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  • 1. M&M Conference 12/2/08
  • 2. M&M Conference
    • CH
      • 56 y/o male presents with a 2-3 day hx of right upper quadrant pain with nausea and vomiting
      • Pain
        • Onset-2 to 3 days prior to presentation
        • Duration-lasted 10 to 20 minutes at each instance
        • Localized, no radiation
        • No clear aggravating, alleviating factors
        • Nausea and vomiting occurred spontaneously
  • 3. M&M Conference
    • Vomiting
      • Bilious
      • Occurred spontaneously
      • Approximately 20 to 50 cc per episode(total of 4 times)
    • Denied dysuria, urgency, frequency
    • Denies change in bowel habits, decrease in appetite, & weight loss
  • 4. M&M Conference
    • PMHx-Neurofibromatosis, Seizure disorder, HTN, scoliosis, GERD, CVA 2001
    • PSX-Abdominal exploration-RLQ
      • “ Back Surgery”
        • Retroperitoneal schwannoma
    • Meds-Clonidine, lisinopril
    • SHX- Smoke + 30 yrs, remote history of alcohol and IVDA
    • FHx-Father cancer, coronary disease
  • 5. M&M Conference
    • Vitals- T 37.1 P-89 BP-150/88 99% RA
    • Gen-AAOx 3, mild distress
    • HEENT- anicteric, no lymphadenopathy, neck-supple
    • CV-RRR
    • Lung-CTAB
    • Abd- Soft, ND, BS+-active
      • RUQ tenderness- no radiation, no masses, no scars
      • Scaphoid abdomen
    • Ext- no c/c/e
  • 6. M&M Conference
    • Labs
      • Na-138 K-3.6 Cl-110 CO2-19 BUN-6 Crea-.52
      • Gluc-132 ALP-127 AST-84 ALT-76 Amylase-95 Lipase-26
      • T. Bili-0.7 D. Bili-0.2
      • WBC-14.4 H/H-14.1/41.5 Plts-264
  • 7. M&M Conference
    • CT A+P- Cholelithiasis. Spinal changes secondary to neurofibromatosis
    • HIDA-Nonvisualization of the gallbladder through approximately one hour c/w acute or chronic choleycystitis evidence. No evidence for common duct obstruction
  • 8. M&M Conference
    • GI
      • EGD
        • Mild gastritis, no signs of peptic or duodenal ulcer
    • Cardiology
      • Old inferior infarct
      • Echo-no abnormalities
      • Low risk for abdominal surgery
  • 9. M&M Conference
    • A/P
      • 56 y/o M with acute/chronic cholecystitis
      • Plan to OR for Laparoscopic Cholecystectomy
  • 10. M&M Conference
    • Post-Operative DX- Chronic Cholecystitis
    • Procedure- Laparoscopic Cholecystectomy
    • Operative Report-
      • Open Hasson port-infraumbilical placement
        • Performed due to short, scaphoid abdomen and previous RLQ exploration
      • Liver
        • Somewhat enlarged, nodular surface
      • Gallbladder
        • Typical location, but off to the right of the right lobe of liver
        • Friable, some tearing of gallbladder occurs when grasping it initially
        • Some Bile leakage noted
  • 11.  
  • 12. M&M Conference
      • Cystic artery
        • Identified first, anterior location
        • Once transected, cystic duct in full view
      • Cystic duct
        • Dissection occurs near the gallbladder
        • Transected
      • Cholecystotomy made upon removal of gallbladder from liver bed
        • Gallstones dislodged and eventually retrieved
      • Area thoroughly irrigated
      • Drain placed in liver bed
      • EBL-minimal
      • Path
        • Cholelithiasis with acute and chronic cholecystitis
  • 13. M&M Conference
    • POD#1
      • Vitals stable
      • Strong urine output
      • T.bili increased to 1.2 from 0.9
        • JP
          • -bilious mixed with serosanguions drainage
          • 270cc/16hrs
    • POD#2
      • Vitals stable
      • Strong urine output
      • T.Bili increased to 1.5
        • JP
          • More bilious content
          • 230cc/24hrs
  • 14. M&M Conference
    • POD#3
      • HIDA
        • Probable biliary leak as evidence by tracer being cleared by the drainage catheter
      • ERCP
        • Mild extravasation in common hepatic duct
        • Stent place with sphincterotomy
    • POD#4-6
      • Vitals stable
      • Pain controlled
      • Drain output minimal
      • D/ced with JP drain
  • 15. M&M Conference
    • Assessment
      • 56 y/o male s/p Laparoscopic cholecystectomy secondary to chronic cholecystitis
    • Complication
      • Biliary Leak secondary to common hepatic duct injury
      • Stent placed
  • 16. Complication s/p Lap Chole
    • Complications post cholecystectomy
      • 1) Leakage of Bile
        • Slippage of cystic duct clip
        • Injury to common hepatic duct
        • Injury to common bile duct
        • Injury to liver bed
        • Duct of lushka
          • accessory bile duct that does not communicate with the gallbladder lumen
  • 17. Complication s/p Lap Chole
      • 2)Jaundice
        • Injury to common bile duct
        • Missed stone in common bile duct
        • Asscociated pancreatitis
      • 3) CBD or Hepatic stricture
        • Ischemia
        • Pancreatitis
  • 18. Compication s/p Lap Chole
    • w/u post-op Nausea/Vomiting/Jaundice
            • s/p Lap Cholecystectomy
            • 1 st step- Ultrasound
            • - +
            • ERCP Fluid collection- Perc drain
            • + /
            • No fluid, + -
            • but dilated duct Bilious No Bile
            • / / /
            • Stone removal, ERCP Cont drain
            • Stent placement

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