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Intuitive > Chole > Flashcards

Chole Flashcards

1
Q

What makes up Calots Triangle

A
  1. Fundus
  2. Infundibulum
  3. Gallbladder neck
  4. cystic duct
  5. Inferior edge of the liver
  6. Common hepatic duct
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2
Q

What makes up the critical view of safety

A

Cystic duct
cystic artery
clear view of the liver bed

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3
Q

What is the pathway of bile

A

Travels from the GB - to the cystic duct - into the common bile duct - down to the sphincter of oddi - into the duodenum

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4
Q

What are the two disease states of the gallbladder

A

Cholelithiasis
Choledocholithiasis

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5
Q

What is cholelithiasis

A

formation of gallstones in the gallbladder

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6
Q

What is choledocholithiasis

A

gallstones in the common bile duct

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7
Q

What is ideal patient selection for early cases

A

Good performance status ASA 1-11
Non obese <30 BMI
no previous upper abd. surgery
Age 18-80
Symptoms consistent with gallbladder disease
suitable for lap. chole

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8
Q

Patient Positioning

A

Supine
strap across thighs
reverse trend ~ 10 degrees
tilt to patient L - elevate Patient R
Lower Table
Slide table if needed for C-arm to fit under the table

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9
Q

When/ how much ICG should you use

A

It should be administered about 45 minutes before case start to see Duct and 30-60 seconds to see artery

2.5 mg/ml solution - 25mg w/ 10ml sterile water

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10
Q

Port Placement - 4 arm

A

Endo 2cm superior to the umbilicus
L&R hand 8cm lateral
Hockey stick the 4th arm on the L side - holds the falciform as well as the fundus

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11
Q

Typical instruments used

A

Hook / med-large clip applier / suction irrigator - Arm 3
Prograsp / cadiere forceps - Arm 4
Fenestrated bipolar / force bipolar - arm 1

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12
Q

Port Placement with C-arm

A

Space arms 2-3 to leave space for c-arm space arms 1& 4 a fist width of clearance
Lower patient clearance joints
Cart opposite side of bed

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13
Q

Procedure steps 1-6

A
  1. Initial exposure
  2. Dissection of calots triangle and identify critical view of saftey
  3. Confirm with Firefly
  4. Ligation and division of cystic duct artery
  5. cystic plate dissection
  6. Specimen removal
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14
Q

Initial exposure - what happens & DV value

A

Take down adhesions
grasp and retract the fundus of the GB to expose cystic pedicle - using arm 4

DV value - 3DHD view - consistent/ steady view of field

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15
Q

Dissection of calots triangle - what happens & DV value

A

incise peritoneum close to GB neck to expose the landmarks
See the critical view of safety- ensure only Cystic duct and cystic artery are entering GB

DV value - Does not have to rely on assistant for retraction or view. Wrists can provide precise dissection

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16
Q

What is a classical injury

A

An injury to the common bile duct - Partial may require suture or stent
a complete will require a hepaticojejunostomy

17
Q

Firefly - what can firefly identify
DV value

A

Ducts and arteries - gives surgeon more confidence
DV - reduce the need for a C-arm

18
Q

Indication for C-arm

A

Unclear ductal anatomy
possible stones in the bile duct

19
Q

Ligation and division of cystic artery and duct

A

Place two clips proximal and 1 clip distal on the duct and 1 distal and 1 prox for the artery

Use cold cutting as energy could spread down the artery/duct and make the artery or duct shrink and the clip fall off

20
Q

Nuances of the clip applier

A

Use two to increase efficiencies
Roll your hand when taking control of the instrument
Using two will not cost you more money

21
Q

Cystic plate dissection - what happens

A

The GB is dissected off the cystic plate of the liver. Start at the neck and work your way up.

22
Q

Specimen removal

A

Inspect to ensure no bleeding or bile leakage
deploy the bag and insert the specimen - will have to lengthen the port to have the specimen fit out. Ensure you close the fascia with the removal

23
Q

How do you use the purple bag

A

open the bag, when specimen is inside and you are ready to remove, push the white lever all the way down while pressing the purple to break the lever to all it to come off so just the strings are left.

24
Q

What is the cart approach

A

Upper abdominal and the correct patient side

25
Q

What are the complexity multipliers for Chole

A

Obesity
Prior surgery / adhesions
Aberrant anatomy
other comorbidities - smoking / poor lifestyle

26
Q

Two disease states for Chole

A

cholelithiasis
acute cholelithiasis

27
Q

3 things to know before you go to an NDVCO

A

Procedure steps
Questions that I would like to ask
desired next steps

28
Q
A

Intuitive (2 decks)

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