HOLETsISTOSTOMYYa (Greek chole bile + cystostomy) — operation of creation of outside fistula of a gall bladder.
For the first time the cholecystostomy was made in 1867 by J. S. Bobbs. In Russia such operation was for the first time carried out by E. V. Pavlov in 1884. It was the first in our country operation on the bilious ways which had a favorable outcome.
To a cholecystostomy in the majority sluchav resort as to a compulsory measure at acute cholecystitis (see) when because of weight of the general condition of the patient x the oletsispgekto-miya (see) is intervention extremely risky or impracticable for technical reasons. Removal outside of the infected bile through fistula of a gall bladder promotes a decompression of bilious ways and gradual elimination of the acute inflammatory phenomena. At acute pancreatitis (see) a cholecystostomy promotes unloading of bilious ways, elimination of flowing of bile to pancreatic canals that favorably influences the further course of a disease. The cholecystostomy is carried out also at the expressed jaundice at patients with a tumor of a head of a pancreas (see). In this case it is a stage of preparation for the main radical intervention.
Operation is carried out under anesthetic or local anesthesia. An abdominal cavity open with a small section in right hypochondrium (see the Laparotomy), make audit of a gall bladder, bilious channels and a pancreas. Then the bottom of a gall bladder is isolated from an abdominal cavity gauze napkins, put a purse-string stitch on a bottom of a bubble and punktirut it a thick needle (fig. 1, a). Stones delete with special nippers or spoons, to-rye enter into a gleam of a bubble after a section of its wall a scalpel or scissors (see the Cystifellotomy). It is necessary to be convinced of lack of stones in a neck of a gall bladder and in a vesical channel since they can interfere with outflow of bile from the general bilious and hepatic channels outside. At detection of such stones they are brought in a gleam of a gall bladder and deleted. Then by means of an intraoperative holangiografiya (see) investigate passability of bilious channels. If operation it is necessary
for Fig. 1. Diagrammatic representation of the main stages of a cholecystostomy: and — a puncture of a gall bladder in the field of its bottom after preliminary annular pication; — the drainage tube (/) with side openings on the end is entered into a gall bladder (2), the gall bladder is hemmed to a parietal peritoneum (3), the free end of a drainage tube (4) is removed through an operational wound in a front abdominal wall and
fixed to skin.
to finish quickly, delete only easily available concrements, and postpone a X-ray contrast research.
Formation of an ostomy is begun with introduction of a drainage tube to a cavity of a gall bladder through an opening in its day on depth of 5 — 7 cm. Diameter of a tube of 1 cm, on its end is available several small side openings. Instead of a tube Pezzer's catheter can be used (see fig. 15 to St. Catheters, t. 10, Art. 209), more convenient for fixing in a bubble. The tied purse-string seam strongly holds a drainage on site. Near the first purse-string seam it is reasonable to impose the second. Then the gall bladder together with a drainage tube is brought to a wound of a front abdominal wall and hemmed for a serous cover to a parietal peritoneum separate seams. The operational wound is layer-by-layer taken in to a drainage, to-ry in addition fixed to skin of odes - it - two seams (fig. 1, b).
In cases when the gall bladder is located deeply or wrinkled and it it is impossible to bring and hem freely to a front abdominal wall, carry out a cholecystostomy on an extent: after fixing to Wad Dra
of a foot tube purse-string seams in a gall bladder it is surrounded with gauze napkins or an epiploon for the purpose of an otgranicheniye from a free abdominal cavity and hemmed to edges of an operational wound (fig. 2). The tube is fixed separate seams to skin, extended and lowered in a glass jar or in a plastic bag. Control quantity allocated during a day of bile and carry out its bacterial. research. The drainage tube in the postopera
the tsionny period is used for introduction of antibiotics, antiseptic agents and radiopaque substance during the carrying out rentgenol. researches of bilious ways. The gauze tampon is deleted on 7 — the 8th day when around it unions were formed.
If inflammatory process in a gall bladder and bilious ways abates, the bile which is emitted through an ostomy takes a normal form, the quantity does not exceed it 300 — 400 ml a day, coloring a calla and urine becomes normal, then in 8 — 10 days make a fistulogra-fiya (see) through a drainage. In the absence of concrements in a gall bladder and bilious channels and free outflow of bile in a duodenum in the next 3 — 5 days start a perezhimaniye of a drainage for the purpose of a training, gradually increasing time of crossclamping. Lack at the same time of pain allows to remove a drainage (as a rule, later 2 — 3 weeks after operation). In several days after removal of a drainage fistula is independently closed.
At impassability of terminal department of the general bilious channel through holetsistosty several days later after operation pure bile begins to be emitted in a large number (700 — 800 ml), the kcal remains akholichny. Fistulografiya confirms impassability of the general bilious channel (as a result of obstruction with a concrement, an inflammatory stricture or a prelum of a channel a tumor of a head of a pancreas). In similar cases recovery of outflow of bile after subsiding of the inflammatory phenomena and improvement of the general
condition of the patient requires repeated intervention. As long loss of bile through an ostomy is followed by considerable disturbance of electrolytic balance, a digestive disturbance and deficit of phthiocol (see. Bilious fistulas), before repeated operation it is necessary to enter systematically given vent bile into a stomach — through a stylet or to allow to drink with beer or sweet tea.
During the leaving in a gall bladder of stones repeated operation as after removal of a drainage the outside bilious fistula which is not tending to independent closing usually forms is also necessary. Removal of a gall bladder with a syringectomy leads to an absolute recovery of patients.
In a crust, time holetsistosty impose by means of a laparoscopy more often (see Peritoiyeoskopiya). At the small sizes of a gall bladder under control of a laparoskop make a puncture it through tissue of a liver and on a needle establish a thin polyethylene drainage in a gleam of a gall bladder. It allows to evacuate the infected bile from a gall bladder and to wash out it solutions of antibiotics and antiseptic agents. After subsiding of the acute phenomena and improvement of the general condition of the patient it is possible to execute a planned operative measure — a cholecystectomia.
At the increased gall bladder it is possible to make a section of fabrics of a front abdominal wall over a bottom of a gall bladder 4 — 5 cm long and a fenestrated forceps to take a bottom of a gall bladder through a wound of an abdominal wall and to create holetsistosty, previously having removed pi
of Fig. 2 which are available kosh from a gleam of a bubble. The diagrammatic representation of a cholecystostomy on an extent: the drainage
tube with side openings on the end (1) is entered into a gall bladder (2); the free end of a drainage tube between a bottom of a gall bladder and’ a front abdominal wall is surrounded with a gauze tampon (3) and fixed to skin (4).
cops. All stages of this intervention are controlled through laparoskop. In the absence of stones in a gall bladder, is more often at patients with acute pancreatitis or with mechanical jaundice owing to a prelum of terminal department of the general bilious channel a tumor of a head of a pancreas, quite adequate intervention is mik-rokho the letsistostomiya made under control of a laparoskop, consisting in carrying out a thin catheter by a puncture through tissue of a liver in a cavity of a gall bladder. The subsequent tactics of maintaining patients and performance control fis-tulogramm do not differ from maintaining patients with holetsistostomy, imposed by means of a laparotomy.
According to B. A. Koroleva, the postoperative lethality at a cholecystostomy makes 8%, and the frequency of repeated operations — 22,5%. Bibliography: Queens B. A., Pikov-skiyd.l. and Piles and a certain I. N. of X about a letsistostomiya at acute cholecystitis, M., 1973; M and t yu sh and I. F N. Guide to operational surgery, Gorky, 1982; Operational surgery, under the editorship of. I. Litt-manna, the lane with Wenger., Budapest, 1982; Smirnov E. V. Surgeries on the bilious ways, JI., 1974.
O. B. Milonov.