Cholecystectomy.
—Cholecystectomy includes the removal of the whole or the greater part of the gall-bladder. It has already been stated that this is a reservoir, convenient and advantageous, but not needed in a way, and not essential to life. It figures as a superfluous organ, then, similar to the appendix, and there is no reason why, when diseased and troublesome, it should not be extirpated. Its removal will sometimes be a matter of choice, and at other times a necessity. The former is the case when the surrounding conditions lend themselves to its dissection from the lower surface of the liver without too much violence to other tissues; the latter when it is involved in malignant processes or when its interior is seriously infected. An incomplete method of treating the gall-bladder under the latter circumstances might include the scraping or removal of its thickened mucosa, without removing the entire thickness of its structure. In this case, however, drainage would be required. That the gall-bladder may be completely separated and thus isolated, with comfort and speed, requires that its wall be sufficiently strong to stand the ordinary manipulation. This may not be true of the perfectly normal gall-bladder, but in such case no one would think of removing it, whereas the cyst, which is diseased sufficiently to justify removal, will usually permit of the necessary manipulation. Even if somewhat torn in the process the procedure may be effected without much added difficulty. This procedure consists essentially in separation of the overlying peritoneum and enucleation of the gall-bladder from its bed or the depression in the liver in which it lies, which, as already indicated, may be narrow or wide and deep. Actual separation from liver tissue will be followed by oozing and at least two or three vessels in the surrounding structures and at the neck of the gall-bladder will require to be secured. Removal should not be attempted in cases which do not permit of it, but may be practised in those cases not too infected, when after emptying the sac (full of calculi, for instance) it can still be established with the probe that the common duct is patulous. These are ideal cases for such complete work. The gall-bladder having thus been isolated down to its cystic termination, the surgeon proceeds much as though it were the appendix, by firmly ligating the duct with chromic gut, guarding against escape of contents while it is divided on the distal side of the ligature thus applied. The stump of the duct is then cauterized with pure carbolic, after which oozing is checked by tamponing for a few moments. It then is often possible to bring together the peritoneum beneath the torn liver surface and almost completely cover it anew. The liver tissue will bear a ligature or suture not too tightly drawn. If the case have been one otherwise surgically clean, and the operation properly conducted, the abdominal wound may be closed without drainage. If, however, doubt be felt a small cigarette or a tubular drain may be placed, to be left not more than thirty-six hours. Every infected gall-bladder, if not removed, should be thoroughly cleansed, its interior being mopped with gauze, preferably with the addition of hydrogen dioxide. An important step, next to attention to the gall-bladder proper, is to demonstrate the patency of the ducts. This is done by gently passing a probe, which should be bent to suit the case, along the duct and into the intestine. This, of course, cannot be done if calculi are discovered by manipulation, neither can it always be done when calculi are not present. Gallstones in the duct can usually be distinguished by the fingers with which the exploration is made, and failure to thus pass a probe may be brought about by stricture rather than by calculous obstruction. The importance of this determination will be seen in removing the gall-bladder, as to remove it in an obstructed case is to leave no outlet for bile except into the abdominal cavity, whereas to fail to drain such a case is to plainly neglect to meet the indication.
Fig. 628
General scheme of cholecystectomy; detachment of gall-bladder and duct from their investments; ligation of cystic duct and arteries. (After Kehr.)
Cholecystendysis.
—The term cholecystendysis, now almost obsolete, implies practically a cholecystotomy with drainage, the gall-bladder having been opened for the purpose of removal of one stone or more and then united to the abdominal wound.
Of the operations upon the ducts there is something to be said in addition to the directions already given. Inasmuch as they lie more deeply they are more difficult of access, and variously shaped retractors, with walling off the cavity with gauze, are more often required, while in proportion as deep adhesions have enwrapped the structures they are made more difficult of exposure. At present surgeons have less hesitation in leaving duct incisions unclosed than was formerly felt. It was formerly held that every incision into a duct should be closed with sutures. It has been later found that satisfactory results ensue when the end of the drainage tube is left resting, or even fastened, within the duct opening, the operation being thus made shorter and simpler and the difficulties of deep suture thus obviated. As elsewhere noted the common duct may become enormously dilated, and may be almost mistaken for the small intestine. The passage-way between this duct and the gall-bladder may be so obstructed that double drainage will be of advantage, or this may be a case where partial removal of the gall-bladder may be effected, with drainage of the common duct. Such cases should be judged upon their merits. The more infectious the existing condition the more is free drainage demanded. When a stone is impacted in the ampulla of Vater there should be no hesitation in dividing the walls of the duodenum in order to extract it. In such a case the duodenum is sutured, but the duct or the gall-bladder must be drained ([Fig. 629]).
These deep operations require free incision, several inches in length, and it will astonish the beginner to see how the liver may be delivered from the abdominal cavity through such an opening. Much assistance will here be gained by a large pillow or sandbag placed beneath the back. Bleeding vessels need to be secured, at least temporarily, with forceps, and usually with sutures or ligatures en masse. The exposed or torn surfaces of the liver will ooze freely at first, but bleeding usually ceases with the pressure of a gauze tampon. From the uninflamed gall-bladder the peritoneum is usually easily separated, with but trifling hemorrhage. For deep work traction on the middle portion of the duodenum makes more prominent the junction of this part of the bowel with the gastrohepatic omentum, at which point the peritoneum may be incised and separated along the free border of the duodenum until this portion is free from external peritoneal covering. There will be exposed here the second portion of the common duct where it lies upon the pancreas, it being more or less embedded in the latter further along. When it is necessary to cut away more tissue it is better to sacrifice a portion of pancreas rather than of duodenum itself. Blunt dissection alone should be made here. When it is necessary to cut it will be better to use the thermocautery.
Fig. 629