Cholecystostomy

Gallbladder ostomy is a relatively simple first-aid operation aimed at draining bile, reducing bile pressure, eliminating biliary tract inflammation, and critically ill patients who have poor tolerance and must be drained in time to remove obstructive cholecystitis or cholelithiasis. It can save lives, improve the whole body and local conditions, and lay the foundation for reoperation. This procedure must be performed when the cystic duct and the common hepatic duct are obstructed. Now, because most patients are eligible for primary cholecystectomy and the use of gallbladder catheter drainage, this procedure has been used less frequently. Treatment of diseases: cholecystitis Indication 1. Acute necrotizing cholecystitis, gallbladder empyema or gallbladder perforation, cholelithiasis with toxic shock, sepsis. 2. Cholecystitis, cholelithiasis is serious, the liver and duodenal ligament area has severe inflammation, edema, separation is easy to hemorrhage, adhesion is heavy, anatomical relationship is unclear, gallbladder resection is difficult. 3. Biliary obstruction caused by cancer in the lower part of the common bile duct and the ampulla of the ampulla, difficulty in internal drainage, or as the first preparatory operation for radical surgery. 4. Traumatic rupture of the base or body of the gallbladder, and the patient's general condition is poor. Preoperative preparation 1. Correct water, electrolyte and acid-base balance disorders. 2. Apply broad-spectrum antibiotics to control infection. 3. The blood coagulation mechanism of patients with jaundice is poor. Vitamin K is needed before surgery, and intravenous hemostatic agents are applied intraoperatively. 4. Critically ill patients should be transfused. 5. Patients with toxic shock should actively rescue shock treatment, but after a period of rescue, if the shock is still not improved, then surgery should be rescued. 6. Patients with intestinal paralysis or bloating, decompression of gastrointestinal decompression tube before operation. Surgical procedure 1. Position: supine position, the head and chest are slightly raised in the right waist, and the pad is placed under the knee to relax the abdominal muscles. 2. Incision: generally use the right upper rectus abdominis incision, about 12cm long, if the patient is obese or rib angle is wide, you can also use the ribs oblique incision (kocher's incision), the outside should not exceed the 9th rib tip, otherwise it will affect a lot Motor nerves. 3. Exploration: Due to serious illness, it is not advisable to conduct extensive exploration, mainly to check the gallbladder and biliary system. Observe the location, size, color of the gallbladder, whether there is congestion, edema, necrotic perforation, gallstone meat with or without stones, aphids, especially the gallbladder neck with or without stone incarceration. If there is no necrotic perforation in the gallbladder, the gallbladder can be lightly squeezed and the test can be emptied to prove the presence or absence of stone obstruction. Adhesion around the gallbladder is a natural barrier to protect the gallbladder. If it does not interfere with the exploration, it is best not to completely separate it. When the condition allows, the biliary tract should be further explored, and the liver, spleen and pancreas should be explored. 4. Puncture decompression: The bottom of the gallbladder is exposed, and the surrounding is protected by a saline gauze pad. The ostomy was selected 2 cm below the surface of the liver. First, a purse with a diameter of 1 cm was sutured on the wall of the gallbladder, and no ligation was allowed. Gently lift the suture and puncture it at the center to extract the bile from the decompression. Observe the color of the bile, turbidity, and whether there is a purulent change, and send it to the microscopic examination and culture. 5. Gallbladder fistula: In the puncture hole area, poke a small mouth with a sharp edge knife, the size of the incision to enter the index finger is appropriate. Use the aspirator to drain the gallbladder. If gallstones are found, use a curette or stone pliers to remove the stones. If necessary, use your fingers to penetrate into the gallbladder to detect the presence of stones. Sometimes there are many small stones in the gallbladder, which can be wiped out with saline gauze. The cystic duct is embedded with stones, which can be gently pushed by hand, and the stones are moved into the gallbladder and then removed. A clam-shaped or umbrella-shaped tube is placed in the gallbladder, which is about 3 to 4 cm deep. The muscle layer of the gallbladder wall incision is turned inward, the purse string is tightened and ligated. 0.5cm away from the suture line of the purse, a purse-string suture and ligation were fixed. If the gallbladder incision is large, the gallbladder can be used as a full-thickness suture with a silk thread, and the outer layer can be inverted and sutured. If there is a necrotic area in the wall of the gallbladder, a part of the omentum may be covered on the wall of the gallbladder for protection, and the drainage tube is taken out through the omentum. However, it is not necessary under normal circumstances to avoid the increase of tissue adhesion and increase the difficulty of separation of the second stage of surgery. 6. Treat the drainage tube and suture the abdominal wall: After exhausting the abdominal pus, put a cigarette under the gallbladder for drainage, and take a small mouth from the right abdominal wall together with the gallbladder drainage tube. The drainage incision should not be too tight, so as to avoid difficulties when pulling cigarettes. A few needles can also be attached to the bottom of the gallbladder around the drainage tube and the peritoneum. Drainage tube in the abdominal cavity should be careful not to make it twisted or too tight. The drainage tube is fixed at the suture of the skin to prevent it from falling off. The cigarette is drained with a safety needle to prevent slipping into the abdominal cavity. Covering the omentum around the gallbladder, preventing bile leakage and gallbladder adhesion to the gastrointestinal tract, creating favorable conditions for the second operation. The abdominal wall incision was sutured layer by layer. The drainage tube should be padded with gauze and fixed on the abdominal wall to prevent shedding and twisting. 7. If the gallbladder lesion is mild, the biliary pressure is not high, and the gallbladder is not enlarged, the lesion may be mainly in the common bile duct, the common hepatic duct or the intrahepatic bile duct. The patient should not do even if it has symptoms of jaundice, high fever or toxic shock. Gallbladder ostomy. The common bile duct and the common hepatic duct should be explored, the source of the disease should be relieved, and the t-tube drainage of the common bile duct should be performed.

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