Perforated GB - Forum

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सर्जन

Perforated GB - Ärzteforum

Post#1 »

I would appreciate your comments on the following patient:

48 year old male pt came to me with features of typical acute cholecystitis of 3 days duration. He was put on cephalosporin and was observed for 24 hours. His condition went downhill with high fever, increase in leucocyte count from 14000/cmm to 20000/cmm and increase in size of a lump in rt hypochondrium. Ultrasono reported a complex mass in the region of GB. I decided to explore and operated on him this morning. The GB was a mess. About 300 cc thick pus was aspirated out, there was no fundus and most of the body of GB was a mass of black necrosed tissue which simply peeled out on touch. The region of Calot's triange was a thick odematous without any identifiable anatomy.

What is the best course of action in this condition?


User avatar
Surgeon

Re: Perforated GB - Ärzteforum

Post#2 »

Cauterize the gallbladder bed and drain it. You may not even have to go back for a secondary procedure.

Hans

Re: Perforated GB - Ärzteforum

Post#3 »

I once encountered a similar operative site in a gangrenous cholecystitis and had extreme difficulty in identifying the cystic duct because as you mentioned the gallbladder simply "tore" out of its bed..Preparation of the hepatoduodenal ligament was very frustrating because of the inflammation and the vulnerability of the tissue leading to instantaneous bleeding upon touching. Anticipating an open unidentified cystic duct I lavaged the op-site intensively and simply left an easy-flow drain in place. Postoperatively no bile leakage occurred! The patient was discharged with normal laboratory values and a normal post-cholecystectomy ultrasound. I don't know if this would lead to
a similarly favorable result in your case but I would rather risk a bile leakage instead of injuring the common bile duct at a proximal level while looking for the remains of a cystic duct. Should bile leak then I would suggest inserting a stent into the common bile duct (endoscopically).

Poland

Re: Perforated GB - Ärzteforum

Post#4 »

Obviously one cant identify the cystic duct and artery in that mass,but
surprisingly sometimes it is possible with water jet dissection og the
oedmatous tissues,. Failing to identify the cystic duct , i would
attempt a partial cholecystectomy and close the GB away from the CBD amd
drain , Failing that! I would just do a cholecystostomy.

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Lady Surgeon

Re: Perforated GB - Ärzteforum

Post#5 »

I can
almost always find the cystic duct even in the most difficult cases, by
starting at the top of the gallbladder and working downward strictly on the
gallbladder, until I have the gallbladder hanging free on its pedicle of
cystic duct and cystic artery. Obviously, there is a lot less blood loss if
you can first control the cystic artery, but this is not always possible
either.

User avatar
Lady Surgeon

Re: Perforated GB - Ärzteforum

Post#6 »

I assume you couldn't find any anatomic features in this mess, so I would just drain it well, accepting the inevitable cystic duct fistula. I would wait at least 6 weeks before trying to go back in and identify things. Possibly ERCP with sphincterotomy and or stent placement would decrease the cystic duct fistula output and allow it to close--I am not sure about a totally open cystic duct stump--whether this will close with common bile duct stenting.

Jorjo

Re: Perforated GB - Ärzteforum

Post#7 »

Lady Surgeon wrote:I am not sure about a totally open cystic duct stump--whether this will close with common bile duct stenting.


Totally opened cystic duct will close spontaneously in most of
the patients with external drainage only, this may take 4-6 weeks. In
patients without external drainage, as in post LC slipped clip from
cystic duct due to increased pressure in biliary tree i.e. CBD stone
impaction, endoscopic stenting and percutaneous US guided drainage of
sizable bile collection is the treatment of choice. Persistent biliary
fistula 6 weeks after external drainage is an indication for endoscopic
stenting.

Grandpa Phil

Re: Perforated GB - Ärzteforum

Post#8 »

Lady Surgeon wrote:I can
almost always find the cystic duct even in the most difficult cases, by
starting at the top of the gallbladder and working downward strictly on the
gallbladder, until I have the gallbladder hanging free on its pedicle of
cystic duct and cystic artery. Obviously, there is a lot less blood loss if
you can first control the cystic artery, but this is not always possible
either.


Are you worried by using electrocautery here? When you are
nearly down from the fundus to the cystic duct the GB is attached only
by the cystic duct - if you now use the electrocautery, the cystic duct
itself will be fried even if you apply the cautery to the GB. Even more
important would be if the fundus had flopped down and was just touching
bowel which would then be fried instead! I have not had this problem,
but met someone at a meeting who felt it was the only possible
exploration for a delayed perforation of hepatic flexure he had had.
Perhaps you do not use the cautery for this part of the
dissection - but that is difficult in these terribly stuck GBs.

User avatar
A Doctor

Re: Perforated GB - Ärzteforum

Post#9 »

A retrograde cholecystectomy starting from the remnant of the body of
the gallbladder if possible. Seems from your description that this is
probably not an option. If so, drain the gallbladder fossa and
subhepatic area and IV antibiotics.

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