Aralin 1Pag-manage ng dense inflammation at difficult dissection: subtotal (fenestrating/reeves) cholecystectomy techniques, intraoperative drainage, use ng drainsSumasaklaw sa mga estratehiya para sa pag-manage ng dense inflammation at difficult gallbladder dissection, kabilang ang subtotal cholecystectomy variants, ligtas na paggamit ng energy devices, intraoperative drainage, at indications para sa pag-iwan ng drains in situ.
Pagkilala ng difficult gallbladder nang maagaFundus-first at subtotal cholecystectomy optionsFenestrating versus reconstituting techniquesSafe use ng energy sa inflamed tissuesDrain placement sa difficult dissectionsAralin 2Postoperative care at common complications: bile leak recognition, postoperative antibiotics, drain management, follow-up imaging indicationsSumasaklaw sa routine postoperative care pagkatapos ng laparoscopic cholecystectomy, early recognition ng bile leak at infection, rational antibiotic use, drain indications at management, at criteria para sa postoperative imaging at specialist referral.
Standard recovery milestones at discharge criteriaRecognition ng bile leak at biloma formationPostoperative antibiotics: kailan indicatedDrain placement, monitoring, at timely removalIndications para sa postoperative ultrasound o CTAralin 3Patient positioning at operating room layout: supine na may reverse Trendelenburg at left tilt, surgeon/assistant/monitor positions para sa ergonomicsInilalahad ang optimal na patient positioning para sa laparoscopic cholecystectomy, kabilang ang supine, reverse Trendelenburg, at left tilt, at detalyeng ergonomic placement ng surgeon, assistant, scrub nurse, at monitors upang i-optimize ang visualization at safety.
Supine at reverse Trendelenburg positioningLeft tilt at table adjustments para sa exposureSurgeon at assistant standing positionsMonitor height, distance, at alignmentInstrument table at scrub nurse placementAralin 4Control ng cystic duct at artery gamit ang basic devices: selection at application ng clips, adequate stump length, specimen extraction techniquesIpinaliliwanag ang ligtas na control ng cystic duct at artery gamit ang clips at basic devices, kabilang ang clip selection, spacing, at stump length, pati na ang ligtas na division, retrieval, at extraction ng gallbladder specimen sa routine cases.
Pagpili ng clip size at material para sa cystic structuresNumber, spacing, at orientation ng clipsEnsuring adequate cystic duct stump lengthSafe division ng cystic duct at arterySpecimen bag use at extraction techniquesAralin 5Port placement at instrument choices: four-port technique (sizes at exact abdominal landmarks), use ng traction sutures o retraction methods gamit ang basic toolsTinutukoy ang standard four-port placement na may precise landmarks, port sizes, at angles, at tinatalakay ang instrument selection, kabilang ang graspers, dissectors, energy devices, at optional traction sutures o alternative retraction methods.
Umbilical camera port placement at sizeEpigastric working port positioningRight subcostal accessory port landmarksPagpili ng graspers, dissectors, at scissorsUse ng traction sutures para sa gallbladder fundusAralin 6Exposure ng Calot’s triangle at dissection strategies: fundus-first vs antegrade approaches, gentle gallbladder traction, use ng blunt at sharp dissection gamit ang electrocauteryTinatapos ang mga technique upang ma-expose nang ligtas ang Calot’s triangle, na naghahambing ng antegrade at fundus-first approaches, pag-optimize ng traction vectors, at paggamit ng blunt at sharp dissection gamit ang electrocautery habang pinoprotektahan ang adjacent structures.
Traction directions para sa optimal Calot’s exposureAntegrade versus fundus-first dissectionBlunt versus sharp dissection techniquesSafe use ng monopolar electrocauteryPag-iwas sa pinsala sa CBD at hepatic arteryAralin 7Contraindications at relative considerations para sa laparoscopic cholecystectomy: severe cardiopulmonary disease, uncorrected coagulopathy, unclear anatomy, suspicion ng gallbladder cancerInilalahad ang absolute at relative contraindications sa laparoscopic cholecystectomy, kabilang ang severe cardiopulmonary disease, coagulopathy, unclear anatomy, at suspected malignancy, at tinatalakay ang risk-benefit assessment at alternative strategies.
Absolute versus relative contraindicationsImpact ng severe cardiopulmonary diseaseManagement ng uncorrected coagulopathyHandling ng unclear anatomy o prior surgerySuspicion ng gallbladder cancer at stagingAralin 8Typical klinikal na presentasyon ng symptomatic cholelithiasis at chronic cholecystitis: pain pattern, Murphy’s sign, labs at imaging findingsPinag-uukulan ang typical symptoms at signs ng biliary colic at chronic cholecystitis, na nagko-correlate ng pain patterns, Murphy’s sign, laboratory abnormalities, at key ultrasound at CT findings upang gabayan ang diagnosis at surgical planning.
Typical biliary colic pain pattern at triggersMurphy’s sign at focused abdominal examinationLaboratory patterns sa acute at chronic cholecystitisUltrasound features ng stones at gallbladder wallCT at iba pang imaging roles sa equivocal casesAralin 9Critical view of safety: definition, stepwise steps upang maabot ito, documentation at criteria para sa pagtigil at pag-convertBinigyang-kahulugan ang critical view of safety, detalyeng stepwise dissection na kinakailangan upang maabot ito, binibigyang-diin ang documentation gamit ang images o video, at nililinaw ang criteria para sa pag-abort ng dissection, bailout procedures, o conversion sa open surgery.
Formal definition ng critical view of safetyStepwise dissection upang ma-expose ang Calot’s trianglePagkukumpirma at pagdokumenta ng critical viewCommon pitfalls at misinterpretationsCriteria para sa bailout o conversion sa openAralin 10Preoperative evaluation para sa biliary surgery: LFT interpretation, ultrasound assessment ng gallbladder at ducts, indications para sa MRCP o ERCP, perioperative antibiotic choicesTumatugon sa preoperative evaluation para sa biliary surgery, kabilang ang interpretation ng liver function tests, ultrasound assessment ng gallbladder at ducts, indications para sa MRCP o ERCP, at ebidensya-base na pagpili at timing ng perioperative antibiotics.
Pattern recognition sa liver function testsUltrasound assessment ng gallbladder at CBDKailan mag-order ng MRCP versus ERCPRisk stratification para sa choledocholithiasisPerioperative antibiotic selection at timingAralin 11Immediate management ng suspected bile duct injury: recognition signs, intraoperative cholangiography considerations, damage-limitation measures, kailan tawagan ang biliary surgery/transferNakatuon sa early recognition ng suspected bile duct injury, intraoperative cholangiography options, immediate damage-control strategies, documentation, at criteria para sa urgent consultation o transfer sa hepatobiliary center.
Intraoperative signs na nag-suggest ng bile duct injuryRole at technique ng on-table cholangiographyDamage-limitation strategies at kailan magtigilDocumentation at communication sa teamCriteria para sa referral sa biliary surgery centersAralin 12Paglikha ng pneumoperitoneum at safe access: open (Hasson) vs Veress needle technique, insufflation pressures, trocar insertion safety checksIpinaliliwanag ang ligtas na paglikha ng pneumoperitoneum gamit ang open at Veress techniques, recommended insufflation pressures, trocar insertion angles, pag-iwas sa entry-related complication, at pagkukumpirma ng adequate working space bago magpatuloy.
Patient selection para sa open versus Veress entryVeress needle insertion tests at checksHasson open technique step by stepRecommended insufflation pressures at flowSafe primary trocar insertion at verification
