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M

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

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