The operation for stones located in the gall-bladder is comparatively easy in the absence of adhesions and acute inflammation. Cholecysto tomy is performed by making a vertical incision 2 to 2 Is inches long external to the border of the right rectus muscle, commencing r to 2 inches below the costal arch. This is the usual situation of a tumour if present. The point of the tenth rib is a good guide in the absence of swelling. flaying felt the gall-bladder by the finger thrust into the wound (after ligature of all bleeding-points), its contents arc evacuated by a free incision made in the fundus, and the calculi removed by a scoop after the peritoneal cavity has hem carefully isolated b) gauze packing. The margins of the wound in the bladder walls are invaginated and secured by a catgut purse string suture around a piece of rubber tubing quite long enough to carry the contents of the gall-bladder over the edge of the bed and into a receptacle placed to receive them there.
After all discharge has ceased, the tube may be removed and the fistu lous opening left to close spontaneously. The tube can usually be removed after about S or io days. This operation is indicated in all cases of empyema of the gall-bladder, whether due to calculi or not, but where the cystic duct is found impervious or where the gall-bladder has been func tionless—i.e., does not contain bile—it should be removed as presently to be described.
Cholecvstendysis is indicated in a small percentage of cases where the gall-bladder is quite healthy and its contents free from pus. It consists in the removal of a small calculus through a limited incision in the walls of the gall-bladder, which arc then closed by a double row of sutures and the organ returned within the abdominal cavity, the skin wound being closed afterwards without providing drainage. The operation of incising the gall-bladder and suturing it with or without drainage has, in the hands of Fehr, a mortality of only 2 per cent., and the statistics of Mayo give only
a death-rate of 1•47 per cent.
When acute cholecystitis is found to be present and the walls of the gall-bladder are in a sloughing or gangrenous condition, or where these complications are absent and the gall-bladder is found to be greatly thick ened by chronic fibroid changes, or where the cystic duct is strictured or contains a firmly implanted calculus, the operation of removal of the gall bladder—Chaecystectomy—must be performed. This is effected by separating the organ from the lower surface of the liver, ligaturing the cystic duct and the cystic artery separately, after which the gall-bladder is taken away and the stump of the cystic duct cauterised or its mucous membrane dissected out. The operation should be carried out whenever anv growth is discovered in the walls of the gall-bladde•, whether calculi be present or not. It is distinctly contra-indicated if the common bile duct is obliterated.
The operation of Cholecystenterostomy is indicated where there is a permanent stricture of the common duct or where this is obstructed by inflammatory or cirrhotic changes in the head of the pancreas, or by cancer in this latter situation or in the duct itself. It consists in short circuiting or establishing a direct communication between the gall-bladder and duodenum or jejunum. When it is possible to effect a junction be tween the upper dilated portion of the constricted duct and the bowel the operation known as Choledochenterostomy may he admissible. These operations are also indicated for the relief of permanent hiliary fistulte which open on the surface of the body and cause the discharge of large quantities of bile.
When external fistube are the result of gall-stones left in site which could not be removed at the time of operation these may sometimes be dissolved by the injection of Oil of Turpentine through a rubber tube passed along the duct to the impacted stone.