Gallbladder

Question 1

What must you do during a common bile duct exploration to allow for palpation of the retroduodenal & intra-pancreatic bile duct for stones?

Answer 1

You have to do an extensive kocher maneuver

Only dissect on the anterior portion of the duct (vessels run laterally). But slightly medial to the anterior midline to avoid entering septum of the fused cystic & common hepatic duct

Ductotomy should be 1.5 cm

Close primarily over a T-tube

Question 2

What is the champagne sign on the gallbladder?

Answer 2

It’s the sign of emphysematous cholecystitis with gas bubbles arising in the fundus of the gallbladder

Question 3

What is the cut off for gallbladder wall and distention on U/S?

Answer 3

Wall >3 mm

Distension > 5cm

Question 4

What are the commonly used intraperitoneal agents for chemotherapy in pts with pseudomyoma peritonei?

Answer 4

Cisplatin, doxorubicin, & mytomycin-C

Question 5

What are the steps of a transduodenal sphincteroplasty?

Answer 5

1. Extensive kocher maneuver
2. Transverse or longitudinal duodenotomy on the lateral duodenal wall at the junction of the lower 1/3rd and upper 2/3rds of the duodenum
3. Identify the papilla
4. Cut the ampullary spincter at the 11 o’clock position
5. Extend this to include the entire tract of the spinchter of oddi
6. Extract all the stones (if CBD stones are present)
7. Suture the wall of the CBD to the duodenal mucosa w/ interrupted fine absorbable sutures
8. Close lateral duodentotomy

Question 6

What is the 1st line therapeutic option for partial distal bile duct injury?

Answer 6

Placement of endobiliary covered stent

NOTE: risk of future recalcitrant bile duct stricture that may require endoscopic dilation OR resection and reconstruction via choledochoduodenostomy or HJ

Question 7

What is a good way to identify pts w/ sphincter of Oddi dysfunction that could benefit from a transduodenal sphincteroplasty?

Answer 7

Morphine + neostigmine

Morphine will result in sphincter contract. Neostigmine will cause biliary contraction.

Question 8

What is the most common complication following placement of a per chole tube?

Answer 8

Bile leak upon placement of tube

Question 9

What is the management of perforated acalculous cholecystitis?

Answer 9

Early cholecystectomy & IV abx

Acalculous pts are at higher risk for having gangrene and perforation