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Cholecystostomy is a palliative and always a forced operation. The desire to do it in individual patients in terms of the smallest surgical intervention for cholelithiasis is difficult to combine with the need to remove all the stones from the bladder, especially the often existing clogging stone in the neck, in the Hartmann pocket, sometimes firmly wedged there. It is also important to establish the absence of stones in the hepatocholedochus. There is a second collision. On the one hand, it is desirable to divide the splices between the bile ducts and neighboring organs as little as possible, since it is necessary to open and drain the bladder with heavily infected contents. On the other hand, to remove a stone from the neck, it is often necessary to manipulate it with a finger from the outside. Each patient should solve these issues differently. The measure of palliative intervention may be different. It happens that you have to consciously take the risk of leaving a stone in the neck. With obstructive jaundice, cholecystostomy should be avoided.
Two-stage cholecystostomy is no longer used. The fistula is applied immediately at the first intervention. The operation is performed in such a way that after exposing the bladder and separating the organs soldered to it, it is thoroughly delimited with tampons and napkins. It is necessary to separate the splices only for such a length as to open the bladder, its neck and the hepatic-duodenal ligament. The most prominent part of it is captured by two silk holders. A thick needle is inserted between them and the contents of the bladder are sucked out through it with a 100-gram syringe. Then the needle is removed, and the bubble in this place is opened with a 3 cm long incision. Through it, the tip of the suction device removes the remainder of the liquid. Then, with the index finger of the left hand inserted into the bubble, it is examined, and with the help of a large blunt spoon inserted along the finger, stones and putty-like mass are removed. Sometimes, with a very large stone, it is easier to remove it with the help of a Buyalsky shovel or both a finger and a shovel. When extracting such a stone through an incision, the finger will have to be removed, and then re-inserted for a second examination. Special attention should be paid to removing the stone from the neck, from the Hartmann pocket. To do this, you may need to squeeze it out from the outside with your finger or fingers of your right hand.
To feel the ducts, the surgeon needs to close the bladder and the hole in it well and change gloves, and at the end of the feeling, restore the disturbed separation of the bladder. A 1 cm thick soft rubber tube or a thick Petzer catheter is inserted into its cavity, and the incision is tightly sewn up to the tube. If the condition of the bubble wall allows this to be done reliably, you can put a pouch seam around the drainage and tightly cover the tube with it, screwing the edges of the incision into the bubble. If the bladder is large enough and is discharged into the wound without tension, it is carefully sewn to the peritoneum and several stitches to the aponeurosis of the posterior vaginal wall of the rectus muscle; nodular silk sutures should not capture the mucous membrane. You can not sew the mucous membrane of the bladder to the muscles and especially to the skin, you will get a non-healing lip-shaped fistula. If there are reasons to fear necrosis of the bladder wall, it is necessary to delimit the entire bubble with tampons. If there are no such concerns, along the bladder sewn to the anterior abdominal wall, a narrow thin gauze graduate is inserted into the abdominal cavity, which are left together with drainage. The wound of the abdominal wall is narrowed by sutures. Graduates and drainage change 8-10 days after surgery.
If it is impossible to bring the bladder to the abdominal wall and, therefore, it is impossible to sew it into the wound, cholecystostomy should be avoided. It can be done only in case of the most urgent need. Here it is necessary to sew a drainage tube into the bubble especially carefully and hermetically and then surround it and the bubble well from all sides with straight-line tampons, counting on the subsequent separation of the bubble from the abdominal cavity. When feasible, the bladder and drainage should be wrapped with an oil seal before tamponade.
If, during an operation on the biliary tract, an incision of the abdominal wall immediately reveals the cavity of the delimited abscess and, after sucking out the pus, a gallbladder with stones opens, on which a fistula should be applied, the operation should be as simple as possible — it is necessary to remove the stones and impose a fistula.
If the gallbladder is not visible after emptying the abscess, you should not look for it and you should limit yourself to a loose tamponade of the purulent cavity with straight-line tampons. If necessary, in the future, after the wound has healed, it will be possible to perform a radical operation. İdmana mərc oynamağa başlayanda mənə geniş seçim seçimi, sürətli ödənişlər və peşəkar dəstək verəcək platforma tapmaq istədim. Və tapdım mostbet-aze90 axtardığım hər şeyi haradan aldım. İdman tədbirlərinin böyük seçimi, operativ ödənişlər və həssas müştəri dəstəyi idman mərcləri təcrübəmi həqiqətən unikal edir.