Removing a patient's gall-bladder is the standard method of treating chronic gall-bladder disease, but it is not an operation for the occasional surgeon, so if you do see a patient with cholecystitis, or gallstones, try to treat him non- operatively as in Sections 13.2 and 13.3.

If his symptoms persist, and you are experienced, you may feel justified in removing more normal-looking, easier gall- bladders on the indications given below. This is something which district hospitals in areas where gall-bladder disease is common, should be able to do. Even so, it is right at the edge of this particular system of surgery. Whatever you do, don't try to remove the more difficult fibrotic, contracted gall-bladders. These really are for the experts. Unfortunately, you will not know if a patient's gall-bladder is going to be easy or difficult, until you are inside his abdomen. So, be prepared to close it, or do a cholecystostomy, if you find that he has a difficult one. We describe the retrograde method of removing the gall-bladder in which you first dissect and tie its neck. An alternative method is to start at the fundus.

The main danger is injuring his common bile or hepatic ducts. But, provided you don't operate when chronic inflammation has scarred his gall-bladder and porta hepatis severely, you should be able to avoid this.

A patient's symptoms and your findings, when you operate, are likely to bear little relation to one another. A few small stones may give him severe colic, while a gangrenous gallbladder may cause him little distress. So don't let moderate symptoms lead you to expect an ''easy gall-bladder', and don't operate in a hurry. The commonest cause of an injured bile-duct or hepatic artery is an ''easy' gall-bladder done quickly. Another cause is the anatomical variability shown in Fig. 13-3.

Fig. 13-3 THE ANATOMY OF THE BILIARY SYSTEM. A, the normal relationships of structures in this region.

B, to F, the relations of the right hepatic artery. In B, (and A) it runs posteriorly to the common hepatic duct (64%). In C, it runs anteriorly (24%), and in D, it arises from the superior mesenteric artery (9%). In E, it runs anteriorly to the portal vein (91%) and in F, posteriorly (9%).

G, to L, variations in the bile passages. Note the accessory hepatic ducts in positions of surgical danger. M, a small pouch (Hartmann's pouch) may project from the right wall of the neck of a diseased gall-bladder downwards and backwards towards the duodenum. When it is well marked the cystic duct arises from its upper left wall and not from what appears to be the apex of the gall-bladder.

1, the fundus of the gall-bladder. 2, the neck of the gall-bladder. 3, the cystic duct. 4, the common bile-duct. 5, the common hepatic duct. 6, the right hepatic duct. 7, the left hepatic duct. 8, the portal vein. 9, the right branch of the portal vein. 10, the left branch of the portal vein. 11, the porta hepatis. 12, the aorta. 13, some fibres of the diaphragm. 14, the coeliac artery. 15, the left gastric artery. 16, the splenic artery. 17, the right gastric artery. 18, the gastroduodenal artery. 19, the hepatic artery. 20, the right hepatic artery. 21, the left hepatic artery. 22, Hartmann's pouch. 23, the cystic artery. 24, the epiploic foramen (entrance to the lesser sac).After ''Grant's Method of Anatomy', (9th edn 1975 edited by JV Basmajian). Williams and Wilkins, with kind permission.

ELECTIVE CHOLECYSTECTOMY INDICATIONS. (1) You must be fairly experienced. (2) You must be sure of the diagnosis. (3) The patient must have symptoms which justify the operation. (4) He must not be too fat. (5) There must be no complicating factors. (6) You must be unable to refer him. (7) You must be prepared to back out, or do a cholecystostomy, if you find that he has a difficult gall- bladder.

ANTIBIOTICS. The main cause of death in gall-bladder surgery is postoperative sepsis. Give him a perioperative antibiotic (2.9) if he is: (1) Over 50. (2) Actively infected. (3) Jaundiced. Or, (4) when you are likely to have to explore his bile-ducts.

ANAESTHESIA. (1) A general anaesthetic with good muscle relaxation. (2) Subarachnoid (spinal) anaesthesia.

EQUIPMENT. A general set. A self-retaining and a Deaver's retractor. You will need two assistants and a trolley nurse.

INCISION. Make a midline or upper right paramedian incision extending up to his costal margin (A, in Fig. 13-4).

Feel for his gall-bladder. Feel for stones. Feel both lobes of his liver to be sure they are smooth and normal. If his gall- bladder seems far up under his rib cage, run your hand over its right lobe, divide his falciform ligament across the dome of his liver, and draw it down. Put some large packs between his diaphragm and his liver[md]don't forget to remove them afterwards!

Insert a self-retaining retractor, and try to see his gall- bladder. Use long tissue forceps to place large moist abdominal packs over the hepatic flexure of his colon, his duodenum, and his stomach. Ask your first assistant to draw these downwards and medially. You should now be able to see under his liver clearly.

Protect his liver with a pack, and ask your second assistant to retract it upwards and laterally with a large Deaver's retractor (B). Look at his gall-bladder.

If his gall-bladder is acutely inflamed, do a cholecystostomy (13-1).

If it is very small, shrunken, thick-walled, contains stones, and is firmly stuck to nearby structures, leave it alone, or take out the stones and do a cholecystostomy and close the wound. Removing such a gall-bladder will be very difficult.

If it looks and feels reasonably normal, apart from a few stones, and is attached by fine adhesions only, it should be safe to proceed.

Find his cystic duct, his common bile-duct, and his hepatic artery, in the free edge of his lesser omentum. His epiploic foramen (of Winslow) lies behind it; you should be able to pass one or two fingers through it into his lesser sac.

Place a gall-bladder clamp, or sponge-holding forceps on Hartmann's pouch (C). This is a widened area in the lower part of the patient's gall-bladder, just before it tapers off into his cystic duct. Pull gently upwards on these forceps, so as to stretch the tissues and make dissection easier.

Incise the triangle of peritoneum between Hartmann's pouch and the common bile-duct. This will appear when you apply traction to the sponge-holding forceps on Hartmann's pouch. It is a most important step. Start by making a small nick in the peritoneum with a long pair of Metzenbaum scissors. Carefully insert the tips of the scissors, then, using ''the push and spread technique' (4-8), or a Lahey dissecting swab, open up enough of the patient's peritoneum to expose the deeper structures.

CAUTION ! Be careful not to cut any small blood vessels. Bleeding will make the operation difficult. By spreading the blades of the scissors (but not too far!) before you cut, or using a Lahey dissecting swab, you should be able to separate peritoneum only.

Take a pledget of gauze in the beak of a pair of curved artery forceps (a ''peanut' or Lahey swab, as shown in C, and E, Fig. 13-4), and gently push apart the peritoneum, so that you see his common bile-duct.

Now, use your left hand to try to feel his cystic duct as it leaves his gall-bladder to join his common bile-duct. It may be helpful to lift up the clamp on his gall-bladder while you do this, so as to stretch the ducts.

CAUTION ! There are some important anatomical variations: (1) The common bile-duct and the cystic duct may join high or low, as in G, to L in Fig. 13-3. (2) The right hepatic artery may pass behind the common hepatic duct (A,and B, more common) or in front of it (C, less common). (3) The cystic artery may be closely bound to the common hepatic duct. (4) The cystic artery usually (64%) arises from the right hepatic artery. It may cross behind (usually) or in front of (unusually) the common hepatic and cystic ducts to reach the gall-bladder. Sometimes, it arises from the common hepatic (27%) or the left hepatic artery (5%), or from other arteries in the region (rare). (5) Be sure of your landmarks before you start to divide anything. (6) Use a Lahey swab and dissect by the ''push and spread' method.

Find the junction of the patient's cystic and common bile ducts, as described above. Be sure to identify 2 cm of his common duct, both proximal and distal to the junction. This will give you an idea of its course and direction. The common bile- duct lies to the right of the structures going to the porta hepatis, and is a greenish colour[md]identifying it is one of the keys to safe gall-bladder surgery.

If you have found the junction of his cystic and common bile ducts, and you are sure that what you presume is his cystic duct is going to his gall-bladder, and nowhere else, define it further, using blunt dissection. Then tie it off, by the following method, close to his common bile-duct, but not too close.

Using a long pair of Lahey forceps, gently open up the cleft between his cystic and common hepatic ducts. Pass a tie of ''0' chromic catgut through this cleft, and around his cystic duct, and tie it (F). Place another Lahey clamp on his cystic duct just above the tie close to his gall-bladder. Cut his cystic duct between the two ties close to the gall-bladder.

CAUTION ! Only divide and tie structures that are passing to his gall-bladder. A long stump to the cystic duct is not important, unless it contained an obvious stone.

If his cystic artery runs posterior to his common hepatic and cystic ducts (usual), take extra care. Using Lahey's forceps on his divided cystic duct, and traction with your left hand, feel carefully with your right thumb and index finger for any bands or structures that are still tethering his gall-bladder. One of these is probably his cystic artery, or a branch of it. Don't cut these structures; isolate them with finger dissection. Don't expect to feel any pulsation in such a small vessel. If a strand of tissue runs to his gall-bladder, assume it is his cystic artery, tie, and divide it. Expect to find other branches and deal with them in the same way.

If his cystic artery runs anterior to his common hepatic and cystic ducts (unusual), define it by blunt dissection, and make sure that it is indeed going to his gall-bladder.

CAUTION ! Don't tie his right hepatic artery by mistake.

If you are sure you have found his cystic artery, tie it close to his gall-bladder with 2/0 black silk, leaving a long tail, so that you can easily find it if it bleeds. Leave a short cuff of tissue, distal to the tie.

You should now be able to strip his gall-bladder from its bed by pulling it gently upwards on the clamps. Cut any peritoneal bands that join it to his liver, but tie off anything else[md]there may be a vessel or an anomalous bile-duct inside a band.

If the bed of his gall-bladder oozes, press a warm pack into it. If small veins continue to bleed, cauterize them. It is unnecessary and dangerous to close the peritoneum over the bed of the gall-bladder as in I, Fig. 13-4.

CAUTION ! Check to make sure that the stump of his cystic duct is secure and that no bile is leaking.

CLOSING THE WOUND. Either leave no drain, or place a soft rubber drain through a stab wound down to his porta hepatis. Close his abdominal wound as in Section 9.8.

DIFFICULTIES [s7]REMOVING THE GALL-BLADDER If, when you open his abdomen, you find an INFLAMMATORY MASS or an unrecognizable mass of tissue, withdraw and close the wound. If you cannot refer him, consider operating later, when the inflammation has subsided.

If you INJURE HIS CYSTIC DUCT early on, tie it between ligatures and divide it. If you injure it very near its union with the common bile-duct, divide it carefully, tie it, and close the common duct opening with interrupted 3/0 catgut sutures.

If you find that you have DAMAGED HIS COMMON BILE-DUCT you will have done so in one of three ways: (1) By ligature; undo the ligature. (2) By clamp; take off the clamp and inspect the damage. Do a choledochostomy higher up, and pass a fine catheter through the damaged area. Proceed as for a choledochostomy (13-2). (3) By partly dividing it. Leave a T-tube threaded up and down the duct and proceed as for choledochostomy. Refer him. If this is impossible, keep the T-tube in for 3 months, and then do a T-tube cholangiogram and remove it. Learn from your mistakes, learn to be able to forgive yourself, and carry on.

If his CYSTIC ARTERY BLEEDS from the depths of his wound, this can be alarming. Don't clamp blindly. (1) Insert warm moist packs, apply pressure and wait 5 minutes by the clock. The spurting vessel will then be easier to find and control. Or, (2) put your index finger into the epiploic foramen (of Winslow) and squeeze the structures (portal vein, bile-ducts, and hepatic artery) in the free edge of the lesser omentum between your index finger and your thumb. This will control bleeding from the stump of the cystic artery. Transfix it carefully with 3/0 silk.

If FRESH BLOOD DISCHARGES from the drain, his pulse rises, his blood pressure falls, and he has signs of a haemoperitoneum, his cystic artery is probably bleeding. Reopen his abdomen and control it.

If BILE COMES FROM THE DRAIN, his temperature and white count rise, and he has pain, suspect that infected bile and exudate are pooling under his liver. Give him an antibiotic. If he does not improve reopen his abdomen and make sure the area is adequately drained.

Fig. 13-4 REMOVING THE GALL-BLADDER. A, the incision. B, exposing the gall-bladder. C, exposing the cystic duct. Note that the second forceps holds a Lahey swab. D, tying the cystic artery. E, freeing the cystic duct. F, tying the cystic duct. G, if the cystic duct is very large and thickened, transfix and tie it like this. H, separating the gall-bladder from the liver. I, a further possible stage in removing the gall-bladder. Don't close its bed like this, it is unnecessary and may cause damage. After Rob C and Smith R, ''Operative Surgery,' (2nd edn 1969), Vol. 4 p. 404. Butterworths, with kind permission.