Surgical Care at the District Hospital
Part 1 2 3 4 5 6 Primary Trauma Care Manual
The Abdomen
Laparotomy and Abdominal Trauma
Labarotomy
Abdominal trauma
Acute Abdominal Conditions
Assessment and diagnosis
Intestinal obstruction
Peritonitis
Stomac and duodenum
Gallbladder
Appendix
Abdominal Wall Hernia
Groin hernia
Surgical repair of inguinal hernia
Surgical repair of femoral hernia
Surgical treatment of strangulated groin hernia
Surgical repair of umbilical and para-umbilical hernia
Surgical repair of epigastric hernia
Incisional hernia
Urinary Tract and Perineum
The urinary bladder
The male urethra
The perineum
Gallbladder
 





The indication for cholecystostomy is severe acute cholecystitis with a distended gallbladder that is in danger of rupture.

A relative indication is uncomplicated acute cholecystitis diagnosed by the non-specialist surgical practitioner during laparotomy for an “acute abdomen”. The gallbladder will be inflamed, red, oedematous, distended and coated with a film of exudate. It may contain stones. If the gallbladder is tense and appears likely to rupture, proceed with a cholecystostomy. Cholecystectomy should be performed only by a qualified surgeon. For the non-specialist, an alternative to cholecystostomy is to close the abdomen and refer the patient for elective cholecystectomy after the acute attack has subsided.

Technique

Cholecystostomy

:: Begin antibiotics once the diagnosis is made. Pack the gallbladder off with gauze to prevent spillage of infected bile into the peritoneal cavity. Insert 2 purse-string 2/0 absorbable stitches into the fundus (Figure 7.8). Aspirate the infected bile with a needle and syringe to empty the gallbladder (Figure 7.9). Incise the fundus with a pointed knife in the centre of the purse-string sutures (Figure 7.10) and apply suction (Figure 7.11). Extract any stones using suitable forceps (Figure 7.12).

Figure 7.8
Figure 7.8

Figure 7.9
Figure 7.9

Figure 7.10
Figure 7.10

Figure 7.11
Figure 7.2

Figure 7.12
Figure 7.12

:: Introduce the tip of a Foley catheter through a stab wound in the abdominal wall and then into the gallbladder (Figure 7.13). Tie the purse-string sutures, the inner one first, leaving the ends long. Inflate the balloon (Figure 7.14). Bring the ends out through the abdominal wall with the catheter and anchor them to the stab wound. This opposes the gallbladder wall and the cholecystostomy to the abdominal wall. Do not place tension on the gallbladder to bring it into contact with the abdominal wall. The procedure is safe as long as the purse string around the Foley catheter provides a watertight closure. A latex drain may be placed in the hepatorenal pouch and brought out through a separate stab incision. It may be removed after 48 hours.

Figure 7.13
Figure 7.13

Figure 7.14
Figure 7.14

::

Close the laparotomy incision. Secure the catheter with the ends of the second purse-string suture and connect it to a sterile closed drainage system.

 

:: Continue antibiotics, nasogastric suction and intravenous fluid administration for 2 to 3 days. After 10 days, intermittently clamp the catheter for increasing periods of time. Remove the catheter when no further leakage occurs. The sinus track will close rapidly. Alternatively, leave the catheter in place and refer the patient for cholecystectomy by a surgical specialist.

 



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  Kep Points  
 
Cholecystitis:

Is caused by obstruction of the cystic duct by gall stones



 
Presents with epigastric cramps then pain which radiates to the right upper quadrant


 
May be treated by drainage of the gallbladder (cholecystostomy)



 
When complicated with pyogenic infection, requires urgent cholecystostomy and intravenous antibiotics


 
Should be referred to a surgical specialist if the patient is jaundiced.