cholelithiasis-lecture.pptx

Surgical lecture for cholelithiasis

1. Predisposing factors Obesity Female sex hormones – estrogen & OCPs Increasing age Pregnancy Drugs- octreotide, clofibrate High fat diet Diabetes mellitus

2. LITHOGENIC BILE Increase cholesterol- obesity,diet Decrease bile acids- OCPs,genetic factors,PBC,ileal disease,ileal resection Increase bilirubin- Hemolytic Anemia NUCLEATION Excess pronucleating factors-e.g. mucin Decreased anti- nucleating factors- e.g. Apolipoproteins STASIS OR HYPOMOTILITY OF GALL BLADDER OCPs Vagotomy Fasting Pregnancy Prolonged parenteral nutrition

3. Types of Gall stones Cholesterol stones – radiating crystal like appearance Mixed stones - Most common type of stones; contains cholesterol, calcium salts of phosphates and carbonates, palmitate ,proteins and are multiple faceted. Pigment stones - small, black or greenish black, multiple and often sludge like

4. Pigment stones Black pigment stones Most common Formed in gall bladder Made of Calcium bilirubinate,phosphate,bicarbona te Common in hemolytic disorders,cirrhosis Multiple , small & hard in consistency Brown pigment stones Rarely form in gall bladder Formed in bile duct Related to bile stasis & infected bile E.coli, Bacteroides

5. Clinical features More common in females Fat,fertile,forty,flatulent 10% Gallstones are RADIO-OPAQUE Asymptomatic in 10 to 20% cases Symptoms- Biliary colic- Right hypochondrium & epigastrium, radiating to chest,back & shoulder, severe , on & off, spasmodic, occurs within hours after meal,usually self limiting and recurring,precipitated by fatty meal. vomiting Fever Increased WBCs

6. MURPHY’s SIGN Patient winces in pain with catch of breath when inflamed gall bladder strikes palpating fingers on inspiration

7. Complications of Gall stones In Gall Bladder- Acute cholecystitis Chronic cholecystitis Empyema of gall bladder Mucocele gall bladder Perforation – leading to biliary peritonitis Gangrene of gall bladder Carcinoma In Bile duct- Obstructive jaundice Cholangitis Acute pancreatitis In Intestine- Acute intestinal obstruction

8. Management Investigations USG abdomen – posterior acoustic shadowing Plain X RAY abdomen LFT- Increased conjugated bilirubin Increased Alkaline Phosphate, GGT, 5’-Nucleotidase TL C

9. D/D of radio-opaque shadow on x-ray Renal stone Calcified 12 th rib tip Phlebolith Faecolith Calcified lymph node Renal cell Ca - calcification Calcified Adrenal tumor

10. Treatment Medical therapy- GALL STONE DISSOLUTION Ursodeoxycholic acid (UDCA) – with a functioning Gall bladder with stone less than 10 mm 10-15 mg/kg/day Pigment stones are non responsive to medical therapy

11. Surgical therapy Laparoscopic cholecystectomy is ideal. Open cholecystectomy is done if patient unfit for laparoscopy through Right Sub-costal(KOCHERS’s) incision. By Dr Aravind

12. Complete Surgical Removal of Gallbladder Most commonest abdominal surgery First described by Langenbuch in 1882 First endoscopic cholecystectomy was performed by Mühe of Böblingen, Germany in 1985 The National Institutes of Health (NIH) Consensus Development Conference in 1992 recognized Laproscopic Cholecystectomy as the new "gold standard" for the treatment of gallstone disease

13. Anatomy Classic anatomy of the biliary tree is present in only 30% Anomalies are the rule, not the exception Calot's triangle Boundaries Cystic duct, Cystic artery, and The common hepatic duct

14. Indications Chronic Cholecystitis. Cholelethiasis . Acute on Chronic Cholecystitis. Acute Cholecystitis with complications. Empyema Gallbladder. Gangrenous Gallbladder. PerforatedGallbladder . Trauma to Gallbladder. Choledocholesthiasis . As a part of other procedure like Whipple Procedure. Carcinoma Gallbladder. Direct Invasion of Hepato-cellular carcinoma. Metastasis to gall bladder. Prophylactic Cholecystectomy in high risk patients. Parasitic Infestation of Gallbladder like in Ascariasis. In Bariatric surgery

15. Preoperative Considerations: Consent Nil by mouth for 8 hrs. Intravenous Fluids. Prophylactic Broad Spectrum Antibiotics. Anaesthesia fitness for General Anaesthesia especially with related to respiratory function. Control of Hypertension & DM in affected patients. Arrangement of 1-2 pints of cross-matched blood. Correction of Any bleeding or clotting disorder.

16. Open Cholecystectomy Right subcostal (Kocher) incision Midline or Paramedian incision Placement of Retractors and abdominal Sponges Adhesions of omentum or viscera adjacent to the gallbladder are divided Fundus held by a sponge holder and retracted towards surgeon Dissection to identify cystic duct, its entry into the common bile duct, and the cystic artery

17. Dissection in Calot’s Triangle Ligation of the cystic duct in close proximity to its junction with the common bile duct has long been considered an essential component of OC. For preventing postcholecystectomy syndrome The cystic artery should be dissected, secured, and divided near the surface of the gallbladder Intraoperative cholangiography Drains are not mandatory

18. After adequate Hemostasis & removal of abdominal packs closure of posterior rectus sheath with absorbable sutures. Anterior Rectus Sheath is closed in continuous fashion by Non-Absorbable sutures. Skin closed

19. Postoperative Management Nil by mouth till bowl sounds are present. Continue Intravenous fluids till patient is oral free. Adequate Analgesia. Continue Intravenous Antibiotics for 72 hours and then change to oral for one week. Change of dressing if soaked early otherwise after 72 hours. Removal of drain when drainage is minimal. Removal of Sutures when wound is healed. Anti-ulcer therapy if needed. DVT Prophylaxis. Send specimen for Histopathology and stones for chemical Analysis if present.

20. Laproscopic Cholecystectomy Traditional approach is 4 port but SILS has become available as well now a days. Has become a gold standard approach for gallbladder removal. If fails then convert to Open Procedure. Difficult to perform in Patients with Previous open Abdominal Surgeries. Carries some increased risk of extra- hepatic duct injuries. Recovery is better and early than open surgery. Needs specialized equipment & training of personnel. Usually avoided in cases of suspected malignant Disease.

21. Infundibulum is grasped, placing traction on the gallbladder in a lateral direction to disalign the cystic duct and common bile duct (CBD) Identify the structures forming the sides of Calot's triangle Infundibulum of the gallbladder given traction superior and medial direction Unnecessary and potentially harmful to dissect the cystic duct down to its junction with the CBD The neck of the gallbladder is thus dissected away from its liver bed, leaving only two structures entering the gallbladder—the cystic duct and artery Both cystic duct and cystic artery are divided between metal clips Intraoperative cholangiography (IOC) Dissection is done from infundibulum to fundus Gall bllader is extracted from one of larger port

22. Advantages and Disadvantages Advantages Less pain Smaller incisions Better cosmesis Shorter hospitalization Earlier return to full activity Decreased total costs operator use Disadvantages Lack of depth perception View controlled by camera More difficult to control hemorrhage Decreased tactile discrimination (haptics) Potential CO 2 insufflation complications Adhesions/inflammation limit Slight increase in bile duct injuries

23. Introduction Open cholecystectomy was standard practice for treatment of symptomatic gall bladder disease until late 1980‟s. At present 90% of cholecystectomies performed by LC which is one of the commonest surgical procedure in world. Unfortunately, widespread application of LC led to concurrent rise in incidence of major bile duct injuries (BDI) ,which are more complicated than after open procedures. Since its introduction and routine use in 1990s, the incidence of biliary injuries has doubled from 0.2% to 0.4% and remained constant despite advances in knowledge, technique, and technology.

24. Classic Laparoscopic Injury Mistaking common bile duct for the cystic duct

25. Inappropriate use of electrocautery near biliary ducts May lead to stricture and/or bile leaks Mechanical trauma can have similar effects Thermal Injuries Lahey Clinic, Burlington, MA.1994

26. Bile duct injuries during cholecystectomy In 1990s, high rate of biliary injury was due to learning curve effect . Surgeon had 1.7% chance of a bile duct injury occuring in first case and 0.17% at the 50 th case. However most surgeons passed through learning curve, steady – state reached , but there has been no significant improvement in the incidence of biliary duct injuries.

27. Biliary Injuries during Cholecystectomy postoperative Biliary tract injuries. On other hand LC has been associated with 2.5- fold to 4-fold increase in the incidence of postoperative BDI compared with OC. Open cholecystectomy has been associated historically with 0.2% to 0.5% risk of

28. These preventable injuries can be morbidity, devastating , mortality, and increasing medical cost, while decreasing the patient‟s quality of life. Biliary injuries will always exist , and we need to be aware of the best methods to avoid, evaluate, and treat them.

29. Risk Factors for Biliary tract injury Surgeon related factors Lack of experience (learning curve) Misidentification of biliary anatomy Intraoperative bleeding Lack of recognition of anatomical variations of biliarytree Improper interpretation of IOC Improperly functioning equipment

30. Risk for biliary tract injury Patient related Acute and chronic cholecystitis Empyema Long standing recurrent disease -> fibrosis Porcelain gallbladder Obesity Previous surgery Male Advanced age

31. The Effect of Acute Cholecystitis on Lap. cholecystectomy complications Complication rate three times greater than for elective LC. Early cholecystectomy (72 h) outcome better than delayed cholecystectomy. Conversion rate to open cholecystectomy is higher than elective cholecystectomy 35% vs 9%.

32. Risk Factors for biliary tract injuries Anatomic Variations ▪ Present in 18 – 39% cases ▪ Dangerous variations predisposing to BTI are present in only 3-6% of cases Abnormal biliary anatomy Short cystic duct, cystic right right duct entering in the duct- Accessory hepatic duct Arterial anomalies Right hepatic artery running parallel to the cystic duct Anomalous or accessory right hepatic artery

33. (Sabiston text book of surgery 19 th edtn.)

34. Summary of Causes of Bile Duct Injuries Misidentification of Common bile duct Common hepatic duct An aberrant duct (usually on the right side) Technical failure su ch as Slippage of clips placed on the cystic duct Inadvertent thermal injury to CBD Tenting of CBD during clip placement Disruption of a bile duct entering directly into gallbladder fossa . (Goal of dissection should be conclusive identification of cystic structure within Calot triangle) (If the cystic duct and cystic artery are conclusively and correctly identified before dividing, more than 70% of bile duct injuries would be avoided )

35. Technique Four methods of identification of cystic structures during cholecystectomy 1) Routine cholangiography Critical view technique Infundibular technique-> widely used Dissection of main bile duct with visualization of cystic duct or common duct insertion-> ( increased chance of either thermal or retraction injury to CBD, aberrant insertion of cystic duct can also complicate this approach)

36. If critical view not obtained due to inflamation or hostile anatomy perform IOC prior to dividing cystic duct . Routine IOC reduces CBD injuries from 0.58% to 0.39 % (American Medicare data base study)

37. Critical view of safety Calot‟s triangle dissected free of all tissue except cystic duct & artery Base of liver bed exposed When this view is achieved, the two structures entering GB can only be cystic duct & artery Not necessary to see CBD

38. Infundibular technique , although widely used, is prone to failure in situations where cystic duct is hidden because of diffuculty retracting the gallbladder as a result of severe inflammation or one or more large stone effacing or fusing the cystic duct-common duct junction. In such situation, area where infundibulum narrows can be interpreted to be cystic duct when it is actually the cystic duct and common duct together.

39. (A)Usual anatomy when infundibular technique applied. Cyst duct- gallbladder junction is characterized by a flaring tunnel shape(boldlines). Arrow represents circumferential dissection of CD- gallbladder junction during infundibular technique. (B) Inflammation can pull CBD on the gallbladder creating similar flaring tunnel shape. As a result, CBD mistaken for cystic duct, resulting in classic injuries. CD, cystic duct;CHD, common hepatic duct. (Strasberg S. Error traps and vasculo-biliary injury in laparoscopic and open cholecystectomy. J Hepatobiliary Pancreat Surg 2008;15(3):285;)

40. Classical LC BDI

41. Type A Cystic duct leaks or leaks from small ducts in liver bed Type B Occlusion of aberrant right hepatic ducts Type C Transection of aberrant right hepatic ducts Type D Partial (<50%) transection of major bile duct Type E Transection involve >50% Subdivided as per Bismuth classification into E1 to E5 Strasburg Classification

42. Bile duct injury Prevention should be main point (much more important than treatment) ALL laparoscopic cholecystectomies ARE difficult! None of them is easy! If injury occurred, … who should treat it? when should it be treated? how should it be treated?

43. Timing of Identification Intra-op Unexpected ductal structures seen Bile leak into field from lacerated or transected duct Post-op Depends on continuity of bile duct & Presence or absence of bile leak

44. Clinical Presentation (post-op) Obstruction Clip ligation or resection of CBD → obstructive jaundice, cholangitis Bile Leak Bile from intra-op drain or More commonly, localized biloma or free bile ascites / peritonitis, if no drain Diffuse abdominal pain & persistent ileus several days post-op → high index of suspicion → possible unrecognized BDI

45. Controlling sepsis, establish biliary drainage, postulate diagnosis, type and extent of bile duct injury. Broad-spectrum antibiotics No need for an urgent laparotomy . Biliary reconstruction in presence of peritonitis results a statistically worse outcome. No need for urgent with reconstruction of biliary tree. Inflammation, scar formation and development of fibrosis take several weeks to subside. Reconstruction of biliary tract is best performed electively after interval of at least 6 to 8 weeks . Post-Operative Detection Plan

46. Investigation Ultrasonagraphy and CT -- Ductal dilatation intra-abdominal collection and dilatation of biliary tree. Cholangiogram ERCP— biliary anatomy and assess the injury PTC— define biliary anatomy proximal to injury MRCP— noninvasive (can miss minor leaks) HIDA scan -- If doubt exists, HIDA scan can confirm leak but not the specific leak site MR angiography— vascular injuries BDI Management

47. Bile leak Immediate intra operative diagnosis injurMinor y Major injury Delayed diagnosis Repair over T-tube No experienced hepato-Biliary surgeon ▪ Clip open duct ▪ Drain ▪ IV antibiotics ▪ Transfer to tertiary centre Duct of Luschka Experienced hepatobiliary surgeon available ▪ Call second surgeon ▪ Roux-en-Y hepatico- jejunostomy Drainage Low -output High-output Observe Resolve < 5-7 days Continued ERCP Cystic duct stump leak Suspected CBD injury ▪ PTC to deliniate anatomy ▪ Control drainage ▪ Repair by experienced hepatobiliary surgeon Sphinctrectomy Stent± sphincterectomy