Biliary Tract Surgery Lecture Powerpoint

Question 1

Gallbladder anatomy review

Answer 1

Gallbladder empties into cystic duct, liver empties into common hepatic duct, the two combine into the common bile duct, combine with the pancreatic duct and empty at the ampulla of vater at the spinchter of oddi into the duodenum

Question 2

The triangle of calot significance and borders

Answer 2

• cystic artery is found within the triangle

- cystic duct, common hepatic duct, and edge of liver make up the borders

Question 3

Indications for cholecystectomy (5)

Answer 3

• biliary colic
• acute cholecystitis
• chronic cholecystitis
• complications of gallstone disease (choledocholithiasis and such)
• dysfunctional gallbladder (theorized to not be real, more valid if responds to cholecystokinin reproducability test)

Question 4

Pre op prep for cholecystectomy (4)

Answer 4

• antibiotics
• DVT prophylaxis (compression stockings and maybe lovenox)
• patient understanding of possible need to convert to open procedure
• cardiac clearance

Question 5

When does a cholecystectomy have to be converted to an open one? (4)

Answer 5

• cannot identify landmarks or structures
• marked inflammation with adhesions of surrounding viscera
• bleeding
• bile duct injury

Question 6

Complications of cholecystectomy (6)

Answer 6

• bile duct injury
• perforation of major vessel
• perforation of small or large bowel
• bile leak
• infection
• CO2 absorption and potential pneumothorax

Question 7

Cholecystostomy definition and indications (4)

Answer 7

• Percutaneous or open tubing of the gall bladder under CT guidance
• indicated in patients with acute cholecystits, acute acalculus cholecystitis, obstructive cholangitis (jaundice), or in patients who will not tolerate cholecystectomy

Question 8

Choledocholithiasis diagnosis (2)

Answer 8

• U/S

- ERCP (also therapeutic)

Question 9

Choledocholithiasis treatment options (2)

Answer 9

• ERCP
• surgery (common bile duct exploration, if stone impacted at the sphincter of oddi then can do choledochoduodenostomy bipass)

Question 10

Falciform ligament of the liver

Answer 10

Fibrous structure that connects the anterior liver to the ventral wall of the abdomen, located approx midline of the abdomen dividing “right” and “left” liver lobes, round ligament also known as ligamentum teres is a remnant of the umbilical vein that protrudes from the anterior free face of this ligament

Question 11

Indications for liver resection (5)

Answer 11

• primary liver neoplasm
• hepatic stick
• hemangioma (benign lesion but can rupture and bleed)
• carcinoma of the gallbladder
• severe trauma to liver that cannot be repaired

Question 12

You can remove __% of liver tissue and the patient will survive, the liver also regenerates and is the only solid organ to do so

Answer 12

80

Question 13

Preop for liver resection (5)

Answer 13

• maximize nutritional status (removal of glycogen stores occurs during resection
• normalize INR because liver produces a lot of proteins responsible for clotting cascade
• blood typing and crossmatching
• DVT prophylaxis
• antibiotics

Question 14

Blood typing screening vs crossmatching

Answer 14

Type and screen determines ABO and Rh and minor antigens vs crossmatch tests patients blood and serum against the donor to see if theres no compatibility issues with minor antigens, problematic as removes blood from use so an individual that needs it in a hurry can’t have it

Question 15

Liver lobes***

Answer 15

Left lobe of the liver is NOT left of the falciform, the left lobe vs right lobe anatomically speaking is based on where the hepatic arteries, ducts, and the portal veins go, the division is a line thru the gallbladder and the inferior vena cava, falciform divides lateral segment of left lobe from medial segment of left lobe, but doesn’t separate right lobe from left. There are 8 segments of the entire liver

Question 16

Segmental resection vs Left lateral segmentectomy vs left medial segmentectomy vs left lobectomy vs right lobectomy vs extended right lobectomy (trisegmentectomy)

Answer 16

Removal of one lobe in a wedge resection vs removal of the lobes left of the falciform ligament vs removal of the lobes part of the left liver but right of the falicform vs taking out the entire left lobe vs taking out the entire right lobe vs taking out the entire right lobe + the medial portion of the left lobe

Question 17

Complications of liver resection (3)

Answer 17

• Infection
• excessive bleeding
• hypoglycemia

Question 18

Indications for pancreatic surgery (4)

Answer 18

• neoplasm (exocrine, endocrine, in the duodenal exit)
• trauma
• chronic pancreatitis
• acute necrotizing pancreatitis

Question 19

Pancreatic surgery options (5)

Answer 19

• distal pancreatectomy (spleen side)
• pancreaticdudenectomy (whipple procedure)
• total pancreatectomy
• peustow procedure
• pancreatic head resection

Question 20

Pancreas blood supply (3)

Answer 20

• direct branches from splenic artery
• gastroduodenal artery
• pancreaticoduodenal artery

Question 21

Whipple procedure

Answer 21

-surgery involving hooking the jejunum to the pancreas(pancreatojejunostomy) followed by common bile duct attachment to jejunum (choledochojejunostmy) and the stomach attached as well (gastrojejunostomy) while removing the duodenum (can be done to try to preserve the pylorus to limit dumping syndrome

Question 22

Peustow procedure

Answer 22

Chronic pancreatitis surgical treatment involving distal pancreatectomy and opening of pancreatic duct and draining it into jejunum eliminating constrictures

Question 23

Pancreatic resection complications (4)

Answer 23

• anastamotic leak (need drains inserted until it seals off)
• infection
• pancreatic exocrine insufficiency resulting in malabsorption
• endocrine insufficiency making diabetes difficult to manage