Hepatobiliary Surgery Flashcards
Fracture and penetrating wounds to the liver are usually due to?
Trauma
Fracture - blunt trauma (HBC)
Penetrating - gunshot, arrow, bite
How would you treat a trauma case with damage to the liver?
Conservative
Ligate severed vessels
Partial hepatectomy
Pringle maneuver
The closer the injury is to the hilus, the greater likelihood surgery will be necessary
What is the Pringle maneuver?
Clamp the hepatoduodenal ligament and interrupt flow though hepatic artery and portal vein to control bleeding in liver
What techniques are used for liver biopsy?
FNA
Tru-cut (image guided/ laparoscopically/ exploratory celiotomy)
Laparoscopic
Skin biopsy punch
Guillotine technique
In what animals might you required laraoscopy/ exploratory to get a tru-cut biopsy?
Smaller animals or in deep chested breeds —> liver lives farther under the rib cage
When is the guillotine technique appropriate for biopsy?
Lesions on the edge of liver or diffuse disease
What re the indications for a liver partial lobectomy?
Biopsy Neoplasia Trauma Abscess Cysts
T/F: when removing a portion of the liver, parenchymal fracture and ligation generally results in the most blood loss
True
What type of suturing is done with parenchymal fracture and ligation?
Overlapping sutures
What are alternatives to suture for partial liver lobectomies?
Stapling
Surgities
What are the extrahepatic biliary diseses?
Cholecysitis Biliary mucocele Obstrucion Trauma Neoplasia Choledocholiths
Rupture of a necrotizing cholecystitis can result in?
Septic peritonitis
How do you treat cholecytisitis?
Medically if not ruptured
Surgery
- assess extraheptic biliary tree
- cholecystectomy
What is the pathogenesis of biliary mucocele?
Hyperplasia of mucus-secreting cells and excessive mucus secretion
Alteration in gallbladder motility
Accumulation of inspissated boiled
Over-distention of gallbladder can result in rupture
+/- cholecystitis
Signalment associated with biliary mucocele ?
Small and medium size dogs - Shelties, cocker spaniel
Clinical signs with biliary mucocele ?
Vomiting
Anorexia
Lethargy
Pu/PD
Diarrhea
None
Most common lab abnormalities with biliary mucocele ?
Increased ALP and ALT
Increased GGT
Increase Tbili
What imaging can be done to identify biliary mucocele?
Survey rads
US
— enlarged gallbladder with echogenic bile
—striated or stellate patter “kiwi sign”
Treatment for biliary mucocele ?
Medical — cholerectics (maybe works?)
Cholecystectomy
Confirm bile duct patency
Culture bile
Antibiotics
What are indications for a cholecystectomy?
Necrotizing cholecystitis Chronic cholecystitis Biliary mucocele Cholelithisaisis Neoplasia Trauma
Method of cholecystectomy?
MUST maintain hepatic ducts and common bile duct
Duodentomy with catheterizaiton of bile duct
Blunt dissection of gallbladder from hepatic fossa
Ligate cystic duct and cystic artery
Flush saline through bile duct - check for leakage
Complications to cholecystectomy?
Bile peritonitis
- failure to adequately ligate bile duct
- failure to recognize and ligate small ducts entering cystic duct
Bleeding
-failure to ligate cystic artery
What are causes of intralumenal biliary obstruction?
Inflammatory disease Choleliths and choledocholiths Neoplasia Inspissated bile Parasites
What are extraluminal causes of biliary obstruction?
Pancreatic or duodenal disease
What is a choledochotomy?
Incision into dilated common bile duct
Indication for choledochotomy?
Choledocholithiasis
Biliary sludge
What is the most common method to relieve obstruction due to extraluminal compression?
Bile duct stenting
Also done to temporarily divert bile after suturing the bile duct
When is biliary diversion indicated?
Irreparable obstruction or trauma of common bile duct (eg tumor )
What are methods of biliary diversion?
Choledochoenterostomy
Cholecystoduodenostomy
Cholecystojejunostomy
When doing an cholecystoduodenostomy, the initial size of the stoma needs to be _________ cm long to reduced the risk of gallbladder becoming impacted with ingesta
2.5-3
Complications of biliary diversion?
Leakage
Cats - high morbidity and morality and chronic vomiting
Dog - ascending infection and bleeding at stoma site
What can cause bile peritonitis?
Trauma (more common to bile duct)
Spontaneous rupture (gallbladder)
Iatrogenic
What is the appearce of bile peritonitis ?
Green, greenish-brown discolouration
Abdominal effusion
How can you confirm bile peritonitis?
Abdominocentesis
- 4-quadrant tap
- US guided aspirate
- DPL
Positive is fluid bilirubin is >2x serum
T/f: Prognosis of sterile bile peritonitis is good if the underlying cause is eliminated
True
T/f: Prognosis of infected bile peritonitis is good if the underlying cause is eliminated
False
Poor prognosis — septic peritonitis
