Biliary Tract Surgery Lecture Powerpoint Flashcards
Gallbladder anatomy review
Gallbladder empties into cystic duct, liver empties into common hepatic duct, the two combine into the common bile duct, combine with the pancreatic duct and empty at the ampulla of vater at the spinchter of oddi into the duodenum
The triangle of calot significance and borders
- cystic artery is found within the triangle
- cystic duct, common hepatic duct, and edge of liver make up the borders
Indications for cholecystectomy (5)
- biliary colic
- acute cholecystitis
- chronic cholecystitis
- complications of gallstone disease (choledocholithiasis and such)
- dysfunctional gallbladder (theorized to not be real, more valid if responds to cholecystokinin reproducability test)
Pre op prep for cholecystectomy (4)
- antibiotics
- DVT prophylaxis (compression stockings and maybe lovenox)
- patient understanding of possible need to convert to open procedure
- cardiac clearance
When does a cholecystectomy have to be converted to an open one? (4)
- cannot identify landmarks or structures
- marked inflammation with adhesions of surrounding viscera
- bleeding
- bile duct injury
Complications of cholecystectomy (6)
- bile duct injury
- perforation of major vessel
- perforation of small or large bowel
- bile leak
- infection
- CO2 absorption and potential pneumothorax
Cholecystostomy definition and indications (4)
- Percutaneous or open tubing of the gall bladder under CT guidance
- indicated in patients with acute cholecystits, acute acalculus cholecystitis, obstructive cholangitis (jaundice), or in patients who will not tolerate cholecystectomy
Choledocholithiasis diagnosis (2)
- U/S
- ERCP (also therapeutic)
Choledocholithiasis treatment options (2)
- ERCP
- surgery (common bile duct exploration, if stone impacted at the sphincter of oddi then can do choledochoduodenostomy bipass)
Falciform ligament of the liver
Fibrous structure that connects the anterior liver to the ventral wall of the abdomen, located approx midline of the abdomen dividing “right” and “left” liver lobes, round ligament also known as ligamentum teres is a remnant of the umbilical vein that protrudes from the anterior free face of this ligament
Indications for liver resection (5)
- primary liver neoplasm
- hepatic stick
- hemangioma (benign lesion but can rupture and bleed)
- carcinoma of the gallbladder
- severe trauma to liver that cannot be repaired
You can remove __% of liver tissue and the patient will survive, the liver also regenerates and is the only solid organ to do so
80
Preop for liver resection (5)
- maximize nutritional status (removal of glycogen stores occurs during resection
- normalize INR because liver produces a lot of proteins responsible for clotting cascade
- blood typing and crossmatching
- DVT prophylaxis
- antibiotics
Blood typing screening vs crossmatching
Type and screen determines ABO and Rh and minor antigens vs crossmatch tests patients blood and serum against the donor to see if theres no compatibility issues with minor antigens, problematic as removes blood from use so an individual that needs it in a hurry can’t have it
Liver lobes***
Left lobe of the liver is NOT left of the falciform, the left lobe vs right lobe anatomically speaking is based on where the hepatic arteries, ducts, and the portal veins go, the division is a line thru the gallbladder and the inferior vena cava, falciform divides lateral segment of left lobe from medial segment of left lobe, but doesn’t separate right lobe from left. There are 8 segments of the entire liver
Segmental resection vs Left lateral segmentectomy vs left medial segmentectomy vs left lobectomy vs right lobectomy vs extended right lobectomy (trisegmentectomy)
Removal of one lobe in a wedge resection vs removal of the lobes left of the falciform ligament vs removal of the lobes part of the left liver but right of the falicform vs taking out the entire left lobe vs taking out the entire right lobe vs taking out the entire right lobe + the medial portion of the left lobe
Complications of liver resection (3)
- Infection
- excessive bleeding
- hypoglycemia
Indications for pancreatic surgery (4)
- neoplasm (exocrine, endocrine, in the duodenal exit)
- trauma
- chronic pancreatitis
- acute necrotizing pancreatitis
Pancreatic surgery options (5)
- distal pancreatectomy (spleen side)
- pancreaticdudenectomy (whipple procedure)
- total pancreatectomy
- peustow procedure
- pancreatic head resection
Pancreas blood supply (3)
- direct branches from splenic artery
- gastroduodenal artery
- pancreaticoduodenal artery
Whipple procedure
-surgery involving hooking the jejunum to the pancreas(pancreatojejunostomy) followed by common bile duct attachment to jejunum (choledochojejunostmy) and the stomach attached as well (gastrojejunostomy) while removing the duodenum (can be done to try to preserve the pylorus to limit dumping syndrome
Peustow procedure
Chronic pancreatitis surgical treatment involving distal pancreatectomy and opening of pancreatic duct and draining it into jejunum eliminating constrictures
Pancreatic resection complications (4)
- anastamotic leak (need drains inserted until it seals off)
- infection
- pancreatic exocrine insufficiency resulting in malabsorption
- endocrine insufficiency making diabetes difficult to manage
