PowerPoint presentation on Choledochal Cysts, also known as biliary cyst, uploaded by Dr. Vaskar Humagain, first presented in 31st December, 2013. This presentation contains all the information about Choledochal Cysts, the original and revised Todani classification of choledochal cysts, pathogenesis, other associated congenital anomalies, clinical features in infant and adult, management of choledochal cysts. Comments are highly welcome :)
Component seperation technique for the repair of very large ventral hernias nikhilameerchetty
Includes all the ventral hernia repairs with the loss of domain and the various methods of component separation technique with their success rate for their repair ,few videos showing the methods of repair in addition to the latest techniques of repair .
The incidence of biliary injury after laparoscopic cholecystectomy (LC) has shown a declining trend though it may still be twice that as with open cholecystectomy. Major biliary or vasculobiliary injury is associated with significant morbidity. As prevention is the best strategy, the concept of a culture of safe cholecystectomy has been recently introduced to educate surgeons and apprise them of basic tenets of safe performance of LC. Various aspects of safe cholecystectomy include: (1) thorough knowledge of relevant anatomy, various anatomical landmarks, and anatomical variations; (2) an understanding of the mechanisms involved in biliary/vascular injury, the most important being the misidentification injury; (3) identification of various preoperative and intraoperative predictors of difficult cholecystectomy; (4) proper gallbladder retraction; (5) safe use of various energy devices; (6) understanding the critical view of safety, including its doublet view and documentation; (7) awareness of various error traps (e.g., fundus first technique); (8) use of various bailout strategies (e.g., subtotal cholecystectomy) in difficult gallbladder cases; (9) use of intraoperative imaging techniques (e.g., intraoperative cholangiogram) to ascertain correct anatomy; and (10) understanding the concept of time-out. Surgeons should be facile with these aspects of this culture of safety in cholecystectomy in an attempt to reduce the incidence of biliary/vascular injury during LC.
Component seperation technique for the repair of very large ventral hernias nikhilameerchetty
Includes all the ventral hernia repairs with the loss of domain and the various methods of component separation technique with their success rate for their repair ,few videos showing the methods of repair in addition to the latest techniques of repair .
The incidence of biliary injury after laparoscopic cholecystectomy (LC) has shown a declining trend though it may still be twice that as with open cholecystectomy. Major biliary or vasculobiliary injury is associated with significant morbidity. As prevention is the best strategy, the concept of a culture of safe cholecystectomy has been recently introduced to educate surgeons and apprise them of basic tenets of safe performance of LC. Various aspects of safe cholecystectomy include: (1) thorough knowledge of relevant anatomy, various anatomical landmarks, and anatomical variations; (2) an understanding of the mechanisms involved in biliary/vascular injury, the most important being the misidentification injury; (3) identification of various preoperative and intraoperative predictors of difficult cholecystectomy; (4) proper gallbladder retraction; (5) safe use of various energy devices; (6) understanding the critical view of safety, including its doublet view and documentation; (7) awareness of various error traps (e.g., fundus first technique); (8) use of various bailout strategies (e.g., subtotal cholecystectomy) in difficult gallbladder cases; (9) use of intraoperative imaging techniques (e.g., intraoperative cholangiogram) to ascertain correct anatomy; and (10) understanding the concept of time-out. Surgeons should be facile with these aspects of this culture of safety in cholecystectomy in an attempt to reduce the incidence of biliary/vascular injury during LC.
A Rare Case of Choledochal Cyst Connecting Intra- And ExtraHepatic Ductsemualkaira
Choledochal cysts are rare congenital dilatations of the
extra and/or intrahepatic bile ducts found primarily in children
and estimated of much higher incidence in Asia, where it reaches
approximated 1:1000, as compared to Western population [1,2].
A choledochal cyst increases the risk of malignant transformation up to 10% and patients may still be exposed at higher risk for
biliary malignancies even after surgical resection
Management of Perforated Duodenal Diverticulum: Case Reportasclepiuspdfs
It has been reported that duodenal diverticula are common but perforated duodenal diverticulum is a rare entity. At this time, there is no standardized management for perforated duodenal diverticulum. In these cases, patients usually complain of vague abdominal pain and computed tomography scan is mostly ordered used as an important diagnostic method. Diagnosis and the severity of the disease need to be assessed before any intervention. Essentially, the perforated small bowel is treated with surgical intervention. However, conservative treatment with broad-spectrum antibiotics and strict nil per os has been offered in the past for stable patients. Below, we report one case of perforated duodenal diverticulum that we managed with conservative treatment.
Abstract
This case report describes the diagnosis and management of a large mesenteric cyst in a 55 year old lady who presented with abdominal distension & with mass in the left upper quadrant. Mesenteric cysts are rare, benign, abdominal tumors to which <1000 cases have been reported in the literature. While 40% of cases are incidental findings found either through physical examination or imaging, they can cause non-specific abdominal symptoms including pain, altered bowel habits, nausea/vomiting or anorexia. Less commonly, 10% of cases can present with bowel obstruction, volvulus, torsion or shock. In general, the lack of characteristic clinical and radiological features presents as a diagnostic difficulty.
The mainstay in imaging is computerized tomography (CT). CT identifies and helps aid the decision to pursue a laparoscopic or open laparotomy approach, where complete surgical resection is the ultimate goal. In our patient a CT Abdomen & Pelvis showed a large, loculated cystic mass measuring 30cm in cranio-caudal length and 16cm in the transverse and anterior/posterior diameter. While different approaches have been described in the literature to surgically resect such cysts, our approach was largely reflective of size and adherence to surrounding structures in this case. A laparotomy was performed using an upper mid-line 7 cm incision; 4500cc of fluid was aspirated from the cyst which was found to originate from the small bowel mesentery. A complete resection of the multi-loculated cystic sac was done that included the resection of the middle mesenteric vein. The post-operative period was uneventful. The patient was discharged on post-operative day 2. The Histopathology identified the mass as a multi-loculated peritoneal inclusion-type cyst.
Rupture of a Hydatid Cyst into the Bile Ductasclepiuspdfs
Cholestasis secondary to a cystobiliary communication is a rare complication associated with hepatic hydatidosis. The most established surgical procedure is the evacuation of the contents of the cyst (daughter cysts) without spills, sterilization of the cyst cavity with scolicide agents to prevent the dissemination of the hydatids to the peritoneal cavity, and cavity management (capitonnage) together with the closing of the communication.
Choledochal cysts should be considered in the differential diagnosis in all patients with a history of biliary colic, recurrent cholangitis or pancreatitis with associated dilatation of bile duct, particularly if they are <40 years of age. Delay in the diagnosis increases the incidence of associated biliary pathology and suboptimal surgical therapy
itus inversus totalis is a rare congenital entity characterized by right-to-left transposition of the viscera of the thorax and abdomen. We present the case of a 58-year-old female patient with a history of cholecystectomy 18 years ago, when a diagnosis of situs inversus was made, who presented to the emergency department with obstructive jaundice. With the surgical history and prior knowledge of her condition, an imaging approach and successful endoscopic treatment was performed. Cholelithiasis and situs inversus are a rare combination of entities; this binomial reminds us that in medicine there are no absolute concepts.
Chronic diarrhea as a result of colonic fistulas -two case reports with different origin. When it comes to chronic diarrhea symptom, the first thing
one thinks of is never a surgical cause, but an infectious disease. The aim of this paper is to show 2 different cases of chronic diarrhea, resulting from
benign surgical causes - colonic fistula. The first case is a result of cholecystocolic fistula, while the second is the result of gastrojejunocolic fistula.
Colonic fistulas originate from different causes: malignancy, NSAID, diverticulosis of the colon, cholecystitis, pancreatitis, lymphoma, or after radiation
therapy. They can also result from a trauma, which can be post-surgical.
Introduction:
Cholecystocolic fistula occurs as a result of the inflammation of the gallbladder. It arises from existing adhesions. The incidence rate
is not high, but the complication is not a rarity per se. It is less frequent complication than cholecystoduodenal fistula. The main symptoms are secretory
diarrhea, vitamin K malabsorption and weight loss, and thus suspicion of malignancy is usual. The treatment is surgical removal of the gallbladder,
fistula and part of the colon en bloc.
Case report:
A 73-year old male patient was admitted to the department after 5 months of medical treatment. Laboratory tests, coproculture,
colonoscopy, abdominal ultrasonography, and gastroduodenoscopy were performed - the diagnosis was not established. The diagnosis was made by
means of irrigography and short and narrow cholecystocolic fistula was confirmed. The possibility of malignant disease was not completely excluded.
The patient underwent surgery after parental nutrition-adhesions, gallbladder, and the prepared fistula were removed as well as the longitudinal part
of the transverse colon, which was simultaneously repaired. Ex-tempore diagnosis-the surgical specimen originated from inflammation, not from
malignancy. The post-operative course was uneventful. The first post-operative stool was normal. The patient gained some weight after a few months.
Conclusion:
Along with the contemporary diagnostics methods, contrast examination plays an important diagnostic role. When infection is
excluded as the cause of chronic diarrhea, cholecystocolic fistula should be considered. Malignant disease should be excluded before the surgery, or it
may be diagnosed during the surgery, which would determine the course of the treatment. The treatment of benign cholecystocolic fistula is surgical
en bloc procedure.
Tuberculous Ileal Perforation in Post-Appendicectomy PeriOperative Period: A ...iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
Abdominal Imaging Case Studies #27.pptxSean M. Fox
Drs. Kylee Brooks and Parker Hambright are Emergency Medicine Residents and Drs. Alexis Holland and William Lorenz are Surgery Residents at Carolinas Medical Center in Charlotte, NC. They are interested in medical education. With the guidance of Drs. Kyle Cunningham, Brent Matthews, and Michael Gibbs, they aim to help augment our understanding of emergent abdominal imaging. Follow along with the EMGuideWire.com team as they post these monthly educational, self-guided radiology slides. This month’s cases include:
• Iatrogenic Esophageal Perforation
• Emphysematous Cystitis
• Meckel’s Diverticulum
• Paraesophageal Hernia
Laparoscopic Excision of Foregut Duplication Cyst of StomachApollo Hospitals
Retroperitoneal gastric duplication cysts lined by ciliated columnar epithelium are extremely rare lesions and its presentation during adulthood is a diagnostic challenge for treating clinicians. This entity often resembles cystic pancreatic neoplasm, retroperitoneal cystic lesions and sometimes as an adrenal cystic neoplasm. Correct diagnosis on the basis of radiological investigation is difficult and histopathologic analysis. We report a case of gastric duplication cyst in a 16year old girl that mimicked as a retroperitoneal /pancreatic /adrenal cystic lesion and was successfully managed by laparoscopy.
Embracing GenAI - A Strategic ImperativePeter Windle
Artificial Intelligence (AI) technologies such as Generative AI, Image Generators and Large Language Models have had a dramatic impact on teaching, learning and assessment over the past 18 months. The most immediate threat AI posed was to Academic Integrity with Higher Education Institutes (HEIs) focusing their efforts on combating the use of GenAI in assessment. Guidelines were developed for staff and students, policies put in place too. Innovative educators have forged paths in the use of Generative AI for teaching, learning and assessments leading to pockets of transformation springing up across HEIs, often with little or no top-down guidance, support or direction.
This Gasta posits a strategic approach to integrating AI into HEIs to prepare staff, students and the curriculum for an evolving world and workplace. We will highlight the advantages of working with these technologies beyond the realm of teaching, learning and assessment by considering prompt engineering skills, industry impact, curriculum changes, and the need for staff upskilling. In contrast, not engaging strategically with Generative AI poses risks, including falling behind peers, missed opportunities and failing to ensure our graduates remain employable. The rapid evolution of AI technologies necessitates a proactive and strategic approach if we are to remain relevant.
Macroeconomics- Movie Location
This will be used as part of your Personal Professional Portfolio once graded.
Objective:
Prepare a presentation or a paper using research, basic comparative analysis, data organization and application of economic information. You will make an informed assessment of an economic climate outside of the United States to accomplish an entertainment industry objective.
Palestine last event orientationfvgnh .pptxRaedMohamed3
An EFL lesson about the current events in Palestine. It is intended to be for intermediate students who wish to increase their listening skills through a short lesson in power point.
2024.06.01 Introducing a competency framework for languag learning materials ...Sandy Millin
http://sandymillin.wordpress.com/iateflwebinar2024
Published classroom materials form the basis of syllabuses, drive teacher professional development, and have a potentially huge influence on learners, teachers and education systems. All teachers also create their own materials, whether a few sentences on a blackboard, a highly-structured fully-realised online course, or anything in between. Despite this, the knowledge and skills needed to create effective language learning materials are rarely part of teacher training, and are mostly learnt by trial and error.
Knowledge and skills frameworks, generally called competency frameworks, for ELT teachers, trainers and managers have existed for a few years now. However, until I created one for my MA dissertation, there wasn’t one drawing together what we need to know and do to be able to effectively produce language learning materials.
This webinar will introduce you to my framework, highlighting the key competencies I identified from my research. It will also show how anybody involved in language teaching (any language, not just English!), teacher training, managing schools or developing language learning materials can benefit from using the framework.
2. Choledochal cysts are focal or diffuse dilatations of the biliary tree
Most commonly present in childhood but increasingly being
recognized in adults.
represent significant clinical challenges where proper evaluation
and management are paramount to prevent serious clinical
sequelae.
3. incidence of choledochal cysts varies significantly throughout the
world.
In Asia, incidence is as high as 1 in 1000 population with 50% cases
representing from Japan
In Western Countries, choledochal cysts occur less frequently with
reported cases ranging from 1:13,000 to 1:150,000 population.
4. Occur more commonly in females with a M:F ratio of 1:3-4
Classically present in childhood, but recent series report as
many as 25% of cases presenting in adults.
5. Proper management of choledochal cysts requires consideration of their
classification.
Original Classification by Alonso-Lej and associates exclusively involved the
extrahepatic duct
The classification was revised by Dr. Todani and colleagues in 1977 to include
intrahepatic cystic anomalies
6. Type I (50-85%): They are characterized by cystic or fusiform dilation
of the common bile duct.
Type IA is defined by cystic dilation of the entire extrahepatic biliary
tree,
Type IB is defined by focal, segmental (often distal) dilation of the
extrahepatic bile duct.
Type IC is defined by smooth, fusiform (as opposed to cystic) dilation
of the entire extrahepatic bile duct.
9. Type II ( 2%): true diverticula of the extrahepatic bile duct and
communicate with the bile duct through a narrow stalk.
Type III ( 5%) : Cystic dilatation of the intraduodenal portion of the
extra hepatic common bile duct; also known as a choledochocele
Type IV (30-40%): Involve multiple cysts of the intrahepatic and
extrahepatic biliary tree; IV A > IV B
Type V: Caroli’s Disease
14. Cause not currently known. Most cysts are congenital in nature.
It is unclear whether cases of choledochal cysts diagnosed in adults
are acquired or late manifestations of congenital cysts.
There may be multiple mechanisms involved in the creation of biliary
cysts
The high incidence of biliary cysts in Asia suggests a role for either
genetic or environmental factors.
15. Congenital weakness in the bile duct wall
Abnormal biliary epithelial proliferation before bile duct cannulation is
complete
Bile duct obstruction or distension in the prenatal or neonatal periods
Fetal viral infection
Pancreaticobiliary maljunction
16. Pancreaticobiliary maljunction is defined as an extramural junction
of the pancreatic and biliary ducts in the duodenum beyond the
intramural sphincter function
characterized by a long common channel (typically over 2 cm)
Increased reflux of pancreatic juice into the biliary tree -- >
18. Children: thick and dense fibrotic cyst wall with evidence of acute
and chronic inflammation.
Adult: common findings are inflammation, erosions, sparseness of
mucin glands, and metaplasia
Type III cysts are most often lined by duodenal mucosa, although
they sometimes are lined by bile duct epithelium.
19. Classic triad : pain, jaundice, and abdominal mass. ( ~ 10%)
Infants commonly present with elevated conjugated bilirubin
(80%), failure to thrive, or an abdominal mass (30%).
In patients older than 2 years of age, abdominal pain is the most
common presenting symptom.
Intermittent jaundice and recurrent cholangitis are also
common, especially in patients with a type III cyst.
20. U/S abdomen : to detect the presence
CT scan – more appropriate in adults.
MRCP
Cholangiography: gold standard , PTC or ERC in adults and
intraoperative cholangiography in small children
Liver function tests
24. Type I: excision of the cyst with its mucosa and reconstruction by
Roux-en-Y hepatico-jejunostomy
Type II: excision of the diverticulum and suturing of the CBD wall
Type III: endoscopic sphincterotomy is done.
Type IV: Extrahepatic biliary resection, cholecystectomy, and biliary
reconstruction
Type V: Liver transplantation, hepatectomy
25. Pancreatitis
Suppurative cholangitis
Gallstone and CBD stone formation
Rupture of cyst
Cholangio carcinoma in CBD
26. UTA WAIDNER*, DORIS HENNE-BRUNS AND KLAUS BUTTENSCHOEN
JOURNAL OF MEDICAL CASE REPORTS 2008, 2:5 DOI:10.1186/1752-1947-2-5
A 19-year-old Russian woman (height, 1.69 m; weight, 54 kg) with
non-specific upper abdominal pain presented to a local hospital for
evaluation. She complained of recurrent pain for weeks. Clinical
examination revealed neither jaundice nor a palpable abdominal
mass. The clinical laboratory data were normal.
27. UTA WAIDNER*, DORIS HENNE-BRUNS AND KLAUS BUTTENSCHOEN
JOURNAL OF MEDICAL CASE REPORTS 2008, 2:5 DOI:10.1186/1752-1947-2-5
Ultrasonography revealed a hypoechogenic, nearly
spheric, homogenous formation with a smooth contour in direct
contact with the underside of the liver and without any
intermediate layer. The finding was most compatible with a large
hepatic cyst.
28. UTA WAIDNER*, DORIS HENNE-BRUNS AND KLAUS BUTTENSCHOEN
JOURNAL OF MEDICAL CASE REPORTS 2008, 2:5 DOI:10.1186/1752-1947-2-5
Computer tomography showed a clearly
limited, hypodense, homogenous structure with a transverse
diameter of 11 cm in the immediate vicinity of the liver, anterior
to the right kidney, and posterior to the gall bladder
29.
30.
31. UTA WAIDNER*, DORIS HENNE-BRUNS AND KLAUS BUTTENSCHOEN
JOURNAL OF MEDICAL CASE REPORTS 2008, 2:5 DOI:10.1186/1752-1947-2-5
Cystic echinococcosis was excluded serologically.
The larger structure was interpreted as a congenital hepatic cyst
due to the direct contact to segment 5 of the liver.
The smaller structure was judged as an independent hepatic cyst
because it resembled the large cyst
32. UTA WAIDNER*, DORIS HENNE-BRUNS AND KLAUS BUTTENSCHOEN
JOURNAL OF MEDICAL CASE REPORTS 2008, 2:5 DOI:10.1186/1752-1947-2-5
laparoscopic fenestration of the large cyst was done
the cyst was approached via the inferior border.
A puncture was performed, which resulted in the evacuation of
more than 100 ml of bile.
Then, the cyst was opened by a 4 × 3 cm incision.
Laparoscopic evaluation of the inner cyst revealed two bile ducts
33. UTA WAIDNER*, DORIS HENNE-BRUNS AND KLAUS BUTTENSCHOEN
JOURNAL OF MEDICAL CASE REPORTS 2008, 2:5 DOI:10.1186/1752-1947-2-5
Bilirubin increased to 6.21 mg/dl and the patient developed
jaundice on second POD
Due to these ambiguous findings, the patient was transferred to
our university hospital on the third postoperative day. Computer
tomography showed incipient pancreatitis. After re-evaluation of
the original computer tomography, a large choledochal cyst
involving the distal part of the common bile duct was recognized.
The patient underwent repeat surgery on the fourth day after the
original surgery, and a large choledochal cyst, Todani type 1A, with
a diameter of 8–10 cm was found
34. UTA WAIDNER*, DORIS HENNE-BRUNS AND KLAUS BUTTENSCHOEN
JOURNAL OF MEDICAL CASE REPORTS 2008, 2:5 DOI:10.1186/1752-1947-2-5
This case report highlights the difficulties involved in making a
correct diagnosis and the operative treatment for a choledochal
cyst.
35.
36.
37. MUNEYUKI YAMAGUCHI, MD, JAPAN
THE AMERICAN JOURNAL OF SURGERY
VOLUME 140, ISSUE 5, NOVEMBER 1980, PAGES 653–657
Five of the author's cases and 1,428 cases from Japan's literature
are discussed. Half of the patients were infants. The ratio of men
to women was 1 to 3. One hundred fifty-one patients had
malformation of the pancreaticobiliary system, which is said to be
a cause of congenital choledochal cyst. All of the patients have
been followed up. Excision of the cyst is the best procedure for
preventing ascending cholangitis and cystic cancer. Roux-Y
hepaticojejunostomy is also effective for reconstruction of the bile
duct because it rarely causes ascending cholangitis.
38. Bailey and Love’s Short Practice of Surgery, 26th
Edition, 2012, Taylor Francis Group
Maingot’s Abdominal Operations, 11th Edition, 2007, M.J.
Zinner, et.al., Mc Graw Hills Access Surgery
SRB’s Manual of Surgery, 3rd Edition, 2008, Jaypee Publications
UpToDate, 21.2, LWW
Icons Courtesy of Google Images
Editor's Notes
recurrent cholangitis, biliary stones, secondary biliary cirrhosis, or malignancy.
There have been a few case reports of choledochal cysts occurring within families
also known as Caroli'sdisease.Later in 2003,Todani’s classification was revised to reflect the presence or absence of pancreaticobiliary maljunction.5 This further revision has yet to be broadly used.
Type 1A associated with an APBJ. no dilation of the intrahepatic ducts. The cystic duct and gallbladder arise from the dilated common bile duct. Type 1C - Typically, the dilation extends from the pancreatobiliary junction to the intrahepatic biliary tree. Type IC cysts are associated with an APBJ.
Type II ( 2%): true diverticula of the extrahepatic bile duct and communicate with the bile duct through a narrow stalk.Type II: Located proximal to the duodenum.
Type II: Located proximal to the duodenum. Type III : 5 subtypes . type IVA (both intrahepatic and extrahepatic cysts) and IVB (multiple extrahepatic cysts without intrahepatic involvement); type IVA is the second most common type of biliary cyst (30–40%). Type V: Isolated intrahepatic biliary cystic disease, associated with periportal fibrosis or cirrhosis; can be multilobar or confined to a single lobe
Type III ( 5%) : Cystic dilatation of the intraduodenal portion of the extra hepatic common bile duct; also known as a choledochocele
type IVA (both intrahepatic and extrahepatic cysts)
IVB (multiple extrahepatic cysts without intrahepatic involvement
Type V: Isolated intrahepatic biliary cystic disease, associated with periportal fibrosis or cirrhosis; can be multilobar or confined to a single lobe
And several theories have been proposed.
Increased reflux of pancreatic juice into the biliary tree -- > inflammation, activation of proteolytic enzymes, theoretical biliary epithelial damage, alterations in bile composition, and ductal distension. Elevated Spincter of Oddi pressures have also been documented.Cholangiocarcinoma as well as Ca Gall Bladder
Hemifacialmicrosomia with extracraniofacial anomalies - OMENS Plus Syndrome.
choledochal cysts have variable microscopic features, with appearance ranging from normal bile duct mucosa to carcinoma.
This triad is found in only a minority of children at the time of presentation.Mass is to the right and above the umbilicus, smooth, not moving with respiration, not mobile and resonant in 30% of the cases. An abdominal mass becomes less common with increasing age and is rarely appreciated in adults.
Patients with biliary obstruction, either acutely or chronically, may also have biliary dilatation that can mimic a type I cyst. In contrast to a type I cyst, an obstructing lesion will often cause elevated alkaline phosphatase and bilirubin, as well as improvement in biliary dilatation after appropriate treatment. CT: hepatobiliary and pancreatic anatomy, with evaluation for possible biliary malignancy, metastatic disease, and vascular encasement. Cholangiography can demonstrate areas of cystic dilatation, the presence of stones, and excludes complete obstruction of the bile duct (Fig 34–4). It is also effective in demonstrating the presence of pancreaticobiliarymaljunction.
Pancreatitis, bile duct or gallbladder malignancy
Malignacny – radical surgery and chemotherapy
Upper panel: A large cyst,11 cm in diameter, was considered to represent a common hepatic cyst because it was in direct contact with the liver.
The dilated distal common bile duct was also misinterpreted as a second hepatic cyst.
Intraoperative situs: The choledochal cyst was mobilized and fixed with holding sutures. Clips are seen in the cyst, which closed the right and left hepatic ducts.
esected specimen: The gallbladder (left) and the deflated bile duct cyst were removed (right).