**4.4 Transcylindrical cholecystectomy under local anaesthesia plus sedation**

All patients were fitted to the following protocol:


The objective was to obtain a sedation 2-3 on the Ramsay scale and/or a BIS value of 70 to 85 before the application of local anesthesia. For anesthesia of the abdominal wall surgical area was used 300-500 mg of mepivacaine 1% was used. The infiltration began in the line previously marked for incision, which is located in the epigastrium about 4 cm to the right of the midline and 3 cm from the costal margin. Follows the infiltration of the muscular plane and transverse oblique, lateral to the incision site with the intention of blocking the intercostal nerves VII-IX in the lateral costal margin. Finally we infiltrate the rectus muscle

Transcylindrical Cholecystectomy for the Treatment

away with blunt dissection.

Fig. 10. Cholangiography with cylinder in place

of Cholelithiasis and Its Complications: Cholecystectomy Under Local Anesthesia 19

All patients were assessed for pain after the procedure and were discharged when they met the criteria (pain control, oral tolerance, no bleeding, nausea or vomiting, etc.), and follow analgesia regime alternating paracetamol 1g/6 h and metamizole 1g/6h orally at home. At 24 hours, through a telephone call, we assessed the pain at rest and with movement (scale of Andersen). In the fifth day, in outpatient visit, we check for the general status, the

In acute cholecystitis we always use the 5 cm cylinder, the gallbladder is emptied with the help of an aspirator and a bile sample is send for culture. The dissection of the Calot triangle is done with a swab and if there are difficulties in closing the cystic duct is we use a ligature or stitch of poliglycolic acid. The cystic artery is treated in the same manner as above. The haemostasis of the liver may require more time. A Jackson-Pratt drain by counterincision is

If the intraoperative cholangiogram shows the presence of stones and a dilated bile duct (Figure 10 ), we prepare the field for a transcylindrical choledochotomy if the stone could not be pushed through the papilla with a Fogarty catheter. After the cholecystectomy and haemostasis of the liver, we proceed to vary the angle of the cylinder to direct medially, to put it in the hepatoduodenal ligament, taking as reference the cystic duct stump. Once in the position, the bile duct is seen on the lateral border of the ligament once the fat is cleared

sate of the wound and the pain is assessed with a visual analog scale (VAS).

**4.5 Surgical technique in acute cholecystitis and choledocholithiasis** 

the norm in acute cholecystitis and common bile duct exploration.

of abdomen in the epigastric region right under the incision line (Figure 8). Once the cylinder has been introduced the triangle of Calot is infiltrate with 2-4 cc of 2% mepivacaine (Figure 9). At the end of surgery and subcutaneous muscle planes were infiltrated with 10- 20 ml of bupivacaine 0.25%.

Before leaving the operating room the patients receives: paracetamol 1g/ev, dexamethasone 8mg/ev, ondansetron 4mg/ev and ketorolac 1mg/kg, although the latter was avoided in patients 70 years or older.

Fig. 8. Local anesthesia on intercostals nerves IX-VII and incision planes

Fig. 9. Infiltration with mepivacaine 2% of the hepatocystic triangle

of abdomen in the epigastric region right under the incision line (Figure 8). Once the cylinder has been introduced the triangle of Calot is infiltrate with 2-4 cc of 2% mepivacaine (Figure 9). At the end of surgery and subcutaneous muscle planes were infiltrated with 10-

Before leaving the operating room the patients receives: paracetamol 1g/ev, dexamethasone 8mg/ev, ondansetron 4mg/ev and ketorolac 1mg/kg, although the latter was avoided in

Fig. 8. Local anesthesia on intercostals nerves IX-VII and incision planes

Fig. 9. Infiltration with mepivacaine 2% of the hepatocystic triangle

20 ml of bupivacaine 0.25%.

patients 70 years or older.

All patients were assessed for pain after the procedure and were discharged when they met the criteria (pain control, oral tolerance, no bleeding, nausea or vomiting, etc.), and follow analgesia regime alternating paracetamol 1g/6 h and metamizole 1g/6h orally at home. At 24 hours, through a telephone call, we assessed the pain at rest and with movement (scale of Andersen). In the fifth day, in outpatient visit, we check for the general status, the
