Hernia

Surgical access to the gallbladder. Basic operations performed on the gallbladder and bile duct

03.03.2020

Indications: chronic recurrent cholecystitis in the case of long-term ineffective conservative treatment.

Gangrene, phlegmon, perforation and cancer of the gallbladder are urgent indications.

Access for cholecystectomy

Cholecystectomy accesses can be divided into vertical, oblique and angular.

Vertical incisions of the anterior abdominal wall include: upper median, pararectal and transrectal.

Among the slanting sections, one can distinguish the approaches of Kocher, Courvoisier, Fedorov, etc.

Kocher cutstart from the midline and carry out 3-4 cm below and parallel to the costal arch; its length is 15–20 cm.

Courvoisier section- This is an arcuate incision, which is carried out below and parallel to the right costal arch with a bulge downward. Almost identical to the Kocher cut.

Fedorov sectionstart from the xiphoid process and carry out first downward along the midline for 3-4 cm, and then parallel to the right costal arch; its length is 15–20 cm.

Of the subgroup of angular cuts, they are most often used rio Branco cut, which is carried out along the median line 2-3 cm below the xiphoid process down and, not reaching 2 transverse fingers to the navel, turn right and up to the end of the X rib.

There are two types of cholecystectomy:

1) cholecystectomy from the neck;

2) cholecystectomy from the bottom.

With both methods, the most important moment of the operation is the isolation and ligation of the cystic artery and the cystic duct in the area of \u200b\u200bthe hepato-12 duodenal ligament. This moment is associated with the danger of damage to the hepatic artery or its branches, as well as the portal vein. Accidental or forced ligation of the artery causes liver necrosis, and if the portal vein is injured, bleeding is difficult to stop. Before removing the gallbladder, the operative field should be isolated with 3 gauze napkins: one is placed down on the 12 duodenal and transverse colon, the second is placed between the liver and the upper pole of the kidney to the Vinslow hole, and the third is placed on the stomach.

Removal of the gallbladder from the neck

Pulling the liver upward, and the duodenum 12 downward, the anterior peritoneal leaf is carefully cut along the right edge of the hepato-12 duodenal ligament. Cutting through the tissue, the common bile duct and the place where the cystic duct flows into it are exposed. A silk ligature is applied to the isolated cystic duct, and a curved Billroth clamp is applied to the periphery of it, closer to the bladder neck, on the duct. In order not to damage the wall of the common bile duct, the ligature is applied at a distance of 1.5 cm from the confluence of the ducts; keeping longer

the stump is undesirable, since this can subsequently lead to the formation of a sac-like expansion ("False gallbladder")with stone formation. Then the duct is crossed, and the stump is cauterized and covered with a gauze napkin. In the upper corner of the wound, the cystic artery is found, it is carefully tied up with 2 silk ligatures and transected. Then proceed to the allocation of the gallbladder. The incision of the anterior surface of the hepato-12 duodenal ligament is continued on the bladder wall in the form of 2 semi-ovals, going near the axis of the gallbladder and entering its gap. After which he is easily peeled out of his bed in a blunt way. After removal of the bladder, the sheets of the peritoneum are sutured over the bed of the gallbladder with a continuous or interrupted catgut suture, continuing along the incision of the hepato-12-duodenal ligament. Thus, the bed of the bladder and the stump of the duct are peritonized. Isolating napkins are removed and 2-3 gauze swabs 3 cm wide are brought to the stump; they are brought to the bottom of the wound, but not reaching the hepatic-duodenal ligament; gauze tampons are taken out through the emptied wound. They are removed by gradual stretching, starting from the 9-11th day. The abdominal wall is sutured in layers: with a continuous catgut suture - the peritoneum, with an interrupted silk suture - the crossed muscles and the walls of the sheath of the rectus abdominis muscle.

Removal of the gallbladder from the bottomproduced in the reverse order: first, the gallbladder is isolated, and then the methods of isolation and ligation of the cystic artery and duct are carried out. For this, the allocated bubble is pulled back; then the isolated cystic artery will be visible in the upper right corner of the Calot triangle, it is isolated and transected between 2 ligatures in the manner described above. After that, the cystic duct is isolated, ligated and crossed. The further course of the operation is the same as when the blister is isolated from the neck. Isolation of the bladder from the bottom is less advisable, since in this case small stones from the cavity of the bladder are easily thrown into the ducts.

Possible complications:

1. Bleeding from the stump of the artery when the ligature slips.

2. Damage to the anterior right branch of the hepatic artery. The upper border of the Calo triangle is often formed by two arteries - the right hepatic and cystic arteries. In this case, nek-rose occurs right lobe liver.

3. Damage to the anterior right branch of the hepatic artery. In 12% of cases, the right hepatic artery is located anterior to the hepatic duct, sometimes it crosses from left to right at the confluence of the cystic and hepatic ducts. When the Ka-lo triangle is exposed sharp way the artery can be damaged.

4. Damage to the portal vein. In 24% of cases, there is a displacement of the portal vein to the right of the common hepatic duct in the upper half of the hepato-duodenal ligament. Acute discharge of the neck of the gallbladder and cystic duct, which in this variant are located on the anterior surface of the portal vein, is fraught with damage to the latter. Bleeding is very difficult to stop.

5. Leaving an excessively long stump (more than 1.5 cm) leads to the formation of a "false" gallbladder with subsequent stone formation.

6. Leaving an excessively short stump (less than 0.5 cm) leads to disruption of the flow of bile in the common bile duct due to the possibility of developing strictures in it.

7. When moving away from the bottom, the stones can be pushed into the underlying ducts.

Calo triangle:

a) cystic duct (left);

b) common hepatic duct (right);

c) the cystic artery (top).

Approximately 700,000 cholecystectomies are performed annually in the United States. Most are done to relieve symptoms. gallstone disease, mainly about persistent biliary colic. Surgeries are also performed to treat complications (for example, acute cholecystitis, pancreatitis) or as combined (simultaneous) cholecystectomies performed during other open organ surgeries abdominal cavity... Currently, most cholecystectomies are performed using laparoscopic techniques (see).

What are the indications for an open cholecystectomy?

Indications for open or laparoscopic cholecystectomy are usually associated with the need to stop the symptoms of cholelithiasis or treatment of the complicated course of calculous cholecystitis.

The most common of these indications are as follows:

biliary colic
biliary pancreatitis
cholecystitis
choledocholithiasis

Other indications for cholecystectomy are biliary dyskinesias, gallbladder cancer and the need to perform prophylactic cholecystectomy during various interventions on the abdominal organs (this issue is still being discussed by many researchers). For example, prophylactic cholecystectomy was recommended for patients who simultaneously underwent splenorenal bypass surgery for portal hypertension and pain. This is due to the fact that after this type of intervention, an exacerbation of liver pathology is possible, including the development of acute cholecystitis.

Currently, there is a clear trend towards the transition as the operation of choice from standard cholecystectomy to laparoscopic. However, some clinical situations still require a traditional open cholecystectomy. Depending on the clinical situation, the intervention can begin laparoscopically and then transform into an open version of the operation.

Refusal from the laparoscopic method in favor of open surgery or the so-called conversion of the operation can be performed in case of suspicion or visual confirmation of gallbladder cancer, the presence of a cholecystobiliary fistula, biliary intestinal obstruction and in severe cardiopulmonary pathology (eg, heart failure, etc.), when it is not possible to impose a pneumoperitoneum (injecting gas into the abdominal cavity) to perform laparoscopic cholecystectomy.

When identifying gallbladder cancer Before or during surgery, open cholecystectomy should only be performed by an experienced surgeon, as it may require experience and skills in liver resection and hepatobiliary surgery to perform cancer intervention.

Determination of indications for open cholecystectomy in gallbladder cancer is still relevant, since in most cases, gallbladder cancer is detected directly during surgery, which is often performed for gallbladder polyps.

Open cholecystectomy as an option for removing the gallbladder should also be considered in patients with cirrhosis of the liver and blood clotting disorders, as well as in. This is due to the fact that in patients with cirrhosis of the liver and blood clotting disorders, the likelihood of bleeding during surgery significantly increases, and such bleeding can be extremely difficult to control laparoscopically, and an open option of intervention in this case may be more reasonable. In addition, patients with liver cirrhosis and portal hypertension often have an umbilical vein dilatation, which can contribute to the development of serious bleeding even at the stage of laparoscopic access.

Despite the fact that laparoscopic cholecystectomy was recognized by most experts as a safe operation in any trimester of pregnancy, an open version of the intervention is best considered in the third trimester, since the introduction of air and laparoscopic ports into the abdominal cavity during pregnancy is associated with technical difficulties. In rare cases, open cholecystectomy is indicated for patients with previous injuries to the right hypochondrium (for example, penetrating wounds of the gallbladder or other abdominal organs).

As practice shows, most cases of transition to open cholecystectomy after laparoscopic surgery are due to hemorrhagic complications or unclear and complex anatomy. The frequency of transition from laparoscopic cholecystectomy to open surgery is in the range of 1-30%. However, the average conversion rate is 10%.

age over 60,
male gender,
weight over 65 kg,
the presence of acute cholecystitis,
a history of previous surgery on the upper floor of the abdominal cavity,
availability and high level glycosylated hemoglobin,
insufficient experience of the surgeon.

Licciardello's research suggests that the following factors are considered for conversion to open surgery:

age patient;
acute cholecystitis;
accompanying illnesses;
leukocyte or septic condition;
elevated levels of aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, gamma glutamyl transpeptidase, C-reactive protein, and fibrinogen.

What are the known contraindications for open cholecystectomy?

There are very few absolute contraindications for performing open cholecystectomy, mainly associated with the development of serious physiological disorders or with decompensation of cardiovascular diseases, in which general anesthesia is prohibited.

In cases where cholecystectomy is not possible, various options for sparing (palliative) interventions can be used to stabilize the patient's condition. Such interventions include endoscopic retrograde cholangiopancreatography (ECPG) or percutaneous cholecystostomy.

Fig. 1 Percutaneous gallbladder drainage (cholecystostomy)

What anesthesia is used for gallbladder removal surgery?

Most open cholecystectomies are performed under general anesthesia... However, in severe condition and presence absolute readings to surgery, as well as in the presence of an experienced anesthesiologist, it is possible to carry out the operation under epidural or spinal, less often local anesthesia.

What instruments are used during the operation?

The set of instruments for open cholecystectomy is not much different from the standard set used for other operations on the abdominal organs:

kelly Hemostat Clamps, Forceps, Needle Holders and Kocher Clamps, Scissors, Standard Clips, Scalpel, Scalpel Holder, Kitner Dissectors and Electrosurgical Instruments
balfour retractors, Buckwalter retractors, or other self-retaining retractors that can be used depending on the surgeon's preference
suture material or clips can be used to treat the cystic duct and artery, depending on the surgeon's preference and the diameters of the structures being tied. Long instruments may be required depending on the patient's constitution.

To enhance visualization, surgeons can use headlamps or other lighting devices. Several options for cholangiography and drainage catheters may also be needed bile ducts.

How is the patient positioned during cholecystectomy?

The patient is placed on the operating table in the supine position with outstretched arms. It is desirable that the operating table be functional and change position in different spatial planes.

How is cholecystectomy performed?

Open cholecystectomy can usually be performed using one of the approaches: retrograde or antegrade.

A more traditional option - retrograde ("top-down") discharge to remove the gallbladder - begins with a dissection of the peritoneum at the bottom of the gallbladder and is directed towards the Calo triangle and ligament elements. This approach makes it possible to accurately identify the cystic duct and arteries, since they are excreted together with the separation of the gallbladder from its bed.

With the increase in experience of operations and knowledge in laparoscopic technique, surgeons often prefer the antegrade technique of gallbladder removal. With this technique, the peritoneal dissection begins in the Calot triangle with transection and ligation of the cystic duct and artery. And in the future, the gallbladder is isolated from the liver bed towards the bottom.

What preoperative preparation is required before cholecystectomy?

As mentioned earlier, the patient is placed on his back with outstretched arms. Intubation is performed after induction of anesthesia respiratory tract to maintain normal breathing during the operation, that is, artificial ventilation is performed. The patient is placed with a Foley urinary catheter to monitor the balance of fluids and other devices necessary to ensure the operation, if necessary, anticoagulants are administered. If necessary, antibiotics are administered according to indications.

During the operation, the surgeon usually stands to the left of the patient, and the surgeon's assistant to the right. The operating room should also be equipped with equipment for performing intraoperative cholangiography.

What access is used to remove the gallbladder?

To create an excellent view of the gallbladder bed and cystic duct, the Kocher approach is optimal, which is an oblique incision in the right hypochondrium parallel to the costal arch. Alternatively, some surgeons use the upper midline approach, or the so-called upper midline laparotomy, which allows for greater access and additional manipulations. As a rule, the upper-median laparotomy is performed from the xiphoid process to the umbilicus, and such a wide access allows performing any manipulations on gallbladder... Paramedian access is rarely used.

A skin incision is made 1-2 cm to the right of the white line of the abdomen and is carried out along the edge of the costal arch, 4 cm away from its edge (approximately 2 fingers in diameter). The incision is extended to 10-20 cm, depending on the patient's physique.

The anterior rectus abdominis muscles should be dissected along the length of the incision, while it is important to separate the rectus abdominis from the lateral muscles (external oblique, internal oblique and transverse abdominal muscles) using electrocoagulation. Then the back of the rectus abdominis muscles and the peritoneum are dissected. Recently, in order to comply with the principles of aesthetic surgery when removing the gallbladder, mini-approaches have been actively used. To perform the operation through such an access, surgeons use special surgical instruments and early dilating structures.

Fig. 2 Kocher approach and mini-access for cholecystectomy

How is the anatomy of the subhepatic space assessed and pathology confirmed?

Whenever possible, a thorough manual and visual examination should be performed to assess the presence of comorbidities or anatomical abnormalities. Balfour or Buckwalter retractors can be used to improve visualization.

It is imperative to conduct an audit and palpation of the liver, while air can be found in the subphrenic space. With a downward displacement of the liver, it is possible to assess the state of the gallbladder itself and its lower surface. For additional downward displacement, dilators above and to the side of the liver can be used to aid organ exposure. In the future, with the help of retractors, the duodenum is displaced below, which allows access to the liver gates. The next step, the surgeon should palpate the gallbladder for the presence of stones in it. The states of the liver hilum and ligamentous apparatus with the main elements (common bile duct, hepatic artery and portal vein) are assessed by palpation by introducing the left index finger into the Winslow opening (or Winslow opening). Via thumb the hilum of the liver, in particular the common bile duct, can be palpated for stones or tumors.

Fig. 3 Anatomy of the subhepatic space

How is the gallbladder removal stage performed?

The dome of the gallbladder is grasped with a Kelly forceps and lifted up. Adhesions connecting the lower surface of the gallbladder and the transverse colon, or duodenum, are crossed by electrocoagulation.

Removal of the gallbladder can be done in two ways. Traditionally, isolation of the gallbladder in open cholecystectomy is performed using a top-down or retrograde technique, in which the fundus is mobilized first and then the gallbladder is mobilized towards the portal vein. This technique differs from the antegrade isolation technique, in which the incision begins at the hepatic hilum and continues towards the fundus (as is done with laparoscopic cholecystectomy).

Retrograde approach

In the retrograde approach, the visceral peritoneum is dissected 1 cm above the bottom of the gallbladder, then the bottom is grasped with a Kelly forceps and pulled to separate from the bed. Subsequently, the gallbladder is isolated from the bed using electrocoagulation along the lateral and posterior walls, while an aspirator is additionally used to drain the operating field. Such a selection is made up to the exposure of the neck of the gallbladder in the Kahlo triangle, when it is fixed to the tissues only through the cystic duct and the cystic artery.

Removal of the gallbladder is performed very carefully, with the isolation of small bile vessels and their careful coagulation, or bandaging and ligation if necessary (for example, when they expand due to portal hypertension). The appearance of significant bleeding indicates that the allocation is made too deep and requires careful hemostasis. The only drawback of this method of isolation is considered the possibility of migration of a stone fixed in the duct into the common bile duct (common bile duct), which may require additional therapeutic measures.

Fig. 4 Removal of the gallbladder in a retrograde way

Antegrade approach

With the anterograde approach, isolation is initially performed in the area of \u200b\u200bthe hepatic hilum. In this case, the bottom of the gallbladder rises upward. The gallbladder neck is mobilized laterally to expose the elements of the Kahlo triangle. Further, the artery and the cystic duct are ligated and crossed, always subject to the correct anatomical relationships.
After the cystic duct and artery have been transected and completely detached from the Winslow ligament elements, the gallbladder is separated from the posterior wall towards the bottom. Before cutting off the cystic duct, it is necessary to clearly differentiate the place where the cystic duct flows into the common bile duct, and, if necessary, remove the fixed stones. If there is a suspicion of stone migration into the common bile duct, intraoperative cholangiography can be performed through the stump of the severed duct.

How is the stage of mobilization of the cystic duct and artery performed?

After ligation and isolation of the cystic duct, they are sutured, and for this, various suture material, staplers, clips are used.

Non-absorbable sutures are usually used to ligate the cystic duct stump. However, if a biliary-intestinal anastomosis is required or after choledochotomy, this suture material is not suitable due to the high degree of lithogenicity (contributes to the formation of stones at the suture) and the high likelihood of a chronic inflammatory reaction. Therefore, for this, sutures are used that are absorbable in the long term, a few months after the operation, usually they consist of polymers such as polyglactin 910 (Vicryl, Ethicon, Sommerville, NJ) or polydioxanone (PDS, Ethicon). Also, metal (titanium) clips are often used.

If the cystic duct is large and inflamed, mechanical staplers may be used. The cystic artery can also be sutured with various sutures (absorbable or non-absorbable), or clipped, although mechanical staplers are rarely used to ligate the cystic artery during open cholecystectomy.

How is tissue processing in the area of \u200b\u200bcholecystectomy carried out?

Isolation of the cystic duct and artery is performed using a blunt Kitner dissector. The use of a blunt dissector prevents the separation of these elements and unpredictable bile or bleeding. The arteries supplying the gallbladder are found on the inner and outer sides of the duct at 3 and 9 o'clock, in this zone are the anterior and back branches cystic artery, therefore, careful selection of arteries in this area avoids damage and ischemia.
With extreme caution in the area of \u200b\u200bthe Calo triangle, electrocoagulators and other thermal energy devices should be used. They are not recommended for use when working in the immediate vicinity of the bile ducts, since their thermal damage can subsequently result in the formation of strictures (narrowings).

Sudden bleeding from the hilum area is a serious hazard, so surgeons try to avoid blind placement of stitches or clips in this area, as well as the heat exposure of the coagulator. If it is not possible to cope with bleeding, Pringle's technique is often used, which consists in imposing a tourniquet on the gastroduodenal ligament and temporarily blocking blood flow.

Suturing of vascular defects should be performed clearly with differentiation of all elements of the gastroduodenal ligament and the use of non-absorbable suture material.

What are the complications after cholecystectomy?

Despite the fact that open cholecystectomy is a safe operation with a low mortality rate, it still carries certain risks of possible complications. Traditionally, the complication rate for this operation is in the range of 6-21%, although in modern conditions this figure barely reaches 1-3%. For patients with liver cirrhosis and when performing gallbladder removal in children, the use of laparoscopic cholecystectomy can significantly reduce the incidence of complications, while significantly reducing the recovery period.

Bleeding and infection

An integral part of any surgical operation is the risk of bleeding and infection. Potential sources of bleeding are usually the liver bed, the hepatic artery and its branches, and the hepatic hilum. Most sources of bleeding are identified and eliminated intraoperatively. However, sometimes postoperative bleeding can lead to significant blood loss to the abdomen.

Infectious complications can range from wound infections and soft tissue infections to intra-abdominal abscess. The risk of infection can be minimized through careful adherence to the principles of asepsis, as well as the prevention of bile leakage into the abdominal cavity. If there is a significant leakage of bile or migration into the abdominal cavity of the stone, then a thorough revision and sanitation of this area is performed. This reduces the risk of developing an intra-abdominal infection. All stones must be removed to prevent further abscess formation.

Fig. 5 Intraoperative cholangiography

Complications from the biliary tract

The most common biliary complications are bile leakage (leakage) or traumatic injury to the bile ducts. Leakage of bile is possible as a result of incompetence of the clips and slipping of the ligatures from the cystic duct, as well as with injuries of the bile ducts or, most often, when crossing the Lyushka ducts. Lyushka's ducts are underdeveloped epithelial ducts (small ducts) between the gallbladder and the bile ducts. Bile leakage may be accompanied by persistent abdominal pain, nausea and vomiting. At the same time, functional liver tests are often increased. To confirm this complication, endoscopic retrograde cholangiopancreatography (ERCP) is usually performed, which allows you to accurately determine the place of leakage, as well as timely carry out endoscopic correction.

Perhaps the most problematic complication after open cholecystectomy is damage to the common bile duct (common bile duct). Although this is the most well-known complication after standard gallbladder removal, the incidence of trauma during laparoscopic cholecystectomy is 2 times higher. When detecting injury to the bile ducts intraoperatively (during the operation), to eliminate this complication, it is better to contact a surgeon who has extensive experience in the treatment of hepatobiliary pathology, especially with trauma to the bile ducts. If this is not possible, it is best to consider transferring the patient to a highly specialized care center. Often, the delay in the diagnosis of bile duct injury can be several weeks or even months after the initial surgery. As noted earlier, these patients should be referred to an experienced surgeon for proper assessment of management and final treatment.

To expose the liver, gallbladder and bile ducts, more than 30 surgical approaches... These approaches can be divided into three groups: anterior, posterior, and superior.

The anterior approaches are the most numerous; they can be divided into oblique, vertical and angular

To oblique cuts of the front abdominal wall include the following: the Kocher, S.P. Fedorov, Pribram, Sprengel, and others sections. The Kocher and S.P. Fedorov sections are especially widespread, since they create the most direct route and the best access to the gallbladder, bile ducts and the lower surface of the liver.

Kocher cut start from the midline and carry out 3-4 cm below and parallel to the costal arch; its length is 15-20 cm.

Section according to S.P. Fedorov start from the xiphoid process and carry out first downward along the midline for 3-4 cm, and then parallel to the right costal arch; its length is 15-20 cm.

To vertical incisions of the anterior abdominal wall include: upper median, pararectal and transrectal.

Of this subgroup, the most commonly used is a midline incision made between the xiphoid process and the navel. If this access is insufficient, it can be expanded by making an additional right transverse incision.

Lawson Tate's pararectal incisionand transrectal incision by O.E. Hagen-Thorn rarely used, although some clinics give them preference (V.A. Zhmur).

Corner and wavy cuts - Rio Branco, Cherni, VR Braitsev, Mayo-Robson, A. M. Kalinovsky, etc. - give free access to the bile ducts and liver and are widely used.

Of this subgroup of cuts, rio Branco cut, which is carried out along the median line from the xiphoid process down and, not reaching two transverse fingers to the navel, turn right and up to the end of the X rib.

Wide exposure of the liver provides thoracoabdominal approaches F.G. Uglov, Kirchner, Brunschwig, Raiferscheid, etc.

Posterior (lumbar) approaches by A.T.Bogaevsky, N.P. Trinkler are used mainly for lesions, cysts or abscesses of the posterior surface of the liver.

Upper approaches: extrapleural A. V. Melnikov and transpleural Volkman-Israelused to expose the upper-posterior part of the diaphragmatic surface of the liver. These accesses are used for operations for abscesses, cysts and damaged liver.

Operational accesses to the liver

1. Along the edge of the costal arch:

* Courvoisier-Kocher access - from the apex of the xiphoid process two fingers below the costal arch and parallel to it (access to the gallbladder);

* Fedorov access - from the xiphoid process along the white line for 5 cm, turning into an oblique incision parallel to the right costal arch (access to the gallbladder and the visceral surface of the liver);

* Rio Branco access - consists of two parts: the vertical part is drawn along the white line, not reaching two transverse fingers to the navel, and the oblique is wrapped at an angle and goes to the end of the X rib (wide access to the liver).

Oblique incisions of the anterior abdominal wall include the following: incisions of Kocher, S.P. Fedorov, Pribram, Sprengel, etc. The incisions of Kocher and S.P. the most direct route and the best access to the gallbladder, bile ducts and the lower surface of the liver.

Kocher cut start from the midline and carry out 3-4 cm below and parallel to the costal arch; its length is 15-20 cm.

The incision according to SP Fedorov begins from the xiphoid process and is carried out first downward along the midline for 3-4 cm, and then parallel to the right costal arch; its length is 15-20 cm.

Vertical incisions of the anterior abdominal wall include: upper median, pararectal and transrectal.

"Atlas of operations on the abdominal wall and abdominal organs" by V.N. Voilenko, A.I. Medelyan, V.M. Omelchenko

Ligation of the hepatic vein of the left lobe Due to the ligation of the vessels belonging to the lobe of the liver, its color changes. Based on this, the cut-off line of the removed lobe is determined. Left lobe cut off with an electric knife or scalpel. Separate bleeding vessels on the wound surface of the liver are bandaged. The liver stump is peritonized with a sickle-shaped ligament, an omentum or a stomach wall. Drainage and tampon are brought to the bed of the removed lobe. Operating wound ...

Cholecystostomy (cholecystostomia) Cholecystostomy is now rarely performed, mainly for purulent cholecystitis in very severe, debilitated patients, when removal of the gallbladder is contraindicated. The operation is mainly performed under local anesthesia according to A.V. Vishnevsky. To expose the gallbladder, the Kocher incision is often used. Operation technique. An oblique incision along the right costal arch is used to dissect the skin and subcutaneous ...

After completing the revision of the gallbladder and bile ducts, the abdominal cavity is fenced off with four gauze napkins. The first napkin is inserted into the omental opening, the second into the right lateral canal, the third into the pregastric and pre-omental bursa, and the fourth into the space between the liver and the diaphragm. To facilitate the excretion of the gallbladder under the peritoneum covering it, starting from the hepatoduodenal ligament, ...

The operation is performed with irreparable narrowing of the large nipple and to remove stones from the terminal duct. After opening the abdominal cavity and revision of the biliary tract in the supraduodenal part, the common bile duct is opened and a probe is inserted into it, which determines the position and course of the duct. Then a duodenotomy is performed, and above the nipple, the posterior wall of the duodenum and the retroduodenal are dissected ...

Anastomosis of the intrahepatic bile ducts with the stomach or small intestine produced with complete obstruction of the extrahepatic bile ducts caused by a tumor, cicatricial narrowing or deeply located stones. Hepatocholangiogastrostomy according to Dogliotti After opening the abdominal cavity, the left lobe of the liver is mobilized. For this, the sickle-shaped, triangular and partially coronary ligaments are dissected. The left lobe is taken out into the wound and along the line of the proposed resection ...

Kocher cut (E. Th. Kocher)

2) a straight longitudinal incision along the outer surface of the shoulder, used in operations on the shoulder;

3) a straight longitudinal section along the dorsal-radial or dorsal-ulnar surface of the forearm during operations on the radial or ulna;

4) an incision along the dorsal-radial surface in the area of \u200b\u200bthe wrist joint, carried out from the radial side of the extensor II of the finger; applies to both the wrist joint;

5) an arcuate cross section along the outer surface of the proximal end of the thigh, used in operations on the femur;

6) a straight longitudinal section along the posterior-outer surface of the leg during operations on its bones;

7) incision of the anterior abdominal wall of the xiphoid process to the X right rib, used as an access to the liver.

1. Small Medical Encyclopedia. - M .: Medical encyclopedia... 1991-96 2. First health care... - M .: Great Russian Encyclopedia. 1994 3. encyclopedic Dictionary medical terms... - M .: Soviet encyclopedia. - 1982-1984.

See what "Kocher cut" is in other dictionaries:

- (E. Th. Kocher) 1) arcuate incision in the region of the scapula, proposed for its resection or extirpation; 2) a straight longitudinal incision along the outer surface of the shoulder, used in operations on humerus; 3) straight longitudinal section along the back ... ... Big Medical Dictionary

- (A. Weber, 1829 1915, German ophthalmologist; E. Th. Kocher, 1841 1917, Swiss surgeon) incision during resection upper jaw, carried out along the middle line of the upper lip upwards, around the wing of the nose to the level of its root and slightly below the orbit to its outer ... Big Medical Dictionary

ARTHROTOMY - (from the Greek a rthron joint and tome cutting), operative opening of the joint, opening to it b. or m. free access, used: a) to remove purulent exudates, free articular and foreign bodies, b) for setting the old or ... ...

SHOULDER JOINT - (articulatio humeri) is formed by the articular (concave) surface of the scapula (cavitas glenoidalis scapulae) and the head of the humerus. This joint is one of the most mobile. Restriction of movements in it greatly complicates ... ... Great medical encyclopedia

ELBOW JOINT - (articulatio cubiti), connects the bones of the shoulder and forearm, forming the so-called. true (diarthrosis) joint, which includes the distal end of the humerus (bearing the head), the proximal ends of the ulnar and radial (bearing depressions) and is t ... Great medical encyclopedia

HIP JOINT - HELPS, articulatio coxae (coxa, ae Old Latin word; French cuisse), Vesalius' term. The joint is formed by the head of the femur and an unnamed glenoid (fossa acetabuli). The head is considered spherical in shape, somewhat ... ... Great medical encyclopedia

Hernia - HERNIA. Contents: Etiology .................... 237 Prevention .................. 239 Diagnostics ..... .............. 240 Different kinds G ................ 241 Inguinal G .................... 241 Femoral G ....... ........... 246 Umbilical G ... Great medical encyclopedia

DGILLIAM DOLERI - OPERATION (Gilliam, Doleris), performed with incorrect positions of the uterus (retroversio, descensus et prolapsus uteri). Correction of the position of the uterus is achieved by shortening the round ligaments. Operation technique: along the midline of the abdomen ... Great medical encyclopedia