GALL
BLADDER
BY
DR.
HAYDER M. ABDULNABI
MD, CABS
1
ANATOMY
PEAR-SHAPED, 7.5-12.5 CM
NORMAL CAPACITY- 50 ML
FUNDUS, BODY, NECK (TERMINATES IN A
NARROW INFUNBIBULUM)
( HARTMANN’S POUCH- A DILATATION IN THE
NECK DUE TO AN IMACTED STONE)
CRISS-CROSS MUSCLE COAT (WELL
DEVELOPED IN THE NECK)
GLANDULAR MUCOUS MEMBRANE WITH
CRYPTS OF LUSCHA
2
THE CYSTIC DUCT 2.5 CM (CONTAINS
THE SPIRAL VALVE OF HEISTER)
THE COMMON HEPATIC DUCT 2.5CM
(UNION OF RT AND LT HEPATIC
DUCTS)
THE COMMON BILE DUCT 7.5CM
(JUNCTION OF CHD AND THE CYSTIC
DUCT), OF 4 PARTS
3
1- SUPRADUODENAL 2.5CM (RUNS IN
THE FREE EDGE OF LESSER
OMENTUM
2- RETRODUODENAL
3- INFRADUODENAL
4- INTRADUODENAL (PASSES
OBLIQUELY THROUGH 2ND PART OF
DUODENUM, SURROUNDED BY THE
SPHINCTER OF ODDI, OPENS AT THE
SUMMIT OF THE PAPILLA OF VATER
4
THE ARTERIAL SUPPLY OF THE
GALL BLADDER
THE CYSTIC ARTERY (BRANCH OF THE
RT HEPATIC ARTERY), USUALLY
BEHIND THE CBD
ACCESSORY CYSTIC ARTERY
(OCCASIONAL)(BRANCH OF THE
GASTRODUODENAL ARTERY)
5
6
LYMPHATICS
SUBSEROSAL AND SUBMUCOSAL DRAIN INTO
THE CYSTIC LYMPH NODE OF LUND
(SENTINEL LN) THEN TO THE HILUM OF THE
LIVER TO THE COELIAC LYMPH NODES
SUBSEROSAL LYMPHATICS CONNECT WITH
THE SUBCAPSULAR LYMPHATICS OF THE
LIVER (FREQUENT SPREAD OF GALL
BLADDER CA TO THE LIVER)
7
FUNCTIONS OF THE GALL
BLADDER
BILE IS COMPOSED OF 97% WATER, 1-2%
BILE SALTS, 1% PIGMENTS, CHOLESTEROL
AND FATTY ACIDS
LIVER EXCRETION RATE IS 40 ML/HOUR
1- RESERVOIR (FASTING CAUSE RESISTANCE
INCREASE IN SPHINCTER OF ODDI)
(FEEDING DECREASE THE RESISTANCE
AND THE GALL BLADDER CONTRACTS BY
THE ACTION OF CHOLECYSTOKININ
RELEASED BY UPPER INTESTINAL MUCOSA
IN RESPONSE TO FOOD PARTICULARLY
FAT)
8
2- CONCENTRATION OF BILE 5-10 TIMES (
BY ACTIVE ABSORBTION OF WATER,
SOD. CHLORIDE, AND BICARBONATE)
WITH INCREASE IN THE PROPORTION
OF BILE SALTS, PIGMENTS,
CHOLESTEROL AND CALCIUM
3- MUCIN SECRETION, 20ML/HOUR
9
INVESTIGATIONS OF THE
BILIARY TRACT
1- PLAIN RADIOGRAPH-- (RADIO-OPAQUE
STONE 10%, PORCLAIN GALL BLADDER,
LIMEY BILE, AIR)
2- ORAL CHOLECYSTOGRAPHY-- (A CONTROL
X-RAY IS TAKEN THE DAY BEFORE AND
IOPANOIC ACID CONTRAST MEDIUM
TABLETS IS TAKEN ORALLY AT NIGHT, THE
NEXT DAY ERRECT AND SUPINE X-RAY IS
TAKEN TO THE RT HYPOCHONDRIUM AND
X-RAY REPEATED TO OBSERVE GALL
BLADDER CONTRACTION(
10
RADIO-OPAQUE STONES
PLAIN X- RAY
11
PLAIN X-RAY
PORCLAIN GB
12
AIR
PLAIN X-RAY
13
ORAL
CHOLECYSTOGRAM
STONES
14
NONVISUALIZATION
(NONFUNCTIONING) GALL BLADDER IS
DUE TO-- FAILURE OF THE PATIENT
TO TAKE THE TABLETS, VOMITING,
MALABSORBTION, IMPAIRED LIVER
FUNCTION, BLOCKED CYSTIC
DUCT,SEVERE GALL BLADDER
DISEASE (FAILURE OF
CONCENTRATION)
15
3- INTRAVENOUS CHOLANGIOGRAM–
USING INTRAVENOUS RADIO-OPAQUE
MEDIUM TO SHOW THE BILE DUCTS,
MAY BE USED WITH ORAL
CHOLECYSTOGRAM OR
TOMOGRAPHY (A METHOD TO PUT
ONE GIVEN PLANE INTO SHARP
FOCUS WHILE BLURRING OTHERS)
16
4- ULTRASONOGRAPHY (NONINVASIVE)
AND SHOWS BILIARY CALCULI,
DILATION OF BILIARY TREE,CA HEAD
PANCREAS, WALL THICKNESS, GALL
BLADDER SIZE, HALLO SIGN
5- RADIOISOTOP SCANNING– USING
RADIOACTIVE IODINE(131) OR Tc(99)
6- COMPUTED TOMOGRAPHY– IN
OBESE OR PATIENTS WITH GASEOUS
DISTENTION THAT MAKE
ULTRASONOGRAPHY DIFFICULT
17
GB
STONE
ACOSTIC
SHADOW
US
18
CBD
ACOSTIC SHADOW
ULTRASONOGRAPHY
19
STONE
7- ENDOSCOPIC RETROGRADE
CHOLAGIOPANCREATOGRAPHY
(ERCP)– BY CANNULATION OF THE
AMPULLA OF VATER USING FIBEROPTIC
DUODENOSCOPE AND INJECTION OF
CONTRAST MEDIUM ,TO TAKE SAMPLE FOR
CULTURE AND BRUSHING FOR CYTOLOGY.
ITS USE CAN BE EXTENDED TO DO
PAPILLOTOMY TO EXTRACT STONES,
PASSING CATHETER OR DORMIA BASKET,
AND STENT PLACING THROUGH
STRICTURES.
IT MAY CAUSE ASCENDING BILIARY
INFECTION, SO SHOULD BE DONE UNDER
ANTIBIOTICS COVER
20
DUCT OF WIRSUNG
CATHETER IN THE
AMPULLA
ERCP
21
8- PERCUTANEOUS TRANSHEPATIC
CHOLANGIOGRAPHY- INJECTION OF
CONTRAST MEDIUM THROUGH A CHIBA OR
OKUDA NEEDLE (15CM LONG , 0.7MM IN
DIAMETER) INTO THE LIVER THROUGH THE
8TH INTERCOSTAL SPACE IN THE
MIDAXILLARY LINE.
IT CAN BE USED TO PUT A CATHETER FOR
DRAINAGE OR STENT FOR ANTEGRADE
DRAINAGE.
BLEEDING TENDENCY IS A CONTRA
INDICATION AND THE PROCDURE SHOULD
BE DONE UNDER ANTIBIOTICS COVER
22
CHIBA NEEDLE
PER CUTANEOUS TRANSHEPATIC
CHOLANGIOGRAM
23
9- PEROPERATIVE CHOLANGIOGRAPHY– BY
TAKING X-RAY DURING OPERATION AFTER
INJECTING THE CONTRAST BY A
POLYTHENE CATHETER INTRODUCED INTO
THE CBD THROUGH AN OPENING IN THE
CYSTIC DUCT TO DETECT ANY STONE IN
THE CBD BEFORE EXPLORATION.
FAILURE OF THE CONTRAST TO ENTER THE
DUODENUM MAY BE ALSO DUE TO
SPHINCTER SPASM AND HERE
SUCCINYLCHOLINE IS GIVEN TO EXCLUDE
THIS POSSIBILITY
20% OF CASES THE MEDIUM ENTER THE
DUCT OF WIRSUNG AND IT IS NOT
NECESSARILY PATHOLOGICAL
24
CATHETER
PER- LAPAROSCOPIC
CHOLANGIOGRAPHY
25
CATHETER
PER-OPERATIVE
CHOLANGIOGR
AM
26
CBD
DUODENUM
10- OPERATIVE BILIARY ENDOSCOPY
(CHOLEDOCHOSCOPY)
11- PEROPERATIVE
POSTEXPLORATORY
CHOLANGIOGRAPHY (THROUGH THE
T- TUBE)
12- POSTOPERATIVE
CHOLANGIOGRAPHY (T-TUBE), 10-14
DAYS AFTER CHOLEDOCHOTOMY
27
STONE IN
CBD
PER-OPERATIVE
CHOLANGIOGRAPH
28
Rt HEPATIC
DUCT
Lt HEPATIC
DUCT
PER-OPERATIVE
CHOLEDOCHOSCOPE
29
STONE IN COMMON
HEPATIC DUCT
T-TUBE
T-TUBE
CHOLANGIOGRAM
30
CONGENITAL ANOMALIES OF
THE GALL BLADDER AND BILE
DUCTS
1. ANOMALIES OF THE GALL BLADDERABSENCE
PHRYGIAN CAP (HAT OF THE PEOPLE
OF PHRYGIA IN ANCIENT ASIA MINOR)
(FRENCH REVOLUTION LIBERTE CAP)
FLOATING GALL BLADDER—TORTION
DOUBLE GALL BLADDER
31
2. ANOMALIES OF THE DUCTSABSENCE
ATRESIA
CONGENITAL DILATATION OF
INTRAHEPATIC DUCTS
CHOLEDOCHAL CYST
LOW INSERTION OF CYSTIC DUCT
ACCESSORY CHOLECYSTOHEPATIC
DUCT
32
3. ANOMALIES OF THE ARTERIESRT HEPATIC ARTERY AND OR CYSTIC
ARTERY CROSS IN FRONT OF THE
CHD
HEPATIC ARTERY TAKE A TORTOUS
COARSE IN FRONT OF THE ORIGIN OF
THE CYSTIC DUCT
RT HEPATIC ARTERY IS TORTOUS
AND THE CYSTIC ARTERY IS SHORT
(CATERPILLAR TURN)
ACCESSORY CYSTIC ARTERY
33
34
GALL STONES
(CHOLELITHIASIS)
1. MIXED STONES- 90%, CHOLESTEROL
IS THE MAJOR COMPONENT, Ca
CARBONATE, Ca PHOSPHATE, Ca
PALMITATE AND PROTEIN (USUALLY
MULTIPLE AND FACETED)
2. CHOLESTEROL STONES(CHOLESTEROL SOLITAIRE)
3. PIGMENT STONES- (SMALL, BLACK,
MULTIPLE)
35
MIXED STONES
36
MIXED
STONES
37
CHOLESTEROL STONES
38
PIGMENT
STONES
39
LIMEY BILE- OCCUR WHEN THERE IS
GRADUAL OBSTRUCTION TO THE
CYSTIC DUCT OR THE CBD (CHRONIC
PANCREATITIS, CA PANCREAS)
THE GALL BLADDER WILL BE OPAQUE
IN A PLAIN X-RAY (FILLED BY Ca
CARBONATE AND Ca PHOSPHATE)
WHICH IS THE COMPONENTS OF
TOOTH PASTE
40
CHOLESTEROL IS HELD IN SOLUTION
BY THE DETRERGENT EFFECT OF
BILE SALTS AND PHOSPHOLIPID
(LECITHINE)TO FORM MICELLES.
ANY CHANGE IN THE EQUILIBRIUM
BETWEEN THESE THREE ELEMENTS
WILL LEAD TO GALL STONE
FORMATION
41
HYDROPLYLIC END
HYDROPHOBIC
END
(CHOLESTEROL)
BILE SALT MICELLE
42
PATHOGENESIS OF GALL
STONE FORMATION
1. METABOLIC- INCREASE CHOLESTEROL
LEVEL IN BILE(SUPERSATURATED OR
LITHOGENIC BILE), WITH AGE, FEMALE (
CONTRCEPTIVE PILLS), OBESITY,
PATIENTS ON CLOFIBRATE
BILE SALTS DECREASE BY INTERRUPTION OF
ENTERO-HEPATIC CIRCULATION( ILEAL
DISEASSE, RESECTION, BYPASS
SURGERY, CHOLESTYRAMINE)
ESTROGEN DECREASE CONCENTRATION OF
BILE SALT IN THE BILE(CCP)
43
CHOLESTEROL
SOLUBILITY
STATUS
44
2. INFECTION- NIDUS
3. BILE STASIS- GALL BLADDER
CONTRACTILITY DECREASE IN
PREGNANCY, BY ESTROGEN(CCP),
AFTER TRUNCAL VAGOTOMY,
PATIENTS ON TPN ( LACK OF GOOD
ORAL INTAKE) CAUSE DECREASE IN
CHOLYCYSTOKININ SECRETION
45
4. PIGMENT STONES OCCUR WITH
HEMOLYSIS( HEREDITARY
SPHEROCYTOSIS, SICKLE CELL ANEMIA,
THALASSEMIA, MALARIA)
WHERE BILIRUBIN PRODUCTION WILL
INCREASE.
PIGMENT STONES ALSO INCEASE WITH
BENIGN AND MALIGNANT STRICTURES AND
WITH PARASITE INFESTATION OF THE
BILIARY DUCTS( ASCARIS LUMBRICOIDES,
CHLONORCHIS SINENSIS)
46
INCIDENCE OF GALL STONES
FAT, FERTILE, FLATULENT, FEMALE,
FIFTY- IS THE USUAL SUFFERER OF
GALL STONES
IT CAN OCCUR AT ANY AGE AND IN
BOTH SEXES
TOW THIRD ARE ASYMPTOMATIC
SAINT’S TRIAD- GALL STONES
DIVERTICULOSIS
HIATUS HERNIA
47
COMPLICATIONS OF GALL
STONES
1.IN THE GB- SILENT( NO INDICATION FOR OPERATION)
CH CHOLECYSTITIS
AC CHOLECYSTITIS
GANGRENE
PERFORATION
EMPYEMA
MUCOCELE
CARCINOMA
2. IN THE BILE DUCTSOBSTRUCTIVE JAUNDICE
CHOLANGITIS
ACUTE PANCREATITIS
3. IN THE INTESTINEACUTE INTESTINAL OBSTRUCTION (GALL STONE ILEUS)
48
CHRONIC CALCULOUS
CHOLECYSTITIS
THICK, FIBROTIC WALL, BACTERIA
ISOLATED IN LESS THAN 30% OF
CASES FROM THE BILE AND
SUGGESTS A CHEMICAL IRRITANTS IN
THE BILE RATHER THAN BACTERIAL
AS A CAUSE IN THE OTHER CASES
49
CHRONIC
CHOLECYSTITIS
50
SIGNS AND SYMPTOMS
Rt HYPOCHONDRIAL PAINDISCOMFORT TO EXCRUTIATING PAIN(BILIARY
COLIC)
RIADITES TO THE Rt SHOULDER
PRESIPITATED BY FATTY MEAL
ASSOCIATED BY NAUSEA AND VOMITING
TENDERNESS IN THE Rt HYPOCHONDRIUM
MURPHY’S SIGN MAY BE POSITIVE
(IF PAIN LASTS MORE THAN 12 HOURS, TEPERATURE
INCREASE, AND WBC INCREASE, CONSIDER THE
DIAGNOSIS OF AC CHOLECYSTITIS)
51
DIAGNOSIS
ULTRASONOGRAPHY IS USUALLY THE ONLY
INVESTIGATION REQUIRED
TREATMENT
ANALGESICS INCLUDING OPIATES (SIMULTANEOUS
INJECTION OF HYOSCINE BUTYLBROMIDE IS
NEEDED TO ENCOUNTER THE EFFECT OF OPIATES
ON THE SPHINCTER OF ODDI)
ANTIEMETICS
LOW FAT DIET UNTIL-----CHOLECYSTECTOMY
(DISSOLUTION OF GALL STONES HAS NO LONGER A
ROLE IN THE TREATMENT OF GALL STONES)
52
ACUTE CALCULOUS
CHOLECYSTITIS
THE GALL BLADDER OFTEN ALREADY
AFFECTED BY CHRONIC CHOLECYSTITIS
95% OF CASES THE STON IS IMPACTED IN
THE HARTMANN’S POUCH OR
OBSTRUCTING THE CYSTIC DUCT
MICRO-ORGANISMS CAN BE ISOLATED IN
MOST OF THE CASES FROM THE BILE OR
GB WALL
(E.COLI, STRTEP.FECALIS, BACTEROIDES,
RARELY CLOSTRIDIA AND TYPHOID)
53
ACUTE CHOLECYSTITIS
54
SEQUELAE OF ACUTE
CHOLECYSTITIS
1. RESOLUTION- BY BACK SLIPPING OF THE
STONE(MUCOUS MEMBRANE LIFTING),
AND RELEASE OF MUCOID OR
MUCOPURULENT CONTENT
2. EMPYEMA(PYOCELE)- WHEN THE
OBSTRUCTION PERSISTS
3. PERFORATION- LEADS TO LOCAL ABSCESS
OR GENERALIZED PERITONITIS
(FUNDUS AND NECK)
55
SIGNS AND SYMPTOMS
PAIN
NAUSEA AND VOMITING
PYREXIA(38C OR MORE)
TENDERNESS
MURPHY’S SIGN
PALPABLE GB
BOAS’S SIGN
56
DIAGNOSIS
ULTRASONOGRAPHY
DIFFERENTIAL DIAGNOSIS
APPENDICITIS
PERFORATED PEPTIC ULCER
ACUTE PANCREATITIS
ACUTE PYELONEPHRITIS (Rt)
MYOCARDIAL INFARCTION
BASAL PNEUMONIA (Rt)
57
TREATMENT
1.CONSERVATIVE TREATMENT FOLLOWED BY
CHOLYCYSTECTOMY
(90% OF CASES WILL SUBSIDE) BY –
A. NASOGASTRIC ASPIRATION
B. I V FLUID
C. ANALGESIA
D. ANTIBIOTICS (AGAINST GRAM -NEGATIVE
AEROBES)
C. INTERVAL CHOLECYSTECTOMY (4-6 MONTHS)
AFTER THE ACUTE EPISODE HAS RESOLVED
58
2. EARLY CHOLECYSTECTOMY –
SHOULD BE DONE WITH IN 72 HOURS
FROM THE ONSET OF ACUTE
SYMPTOMS (GOLDEN PEROID)
3. EMERGENCY CHOLECYSTECTOMYDONE AT ANY TIME NEEDED, WHEN
DIAGNOSIS IS DOUBTFUL(ACUTE
HIGH RETROCAECAL APPENDICITIS)
OR WHEN THERE IS PERFORATION
59
MUCOCELE AND EMPYEMA
MUCOCELE- THE BILE IS ABSORBED
AND REPLACED BY MUCIN
SECRETION(STERILE BLADDER NECK
OBSTRUCTION BY A STONE OR
MALIGNANCY)
EMPYEMA- GALL BLADDER FILLED
WITH PUS EITHER AS A SEQUELE OF
AC CHOLECYSTITIS OR A MUCOCELE
BECOME INFECTED
60
MUCOCELE OF THE GB
61
MUCOCELE OF THE GB WITH STONE IN THE HART.
POUCH
62
ACALCULOUS CHOLECYSTITIS
CHOLECYSTOSIS
NOT UNCOMMON GROUP OF CHRONIC INFLAMATION
AND HYPERPLASIA OF ALL TISSUE ELEMENT1. CHOLESTEROSIS(STRAWBERRY GB)- WITH A
STRAWBERRY INTERIOR AND YELLOW SPECKS
(SEEDS OF CHOLESTEROL CRYSTALS)
2. CHOLESTEROL POLYPS- MUCH LESS NUMEROUS
AND LARGER THAN THE YELLOW SEEDS
3. CHOLYCYSTITIS GLANDULARIS PROLIFERANS(POLYPS, ADENOMYOMATOSIS, INTRAMURAL
DIVERTICULOSIS)
63
NEW TECHNIQUES FOR GALL
STONES
1. LITHOTRIPSY- EXTRACORPORIAL
SHOCK WAVE
2. PERCUTANEOUS
CHOLECYSTOLITHOTOMY- USING A
NEPHROSCOPE UNDER US
CONTROL
3. LAPAROSCOPIC
CHOLECYSTECTOMY
4. MINICHOLECYSTECTOMY
64
INDICATIONS FOR
CHOLEDOCHOTOMY AT
CHOLECYSTECTOMY
1. STONES FELT IN THE CBD
2. THERE IS JAUNDICE OR HISTORY OF
JAUNDICE OR RIGOR(CHOLANGITIS)
3. DILATED CBD(10mm OR MORE)
4. ABNORMAL LFT IN PARTICULAR A
RAISED ALKALINE PHOSPHATASE
5. PRESENCE OF SINGLE FACTED
STONE IN THE GALL BLADDER
65
POSTCHOLECYSTECTOMY
SNDROME
PERSISTENCE OF SYMPTOMS AFTER GALL BLADDER
REMOVAL DUE TO1. DISEASES OTHER THAN THE BILIARY
TRACT(HIATUS HERNIA, PEPTIC ULCER,
PANCREATITIS, DIVERTICULITIS OR IRRITABLE
BOWWEL SYNDROME)
2. BILIARY CAUSES- A- RETAINED STONE IN THE
CBD
B- LONG CYSTIC DUCT STUMP IS
LEFT
C- CBD OPERATIVE DAMAGE
(STRICTURE FORMATION)
66
STONES IN THE COMMON BILE
DUCT
EITHER SECONDARY DUE TO PASSAGE OF
STONES FROM THE GALL BLADDER OR
RARELY PRIMARY STONES OCCUR WITH
IFESTATION OF THE BILIARY TREE BY
ASCARIS LUMBRICOIDES AND CLONORCHIS
SINUNSIS.
THESE STONES EITHER LEAD TO
OBSTRUCTION OR
INFECTION)CHOLANGITIS)
67
SIGNS AND SYMPTOMS
ASYMPTYMATIC
PAIN
JAUNDICE (INTERMITTENT OR
PERSISTENT)(DARK URINE,PALE STOOL,
PRURITIS)
FEVER AND RIGOR (CHOLANGITIS)
(CHARCOT’S TRIAD)
TENDERNESS
IMPALPABLE GB (FIBROTIC AND INCOMPLETE
OBSTRUCTION)
{ COURVOISIER’S LAW }
68
DIFFERENTIAL DIAGNOSIS
PANCREATIC CA
VIRAL HEPATITIS
DRUG INDUCES
PRIMARY BILIARY CIRRHOSIS
US, ERCP, PTC
DIAGNOSIS
COMPLICTIONS
BILIARY CIRRHOSIS
SUPPURATIVE CHOLANGITIS (LIVER ABSCESSES,
SEPTICAEMIA)
69
PRE-OPERATIVE MANAGEMENT
OF OBSTRUCTIVE JAUNDICE
1. HIGH INTAKE OF GLUCOSE (BUILD UP
LIVER GLYCOGEN STORE)
2. VITAMIN K (FAT SOLUBLE), 10mg IV OR
IM
3. ANTIBIOTICS (BROAD SPECTURUM)
4. HYDRATION (PEVENT RENAL FAILURE)
(5% DEXTROSE TO ENSURE 30
ml/HOUR URINE FLOW)
70
SURGICAL PROCDURES
1. ENDOSCOPIC PAPILLOTOMY (DORMIA BASKET,
BALLOON CATHETER)(STENT TO RELIEVE
SYMPTOMS)
2. PERCUTANEOUS REMOVAL OF STONES BY
BURHENNE METHOD (T- TUBE LEFT FOR SIX
WEEKS AND THEN REMOVED, DILATION OF THE
MATURE TRACT, STEERABLE CATHETER, AND
THEN STONE BASKET)
3. PERCUTANEOUS BILIARY DRAINAGE (PTC), IN THE
VERY ILL
4. SUPRADUODENAL CHOLEDOCHOTOMY WITH OR
WITH OUT TRANSDUODENAL SPHINCTEROTOMY
OR CHOLEDOCHODUODENOSTOMY
71
EXPLORATION OF THE CBD
72
DILATED CBD
DORMIA BASKET
ERCP
73
STRICTURE OF THE CBD
BENIGN– POSTOPERATIVE 80%
INFLAMMATORY
MALIGNANT
POSTOPERATIVE STRICTURE
DUE TO TEQUNICHAL ERROR DURING
CHOLECYSTECTOMY( 15% ONLY
RECOGNIZED DURING SURGERY)
74
CAUSES- 1. BLIND HAEMOSTAT APPLICATION
IN AN EFFORT TO STOP UNEXPECTED
BLEEDING ( PRINGLE’S MANOEUVRE )
2. TOO MUCH TRACTION ON THE GB
3. FAILURE TO IDENTIFY CALOT’S
TRIANGLE(MUCH INFLAMMATION)
4. IGNORANCE OF THE ANATOMICAL
ANOMALIES
5. LACERATION OF CBD (DURING
EXPLORATION)
PRESENTED EITHER AS A- PROFUSE BILIARY
FISTULA OR BILIARY PERITONITIS (DRIN OR
NO DRAIN)
B- DEEPENING
JAUNDICE (BY SUSEQUENT FIBROSIS)
75
INVESTIGATION
US, T-TUBE CHOLANGIOGRPHY, ERCP, PTC
TREATMENT
IMMEDIATE ROUX EN Y CHOLEDOCHOJEJUNOSTOMY
IS THE BEST FOR BENIGN STRICTURES AND
COMPLETE CBD TRANSECTION
IN DEBILITATING PATIENTS, AN EXTERNAL DRAINAGE
CATHETER OR BALLOON DILATION AND A STENT
FOR MALIGNANT STRICTURES
CHOLECYSTOJEJUNOSTOMY
CHOLEDOCHOJEJUNOSTOMY
STENTING
76
CARCINOMA OF THE BG
IT IS RARE AND FOUND IN LESS THAN 1% OF
GB OPERATIONS, GALL STONES FOUND IN
OVER 90% OF CASES, PATIENTS USUALLY
IN THEIR 70S, FEMALE:MALE RATIO OF 5:1
THE USUAL TYPE IS SCIRRHOUS CA, BUT
SEQUAMOUS OR MIXED SEQUAMOUSADENOCARCINOMA MAY BE FOUND
SPREAD BY DIRECT INVASION OF THE LIVER
AND TO THE PORTA HEPATIS
DISTANT METASTASES ARE UNCOMMON
77
SIGNS AND SYMOTOMS
IT MAY BE FOUND DURING
CHOLECYSTECTOMY
MASS DUE TO THE TUMOUR OR
OBSTRUCTION OF CYSTIC DUCT
WHICH LEADS TO MUCOCELE
CHOLECYSTITIS(OBSTRUCTION OF THE
CYSTIC DUCT)
JAUNDICE IN MORE THAN 50% OF
CASES
78
TREATMENT
RESECTION OF THE GB WITH THE
ADGACENT PART OF THE LIVER
PALLATION TO RELIEVE
JAUNDICE(STENT)
5 - YEAR SURVIVAL RATE IS 2-5%, BUT
IF THE TUMOUR FOUND DURING
CHOLECYSTECTOMY, IT WILL REACH
MORE THAN 50%
79
CHOLANGIOCARCINOMA
(BILE DUCT CARCINOMA)
IT IS MORE COMMON THAN GB
CARCINOMA
STONES PRESENT IN LESS THAN 30%
OF CASES
MALE ARE SLIGHTLY MORE THAN
FEMALE
USUALLY ADENOCARCINOMA
THE PATIENTS ARE OLD AND
PRESENTS LATER
80
TRATMENT
HILAR LESIONS RARELY RESECTABLE,
AND MAY NEED EXTERNAL DRAINAGE
FOLLOWED BY RADIOTHERAPY
TUMOURS OF THE LOWER END MAY BE
TREATED BY WHIPPLE’S OPERATION,
OR STENTING
81
BILIARY FISTULAS
EXTERNAL AND INTERNAL
1 .EXTERNAL FISTULAS- NEARLY ALL FOLLOW BILIARY
OPERATION ON THE BILIARY TRACT OR DUODENUM, FROM
INJURY OR LEAKINK ANASTOMOSIS
IT MAY PERSIST IF THERE IS DISTAL OBSTRUCTION
CAN BE ASSESSED BY SINOGRAM OR ERCP
2. INTERNAL FISTULAS- WHEN A GALL STONE ULCERATE
THROUGH THE GB INTO THE STOMACH, DUODENUM, OR
COLON
IT MAY CAUSE AIR TO BE SEEN IN PLAIN RADIOGRAPH
IF LARGE ENOUGH, IT MAY LEAD TO SMALL BOWEL
OBSTRUCTION
OBSTRUCTION OF THE COLON GIVES THE SUSPITION OF
UNDERLYING CARCINOMA CAUSING NARROWING OF THE
LUMEN
82
LAPAROSCOPIC
CHOLECYSTECTOMY
THE INDICTION ARE THE SAME AS FOR OPEN
CHOLECYSTECTOMY
ADVANTAGES
1. LESS POST-OPERATIVE PAIN
2. SMALLER INCISIONS
3. BETTER COSMESIS
4. SHORTER HOSPITALIZATION
5. EARLIER RETURN TO FULL ACTIVITY
6. DECREASED TOTAL COSTS
83
DISADVANTAGES
1. LACK OF DEPTH PERCEPTION
2. VIEW IS CONTROLLED BY CAMERA
3. MORE DIFFICULT TO CNTROL BLEEDING
4. DECREASD TACTILE DISCRIMINATION
5. POTENTIAL CO2 INSUFFLATION
COMPLICATIONS
6. ADHESIONS AND INFLAMMATION LIMIT ITS
USE
7. SLIGHT INCREASE IN BILE DUCT INJURY
84
COMPLICATIONS OF LC
A. GENERAL- 1. HEMORRHAGE
2. BILE DUCT INJURY
3. BILE LEAK
4. RETAINED STONES
5. PANCREATITIS
6. WOUND INFECTION
85
B. PNEUMOPERITONEUM RELATED
1. C02 EMBOLISM
2. VASO-VAGAL RFLEX
3. CARDIAC ARRYTHMIAS
4. HYPERCARBIC
ACIDOSIS
C. TROCAR RELATED
1. ABDOMINAL WALL
BLEEDING, HEMATOMA
2. VISCERAL INJURY
3. VASCULAR INJURY
86
LC THEATRE
87
VERES NEEDLE
88
TELESCOPE
89
DISSECTING CALOT’S
TRIANGLE
90
GB DISSEC. BY
DIATHERMY
91
GB RETRIEVAL BAG
92