You are on page 1of 28

CHOLELITHIASIS

&
CHOLECYSTITIS
* Hendro Wartatmo
Department of Surgery
Sub Division of Digestive Surgery
Terminology :
Cholelithiasis : gall stone / bile stone / gall bladder stone
Cholecystitis : inflammation of the gall bladder
Cholecystotomy : removal of the gall stone by means of incision of the
gall blader and resuture it
Cholecystectomi : removal of the gall blader by means of surgery

Cholelithiasis & 2
Aetiology of Cholelithiasis
Confirmed aetiology : unclear
Predisposing / Suspected factors :

Triple Fs : Fourty, Fatty, Female

Bile viscosity

Nidus : clot of dead bacteria / detached epithelial cells
of gall blader

Genetic

Cholelithiasis & 3
Complications :
Hydrops of the gall bladder
Chronic Cholecystitis
Acute Cholecystitis :

Suppurative, Gangrenous, Perforated
Gall stone ileus

Cholelithiasis & 4
Diagnosis :
Clinical symptoms & Signs :

Dispepsia, Meteorism, Colicky pain, Tenderness over right subcostal
region : spontaneous / by pressure ( Murphys sign )

Mild Jaundice ( moderate : choledocolithiasis, deep : total
obstruction malignancy )

Fever, Leucocitosis Acute Cholecystitis
Imaging :

USG ( 95 % accuracy ) , CT Scan

Cholelithiasis & 5
Ultrasonography

Cholelithiasis & 6
Treatment :
Non operative :

Medication ( stone dissolver ) : < 3 cholesterol stones,
diam. < 0.5 cm, 8 tablets daily for two months ..
Boring, Reccurrent

Extracorporeal Short Wave Lithotryptor ( ESWL ) : < 3
cholesterol stones, diam. < 0.5 cm, patent cystic duct,
no inflammation of gall blader Recurrent stone

Only few cases fulfill the criteria and suitable for these
methode of treatment

Cholelithiasis & 7
Operative Treatments :
Cholecystotomy :

Removal of stones by means of incision and and
resuture it --- reccurrent, no longer used
Cholecystectomy :

Removal of the ( containing stone ) gall bladder

Open : by opening the abdominal wall

Laparascopic : by means of laparascopy surgery ( =
minimal invasive surgery )

Cholelithiasis & 8
Personal Data
Private Hospital, 2000 2001
Number of Surgery : 506
Choledocholithiasis : 8 cases
Cholelithiasis : 154 cases

Uncomplicated : 114
Open Surgery : 36
Laparascopy : 78

Complicated : 40
Open Surgery : 29
Laparascopy : 11

Cholelithiasis & 9
Open Cholecystectomy in
Suppurative Cholecystitis

Distended gall blader

Cholelithiasis & 10
Suppurative Cholecystitis
with Abscess in the
Abdominal wall

Cholelithiasis & 11
Suppurative
Cholecystitis
with Abscess in the
Abdominal wall

Cholelithiasis & 12
Koledokolithiasis

Stone CBD

Cholelithiasis & 13
Laparascopy Cholecystectomy

Cholelithiasis & 14
Cholelithiasis & 15
GasLess Laparascopy

Cholelithiasis & 16
Cholelithiasis & 17
After removal of Gall bladder :

Dyspepsia / malabsorbtion :

Gall blader : bile storage

Digestive proccess w.o gall bladder : direct flow of bile
from liver to duodenum

Adaption in several weeks

Resolved with time / adapttion
No dyspepsia when the gall bladder removed does
not function ( due to inflammation ) before
surgery.
Cholelithiasis & 18
Surgical Complications :
Cholecystectomy : tidy surgery
Many Anatomic variations
Injury of the biliary tract
Treatment :

Surgical repair

Cholelithiasis & 19
National Meeting of Indonesians Digetive Surgeon Ass., Manado 2003

Tips & Tricks for


BILIARY TRACT INJURY

Hendro. W
Department of Surgery
Sardjito General Hospital / Faculty of Medicine Gadjah Mada University,
YOGYAKARTA
Relaparatomie for complications of
Hepato-Pancreatico-Biliary Surgery
Series of personal cases : 1990 1995

Side of Injury Caused by No

CBD Anastomotic Leakage 1


Simple Cholecytectomy 7
Cholecystectomy on Obstr. Jaundice 2
Blunt Trauma 1
CBD Stone 1
Intrahepatic Bil. Tract. Blunt Trauma 2
Gall blader Blunt Trauma 1
Rupture of Simple suture 3
Recurrent stone ( Cholelithotomy ) 1
Pancreatic Tract Blunt Trauma 2

TOTAL 21
( 19 referred patients + 2 own cases )
Case :
Hepaticojejunostomy R en Y for
CBD Injury during Simple Cholecytectomy

Male, 24 yr
Simple Cholecystectomy for Cholelithiasis with Acut cholecystitis 2
months before.
Pulmonary tuberculosis was suspected.
Icteric, distended abdomen, febris
Relaparotomy : 7500 cc of bile in abdominal cavity, CBD had been cut,
3 cm of CBD was missing.
Internal drainage : hepaticojejunostomy R en Y.
Complete recovery

Cholelithiasis & 22
Preoperative distended abdomen + Icteric + Sepsis

Lake of Leaked Bile

Iatrogenic Trauma
Cholelithiasis & 23
Knot 2 Proximal CBD

Knot 3 Distal CBD

Knot 1 Cystic arteri

Missing Part of CBD


Preparation for Internal Drainage

Cholelithiasis & 25
Tube Cholangiography in
Hepaticojejunostomy R en Y

Anastomosis

Efferent Loop

Stent
Day 14
Post Operative

Stent

Cholelithiasis & 27
THANK YOU