6. Hepatobiliary surgery Flashcards by Meleah McMillen

The liver has ____ lobes and the gb lives within the ______ division

6 lobes; gb within the central division

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What are the names of the different divisions of the liver

Right division
Left division
Central division

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What lobes are located in the left division and indicate the severity of sx?

Left Lateral

Left Medial lobe

Left side is easier to deal with surgically bc gallbladder isnt in the way or the caudal vena cava

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What is located in the right lateral love and describe the difficulty of surgery?

Right lateral lobe

Caudate process of caudate lobe

papillary porcess of caudate lobe (2)

common bile duct

Right divison also involves blood supply, the caudal vena cava and portal vein and hepatic artery so this makes it way more challenging in terms of treatment

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What is involved in the central lobe

Right medial lobe

2.(BETWEEN is the gall ballder within hepatic fossa)

Quadrate lobe

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Blunt trauma to the liver often causes?

liver fracture

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Gun shots arrows and bite wounds cause _____ wounds to the liver

penetrating

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What CS do we see in relation to trauma of the liver?

CS related to acute blood loss

weakness
lethary
hypovolemia
distended abdomen filled with blood

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In terms of trauma to the liver do we want to rush to surgery? If not what do we do?

Dont rush to surgery for exploratory start with conservative management and replacing fluids but not too much so it can blow off clots that are trying to form (so use low flow fluids) and Use PCV to monitor over 24 hours

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In terms of trauma, the closer the injury is to the hilus the greater the likihood ______ will be necessary

surgery

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What is the pringle manuever and what are the indications to use it

Having bleeding from the liver? The pringle maneuver stops blood flow temporarily!

Compress the blood flow from the hepatic artery and portal vein temporarily to stop bleeding, stuck your finger in the epiploic foramen and compress those vessels/

No longer than 15-20 minutes dont want to permanently occlude

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Incision into gallbladder

Cholecystotomy

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SX Removal of gallbladder

Cholecystectomy

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Biliary diversion can be done through these 3 procedures?

Cholecystoduodenostomy-bringing gb to duodenum
Cholecystojejunostomy- bringing gb to jejunum
Choledochoenterostomy-bringing gb and common bile duct to portion of small intestine

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Before doing a tru cut needle biopsy what do you need to do? Wht guage of needle

NEED CBC and coag profiles, do this ultrasound guided if worried about bleeding post biopsy so need that too!

14 or 16 guage needle

Can do this through laparoscopy or exploratory celiotomy which is good bc we can stop bleeding we are seeing

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Describe the name of the liver biopsy technique where you compress the hilar vessels with suture and cut distally to it?

Guillotine technique

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What are the indications ofr a partial lobectomy of the liver? (4)

Biopsy
Neoplasia (more on the periphery of the liver)
Trauma (cant really suture liver)
Abscess
Cysts

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Which technique of partial lobectomy generally results in the most blood loss?

Parenchymal Fracture and Ligation

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We can often use the stapling technique for lobestomy procedures but if its located at this region its more challenging, what should we do when using this technique?

Stapling technique; challenging at the hilus; put 3 lines of staples

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When would we use surgities and what is indicated with this technique?

Good for tumors close to the hilus, braided suture with a knot in it, need at LEAST 2 to prevent bleeding

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Choledocholiths means?

stones within the common bile duct or gall bladder

For cholecystitis, if it’s necrotizing it can often cause this pathology?

necrotizing cholecystits can cause Rupture and rupture may result in septic peritonitis

How do we treat Cholecystitis / Cholangiohepatitis?

Can treat medically if not ruptured

Enteric organisms
E. coli, Klebsiella, Enterobacter, anaerobes

Surgery (do an U/S before)

Assess extrahepatic biliary tree
Cholecystectomy

Hyperplasia of mucus secreting cells and excessive mucus secretions can cause?

Biliary Mucoceles

Biliary Mucoceles can cause alterations in gallbladder \_\_\_\_\_\_which causes?

**motility** (motility decreased which causes mucus filled bile to accumulate more and back up into liver)

Biliary mucoceles can cause ana accumulation of ______ \_\_\_\_\_\_

inspissated bile

With biliary mucoceles, overdistension of the gallbladder can result in \_\_\_\_\_\_. Grossly evident in 50% of clinical cases, and histologically present in over 70% of the cases

rupture

Biliary mucoceles can cause _____ from the inflammatory reaction of bile backed up in the liver

cholecystitis

What is the common signalment and CS and lab abnormality seen with biliary mucoceles? * Age * Breeds * CS

* Older (med age 9 y/o) * Small and medium sized dogs such as **_SHELTIES (KIRBY)_** and COCKER SPANIELS * Common CS * **Vomiting** * **Anorexia** * Lethargy * **Pain upon abdominal palpation initially and then stop being painful which is BAD BAD ndicates gb rupture**

What are the lab abnormalities seen with biliary mucocele?

* **Increased total bilirubin causing jaundice 69%** * Elevated alkaline phosphatase 81% * Elevated alanine aminotransferase 79% * Elevated g-glutamyl transferase 67%

What is the name of the diagnostic cs often seen with biliary mucocele and what is it due to? What imaging modality is it on

KIWI sign seen on U/S from enlarged gallbladder with immobile echogenic bile kiwi sign or striated or stellate pattern from mucus siting in the gb

What are some different treatments of biliary mucocele

* Medical Management?? * Choleretics * **_Cholecycstectomy (TREATMENT OF CHOICE_** to remove gb and cystic duct, don't remove the common bile duct) * first make sure there is patency of common bile duct * Culture the bile to rule out infection and see if they need antibiotics

What are the common indications for cholecystectomy? (surgical removal of the gallbladder.) (6)

* Necrotizing cholecystitis * Chronic cholecystitis * Biliary mucocele * Cholelithiasis * Neoplasia * Trauma

When performing a cholecystectomy what do I need to make sure is removed? (3)

* Gallbladder (DUH) * Cystic duct * Cystic artery

Describe where the gb lives (be specific)

GB lives with in the hepatic fossa of right medial lobe and right quadrate lobe within the central divison

What do you need to do to ensure ligatures and holding for cholecystectomy to prevent this from happening?

**Flush through duodenotomy** again to ensure ligatures are holding dont want a **bile peritonitis** secondary to surgery!

Failure to adequately ligate the bile duct and to recognize and ligate small ducts entering the _____ \_\_\_\_\_ can cause this (\_\_\_\_\_\_ \_\_\_\_\_\_)

cystic duct; cause bile peritonitis

BLEEDING from the area where you removed the gb IS CAUSED BY

failure to ligate cystic artery

Biliary obsturction is either ______ or \_\_\_\_\_\_. what are the causes of each. Which ones cause **temporary obstruction resolve with Tx of dz)?**

**Intraluminal** * Inflammatory disease * Choleliths and Choledocholiths (stones within common bile duct too) * Neoplasia * Inspissated bile (mucus) * Parasites **Extraluminal (temporary obstruction resolve with Tx of dz)** * Pancreatic disease (pancreatitis compression on common bile duct) * Duodenal disease

What is the term for Incision into dilated common bile duct, and what are the 2 indications for this procedure

Choledochotomy 2-3 mm wide usually * Choledocholithiasis * Biliary sludge

Bile duct stenting is Most commonly done to relieve obstruction due to _______ \_\_\_\_\_\_\_

**extraluminal compression**

Bile duct stenting is used temporarily for this, describe the basic steps

* Tused to temporarily divert bile after suturing bile duct * Suture catheter to intestinal wall with absorbable suture * When suture breaks down bile duct contraction will dislodge catheter into intestine

When would do a more permanent biliary diversion versus a temporary biliary stenting? We cannot do this unless this?

* Irreparable obstruction (TUMOR) or trauma of common bile duct * Cannot do this if there is disease in the GB

What are the 3 procedures for biliary diversion and which is most common?

* Choledochoenterostomy * attaching the CBD to a portion of duodenum * ***_Cholecystoduodenostomy MOST COMMON_*** * ***_bringing the gb over to the duodenum this is needed bc CBD isnt patent like from a tumor_*** * Cholecystojejunostomy * attaching the CBD to a portion of jejunum

For Cholecystoduodenostomy (the MC form of biliary diversion) the initial size of the ____ needs to be \_\_\_-\_\_\_cm long to reduce this

The initial size of the **stoma** needs to be **2.5 - 3 cm** long to reduce the risk of the gallbladder becoming impacted with ingesta causing cholecystitis and/or cholangiohepatitis

What are some complications of biliary diversion?

* **Leakage** * **Dogs** * Ascending infections bact going from intest. to GB --\>liver * Bleeding at stoma site * **Cats** (only do this bc of tuors in the biliary tree) * Chronic vomiting * _High morbidity and mortality :-(_ * Often related to underlying diseas

Bile peritonitis is caused by \_\_\_\_(which is MC), _____ \_\_\_\_, and iatrogenic?

* Trauma * bile duct is more commo in terms of trauma * Spontaneous rupture * gallbladder

Bile peritonitis is often greenish brown and can be dx by?

**Abdominal effusion** * Compare fluid and serum bilirubin * _Positive if fluid 2 X serum_ **Abdominocentesis** * Four-quadrant tap * Ultrasound guided aspirate * DPL (diagnostic peritoneal lavage to get fluid out)

Sterile bile = ____ \_\_\_\_\_ which generally ____ \_\_\_\_\_. what is the prognosis

Sterile bile = **chemical peritonitis** which generally **well tolerated.** what is the prognosis?? Prognosis good in u/l disease cause is eliminated

Infected bile = _____ peritonitis, what is the prognosis?

septic pertonitis * **Prognosis guarded to poor** * **Morbidity and mortality are high**