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CHOLECYSTECTOMY In cholecystectomy the gallbladder is removed through an abdominal incision (usually right subcostal) after the cystic duct

and artery are ligated. The procedure is performed acute and chronic cholecystitis. In some patients a drain is placed close to the gallbladder bed and brought out through a punctured wound if there is a bile leak. The drain type is chosen based on the physicians prefference a small leak should close spontaneously in a few days. With the drain preventing accumulation with bile. Usually initial 24 hours after surgery; afterward the drain is removed. The drained is typically maintained if there is excess oozing or bile leakage. Used of a T-tube inserted in to the common bile duct during the open procedure is now uncommon it used in only a settingof a complication (ie restrained in common bile duct stone). Bile duct injury is a serious complication of cholecystectomy but it occurs less frequently than with the laparascopic approach. At one time one of the most common surgical procedures in the united states, the procedure has largely been replace by the laparoscopic cholecystectomy. MINI CHOLECYSTECTOMY Mini cholecystectomy is a surgical procedure in which the gallbladder is removed through a small incision. Is extended to removed a larger gallbladder stone. Drains may or may not to be used. The cost saving resulting from the short hospital stay have been identified as a major reason for pursuing this type of procedure. The procedure is controversial because it limits exposure to all the involved biliary structures. CHOLEDOCHOSTOMY Choledochostomy is reserve for the patient with acute cholecystitis who may be to ill to undergo a surgical procedure. It involves making an incision in the common duct usually for removal of a stones. After the stone have been evacuated a tube is usually inserted into the duct for drainage of bile until edema subsides. This tube is connected to gravity drainage tubing the patient is monitored closely and is cholecystectomy is planned for a future date. SURGICAL CHOLECYSTECTOMY Cholecystectomy is performed when the patient condition procedure more extensive surgery when an acute inflammatory reaction is severe. The gallbladder is surgically move in a drainage tube is secure to a purse-string reture. The drainage tube connected to a drainage system peritoneal cavity. After recovery from the acute episode the patient may return for subsequent cholecystectomy despite as lower risk surgical cholecystectomy as a high mortality rate (reported to be as high 20%-30%) because of underlying disease process. PERCUTANENOUS CHOLECYSTECTOMY Percotaneous cholecystectomy has been use to treatment and diagnosis acute cholecystitis in patient who are poor risk for any surgical procedure or for general anesthesia. These may include patient with in sepsis or severe cardiac renal pulmonary or liver failure. Under local anesthesia a fine needle is inserted through abdominal wall in liver edge into the gallbladder under the guidance of ultra sounds or computed tomography (CT). bile is aspirated to ensure adequate placement of a needle and catheter is inserted into the gallbladder to decompress the biliary tract. Almost immediate relief of pain and resolution of sign and symptoms of sepsis and

cholecystitis have been reported with this procedure . antibiotics agent are administered before during and after procedure. GERONTOLOGIC CONSIDERATIONS Surgical intervention for the disease of the biliary tract is the most common operated procedure performed in the elderly. Cholesterol saturation of bile increases with age because increased hepatic secretion of cholesterol and decrease bile acid synthesis. Although the incidence of gallstones increases with age and elderly patient may not exhibits the typical symptoms of fever , pain, chills and jaundice. Symptoms of biliary tract disease in the elderly may be accompanied or preceded by those of septic shock which include oliguria, hypotension change in mental status tachycardia and tachypnea. Although the surgery in the elderly presents a risk because of preexsisting associated diseases. The mortality rate from serious complication of biliary tract disease itself of also high. The risk of death and complication is increased the elderly patient who undergoes emergency surgery for life-treathening disease of life of the biliary tract disease is also high. The risk of death and complication is increase is elderly patient elective cholecystectomy is usually well tolerated and can be carried out with low risk if expert assessment and care are provided before during and after the surgical procedure.