CHOLECYSTECTOMY WITH INTRAOPERATIVE CHOLANGIOGRAM

I. INTRODUCTION

Cholecystectomy is the most commonly performed elective abdominal surgical

procedure in the United States with more than 750 000 performed yearly. Injury to the

common bile duct (CBD) during cholecystectomy occurs infrequently, but it is an important
source of patient morbidity. Serious injuries often require at least 1 surgical repair, and these
repairs have variable long-term outcomes. Furthermore, CBD injury is the leading cause of
medical malpractice claims against general surgeons.

The use of intraoperative cholangiography (IOC), the injection of radiographic

contrast material into the cystic duct to evaluate the CBD, may prevent a CBD injury during
cholecystectomy. Since Mirizzi introduced IOC in the 1930s, its benefit has been extensively
debated. Some surgeons advocate routine IOC use while others advise selective or no use.
Intraoperative cholangiography can provide information about the presence of CBD stones
and show a surgical road map of the CBD. It can provide an early warning for the most
serious type of surgical misperception, the misidentification of the CBD as the cystic duct.
Thus, the information obtained from the IOC may prevent and decrease the severity of CBD
injuries.

Two prior population-based, retrospective studies have suggested a reduction in the

risk of CBD injury with IOC use. Unfortunately, these studies had a relatively small population
size and could not adjust for important surgeon-level factors. The purpose of this study was
to characterize the relationship of IOC use and CBD injury while controlling for patient and
surgeon characteristics; specifically, to distinguish the effect of a surgeon performing IOCs
routinely from the effect of the IOC itself on the rate of CBD injury.

DEFINITION

Cholecystectomy (plural: cholecystectomies) is the surgical removal of the

gallbladder. It is the most common method for treating symptomatic gallstones. Surgical
options include the standard procedure, called laparoscopic cholecystectomy, and an older
more invasive procedure, called open cholecystectomy. A cholecystectomy is performed
when attempts to treat gallstones with ultrasound to shatter the stones (lithotripsy) or
medications to dissolve them have not proved feasible.

Cholecystectomy (ko-lay-sis-TEK-tuh-me) is a surgical procedure to remove your

gallbladder — a pear-shaped organ that sits just below your liver on the upper right side of
your abdomen. Your gallbladder collects and stores bile — a digestive fluid produced in your
liver. Cholecystectomy may be necessary if you experience pain from gallstones that block
the flow of bile. Cholecystectomy is a common surgery, and it carries only a small risk of
complications. In most cases, you can go home the same day of your cholecystectomy.

Cholecystectomy is most commonly performed using a tiny video camera to see

inside your abdomen and special surgical tools to remove the gallbladder. Doctors call this
laparoscopic cholecystectomy.
 Gallbladder and bile duct

The gallbladder serves as a reservoir for bile, a yellow-green fluid produced in your
liver. Bile flows from your liver into your gallbladder where it's held until needed during the
digestion of food. When you eat, your gallbladder releases bile into the bile duct, where it's
carried to the upper part of the small intestine (duodenum) to help break down fat in food.

Cholecystectomy is used to treat gallstones and the complications they cause. Your doctor
may recommend cholecystectomy if you have:

• Gallstones in the gallbladder (cholelithiasis)

• Gallstones in the bile duct (choledocholithiasis)
• Gallbladder inflammation (cholecystitis)
• Pancreas inflammation (pancreatitis)

CHOLELITHIASIS

DEFINITION

• Calculi, or gallstones, usually form in the gallbladder from the solid constituents of
bile and vary greatly in size, shape, and composition.
- Smeltzer, S.C., Bare, B.G. Brunner & suddarth’s Textbook of Mecial-Surgical Nursing
!0th Edition.
 • Stones on the gallbladder or biliary tree are referred to collectively as cholelithiasis.
Most patients have multiple stones, sometimes several dozen. Most gallstones (80%)
are cholesterol gallstones, which form when bile becomes oversaturated with
cholesterol. Pigment gallstones, accounting for the remaining 20% of gallstones are
composed of bilirubin and bile substances other than cholesterol.
- McConnell, T. H., The Nature of Disease Pathology for the Health Professions. 2007

• Gallstones are hard, pebble-like deposits that form inside the gallbladder. Gallstones
may be as small as a grain of sand or as large as a golf ball, depending on how long
they have been forming.
- http://www.nlm.nih.gov/medlineplus/ency/article/000273.htm

ANATOMY AND PHYSIOLOGY

Gastroinstestinal Tract

The gastrointestinal tract (GIT) consists of a hollow muscular tube starting from the
oral cavity, where food enters the mouth, continuing through the pharynx, esophagus,
stomach and intestines to the rectum and anus, where food is expelled. There are various
accessory organs that assist the tract by secreting enzymes to help break down food into its
component nutrients. Thus the salivary glands, liver, pancreas and gall bladder have
important functions in the digestive system. Food is propelled along the length of the GIT by
peristaltic movements of the muscular walls. The primary purpose of the gastrointestinal
tract is to break down food into nutrients, which can be absorbed into the body to provide
energy.

Focus: GALLBLADDER

The gallbladder (or cholecyst, sometimes gall bladder) is a small organ whose
function in the body is to harbor bile and aid in the digestive process.

Anatomy

• The cystic duct connects the gall bladder to the common hepatic duct to form the
common bile duct.
• The common bile romero duct then joins the pancreatic duct, and enters through the
hepatopancreatic ampulla at the major duodenal papilla.
• The fundus of the gallbladder is the part farthest from the duct, located by the lower
border of the liver. It is at the same level as the transpyloric plane.

Microscopic anatomy

The different layers of the gallbladder are as follows:

• The gallbladder has a simple columnar epithelial lining characterized by recesses

called Aschoff's recesses, which are pouches inside the lining.
• Under the epithelium there is a layer of connective tissue (lamina propria).
• Beneath the connective tissue is a wall of smooth muscle (muscularis externa) that
contracts in response to cholecystokinin, a peptide hormone secreted by the
duodenum.
 • There is essentially no submucosa separating the connective tissue from serosa and
adventitia.

Size and Location of the Gallbladder

The gallbladder is a hollow, pear-shaped sac from 7 to 10 cm (3-4 inches) long and 3
cm broad at its widest point. It consists of a fundus, body and neck. It can hold 30 to 50 ml
of bile. It lies on the undersurface of the liver’s right lobe and is attached there by areolar
connective tissue.

Structure of the Gallbladder

Serous, muscular, and mucous layers compose the wall of the gallbladder. The
mucosal lining is arranged in folds called rugae, similar in structure to those of the stomach.

Function of the Gallbladder

The gallbladder stores bile that enters it by way of the hepatic and cystic ducts.
During this time the gallbladder concentrates bile fivefold to tenfold. Then later, when
digestion occurs in the stomach and intestines, the gallbladder contracts, ejecting the
concentrated bile into the duodenum. Jaundice a yellow discoloration of the skin and
mucosa, results when obstruction of bile flow into the duodenum occurs. Bile is thereby
denied its normal exit from the body in the feces. Instead, it is absorbed into the blood, and
an excess of bile pigments with a yellow hue enters the blood and is deposited in the
tissues.

The gallbladder stores about 50 mL (1.7 US fluid ounces / 1.8 Imperial fluid ounces)
of bile, which is released when food containing fat enters the digestive tract, stimulating the
secretion of cholecystokinin (CCK). The bile, produced in the liver, emulsifies fats and
neutralizes acids in partly digested food.

After being stored in the gallbladder the bile becomes more concentrated than when
it left the liver, increasing its potency and intensifying its effect on fats. Most digestion
occurs in the duodenum.

II. ETIOLOGY

Predisposing Factors Justification

Age (40 and above) Most internal functions decline as one ages. Inevitably resulting in
organ degeneration which also affects the body's metabolism of
lipids.

Gallstones is more frequent on women especially who had have had

Gender multiple pregnancies or who are taking oral contraceptives. Increase
level of Estrogen reduces the synthesis of bile acid in women.
Female sex hormones have long been suspected to have a side
effect of gallstone formation by altering respective bile constituents
(mainly the FAT metabolism).

People who have disease of the terminal ileum or who have

Ileal undergone resection of the terminal ileum deplete their bile salt
Disease/Resection pool and run a greater risk of developing cholesterol gallstones.

Race Cholesterol stones are common in Northern Europe and in North and
South America.

Genetics Most clinicians have an impression that gallbladder disease

characterizes some families. Indeed, the younger sisters of women
with gallstone prove to have bile more highly saturated with
cholesterol than the younger sisters of women without gallstones,
all of which suggests that Cholelithiasis does run in families.

Inflammation and Inflammation or infection in the biliary structures may provide a

infection of the focus for stone formation or may alter the solubility of the
gallbladder- constituents, fostering the development of a stone.

Hemolytic Disease In cirrhosis, at least two fifths of patients have gallstones. One
and Hepatic possible mechanism behind the appearance of pigment softness, so
Cirrhosis far unproven, is the excretion of unconjugated bilirubin directly into
the bile, something that might happen in patient with hemolysis or
in the cirrhotic with his high incidence of pigment stones, currently
estimated at 27 %.

Bile stasis Brown pigment gallstones form when there is stasis of bile
(decreased flow), for example, when there are narrow, obstructed
bile ducts.

Excessive intake of high fat or cholesterol food such as pork meat,

animal skin (e.g. chicharon and chicken skin) can result to an
increase in cholesterol level in the body, making it hard for the liver
Faulty Diet to make bile enough to metabolized the all cholesterol present.
Excess cholesterol present builds up and increases the cholesterol
serum level. Normal Liver function would then try to compensate
and excrete excess cholesterol to the bile plus the body would
reabsorb water from the bile making it more concentrated.
Supersaturation of Cholesterol along with other constituents of the
bile (bilirubin, lecithin etc.) builds up microcrystals. When
microcrystals aggregate it would result to Gallstones.
 Weight loss is associated with an increased risk of gallstones
because weight loss increases bile cholesterol supersaturation,
Weight Loss enhances cholesterol crystal nucleation, and decreases gallbladder
contractility

Obesity is a major risk factor for gallstones, especially in women. A

large clinical study showed that being even moderately overweight
Obesity increases the risk for developing gallstones. The most likely reason
is that obesity tends to reduce the amount of bile salts in bile,
resulting in more cholesterol. Obesity also decreases gallbladder
emptying.

Pregnancy Altered physiology of the biliary system during pregnancy may play
a role in accelerating the formation of stones in susceptible women.

Treatment with The contraceptive pill not only promotes thromobphlebitis but points
estrogen/ to an endocrine background of gallstones by the risk of gallstones in
contraceptives young women taking the pill. This is largely as a result of increased
cholesterol secretion into the bile and a decrease in
chenodeoxycholic acid content, along with impaired emptying of the
gallbladder brought about by estrogen.

Frequent Starvation Starvation decreases gallbladder movement causing the bile to

and Prolonged become overconcentrated with cholesterol. The liver also secretes
parenteral nutrition extra cholesterol into bile adding to the supersaturation causing
stone formation. Also, fasting persons have a diminished bile salt
pool and lithogenic bile.Gallbladder stasis plays a key role in
permitting stone formation. Defective or infrequent gallbladder
emptying occurs in the settings of prolonged fasting, rapid weight
loss, pregnancy, and spinal cord injury.

Clofibrate use and Drugs that lower the serum level of cholesterol, notably clofibrate,
other Antilipemic are associated with an increased incidence of gallstones. Clofibrate
drugs presumably increases the secretion of cholesterol into the bile and
apparently also decreases bile acid synthesis, so increasing the
cholesterol saturation of the bile. Clinical reflection of these
physiologic abnormalities has been found in the overwhelming
association between clofibrate therapy and gallstones.

III. SIGNS AND SYMPTOMS

SIGNS AND JUSTIFICATION

 SYMPTOMS
Jaundice results from an abnormally high accumulation of bilirubin in
Jaundice the blood as a result of which there is a yellowish discoloration to the
skin and deep tissues. Jaundice becomes evident when the serum
bilirubin level rises above 2.0 to 2.5 mg/dL.
Pale Stool Bilirubin together with cholesterol is normally absorbed in the
intestines and is usually excreted within the feces. The bile gives the
stool its brown to black color. Obstruction in the bile flow lessens and
may hinder the absorption of bile in the intestines making the stool
pale in color.
Dark Urine Normally urine are not dark in color, excess bilirubin are excreted by
the kidneys as a compensatory mechanism to balance the bile level
in the body.
Pruritus or Prutitus is the most common presenting symptom in persons with
generalized itching cholestasis, probably related to an elevation in plasma bile acids
Pain Due to the gallstones and microcrystals present inside the gall
bladder, the gallbladder can't contract properly which creates pain in
the epigastric area (right side of the abdominal area), often with
reffered pain, above the waist , the right shoulder and the right
scapula or the midscapular region.
-A gallstone produces visceral pain by obstructing the cystic duct or
ampulla of Vater, resulting in distention of the gallbladder or biliary
tree
Epigastric Distress
• Nausea &
Vomiting Less or absence of bile acid in the doudenum means less or no
• Fullness digestion of fats.
• Indigestion
Increased bilirubin When gallstones obstruct the bile going to the intestine, bilirubin
in the blood tends to return the body’s circulation.
Vitamin Obstruction of bile flow also interferes with absorption of the fat-
deficiencies soluble vitamins A, D, E & K. Therefore the patient may exhibit
deficiencies of these vitamins if biliary obstruction has been
prolonged

IV. DIAGNOSTIC TEST

Laboratory Studies
• The workup of cholelithiasis in pediatric patients is similar to that in adults. The goal
is to demonstrate evidence of gall bladder or biliary tract disease.
• Liver function test (LFT) and CBC results are typically within reference ranges.
Abnormalities suggest infection or obstruction, or both.
• All laboratory results in simple cholelithiasis should be within reference ranges. They
are of use in identifying a more complex disease process, including biliary obstruction
and cholecystitis.

Imaging Studies
• Use of kidney-ureter-bladder (KUB) plain radiography in these patients is often
fruitless because many stones are not visible. However, it may be beneficial in
identifying small-bowel obstruction or free air under the diaphragm.

• Ultrasonography of the right upper quadrant (RUQ) is the study of choice for these
 patients. Ultrasonography can be used to identify the location of the stone,
gallbladder wall thickening, and pericholecystic fluid, and a sonographic Murphy sign
aids in diagnosis of the disease process.

• Radionuclide scanning, such as scanning with iminodiacetic acid (IDA) derivatives

(eg, hepatoiminodiacetic acid [HIDA], diisopropyl iminodiacetic acid [DISIDA], and
paraisopropyliminodiacetic acid [PIPIDA] scanning), are also used to assess gall
bladder function, its ability to harbor and concentrate bile, and perhaps more
importantly, its motility response to cholecystokinin or a fatty meal by quantifying the
ejection fraction.

• In children with suspected hepatobiliary complications, magnetic resonance

cholangiopancreatography (MRCP) or endoscopic retrograde
cholangiopancreatography (ERCP) can help delineate the anatomy of the extrahepatic
and intrahepatic biliary tract, identify the presence of ductal stones, and provide a
therapeutic mode of removing a stone or decompressing the biliary tract. ERCP in the
pediatric population has been associated with the same frequency of success and
complications as in adults. As a noninvasive alternative, the MRCP has demonstrated
promise in the evaluation of choledocholithiasis but is less available at many
institutions.