Hepatobiliary Surgery

Question 1

Fracture and penetrating wounds to the liver are usually due to?

Answer 1

Trauma

Fracture - blunt trauma (HBC)

Penetrating - gunshot, arrow, bite

Question 2

How would you treat a trauma case with damage to the liver?

Answer 2

Conservative
Ligate severed vessels
Partial hepatectomy
Pringle maneuver

The closer the injury is to the hilus, the greater likelihood surgery will be necessary

Question 3

What is the Pringle maneuver?

Answer 3

Clamp the hepatoduodenal ligament and interrupt flow though hepatic artery and portal vein to control bleeding in liver

Question 4

What techniques are used for liver biopsy?

Answer 4

FNA
Tru-cut (image guided/ laparoscopically/ exploratory celiotomy)

Laparoscopic
Skin biopsy punch
Guillotine technique

Question 5

In what animals might you required laraoscopy/ exploratory to get a tru-cut biopsy?

Answer 5

Smaller animals or in deep chested breeds —> liver lives farther under the rib cage

Question 6

When is the guillotine technique appropriate for biopsy?

Answer 6

Lesions on the edge of liver or diffuse disease

Question 7

What re the indications for a liver partial lobectomy?

Answer 7

Biopsy 
Neoplasia 
Trauma 
Abscess 
Cysts

Question 8

T/F: when removing a portion of the liver, parenchymal fracture and ligation generally results in the most blood loss

Answer 8

True

Question 9

What type of suturing is done with parenchymal fracture and ligation?

Answer 9

Overlapping sutures

Question 10

What are alternatives to suture for partial liver lobectomies?

Answer 10

Stapling

Surgities

Question 11

What are the extrahepatic biliary diseses?

Answer 11

Cholecysitis 
Biliary mucocele 
Obstrucion 
Trauma 
Neoplasia 
Choledocholiths

Question 12

Rupture of a necrotizing cholecystitis can result in?

Answer 12

Septic peritonitis

Question 13

How do you treat cholecytisitis?

Answer 13

Medically if not ruptured

Surgery

• assess extraheptic biliary tree
• cholecystectomy

Question 14

What is the pathogenesis of biliary mucocele?

Answer 14

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

Question 15

Signalment associated with biliary mucocele ?

Answer 15

Small and medium size dogs - Shelties, cocker spaniel

Question 16

Clinical signs with biliary mucocele ?

Answer 16

Vomiting
Anorexia
Lethargy

Pu/PD
Diarrhea
None

Question 17

Most common lab abnormalities with biliary mucocele ?

Answer 17

Increased ALP and ALT
Increased GGT
Increase Tbili

Question 18

What imaging can be done to identify biliary mucocele?

Answer 18

Survey rads

US
— enlarged gallbladder with echogenic bile
—striated or stellate patter “kiwi sign”

Question 19

Treatment for biliary mucocele ?

Answer 19

Medical — cholerectics (maybe works?)

Cholecystectomy
Confirm bile duct patency
Culture bile
Antibiotics

Question 20

What are indications for a cholecystectomy?

Answer 20

Necrotizing cholecystitis 
Chronic cholecystitis 
Biliary mucocele 
Cholelithisaisis 
Neoplasia 
Trauma

Question 21

Method of cholecystectomy?

Answer 21

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

Question 22

Complications to cholecystectomy?

Answer 22

Bile peritonitis

• failure to adequately ligate bile duct
• failure to recognize and ligate small ducts entering cystic duct

Bleeding
-failure to ligate cystic artery

Question 23

What are causes of intralumenal biliary obstruction?

Answer 23

Inflammatory disease 
Choleliths and choledocholiths 
Neoplasia 
Inspissated bile 
Parasites

Question 24

What are extraluminal causes of biliary obstruction?

Answer 24

Pancreatic or duodenal disease

Question 25

What is a choledochotomy?

Answer 25

Incision into dilated common bile duct

Question 26

Indication for choledochotomy?

Answer 26

Choledocholithiasis

Biliary sludge

Question 27

What is the most common method to relieve obstruction due to extraluminal compression?

Answer 27

Bile duct stenting

Also done to temporarily divert bile after suturing the bile duct

Question 28

When is biliary diversion indicated?

Answer 28

Irreparable obstruction or trauma of common bile duct (eg tumor )

Question 29

What are methods of biliary diversion?

Answer 29

Choledochoenterostomy

Cholecystoduodenostomy

Cholecystojejunostomy

Question 30

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

Answer 30

2.5-3

Question 31

Complications of biliary diversion?

Answer 31

Leakage

Cats - high morbidity and morality and chronic vomiting

Dog - ascending infection and bleeding at stoma site

Question 32

What can cause bile peritonitis?

Answer 32

Trauma (more common to bile duct)

Spontaneous rupture (gallbladder)

Iatrogenic

Question 33

What is the appearce of bile peritonitis ?

Answer 33

Green, greenish-brown discolouration

Abdominal effusion

Question 34

How can you confirm bile peritonitis?

Answer 34

Abdominocentesis

• 4-quadrant tap
• US guided aspirate
• DPL

Positive is fluid bilirubin is >2x serum

Question 35

T/f: Prognosis of sterile bile peritonitis is good if the underlying cause is eliminated

Answer 35

True

Question 36

T/f: Prognosis of infected bile peritonitis is good if the underlying cause is eliminated

Answer 36

False

Poor prognosis — septic peritonitis