to
rule out neoplastic disease as a cause of the obstruction
or confirm pancreatitis. Complications include haemorrhage, incisional breakdown and peritonitis, stricture of
the stoma, ascending cholangitis and gastric ulceration.
2. Choledochal Stenting
This is a very simple technique that can be used if the
common bile duct can be catheterised through the enterotomy. This is ideal for traumatic tears of the common
bile duct, reversible obstructions or removal of choleoliths
in the common bile duct. A small feeding tube is passed
into the duodenal papilla. There should be good flow of
bile through the tube. The largest size that will fit should
be chosen but not too large to damage the papilla. The
tip is cut leaving 3-4 cm of tube in the duodenum. Always
place a stay suture in the end of the tube before cutting
it as to not lose the end in the common bile duct. The
duodenal end is now sutured to the submucosa of the
duodenum to keep it in place. An absorbable monofilament should be used. The theory behind this is that once
the cause has been reversed or the common bile duct
has healed the suture will dissolve and pass out in the
stool. The stent can be removed via endoscopy if it has
not passed out in 2-3 months. The stent can lead to ascending cholangiohepatitis if not removed or passed out.
3. Cholecystostomy Tube
This diverts bile from the biliary system to an external collecting system. This can be done rapidly in compromised
patients and does not alter the anatomy of the biliary
system. It can only be used as a temporary solution in
patients with permanent obstruction or in patients with
a temporary obstructive disease. It should only be done
when the gallbladder wall is considered to be healthy. A
Foley’s catheter is placed through the right lateral wall of
the abdomen. This Foley’s is then placed through a stab
incision in the apex of the gallbladder. A purse string is
placed around the incision and the cuff inflated of the
Foley’s. This is connected to a collection system externally and bile is diverted.
Fig 2: Ruptured gallbladder mucocoele
Gallbladder Disease
Cholecystectomy
Gallbladder mucocoele is the most common disease affecting the gallbladder. It appears to be caused by cystic
mucosal hyperplasia. This can lead to extra hepatic biliary obstruction or bile peritonitis from rupture of the
gallbladder. The procedure of choice is a cholecystectomy. This entails removal of the entire gallbladder. Before performing a cholecystectomy the patency of the
common bile duct must be assessed. This is performed
through an enterotomy as described in the previous section on cholecystoenterostomy. The gallbladder is then
bluntly dissected as described until the junction of the
cystic duct, gallbladder and common bile duct can be
seen. The common bile duct is now ligated above the
section where the cystic ducts enter and the gallbladder
removed. The fossa where the gallbladder was removed
is now assessed for haemorrhage, which can be controlled. The gallbladder should be submitted for histopathological examination.
Cholecystotomy
There are few indications for cholecystostomy, they include removal of choleoliths, biopsy and any procedure
requiring access to the lumen of the gallbladder. This
should never be performed if the gallbladder wall is unhealthy. The gallbladder has a poor suture holding ability
when diseased and trying to suture can lead to leakage
and peritonitis. The gallbladder is packed off with sterile
swabs and an incision is made in the gallbladder. The bile
should be suctioned out and the choleolith removed.
The gallbladder is then sutured with a monofilament absorbable suture and the area lavaged.
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