Surgical lecture for cholelithiasis

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

3. 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

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

5. 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

6. 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

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

8. 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

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

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

11. 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

12. 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

15. 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

16. 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

18. 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

19. 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.

20. 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

21. 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

24. 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

25. 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.

26. 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.

27. 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

29. 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 CO2 insufflation
complications
Adhesions/inflammation limit
Slight increase in bile duct
injuries

30. 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.

31. Classic Laparoscopic Injury
Mistakingcommon bile duct for the cystic duct

32. ▪ 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

33. 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 50th 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.

34. 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

35. ▪ 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.

36. 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 ofbiliarytree
Improper interpretation of IOC
Improperly functioning equipment

37. 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

38. 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%.

39. 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

40. (Sabiston text book of surgery 19thedtn.)

42. 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 such 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 )

43. 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)

44. ▪ 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)

45. 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

46. ▪ 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.

47. (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;)

48. Classical LC BDI

49. ▪ 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

50. 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?

51. 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

52. 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

53. ▪ 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

54. ▪ 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

55. 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