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Question. Injury to the common bile duct during laparoscopic cholecystectomy is most likely to occur as a result of A. use of a 30 degree scope B. lateral retraction of the infundibulum Dissection of the cystic duct-gallbladder junction Dissection of the triangle of Calot

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  1. Question • Injury to the common bile duct during laparoscopic cholecystectomy is most likely to occur as a result of • A. use of a 30 degree scope • B. lateral retraction of the infundibulum • Dissection of the cystic duct-gallbladder junction • Dissection of the triangle of Calot • Intraoperative cholangiography

  2. Question • Injury to the common bile duct during laparoscopic cholecystectomy is most likely to occur as a result of • A. use of a 30 degree scope • B. lateral retraction of the infundibulum • Dissection of the cystic duct-gallbladder junction • Dissection of the triangle of Calot • Intraoperative cholangiography

  3. Question • Injury to the common bile duct during laparoscopic cholecystectomy is most likely to occur as a result of • A. use of a 30 degree scope • B. lateral retraction of the infundibulum • C. Dissection of the cystic duct-gallbladder junction • D. Dissection of the triangle of Calot • E. Intraoperative cholangiography

  4. ANATOMY • Triangle of Calot • Common Hepatic duct • Cystic duct • Inferior surface of the Liver • Cystic Artery is within • Anatomic variants • Cystic Duct may be absent, short, posterior, low or anterior to CBD, or directly from the RHD • Cystic artery may arise from gastroduodenal artery

  5. ANATOMY • Injuries (Causes) • Failure to occlude duct • Too deep a dissection plane • Thermal Injury • Tenting injury • Misidentification • CBD thought to be cystic duct • Injury of aberrant duct

  6. ANATOMY • Injuries (Bismuth classification) • Type A Cystic duct leaks/Liver bed duct injury • Type B/C Aberrant Right hepatic ducts • Type D Lateral injury to major duct • Type E Transection/Ligation • Immediate referral is preferred • 1-6 weeks – Drain/stent & operate in 3months

  7. ANATOMY • Portahepatis (Hepatoduodenal lig) • Portal vein posterior • Common hepatic artery to left anterior • CBD to the right anterior

  8. PHYSIOLOGY • Bile • Lecithin • Bile Salt • Cholesterol • Gallbladder Contraction • Cholecystokinin • Fatty acid • Amino acid

  9. CHOLELITHIASIS • 10-20% of population • Female age obesity family hx • Crystallization-contraction of bile salt pool • 1-2% develop symptoms • Types • Cholesterol • Pigmented • Brown/Black

  10. Asymptomatic Stones • Prophylactic cholecystectomy not indicated • Exceptions • Transplant • Renal- NO • Cardiac -YES • Chronic TPN -Probably YES • 35 develop stones • Develop symptoms more than expected • Bariatrics-NO • Hemoglobinopathy -YES • 50 develop complication • Crisis mimics biliary colic

  11. Asymptomatic Stones • Incidental cholecystectomy • During laparotomy stones are discovered • Over 70 -higher incidence of sepsis/MSOF when CCY NOT done

  12. ACUTE CHOLECYSTITIS • Signs and Symptoms • Labs • Leukocytosis • Bilirubin • Choledocholithiasis • Mirizzi syndrome • Amylase • Radiographic • Ultrasound • CT • HIDA

  13. ACUTE CHOLECYSTITIS • Treatment • Antibiotics-broad spectrum • Ecoli, Klebsiella, Clostridium, Proteus, Enterobacter • CBD stones • Preop -ERCP • Intraop • CBDE • Postop ERCP • Surgery • Expose Calot triangle • Fundus superior • Infundibulum lateral/inferior • Critical view of safety • Avoid electrocautery

  14. ACUTE CHOLECYSTITIS • Cholangiogram • Anatomy • LFT elevation • H/O pancreatitis/jaundice • Injury • Timing • Early is better • Complications of AC • Gangrene.empyema.perforation • Male, older, T>38,WBC>18 • Mortality 20%

  15. ACUTE CHOLECYSTITIS • Complications of LC • Bile duct injury - 0.3% • Manage w/ERCP/stent • T-tube • Hepaticojejunostomy • Stone spillage 10% • Abscess

  16. ACUTE CHOLECYSTITIS • Acute acalculous cholecystitis • 4-8% of AC cases • M>F/Critically ill • Trauma/surgery/burns • Childbirth • Mult transfusions • Shock/sepsis • TPN/narcotics • SLE/Sarcoidosis/Polyart nodosa

  17. Acute acalculous cholecystitis • Dx usually delayed • HIDA, US., CT • High risk of gangrene • Treatment • Percutaneous cholecystostomy • Cholecystectomy

  18. Critically Ill • Cholecystostomy 95-100% successful • Facilitates delayed LC • No change in mortality vs conservative therapy. • Higher conversion, complication rate during subsequent lap chole

  19. PREGNANCY • 0.04% develop AC • Conservative Rx if poss • 7% develop preterm labory • Positioning • L side down ( take pressure off IVC)/ Rev Trend • SCD’s • Low pneumoperitoneum • Supraumbilical trocar w/ Hasson technique • US for CBDE/Lead shielding for cholangiogram • Monitor fetus pre/post-op

  20. Pregnancy • If possible (and necessary) surgery should be done in 2nd trimester • 1st trimester – open and lap assoc w/ spontaneous abortion • 3rd trimester – injury to uterus and premature labor • Control symptoms – wait for 2nd trimester or delivery. Recurrence 50-75% • If pain intractable or course worsens – cholesystostomy is reasonable until 2nd trimester/ delivery is reached.

  21. Question • A 27 yo woman who is 16 weeks pregnantpresents with 12 hours of RUQ abdominal pain and vomiting. She is afebrile and stable hemodynamically. She has a WBC of 13,200 and normal LFT’s. Ultrasound reveals cholelithiasis and distention, but no pericholecystic fluid or thickening. • Antibiotics and IV fluids are started, but after 12 hours her symptoms and exam worsen and her T=100.5 • The best management would be: • A. Magnesium sulfate • B. percutaneous cholecystostomy • C. Laparoscopic cholecystectomy • D. ERCP • E. Broaden antibiotic coverage

  22. Question • A 27 yo woman who is 16 weeks pregnantpresents with 12 hours of RUQ abdominal pain and vomiting. She is afebrile and stable hemodynamically. She has a WBC of 13,200 and normal LFT’s. Ultrasound reveals cholelithiasis and distention, but no pericholecystic fluid or thickening. • Antibiotics and IV fluids are started, but after 12 hours her symptoms and exam worsen and her T=100.5 • The best management would be: • A. Magnesium sulfate • B. percutaneous cholecystostomy • C. Laparoscopic cholecystectomy • D. ERCP • E. Broaden antibiotic coverage

  23. Acute Cholangitis • ETIOLOGY • Bile Stasis • Growth of bacteria • Stones • Papillary stenosis • Mirizzi syndrome • Choledochal cyst • Sclerosing cholangitis • Parasites/viral • Iatrogenic

  24. Acute Cholangitis • Charcot Triad • Abdominal pain • Fever • Jaundice • Reynolds Pentad - ADD: • Shock • Altered mental status

  25. Common Duct Stones • PRE-OP • ERCP • 70-90% effective • 40-60% no stones • Morbidity 5-19% • Mortality 1.9% • Longer LOS • Lap CBDE • 70-90% effective

  26. Common Duct Stones Intraop • Small stones • Glucagon to relax Oddi • Flush • LCBDE • OCBDE • Unable to do LCBDE • ERCP not possible • Impacted stone • Longer LOS/higher morbidity • ERCP/ES • Postop • ERC/ES

  27. Open CBDE • Contraindication • Small duct w/ small stones– risk of stricture • Portal HTN • Severe inflammation • Cholangitis w/shock

  28. Open CBDE • Steps • Flush/milk • Fogarty balloons • Choledochoscope • Baskets • If unsuccessful: • Transduodenal sphincterotomy • Anterior 10-11 oclock • avoid PD • Close if >10mm • Choledochoduodenostomy

  29. Question • The most effective long term treatmentfor extrahepatic choledochal cysts is • Antibiotics and Urodeoxycholic acid • Placements of self expanding stents • Resection • Laser ablation • Endoscopy/ES • The most common form of choledochal cyst is • Extrahepatic diffuse • Extrahepatic saccular • Intraduodenal (choledochocele) • Intra- and Extrahepatic • Intrahepatic only (Caroli’s)

  30. Choledochal Cysts • Type I Extrahepatic and fusiform (MOST COMMON) • Type II Extrahepatic and saccular • Type III Intraduodenal (choledochocele) • Type IV Extrahepatic and Intrahepatic (Next M.C.) • Type V Intrahepatic only (Caroli’s disease) • Uncommon in West, but incidence increasing • Triad of Symptoms: RUQ mass, pain, jaundice is RARELY EVIDENT • Adults usually present w pancreatitis or cholecystitis • Dx: Imaging U/s, MRCP/CT/ERCP

  31. Choledochal Cysts • Complications • Stone formation • Recurrent sepsis • MALIGNANT DEGENERATION (10%) • Treatment • Cyst excision w/ hepaticojejunostomy • Jejunal interposition may be better for surveillance

  32. Question • A 33 yo woman presents w 4 weeks of anorexia, weight loss, fatigue and jaundice. Evaluation including ERCP reveals primary scleerosisng cholangitis (PSC) • PSC • Occurs mostly in women • Has a known etiology • Is associated with retroperitoneal fibrosis • More oftern assoiated with Crohn’s disease than Ulcerative colitis • Lacks pathogomatic signs

  33. Question • A 33 yo woman presents w 4 weeks of anorexia, weight loss, fatigue and jaundice. Evaluation including ERCP reveals primary scleerosisng cholangitis (PSC) • PSC • Occurs mostly in women • Has a known etiology • Is associated with retroperitoneal fibrosis • More oftern assoiated with Crohn’s disease than Ulcerative colitis • Lacks pathogomatic signs

  34. Question • A 33 yo woman presents w 4 weeks of anorexia, weight loss, fatigue and jaundice. Evaluation including ERCP reveals primary scleerosisng cholangitis (PSC) • The most definitive treatments would be • Long term antibiotics • Urodeoxycholic acid • Long term steroids • Roux-en-Y choledochoduodenotomy • Hepatic transplantation

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