Gall bladder removal surgery done through key hole technique is laparoscopic cholecystectomy. The main indication is acute or chronic calculus cholecystitis. Technical difficulty will be there in case of complicated gall bladder like gangrenous or perforated gall bladder or in patient with chronic liver disease.
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Gall bladder surgery done through mini-laparoscope. In routine laparoscopic surgery,the first entry point of laparoscopic procedure is through 10 mm incision around the umbilicus. In mini laparoscopic procedure, the entry is made through 5mm incision. Experience of the surgeon and availability of high-tech instruments are important to perform this procedure. The advantage is that the patient will have much lesser pain than routine laparoscopic procedure. Also, the possibility of development of hernia in that area is almost nil.
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This done for a retained gall bladder following previous gall bladder surgery. The reason for retained gall bladder may be due to previous complicated gall bladder surgery, poor visualization of calot’s triangle during first surgery or due to retained stone in the cystic duct. The development of recurring pain is the indication for the surgery.
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In this procedure, a part of gall bladder close to Calot’s triangle is left and remaining part is removed. The reason for leaving behind a part of gall bladder is either because of poor general condition of the patient which may necessitate the faster completion of procedure or technical difficulties because of long standing disease. The anticipated post-surgical sequalae is the development of bile leak from the retained gall bladder which may necessitates ERCP and stenting procedure.
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This procedure is done for gall stone disease with suspected cancer of gall bladder or early gall bladder cancer. Here, a thin rim of liver tissue is removed along with the gall bladder. The main precaution is that the specimen is removed through endobag to avoid spillage of tumour cells.
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This is done to remove common bile duct stones which could not be removed through endoscopic procedures like ERCP. The other indications are presence of gastric outlet obstruction, post gastrectomy and large stone in the bile duct. After laparoscopic gall bladder removal with common bile duct exploration, T tube will be placed in the bile duct and sutured for better healing of the bile duct.
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This is done for pseudocyst of pancreas which is a sequalae of biliary pancreatitis. In this condition there will be fluid collection around the pancreas with or without any pancreatic necrosis. If it persists even after six weeks of pancreatitis with symptom or if the cyst size is more than 6cm then it requires drainage. Here the cyst will be drained into the stomach through laparoscope. Depending on the site of the cyst, sometime the cyst will be drained into small intestine (Cysto-jejunostomy).
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Pancreatic necrosis is one of the complications of biliary pancreatitis. Most of the time the pancreatitis will resolve. But rarely leads to pancreatic necrosis with infection and sometime ends up with organ failure. So, in case of acute pancreatitis with infection or organ failure may require removal of pancreatic necrosis which can be done through laparoscopy if patient general condition is stable.
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This is an Endoscopic procedure done under General anaesthesia, to remove the stones from the bile duct or to relive the obstruction of the biliary system. The Endoscope used is duodenoscopy, which identify the ampulla of Vater and helps to remove the stones from the bile duct.
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Today gall bladder surgeries are done through laparoscopic technique only. But rarely in patients with severe comorbid conditions like severe lung disease or heart problem, the gall bladder surgery has to be done through open technique. In case of acute on chronic cholecystitis, with severe adhesions over the gall bladder area and history of multiple abdominal operations are indications for open cholecystectomy.
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Open cholecystectomy with common bile duct exploration with T tube drainage is done in case of Gall stone disease complicated by multiple large bile duct stones which cannot be removed by ERCP. In this procedure, Abdomen is opened through Right sub-costal incision, Gall bladder will be removed followed by opening of bile duct and all the stones will be cleared. The stone clearance is confirmed by intra-operative cholangiogram or choledocoscopy. Once this procedure is over, bile duct opening is closed over a T tube to prevent the bile duct structure
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Gall stones with several bile duct stones and a moderately well-dilated common bile duct are an indication for this surgery. Sometimes bile duct will be packed with stones and in these patients, there is a possibility of recurrence of bile duct stones even after removing the stones from bile duct and removal of gallbladder. In this procedure, abdomen is opened through Right sub-costal incision, Gall bladder will be removed followed by opening of bile duct and all the stones will be cleared. Then, the bile duct is joined with first part of duodenum to create an alternate passage which prevent the recurrent stone formation in the bile duct.
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This is an abnormal situation in which common bile duct is anastomosed with a loop of bile duct known as Hepaticojejunostomy as in cases of type III and IV Mirizzi’s syndrome.
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This procedure is done in case of Severe acute pancreatitis with pancreatic necrosis with poor general condition. Whenever, Patient has Multiple organ dysfunction with High risk for general anaesthesia, Open pancreatic necrosectomy is performed. Here, Abdomen is opened through mid-line incision and lesser sac will be exposed to remove the infected pancreatic necrosis.
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This is a rarely done procedure for Acute cholecystitis with systemic complications. When patient is not fit for General Anaesthesia, then the gall bladder is drained percutaneously to remove the infected contents from the gall bladder. This procedure usually improve the general condition of the patient and Cholecystectomy will be done electively.
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This is a procedure done to decompress the biliary system where ERCP is not possible like history of Previous Gastric surgery or End-to- side Hepaticojejunostomy with Bile duct obstruction due to stones or stricture. This procedure decompresses the biliary system and so decrease the sepsis. Percutaneous trans hepatic biliary drainage is done by placing a catheter into the biliary system from skin through the liver. Once patient recovered from the sepsis the definitive procedure will be done.
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Indocyanine green (ICG) is a fluorescent dye contains less than 5% sodium iodide. This dye is used during laparoscopic cholecystectomy to identify the biliary anatomy to avoid bile duct injuries. This dye is injected 45 minutes before surgery. Forty-five minutes after injection of ICG intravenously, most of the ICG will be concentrated in the biliary system. This can be seen by compatible laparoscopic system.
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Chronic pancreatitis is a condition in which there will be ongoing inflammation of pancreas. the main mode of presentation is pain abdomen. MRCP will give an idea about the magnitude of chronic pancreatitis. ERCP (ERP) will be useful in selected patients with pancreatic ductal dilatation.
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Endourology is a endoscopic surgical procedure done for urological problems like urinary stone disease. The commonly done procedures are cystoscopy and ureteroscopy done through natural orifice like urethra. PCNL is another minimally invasive procedure done for kidney stone. Laparoscopic uretero-lithotomy or pyelolithotomy are other minimally invasive procedures done for ureteric and kidney stones.
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