Gall bladder stone disease surgical perspective

Gall bladder stone disease from surgeons point of view

1. GALLSTONE DISEASE PRESENTOR- DR. VISHAL VAISHNAVI MODERATOR- DR. SAURABH SINGH (PLASTIC AND RECONSTRUCTIVE SURGEON A.P, GENERAL SURGERY)

2. TOPICS ANATOMY OF BILIARY TREE GALL STONE AETIOPATHOGENESIS CLINICAL FEATURES TYPES OF GALLSTONES COMPLICATIONS INVESTIGATIONS TREATMENT

3. GALLBLADDER Elongated Pear shaped sac holds about 25-30 ml of bile. Location- Fossa for Gallbladder, inferior surface of the right lobe of the liver along the right edge of the quadrate lobe. Dimensions- Length= 7.5 – 12 cm Width= 3 cm (at its widest part)

4. PARTS AND RELATIONS Divided into- Fundus, Body, Neck and Cystic duct Fundus - Projects from inferior border of the liver and touches the anterior abdominal wall at the tip of 9 th costal cartilage. Completed surrounded by Peritoneum, Anteriorly- Ant. Abdominal Wall, Posteriorly – Transverse Colon Continous through the body of the gall bladder with the narrow neck. Body- It is upward, backward and to the left to join the neck at the right end of the Porta hepatis Upper surface- Liver but devoid of peritoneum Lower surface- Covered by peritoneum & related to 2 nd part of the duodenum

5. Contd. PARTS AND RELATIONS Neck - Related inferiorly- 1 st part of the duodenum Hartmann’s pouch: Gall stones lodged in this pouch may cause adhesion. Neck turns sharply downward to become cystic duct. Cystic duct - Backwards, downwards runs in the lesser omentum with common hepatic duct and joins it at an acute angle to form the bile duct. Dimensions= 3-5 cm

6. ARTERIAL SUPPLY Cystic Artery, is a end artery br. Of Right Hepatic Artery

7. CALOT`S TRIANGLE

8. VENOUS SUPPLY No. of small veins, which pass from the superior surface of gall bladder to the liver through gallbladder bed to drain into hepatic vein LYMPHATIC SUPPLY Cystic Lymph node of Lund Lymph node alongside upper part of celiac bile duct, which finally drains into celiac group of lymph nodes.

9. NERVE SUPPLY Cystic Plexus formed by sympathetic (T7-T9) parasympathetic( Right &Left Vagus Nerve) fibres of the Right Phrenic Nerve

10. FUNCTIONS Storage & concentration of bile Discharges into Duodenum by Muscular Contractions Secretion of mucus apprx . 20ml/day

11. CHOLELITHIASIS Gallstones are the most common biliary pathology Western countries 10-15% population affected, more than 80% cases are asymptomatic

12. ETIOLOGY & RISK FACTORS Metabolic Infection & Infestation Bile stasis Increased Bilirubin production- SCA, Hereditary spherocytosis Abnormal mucus formation

13. CLINICAL FEATURES Gallstones may remain asymptomatic, if symptoms occur- Right upper quadrant/ epigastric pain Dyspepsia Flatulence Food intolerance particularly to fats Biliary colic present in 10-25% patients

14. TYPES

15. PATHOGENESIS

16. PIGMENTED STONES (Black)

17. (Brown) PIGMENTED STONES Primarily bile duct stones Form in presence of infection(E.coli & Bacteroides) Usually multiple & radiolucent MIXED STONES Most common Composed Cholesterol, Calcium carbonate, Calcium palmitate & Calcium phosphate. May be Radio opaque depends on calcium amount

18. COMPLICATIONS IN THE GALL BLADDER 1.Silent Asymptomatic stones 2.Biliary colic 3.Acute cholecystitis 4.Chronic cholecystitis 5.Empyema of gall bladder 6.Perforation causing biliary peritonitis 7.Mucocele of gallbladder 8.Carcinoma of gallbladder IN THE CBD Secondary CBD stones Cholangitis Pancreatitis Mirizzi Syndrome IN THE INTESTINE 1.Gall stone ileus due to cholecystoduodenal fistula

19. BILIARY COLIC Definition Acute onset of pain in right hypochondrium, severe spasmodic in nature and radiating to back of shoulder. Aggravated by fatty meal relieved by its own in minutes to hours.

20. ACUTE CHOLECYSTITIS Biliary colic attack for more than 24hrs Bacterial causes( E.coli,kiebsiella,salmonella,cl.welchii ) Classification acute calculous cholecystitis acute acalculous cholecystitis(10%)

21. PATHOGENESIS

22. CLINICAL FEATURES Sudden onset of pain in right hypochondrium with tenderness, guarding, rigidity. Palpable tender, smooth gallbladder BOA’s sign Fever, Nausea tachycardia toxic features Murphy's sigh positive

23. Complications Resolution Perforation(5-10%) Peritonitis Pericholecystic abscess Cholangitis and septicemia Empyema gallbladder ,gangrenous gallbladder

24. INVESTIGATIONS USG ABDOMEN HIDA SCAN CBC LFT

25. TREATMENT Initially conservative NPO I.V FLUIDS ANTIBIOTICS ANALGESICS Definitive cholecystectomy Laparoscopic cholecystectomy is procedure of choice

26. ACUTE ACALCULOUS CHOLECYSTITIS Common in ICU patients due to bile stasis and ischemia. Diabetics who have undergone major non biliary surgery, pts who are on TPN, atherosclerotic. Pathology oedema and necrosis of gall bladder wall with features of acute inflammation. Acute presentation. Gangrene,perforation,empyema very common(70%)

27. CHRONIC CHOLECYSTITIS DEFINATION Multiple attack of acute cholecystitis will lead to small, shrunken and fibrosed gallbladder(non functioning &non distending) CLINICAL FEATURES Persistent/colicky pain in right hypochondrium Flatulent dyspepsia Intolerance to fatty meals Biliary dyspepsia Complications Cholangitis Pancreatitis Mirizzi’s syndrome

28. DIFFERENTIAL DIAGNOSIS Peptic ulcer Pancreatitis Hiatus hernia INVESTIGATION USG ISOTOPE STUDY LFT TLC TREATMENT CHOLECYSTECTOMY(OPEN/LAP)

29. MUC0CELE In cases of stones leading to obstruction of cystic duct, without any infection/inflammation, absorption of bile through gallbladder mucosa and replaced by mucus allowing gallbladder to distend. Clinical features Painless swelling in right hypochondrium Non-tender, smooth, soft, globular, palpable gall bladder Dyspepsia

30. Complications Empyema of gallbladder (if infected) Pseudomyxoma peritonei(if ruptured) INVESTIGATIONS USG LFT TREATMENT Cholecystectomy(lap/open)

31. EMPYEMA Type of acute cholecystitis wherein the gallbladder filled with pus. Pus due to:- Infection of mucocele Infection of gallbladder due to any other foci via blood stream. Commonly observed in impacted stone, diabetics, immunosuppressed, long time steroid therapy.

32. CLINICAL FEATURES Fever Toxicity Pain Tenderness in right hypochondrium Tender, smooth, globular gallbladder palpable in right hypochondrium . COMPLICATIONS Septicemia Rupture Peritonitis INVESTIGATIONS USG CBC LFT PT/INR RADIOISOTOPE SCAN TREATMENT ANTIBIOTICS CHOLECYSTECTOMY-an emergency procedure

33. GALL STONE ILEUS

34. CLINICAL FEATURES Severe abdominal pain colicky type Vomiting Distension H/O suggestive of Recurrent cholecystitis Rigler’ triad- Pneumobilia + Apparent Gallstones + Enteric obstruction

35. INVESTIGATIONS Plain X- Ray Abdomen erect posture USG abdomen CT is diagnostic

36. TREATMENT Cholecystectomy, correction of fistula with T-tube drainage done in same sitting if patient general condition is good. If general condition of patient is not good, then done it after 12 weeks. If surgery not done recurrent gallstones likely to occur.

37. INVESTIGATIONS FOR DETECTING GALLSTONES Plain radiograph Transabdominal ultrasonography Complete Blood Count LFT Radioisotope scanning C.T MRI ERCP PTC

38. CHOLECYSTECTOMY INDICATIONS FOR LAPROSCOPIC CHOLECYSTECTOMY Symptomatic Cholelithiasis Biliary Colic Acute Cholecystitis Gallstone Pancreatitis Asymptomatic patient prophylactically cholecystectomy done Single stone more than 2 cm Multiple GB stones Patient on diabetes & Renal transplant Immunosuppressive therapy

39. CONTRAINDICATIONS ABSOLUTE Unable to tolerate general anesthesia Refractory Coagulopathy Suspicion of Ca gallbladder RELATIVE Previous upper abdominal surgery Cholangitis Diffuse peritonitis COPD Pregnancy Cholecystoenteric fistula

40. OPEN CHOLECYSTECTOMY Kocher’s incision Open approach is used if patient is not fit for laparoscopic surgery Suspected CBD stones Mirizzi Syndrome Suspected Ca Gall Bladder During laparoscopic cholecystectomy, there is on table difficulty in dissection at calot’s triangle then conversion into open approach may be required

41. DISSECTION Calot’s triangle Boundaries- Cystic duct, cystic artery and common hepatic duct. Adhesions of omentum or viscera adjacent to the gallbladder are divided with sharp dissection or electrocautery. Meticulous dissection and positive identification of cystic duct, entering into common bile duct & cystic artery are absolutely mandatory & significantly reduce the likelihood of bile duct injury.

42. ADVANTAGES & DISADVANTAGES OF LAPROSCOPIC TO OPEN CHOLECYSTECTOMY ADVANTAGES Less pain Smaller incision Better cosmesis Earlier return to full activity DISADVANTAGES Lack of depth perception View controlled by camera operator Difficult to control hemorrhage Co2 related complications Adhesions/ Inflammation limit use

43. COMPLICATIONS Hemorrhage Bile duct injury/ leak Retained stones Pancreatitis Wound infection Incisional hernia Pneumoperitoneum Related Co2 embolism Vasovagal reflex Arrhythmias Trocar Related Bleeding Visceral injury

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