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Intuitive CAST > Cholecystectomy > Flashcards

Cholecystectomy Flashcards

1
Q

What is a Cholecystectomy

A

A surgical procedure to remove the gallbladder

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2
Q

What is the primary function of the gallbladder

A

store and concentrate a fluid called bile

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3
Q

What is Bile

A

A fluid that helps break down fat from food in your intestines

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4
Q

Why is a Cholecystectomy performed?

A

hardened deposits of digestive fluid can be formed in the gallbladder - removal of gallbladder is a common way to treat that

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5
Q

What must be retracted to gain access to the gallbladder

A

Liver

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6
Q

What quadrant is the gallbladder in?

A

RUP - right upper quadrant

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7
Q

What connects the liver and the gallbladder

A

Biliary tract

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8
Q

What is the role of the pancreas

A

regulating the level of sugar in the blood

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9
Q

define Cystic Plate

A

a white fibrous tissue that separates the gallbladder from the liver. Also known as the liver bed.

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10
Q

What two structures need to be clipped and ligated

A

cystic duct and the cystic artery

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11
Q

What is the Sphincter of Oddi

A

a muscular valve that opens and closes to allow digestive juices to enter the duodenum

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12
Q

What organ produces Bile

A

Liver

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13
Q

Where is bile released?

A

Into the small intestines

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14
Q

What is the pathway of Bile

A

Bile is released from the liver via the R&L hepatic duct ( which join to form the common hepatic duct)
The common hepatic ducts then joins with the cystic duct - to form the common bile duct
The Common bile duct then merges with the pancreatic duct- which delivers pancreatic secretions to the bile mixture
Bile enters the duodenum through the sphincter of Oddi

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15
Q
A
  1. Bile ducts
  2. Intrahepatic bile ducts,
  3. Left and right hepatic ducts,
  4. Common hepatic duct,
  5. Cystic duct,
  6. Common bile duct,
  7. Ampulla of Vater,
  8. Major duodenal papilla
  9. Gallbladder.
    10–11. Right and left lobes of liver.
  10. Spleen.
  11. Esophagus.
  12. Stomach.
  13. Pancreas: 16. Accessory pancreatic duct, 17. Pancreatic duct.
  14. Small intestine: 19. Duodenum, 20. Jejunum
    21–22. Right and left kidneys.
    The front border of the liver has been lifted up (brown arrow).[1]
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16
Q

What does CCK (cholecystokinin) stand for

A

to move the bag of bile

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17
Q

What are the two effects the CCK has?

A
  1. Relaxation of the sphincter of Oddi (to open it)
  2. stimulation of gallbladder contraction to release stored bile
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18
Q

What happens when the sphincter of Oddi is open

A

Bile can flow into the duedenum

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19
Q

What happens when the sphincter of oddi is closed

A

bile is forced back up through the common bile duct and cystic duct into the gallbladder, where it is stored and concentrated for later release

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20
Q

Where is bile stored when the gallbladder has been removed?

A

The liver makes bile and it drains through the common hepatic ducts down the common bile duct. It’s stored in the liver

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21
Q

Aberrant bile ducts - why is it a problem

A
  • right hepatic junction
  • fibrous adhestions
  • Cystic duct in front/behind
  • no cystic duct

Can make dissection and identification difficult

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22
Q

What can cause fibrous adhesions

A

Previous surgery
inflammation

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23
Q

What is the problem with fibrous adhesions

A

can fuse the cystic duct and the common bile duct together

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24
Q

What is the problem with a very sort cystic duct

A

makes dissection and ligation difficult

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25
Q

What is the problem with a hepatic duct in front or behind?

A

Can make it very difficult to identify

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26
Q

First steps in a cholecystectomy

A

Liver needs to be retracted by grabbing the fundus of the gallbladder and retracting anteriorly

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27
Q

After the liver has been retracted, what happens

A

The peritoneum covering the gallbladder will need to be dissected, in order to expose the critical structures of the gallbladder

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28
Q

What is the fundus

A

the most distal part of the gallbladder

29
Q

What is the infundibulum

A

Funnel - Where the body of the gallbladder narrows into the neck of the GB

30
Q

Hartmann’s pouch

A

An area within the infundibulum where gallstones may accumulate

31
Q

What structures make up Calot’s Triangle

A

Cystic duct
Common hepatic duct
inferior edge of the liver bed

32
Q

How do surgeons obtain the critical view of safety

A
  1. Visualize the liver bed
  2. Identify exactly two structures entering the GB
    • Cystic duct
    • cystic artery
33
Q

What can firefly do during a cholecystectomy

A

Assist in identification of critical anatomy

34
Q

What are the 3 most common signs and symptoms of Biliary disease

A
  1. biliary colic: RUQ pain approximately 30 minutes following a meal, typically secondary to gallstones
  2. fever
  3. Jaundice: yellowing of skin and the white outer layer of the eyeball
35
Q

What are the two types of:

Gallstone disease

A

Cholelithiasis - Formation of gallstones in the gallbladder
Choledocholithiasis - gallstones in the common bile duct

36
Q

Which requires immediate treatment?

Cholelithiasis or Choledocholithiasis

A

Choledocholithiasis - gallstones in the common bile duct

Acute Cholecystitis - inflammation of the GB, secondary to gallstones

Bile delivery to the digestive system will be obstructed

37
Q

What is it, and when is it performed?

Endoscopic Retrograde Cholangiopancreatography (ERCP)

A
  1. Used to better visualize the ductal anatomy and diagnose ductal disease
  2. A flexible tube with an endoscope is inserted throught the mouth and into the duodenum. When access to the biliary tract is gained, a contrast medium is injected into the biliary and pancreatic ducts for radiologic visualization
38
Q

Benign Billiary Disease

Gallstone disease
- Cholelithiasis
- Choledocholithiasis

Description, Symptoms, Timing of surgery

A

Description: Presence of gallstones in the gallbladder(cholelithiasis) or in the common bile duct (choledocholithasis)
Symptoms: RUQ Pain, acute nausea and vomiting, pain after fatty meal
surgery: elective/planned

39
Q

Benign Billiary Disease

Cholecystitis

Description, symptoms, timing of surgery

A

Description: chronic, low grade inflammation
Symptoms: pain in the right side of the rib cage, vomitting and/or jaundice
Surgery: elective /planned

40
Q

Benign Biliary disease

Acute Cholecystitis

Description, symptoms, timing of surgery

A

Description: acute inflammation of the GB, usually secondary to the gallstone blockage of bile duct
Symptoms: severe RUQ pain and vomiting
Timing: Emergent

41
Q

Benign biliary disease

Gallstone Pancreatitis

Description, symptoms, timing of surgery

A

D: Stone causing inflammation in pancrease
S: Upper abdominal pain that worsens after eating
T: Elective (patient initially admitted for pancreatitis to reslove, cholecystectomy performed during same admission)

42
Q

Benign biliary disease

Biliary dyskinesia

Description, symptoms, timing of surgery

A

D: Dysfunction ofthe gallbladder or sphincter of oddi, causing pain
S: sharp pain, intermitten cramps located under the right ribs
T: elective / planned

43
Q

Define

Classical Injury / Partial injury

A

C: an inadvertent injury or ligation of the common bile duct during surgery
P: can sometimes be repaired using suture, but a more severe injury or complete transection will require a hepaticojejuncostomy.

undiagnosed injury can lead to hepatic failure and even death

44
Q

What is it,

Hepaticojejunostomy

A

A complex surgery and invasive procedure that is commonly done through open surgery by a hepatobiliary specialist.

During this procedure, the biliary system is reconnected to the small intestine by attaching the common hepatic duct to the jejunum

45
Q

Critical for Early cases

Ideal Patient selection

6 markers

A
  • Good Performance status - ASA1-11
  • Non-obese patients (BMI<30)
  • No previous upper abdominal surgery
  • Age 18-80
  • Symptoms consisten with GB disease (e.g. biliary colic)
  • Patient must be a suitable candidates for laparoscopic cholecystectomy
46
Q

Example - Dr. Canfield.

Operating Room Configuration

Patient cart, anesthesiologist, patient-side ast, surgeon, vision cart

A

Patient cart on the patients lefts
Anesthesiologist with direct access to patient
Patient-side assist on patient’s right side, with clear view of a monitor
surgeon with direct line of sight to patient
Vision cart touchscreen accessible to circulating nurse

47
Q

Clinical Application

Firefly for Biliary duct identification

What is it used for? Benefits?

A

After ICG is taken up by the blood plasma, it is secreted into the bile by the liver. Use Firefly to identify extrahepatic biliary ducts. Identification of aberrant ducts, w/o the use of cholangiogram. This may decrease the concern of misidentification of the biliary anatomy

48
Q

Technique

Firefly for biliary duct identification

What is ICG, When should you administer?

A

Reconstitute 25mg of Indocyanine Green (ICG) with 10ml sterile water to obtain a 2.5 mg/ml solution.
Inject 1.5-2.0 ml ICG in peripheral IV
Administer at lease 45 minutes prior to start of case

49
Q

Length of time from injection to flourensense.

Firefly for Cystic Artery Identification

A

Flourescense is seen approx. 30-60 seconds after injection

1.5mL ICG peripheral IV, immediately followed by a 10mL saline flush

50
Q

Patient Positioning and Preparation

A

Supine, secure the patient to the table using a strap across the things
Place patient in reverse trendelemburg ~ 10 degrees and lower the table all the way down
Tilt the bed 10 degrees to elevate the patients right side to aid in visualization
sterile prep the abdomen

51
Q

Port Placement

A

Place initial endoscope port (Arm 3) approximately 2cm superior to the umbilicus. The other ports will be placed on a horizontal line with port 3
- 4, left lateral, 10cm away from 3
- 2, Right lateral, 10cm away from 3
- 1, right lateral, 10 cm away from 3

52
Q

System Deployment & Docking

A

Select “Upper Abdomincal” under anatomy on the helm touchpad.
Dock Arm 3 to the initial endoscope port
Insert the Endoscope (30 degree down) and target the approx. position of the cycstic duct
Align the endoschope arm with the endoscope port and target anatomy
Adjust arms to ensure patient clearance

53
Q

Broad overview

Steps for a Cholecystectomy

by Dr. Canfield

A
  1. Once docked, the assist and surgeon will grasp the GB to create exposure
  2. Calot’s triangle will then be dissected to gain the CVS(critical view of safety)
  3. This is when the surgeon could utilize firefly or elect to complete a cholangiogram
  4. Once anatomy has been identified, the cystic duct and artery will be ligated and divided.
  5. The GB is then dissected off the liver bed and removed from patient
54
Q

Core instruments

Instrument Guide

A
  • Hot shears (monopolar curved scissors)
  • Force bipolar
  • 2x Medium-large clip applier
  • ProGraps Forceps
55
Q

Optional Instruments

Instrument Guide

A
  • ProGrasp Forceps
  • Cadiere Forceps
  • Fenestrated Bipolar Forceps
  • Permanent cautery Hook
  • Endowrist Suction Irrigator
56
Q

3rd Party Ancillary Supplies

Instrument Guide

A

Laparoscopic Graspers
Laparoscopic Scissors
EndoBag for specimen removal (if required)

57
Q

What the instruments are used for

Hot shears, force bipolar, ProGrasp, Large Clip Appliers x2

A

Hot shears: dissection and cold cut
Force bipolar: used when moving dense tissue or grasping on tissue that has tension by switching to “strong mode” for more grasping and retracting strength
ProGrasp: retracting GB toward the patient right shoulder
Clip Appliers: Ligate the cystic duct and cystic artery - use two for efficiency

58
Q

Step 1

Initial exposure

A
  • Take down adhesions (adhesiolysis)
  • Grasp and retract the GB anteriorly to expose the cystic pedicle - Using arm 2 may improve triangulation with working arm 1&4
59
Q

Define

Adhesiolysis

A

The dissection of adhesions or scar tissue

60
Q

Step 2

Dissection of Calot’s triangle and the Critical View of Safety

What are the landmarks of Calots triangle, Structures entering the GB

A
  1. Retract the infundibulum to expose the landmarks of Calot’s triangle: Inferior surface of the liver, cystic duct, common hepatic duct
  2. Incise the peritoneum close to the GB neck
  3. Carefully dissect the structures within Calot’s triangle
  4. After completing dissection of Calots triangle, obtain CVS by dissecting the infundibulum of the cystic plate
  5. Confirm that the only structures entering the GB are: Cystic duct, cystic artery
  6. Avoid ligating the common bile duct!
61
Q

Step 3

Confirmation with Firefly Flourescense Imaging

A

Ductal: identify extrahepatic biliary ducts and to examine the GB for potential accessory ducts
Arterial: confirm cystic artery identification and to reveal aberrant vessels
- This step requires and additional administration of 1.5mL ICG via a peripheral IV followed by a saline flush
- This can be observed approx. 1 min after ICG administered

62
Q

Define, what is it used for

Cholangiography

A

indications
- Part of a routine practice
- unclear ductal anatomy
- possibility of stone in common bile duct

Overview
- Introduce angiocatheter percutaneously
- Catheter is instrted into the cystic duct
- C-Arm is positioned over patient
- Images are captured to hightlight biliary anatomy
- Not in real time

Firefly is not able to see gallstones w/in the anatomy

63
Q

Step 4

Ligation and Division of the cystic Duct and Artery

A
  • Using large clip appliers, ligate the cystic duct and cystic artery
  • Place 2 clips proximally and one clip distally on the cystic duct
  • Place one clip proximally and one clip distally is typically sufficient for the cystic artery
  • Divide the cystic duct and cystic artery using cold cutting with the monopolar curved scissors

place 2 because there is minimal/no clotting to stop blood flow

64
Q

Can you use energy around the clips

A

Not recommended, as it could shrink the tissue and cause the clip to be less effective

65
Q

Proximally

A

towards the patient side

66
Q

Step 5

Cystic Plate Dissection

A
  • Dissect the GB off the cystic plate using catuery
  • Start the dissection att he GB neck, work toward the fundus
  • Dissect until the GB is released
67
Q

Difference

Leakage vs Spillage

A

leakage - the clip is not on correctly and the bile is leaking into
Spillage - bile that flows out, not much of a issue.

68
Q

Step 6

Specimen Removal

A
  • Inspect the cystic plate for evidence of bleeding or bile leakage
  • Prepare for removal of the specimen through the umbilicus
  • Introduce a specimen bag into abdomen
  • If necessary, irrigate the surgical field using the suction irrigator
  • Undock, and remove all ports
  • Remove the specimen bag

Intuitive CAST (8 decks)

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