1. ACUTE CHOLECYSTITIS Acute cholecystitis is inflammation
of gall-bladder.

2. BILIARY ANATOMY

3. Anatomy: vascular supply

4. ETIOLOGY AND PATHOGENESIS
infection
discoordination passage of bile
metabolic disturbance

5. CLASSIFICATION I. Acute calculous cholecystitis
II. Acute non-calculous cholecystitis
1. Catarrhal.
2. Phlegmonous.
3. Gangrenous.
4. Perforated.
5. Complicated:
a) Hydropsy;
b) Empyema;
c) Pancreatitis;
d) Jaundice;
e) Hepatitis;
f) Cholangitis;
g) Infiltrate;
h) Abscess;
i) hepato-renal insufficiency;
j) Peritonitis.

6. Classifying the Biliary Stone Patient
Asymptomatic Cholelithiasis
Incidental Finding on Sonogram
Acute Cholecystitis
Cholelithiasis on Sonogram, clinical Cholecystitis diagnosis or Positive Pipida Scan
Symptomatic Cholelithiasis
Positive Sonogram, normal Liver Function Tests
Cholelithiasis with Suspected Choledocholithiasis
Abnormal Liver Function Tests (Serum Transaminases elevation or Bilirubin >3.0, gallstone pancreatitis)
Cholelithiasis with Choledocholithiasis
CBD Stone on Sonogram, MR Cholangiography or Jaundice
Cholelithiasis with Resolving Gallstone Pancreatitis
Pancreatitis on Sonogram, CT or MER Cholangiography or clinically, Documented High Serum Amylase and Lipase - WITH - Decreasing Serum Pancreatic Enzymes after initial attack

7. Identifying Biliary Stone Patients
1) History and Physical Examination,
2) Liver Function Studies,
3) Sonographic Findings.

8. BILE STONES

9. BILE STONES

10. The pathological sequences during a bout of uncomplicated cholecystitis

11. Sequence of pathological processes with local inflammation around a gallbladder

12. Sequence of pathological processes
Sequence of pathological processes. Formation of an empyema or mucocele of the gallbladder

13. Sequence of pathological processes leading to perforation of the gallbladder

14. Sequence of pathological processes localising a perforation of the gallbladder

15. Symptoms and clinical signs
Pain syndrome. Characteristic for it is great acute pain in right hypochondrium and epigastric area with an irradiation in right supraclavicular area and right shoulder. If pain syndrome has the strongly expressed character, it is named hepatic colic.
Dyspepsic syndrome. Frequent symptoms which disturb a patient, are nausea, frequent vomitting, at first by gastric maintenance, and later — with bile. Afterwards feelings of swelling of stomach, delay of emptying and gases.

16. Symptoms and clinical signs
Murphy's symptoms is a delay of breathing during palpation of gall-bladder on inhalation.
Kehr's symptom is strengthening of pain at pressure on the area of gall-bladder, especially on deep inhalation.
Ortner's symptom — painfulness at the easy pushing on right costal arc by the edge of palm.
Mussy's symptom — painfulness at palpation between the legs (above a collar-bone) of right nodding muscle.
Blumberg's signs are the increases of painfulness at the rapid taking away of fingers by which a front abdominal wall is pressed on. This symptom is not pathognomic for cholecystitis but matters very much in diagnostics of peritonitis.

17. Complications
Hydropsy (mucocele) of gall-bladder is its aseptic inflammation, that arises up as a result of blockade of cystic duct by concrement or mucus. The bile from a bubble is sucked in, and on replacement transparent exudation accumulates in its formation. During palpation increased and unpainfully gall-bladder is marked in patients. Empyema of gall-bladder is unliquidated in time hydropsy, that at repeated infection is transformed in a new form. Gall-bladder in such patients is palpated as a dense, moderately painful formation, however, the symptoms of irritation of peritoneum, as a rule, are absent. The high temperature of body is periodically observed. In blood high leucocytosis with the shift of formula of blood to the left is present.

18. Complications
Biliary pancreatitis. Worsening of the patient’s condition, appearance of pain, frequent vomitting, signs of cardio-vascular insufficiency, high amylasuria, presence of infiltrate in epigastric area and positive Voskresensky's and Mayo-Robson's symptoms are its basic signs. An icterus arises up at violation of passage of bile in duodenum as a result of obturation of choledochus by concrement, by putty or through the edema of head of pancreas. Thus icterus sclera, bilirubinemia, dark urine and light unpainted excrement arise. Cholangitis. The Sharko triad is characteristic for the patient with this pathology. Next to pain syndrome and icterus, the temperature of body rises to 38–39 0С, there is a fever, high leucocytosis and decline of sizes of functional tests of liver is observed.

19. DIAGNOSTIC PROGRAM 1. Anamnesis and physical methods of inspection.
2. Survey sciagraphy of organs of abdominal cavity.
3. Sonography.
4. General analysis of blood and urine.
5. Diastase urines.
6. Biochemical blood test (bilirubin, amylase, alanine aminotransferase, asparaginase, alkaline phosphatase, creatinine).
7. Coagulogram.

20. Tactics and choice of treatment method
1. Bed rest.
2. Hunger of 1–3 days, than diet № 5 by Peuzner.
3. Desintoxication therapy (neohemodes, reopolyglucine).
4. Spasmolytics ( platyphyllin, no-shparum, baralgin).
5. Antibacterial therapy:
6. Inhibitors of protease (contrical, trasilol, gordox).
7. Desensitizing preparation (dimedrole, pipolphen, tavegile).
8. Vitamins (С, В1, В6, В12 vitamins).

21. Indication To Surgical Treatment
All forms of acute calculous cholecystitis
Destructive and complicated forms of noncalculous cholecystitis
Acute catarrhal cholecystitis, conservative treatment of which was uneffective

22. Methods of Operative Treatment
Cholecystectomy from the neck (retrograde)
Cholecystectomy from the bottom (antegrade)
Laparoscopic cholecystectomy

23. CHOLECYSTECTOMY

24. OPERATING ROOM SET-UP

25. OPERATING ROOM SET-UP

26. Equipment

27. STEP 1: Exposing the Cystic Duct and Artery

28. STEP 2: Dissecting the Cystic Duct and Artery

29. STEP 3: Routine Intra-operative Cholangiogram

30. STEP 4: Transecting the Cystic Duct and Artery

31. STEP 5: Dissecting the Body of the Gallbladder

32. CHOLECYSTECTOMY

33. Complications

34. Complications

36. INTRA-OPERATIVE EXAMINATION
Sonography Cholangiography Cholangioscopy

37. INTRA-OPERATIVE SONOGRAPHY

38. INTRA-OPERATIVE SONOGRAPHY

39. The Intra-operative Cholangiography

40. The Intra-operative Cholangiogram

41. The Intra-operative Cholangiogram

42. The Intra-operative Cholangiogram

43. The Intra-operative Cholangiogram

44. The Intra-operative Choledochoscopy

45. The Choledochoscopy

46. Retrieving the CBD Stones

47. CBD Stones