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    biliary tract surgery text

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    © All Rights Reserved
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    5 views18 pages

    Billiar y Tract

    Uploaded by

    Guilherme Kazuo Ogawa
    biliary tract surgery text

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
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    of 18
    15 B.R. Davidson, A.B. Cresswell CONTENTS Introduction 257 Cholecystectomy 257 The difficult gallbladder 262 Intraoperative complications 264 Intra-operative imaging of the biliary tract 265, Surgical exploration of the common bile duct 267 Transduodenal sphincteroplasty 263, Roux en ¥ hepatico-jejunostomy ~ biliary reconstruction 270 Thera Gallstones are common and represent the most frequent indication, for biliary tract surgery. Around 12% of males and 249% of females will develop stones in the gall bladder and of these around 249% per year will become symptomatic ‘Whilst symptomatic stones are generally accepted a a clear indi- cation for surgical intervention (assuming the patient is otherwise Gi), there is no dear evidence of benefit for cholecystectomy for asymptomatic stones. Obstructive jaundice and biliary pancreatitis are amongst the ‘most serious complications of gallstone disease and some stones pre sent de novo with these complications Cholecystectomy isby farthe commonestinterventionand accounts for around 50,000 procedutes a year in the UK. The laparoscopic approach is now firmly established as the technique of choice. How- lever, some surgeons support an open or ‘mini-open’ technique. ‘Though laparoscopic cholecystectomy has become established as 2 routine’ operation and is often performed asa day cas, the impor- tance of good surgical technique should not be underestimated. Thi ‘operation results in an average of 23 claime for negligence peryear‘o the UK NHS Litigation Authority, with a the majority being for bie duct injury and resulting in compensation payments of up co £350,000 per case (Cholecystectomy has traditionally been performed as an elecive procedure wherever possible, with acute episodes of inflammation ‘being treated with antibiotics and allowed to sete for 2-3 months priorto an interval operation There has, however, hen a more recent ‘vogue for the removal of the gallbladder during an index admission ‘with acute symptoms. This approach undoubtedly leads to a more ‘challenging operation in the face of acute inflammation, but has ‘ot been shown to be associated with higher rte of bile duct injury fr conversion to open operation in the published reviews. There is, however, clear health economic evidence that performing choleeys tectomy atthe time of index presentation results in a shorter overall, __ Biliary tract. hospital stay (due to avoidance of recurrent admissions whilst on a ‘waiting lst) and lower total costs. The timing of acute choleaystec- tomy remains contentious, with traditional dogma suggesting that it must be performed within 5 days of the onset of symptoms. It hhas been the authors experience that absolute duration of symptoms isless important than clinical signs and previous history of symptoms in predicting succese with a laparoscopic approach inthe acute setting ‘The advent of endoscopic retrograde cholangiopancreatography (ERCP) combined with endoscopic sphincterotomy and balloon ravi has reduced the tequency with which susgical exploration of the bile duct and treatment of the sphincter of Oddi is undertaken, however, these techniques remain an important past of the surgical armamentasium and can be undertaken by both laparoscopic and ‘open approaches Further interventions on the biliary wee for benign indications are uncommon, but include biliary rac reconstruction and ext sion of choledochal cysts, Such procedures should be confined to specialist centres and require meticulous technique with careful follow-up. (eran Appraise 1 The majority of patients with typical biliary pain undergoing sur gery for documented gallstones may expect an excellent response to their operation in terms of symptom resolution and postoper- ative side-effects 2) Asymptomatic gallstones are common and itis vital to obtain a careful conoborating history before ascribing vague upper ab- dominal symptoms to stones seen on imaging 3) Im patients where symptoms are not typical, there should be a waming that the operation may not provide complete relief and a thorough search for an alternative diagnosis should be un- dertaken prior to surgery {A The aim of the operation ie to remove the gallbladder with divi sion of the cystic duct, which connects the gallbladder to the ‘main biliary tee and the cystic artery, which isthe major blood supply Co the gallbladder and usually branch ofthe right hepatic anery, 5) Significant variation exists in both biliary and hepatic areial anatomy and, although the majority of these variations will have [ile impact on a safely performed cholecystectomy, fll advan {age should be taken of any preoperative imaging that may be available and careful note made of any anatomical anomalies ‘dentiied on ltrsound scans, magnetic resonance cholangio- rams (MRCP) or ERCPs where available. 257 15 258. CALLS Prepare A The majority of patients can be treated laparoscopically. Fitness for surgery should be considered on the bass that an open oper- ation may be requited. The cardiovascular effects of a pneumo- peritoneum should be bore in mind. 2 Patients should be booked to appropriate lists based on any. underlying medical co-morbidity and clues as tothe likely sever- ity oftheir disease process, auch at a long history of severe and ‘constant pain and ultrasound findings of avery thick-walled gall= bladder with surrounding oedema or empyema, 3) Informed consent should be obtained with mention of specific risks such as bleeding infection, injury to surrounding blood ves- sels, bowel or the main bile duct, to include bile leak General ‘complications of surgery sich as venous thromboembolism (WTF), acute coronary events, pulmonary and cerebrovascular ‘events and anaesthetic complications should also be discussed, Tn general terms’ any complications that occur seatively fre {quently (>1 in 1000) should be outlined, along with other rarer, Dut very significant ssks Ensure that a sample of blood has been obtained for group, and save of serum and review the preoperative blood results ~ specifically, the liver function test. 5) IF itis planned to undertake the operation laparoscopicaly, the patient should be warned ofthe possibility of conversion to open surgery depending on intr-operative findings or evens. 6 Instigate adequate VTE prophylaxis, according (o local protocol, ‘which may include the use of pre- or perioperative prophylactic heparin therapy, compression stockings or pneumatic compres sion devices 7) A meta-analysis has shown no benefit to the routine use of ant- biotic prophylaxis in the prevention of wound infection and. septic complications, bu they should be considered ifthe biliary nee is considered to be infected. 18) The operation is conducted under general anaesthesia and care should be taken to ensure that a radiolucent operating table ie ‘used, as regasdless of whether an inta-operative cholangiogram. is performed routinely or selectively, it may be estental in the ‘ase of intraoperative difficulties LAPAROSCOPIC TECHNIQUE Action 1) The patentis positioned supine, and following the application of warming device, antsepticskin preparation should be applied from, an area extending from the nipples to the symphisis pubis with the ‘drapes positioned such thatthe full costal margin and the lower border of the stemum ate within the stele operative field, 2 The convention is forthe operating surgeon to stand on the pa- tients left hand side with an assistant to their let and the scrub ‘murse with instruments on the patient’ right, Some surgeons pre- fer to place the patent in a leyd-Davies position and to operate ‘rom between the legs and a few will stand on the right side ofthe table 3) The monitor is placed atthe surgeon's eye level at the patients right shoulder (Fig 15.1). naesret Laparoscopic ¢ Cm D> qu M Serb ure Fests carers pear Instrument tate Fig, 15.1. The authors favoured operating room set-up for laparoscopic cholecystectomy. 4) The pneumoperitoncum may be safely established by ether an ‘open cut-down of through the use of a Veree needle. Although numerous safe techniques exist for an open approach, the at ‘hors favour a 1-cm vertical supraumbilical incision with sharp scissor dissection down co the linea alba. A stay suture is then placed ether side of the midline and the sheath and peritoneum Incsed to enter the peritoneal cavity whist maintaining upward ‘action on the fascial stay stitches. A Blunt wocar is then used to insert a 10- or I1-mm cannila to be used asthe optical por. An. operating pressure of 12 matlg is fwvoured, B/C a Veress needle technique is preferred, this is introduced {rough a similarly sted skin incision and gentle upward traction applied by grasping the surrounding skin ofthe abdominal wall ‘until two distinct clicks ofthe needle ae felt as it pastes through fret the abdominal wall fascia and then the peritoneum, Correct positioning can be confirmed by either placing a drop of saline at {he injection port ofthe needle withthe valve dosed ~ the fluid should be ‘sucked’ into the needle when the valve is opened and the abdominal wal lifted ~ or, alternatively the insufflation ma chine can be attached and should show a high flow rate and low intra-abdominal pressure, Following insulation of atleast 3 Lof gas and with an intra-abdominal pressure of 12 mmtlg, the nee: dle is removed and an armed, sharp tocar used t0 introduce the first port, again whilst maintaining traction on the upper abdom: inal wall. You must be certain of cortec positioning of the Veress needle and of an adequate periconeum prior to the bling Rsuteotl Late smn) Fig. 15.2. The standard port postions fora laparoscopic cholecystectomy the supraumbilial pots used forthe laparoscope land may need to be placed more cranially in the larger patient. insertion of a sharp port and if in any doubt, should consider reverting to an open introduction technique 6 Following insertion of the optical port, the laparoscope should be introduced and a full inspection of the abdominal contents performed to identify concomitant pathology outside ofthe v Cinity ofthe gallbladder. 7) Tle dhe operating table head-up and to the patient's left in order to facilitate an optimal view. 8) A standard four por laparoscopic cholecystectomy requires the intoduction of three further perts which should be introduced, under direc vision and usually consist ofa further 11-mm port in the epigastrium, one S-mm port in the right upper quadrant and a further 5-mm port in the right lower quadrant (Fig. 15.2) [A three-port cholecystectomy has also been described whereby all retraction is supplied by the surgeon's left hand instrument and thee is no dedicated fandal retractor, There has been no ev- idence that the elimination of the fourth port alters outcome in, leis of postoperative pain or complications ~ nor have there been any studies addressing safety of the three-port technique 19) Divide any omental o: visceral adhesions to expose the fundus of the gallbladder, which is then grasped with a suitably robust, ratcheted instrument inserted through the RLQ port and retracted cranially to expose Hartman's pouch and Calot's triangle (the area between the cystic duct, common hepatic duct and liver), 0 IF the view is obscured by distended duodenum or stomach then the anaesthetist should be asked to aspirate via a nasogastric tube. AU Apply action to Hartmann's pouch using a suitable instrument (Johann or dolphin grasper) in your left hand and use an {instrument for dissection inthe right hand ~ usually a diathermy. Line of pttnesl_ cyte ve "reson 3tery Conran bles Hermans Cys uct ue Fig. 15. ‘The intial peritoneal incision for laparoscopic cholecystectomy should free Hartmann’s pouch and cross Calor’ triangle, Extending the initial incision a litle way along the medial and lateral borders of the gallbladder with the liver will increase mobility of Hartman's pouch and facilitate the dissection of Calot's wviangle. hook, scissors, curved dissecting forceps or a combination of the above, {12 Sake aperitoneal incision atthe medial aspect of thelowerborder ff Hartmann’s pouch and continue to divide the peritoneum around the base ofthe gallbladderand extended alittle way up each ‘ofthe medial and lateral borders with the live (Fig. 153). This will ‘increase mobility and facilitate the dissection of Calo’ wiangle Carefully dissect Calot's uiangle to expose the cystic duct and ar (ery (with the artery usually, but not always lying between the cojstic duct and liver plate and usually related to a cystic lymph node}, Following isolation ofthese structures, about 1/3 of the proximal gallbladder should be dissected from the liver in order to be sure ofthe correct identity ofthe cystic structures the so called critical view of safety (Fg. 15.4) B 1 Only when you are absolutely satisfied that the structures are the cystic artery and duct may they be secured and divided, Mechanical clips are the commonest technique used (either metal Fig. 15.4 Thecritial view of safety includes a ‘clean distection’ of the ‘pstc artery and duct with separation of the proximal 13 of the {gallbladder wall from the liver bed. This ensures that the structures isolated are indeed the cystic structures and that they de net re-enter the liver 259 15 © BILIARY TRACT 260 or polypropylene) and usually the sirctutes are clipped twice proximally and once distally before division with scissors, ensur ng hat a safe cuff of tissue is let beyond the proximal clipe (atleast 3 mm). 415 Now grasp Hartmann's pouch with your left hand and react it cranially to facilitate dissection ofthe gallbladder from the liver ‘bed in the layer of the cystic plate 6 Care should be taken not to stray too deeply towards the liver substance as the middle hepatic vein can lie quite superficially within the gallbladder bed and will be the source of significant and difficultto-control haemorhage if injured 7 A small blood vessel or occasionally a bile duct (of Lushka) may be encountered during dissection of the cystic plate ~ these should be clipped proximally if they ae to be divided {8 The final dissection ofthe fundus of the gallbladder from the liver bed is facilitated by conversion to caudal traction with the fundal sgrasper. However, the cystic stuctures and the gallbladder bed should be checked for haemostasis and bile leaks prior to di sion of the final gallbladder atachments, a retraction is more difficult when the gallbladder has been completely detached. {19 Retrieve the gallbladder in an impermeable extraction bag to min- imige the risk of port site infection and to protect the wound inthe initequent ease ofan incidental carcinoma Estacion is best pet= fotmed through the umbilical port as this fascial incision is ws ally the largest and the simplest to extend and subsequently cose. 120, Make a final inspection of the operative fied to exclude bleeding And bile leaks and remove each port under direct vision, again to check haemostasis. [BH Close the 11-mm fascial defects using an 0 absorbable sure, The 5-mm ports are not often closed routinely, hough some surgeons ‘would advocate doing s to avoid the inftequent hernias encoun- tered through these por sits. BE Close the skin according to your own preference and instil local anaestheticinto each of the wounds, bated on the safe maximum, dose for the individual patient. 1. Ifyou cannot extract the gallbladder from the por site ‘then open a portion of the gallbladder wall that you have been able to deliver between clips and use the laparoscopic sucker to aspirate bile from the portion of ‘the organ that is lodged inside the abdomen, taking care: not to spill bile outside of the bag and onto the wound. 2. Ifthe gallbladder still eannot be removed ~ pass some Rampley’ssponge holding forceps through the hole in the gallbladder and extract some stones, of let the organ pass back into the abdomen (keeping hold of the retrieval bag) and extend the skin and fascial incisions OPEN TECHNIQUE Appraise | The majority of cholecystectomies are now performed laparoseo pically, with the open procedure usually reserved for cates where laparoscopic progress isimpossible or when the gallbladder is be- {ing removed in conjunction with another procedue that it being, performed via an open technique 2) The presence of previous upper abdominal incisions is not an ab- solute contraindication to laparoscopic surgery Itis usually pos sible to insert a laparoscope and take down adhesions (pethaps with a slight modification of the port positioning) in order to proceed to a laparoscopic cholecystectomy, Prepare 1) The same preoperative steps are required as for the laparoscopic procedure. In addition, antibiotic prophylaxis against wound infection is usually given in all cases Action 1 The surgeon usually stands on the patient’ right side with the fiet assistant and scrub nurse opposite. A second asistant is very useful ifavalable, and should stand to the surgeon's left. 2) Make a transverse subcostal incision on the right hand side and deepen this using monopolar diathermy through the fat layer,

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