GALL BLADDER

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GALL BLADDER

• BY
• DR.
• HAYDER M. ABDULNABI
• MD, CABS

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ANATOMY

• PEAR-SHAPED, 7.5-12.5 CM
• NORMAL CAPACITY- 50 ML
• FUNDUS, BODY, NECK (TERMINATES IN A NARROW
  INFUNBIBULUM)
• ( HARTMANNS POUCH- A DILATATION IN THE NECK DUE
  TO AN IMACTED STONE)
• CRISS-CROSS MUSCLE COAT (WELL DEVELOPED IN THE
  NECK)
• GLANDULAR MUCOUS MEMBRANE WITH CRYPTS OF LUSCHA

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• THE CYSTIC DUCT 2.5 CM (CONTAINS THE SPIRAL VALVE
  OF HEISTER)
• THE COMMON HEPATIC DUCT 2.5CM (UNION OF RT AND LT
  HEPATIC DUCTS)
• THE COMMON BILE DUCT 7.5CM (JUNCTION OF CHD AND
  THE CYSTIC DUCT), OF 4 PARTS

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• 1- SUPRADUODENAL 2.5CM (RUNS IN THE FREE EDGE OF
  LESSER OMENTUM
• 2- RETRODUODENAL
• 3- INFRADUODENAL
• 4- INTRADUODENAL (PASSES OBLIQUELY THROUGH 2ND
  PART OF DUODENUM, SURROUNDED BY THE SPHINCTER OF
  ODDI, OPENS AT THE SUMMIT OF THE PAPILLA OF VATER

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THE ARTERIAL SUPPLY OF THE GALL BLADDER

• THE CYSTIC ARTERY (BRANCH OF THE RT HEPATIC
  ARTERY), USUALLY BEHIND THE CBD
• ACCESSORY CYSTIC ARTERY (OCCASIONAL)(BRANCH OF
  THE GASTRODUODENAL ARTERY)

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LYMPHATICS

• SUBSEROSAL AND SUBMUCOSAL DRAIN INTO THE CYSTIC
  LYMPH NODE OF LUND (SENTINEL LN) THEN TO THE
  HILUM OF THE LIVER TO THE COELIAC LYMPH NODES
• SUBSEROSAL LYMPHATICS CONNECT WITH THE
  SUBCAPSULAR LYMPHATICS OF THE LIVER (FREQUENT
  SPREAD OF GALL BLADDER CA TO THE LIVER)

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FUNCTIONS OF THE GALL BLADDER

• BILE IS COMPOSED OF 97 WATER, 1-2 BILE SALTS,
  1 PIGMENTS, CHOLESTEROL AND FATTY ACIDS
• LIVER EXCRETION RATE IS 40 ML/HOUR
• 1- RESERVOIR (FASTING CAUSE RESISTANCE INCREASE
  IN SPHINCTER OF ODDI) (FEEDING DECREASE THE
  RESISTANCE AND THE GALL BLADDER CONTRACTS BY THE
  ACTION OF CHOLECYSTOKININ RELEASED BY UPPER
  INTESTINAL MUCOSA IN RESPONSE TO FOOD
  PARTICULARLY FAT)

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• 2- CONCENTRATION OF BILE 5-10 TIMES ( BY ACTIVE
  ABSORBTION OF WATER, SOD. CHLORIDE, AND
  BICARBONATE) WITH INCREASE IN THE PROPORTION OF
  BILE SALTS, PIGMENTS, CHOLESTEROL AND CALCIUM
• 3- MUCIN SECRETION, 20ML/HOUR

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INVESTIGATIONS OF THE BILIARY TRACT

• 1- PLAIN RADIOGRAPH-- (RADIO-OPAQUE STONE 10,
  PORCLAIN GALL BLADDER, LIMEY BILE, AIR)
• 2- ORAL CHOLECYSTOGRAPHY-- (A CONTROL X-RAY IS
  TAKEN THE DAY BEFORE AND IOPANOIC ACID CONTRAST
  MEDIUM TABLETS IS TAKEN ORALLY AT NIGHT, THE NEXT
  DAY ERRECT AND SUPINE X-RAY IS TAKEN TO THE RT
  HYPOCHONDRIUM AND X-RAY REPEATED TO OBSERVE GALL
  BLADDER CONTRACTION(

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RADIO-OPAQUE STONES
PLAIN X- RAY
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PLAIN X-RAY
PORCLAIN GB
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AIR
PLAIN X-RAY
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ORAL CHOLECYSTOGRAM
STONES
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• NONVISUALIZATION (NONFUNCTIONING) GALL BLADDER IS
  DUE TO-- FAILURE OF THE PATIENT TO TAKE THE
  TABLETS, VOMITING, MALABSORBTION, IMPAIRED LIVER
  FUNCTION, BLOCKED CYSTIC DUCT,SEVERE GALL BLADDER
  DISEASE (FAILURE OF CONCENTRATION)

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• 3- INTRAVENOUS CHOLANGIOGRAM USING INTRAVENOUS
  RADIO-OPAQUE MEDIUM TO SHOW THE BILE DUCTS, MAY
  BE USED WITH ORAL CHOLECYSTOGRAM OR TOMOGRAPHY (A
  METHOD TO PUT ONE GIVEN PLANE INTO SHARP FOCUS
  WHILE BLURRING OTHERS)

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• 4- ULTRASONOGRAPHY (NONINVASIVE)
• AND SHOWS BILIARY CALCULI, DILATION OF BILIARY
  TREE,CA HEAD PANCREAS, WALL THICKNESS, GALL
  BLADDER SIZE, HALLO SIGN
• 5- RADIOISOTOP SCANNING USING RADIOACTIVE
  IODINE(131) OR Tc(99)
• 6- COMPUTED TOMOGRAPHY IN OBESE OR PATIENTS WITH
  GASEOUS DISTENTION THAT MAKE ULTRASONOGRAPHY
  DIFFICULT

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GB
STONE
ACOSTIC SHADOW
US
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STONE
CBD
ACOSTIC SHADOW
ULTRASONOGRAPHY
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• 7- ENDOSCOPIC RETROGRADE CHOLAGIOPANCREATOGRAPHY
• (ERCP) BY CANNULATION OF THE AMPULLA OF VATER
  USING FIBEROPTIC DUODENOSCOPE AND INJECTION OF
  CONTRAST MEDIUM ,TO TAKE SAMPLE FOR CULTURE AND
  BRUSHING FOR CYTOLOGY. ITS USE CAN BE EXTENDED TO
  DO PAPILLOTOMY TO EXTRACT STONES, PASSING
  CATHETER OR DORMIA BASKET, AND STENT PLACING
  THROUGH STRICTURES.
• IT MAY CAUSE ASCENDING BILIARY INFECTION, SO
  SHOULD BE DONE UNDER ANTIBIOTICS COVER

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DUCT OF WIRSUNG
CATHETER IN THE AMPULLA
ERCP
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• 8- PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAPHY-
  INJECTION OF CONTRAST MEDIUM THROUGH A CHIBA OR
  OKUDA NEEDLE (15CM LONG , 0.7MM IN DIAMETER) INTO
  THE LIVER THROUGH THE 8TH INTERCOSTAL SPACE IN
  THE MIDAXILLARY LINE.
• IT CAN BE USED TO PUT A CATHETER FOR DRAINAGE
  OR STENT FOR ANTEGRADE DRAINAGE.
• BLEEDING TENDENCY IS A CONTRA INDICATION AND
  THE PROCDURE SHOULD BE DONE UNDER ANTIBIOTICS
  COVER

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CHIBA NEEDLE
PER CUTANEOUS TRANSHEPATIC CHOLANGIOGRAM
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• 9- PEROPERATIVE CHOLANGIOGRAPHY BY TAKING X-RAY
  DURING OPERATION AFTER INJECTING THE CONTRAST BY
  A POLYTHENE CATHETER INTRODUCED INTO THE CBD
  THROUGH AN OPENING IN THE CYSTIC DUCT TO DETECT
  ANY STONE IN THE CBD BEFORE EXPLORATION.
• FAILURE OF THE CONTRAST TO ENTER THE DUODENUM
  MAY BE ALSO DUE TO SPHINCTER SPASM AND HERE
  SUCCINYLCHOLINE IS GIVEN TO EXCLUDE THIS
  POSSIBILITY
• 20 OF CASES THE MEDIUM ENTER THE DUCT OF
  WIRSUNG AND IT IS NOT NECESSARILY PATHOLOGICAL
  

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CATHETER
PER- LAPAROSCOPIC CHOLANGIOGRAPHY
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CATHETER
CBD
DUODENUM
PER-OPERATIVE CHOLANGIOGRAM
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• 10- OPERATIVE BILIARY ENDOSCOPY (CHOLEDOCHOSCOPY)
• 11- PEROPERATIVE POSTEXPLORATORY CHOLANGIOGRAPHY
  (THROUGH THE T- TUBE)
• 12- POSTOPERATIVE CHOLANGIOGRAPHY (T-TUBE), 10-14
  DAYS AFTER CHOLEDOCHOTOMY

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STONE IN CBD
PER-OPERATIVE CHOLANGIOGRAPH
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Rt HEPATIC DUCT
Lt HEPATIC DUCT
PER-OPERATIVE CHOLEDOCHOSCOPE
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STONE IN COMMON HEPATIC DUCT
T-TUBE
T-TUBE CHOLANGIOGRAM
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CONGENITAL ANOMALIES OF THE GALL BLADDER AND BILE
DUCTS

• 1. ANOMALIES OF THE GALL BLADDER- ABSENCE
• PHRYGIAN CAP (HAT OF THE PEOPLE OF PHRYGIA IN
  ANCIENT ASIA MINOR)
• (FRENCH REVOLUTION LIBERTE CAP)
• FLOATING GALL BLADDERTORTION
• DOUBLE GALL BLADDER

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• 2. ANOMALIES OF THE DUCTS-
• ABSENCE
• ATRESIA
• CONGENITAL DILATATION OF INTRAHEPATIC DUCTS
• CHOLEDOCHAL CYST
• LOW INSERTION OF CYSTIC DUCT
• ACCESSORY CHOLECYSTOHEPATIC DUCT

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• 3. ANOMALIES OF THE ARTERIES-
• RT HEPATIC ARTERY AND OR CYSTIC ARTERY CROSS
  IN FRONT OF THE CHD
• HEPATIC ARTERY TAKE A TORTOUS COARSE IN FRONT
  OF THE ORIGIN OF THE CYSTIC DUCT
• RT HEPATIC ARTERY IS TORTOUS AND THE CYSTIC
  ARTERY IS SHORT (CATERPILLAR TURN)
• ACCESSORY CYSTIC ARTERY

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GALL STONES(CHOLELITHIASIS)

• MIXED STONES- 90, CHOLESTEROL IS THE MAJOR
  COMPONENT, Ca CARBONATE, Ca PHOSPHATE, Ca
  PALMITATE AND PROTEIN (USUALLY MULTIPLE AND
  FACETED)
• 2. CHOLESTEROL STONES- (CHOLESTEROL SOLITAIRE)
• 3. PIGMENT STONES- (SMALL, BLACK, MULTIPLE)

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MIXED STONES
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MIXED STONES
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CHOLESTEROL STONES
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PIGMENTSTONES
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• LIMEY BILE- OCCUR WHEN THERE IS GRADUAL
  OBSTRUCTION TO THE CYSTIC DUCT OR THE CBD
  (CHRONIC PANCREATITIS, CA PANCREAS)
• THE GALL BLADDER WILL BE OPAQUE IN A PLAIN X-RAY
  (FILLED BY Ca CARBONATE AND Ca PHOSPHATE) WHICH
  IS THE COMPONENTS OF TOOTH PASTE

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• CHOLESTEROL IS HELD IN SOLUTION BY THE DETRERGENT
  EFFECT OF BILE SALTS AND PHOSPHOLIPID
  (LECITHINE)TO FORM MICELLES.
• ANY CHANGE IN THE EQUILIBRIUM BETWEEN THESE
  THREE ELEMENTS WILL LEAD TO GALL STONE FORMATION

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HYDROPLYLIC END
HYDROPHOBIC END (CHOLESTEROL)
BILE SALT MICELLE
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PATHOGENESIS OF GALL STONE FORMATION

• METABOLIC- INCREASE CHOLESTEROL LEVEL IN
  BILE(SUPERSATURATED OR LITHOGENIC BILE), WITH
  AGE, FEMALE ( CONTRCEPTIVE PILLS), OBESITY,
  PATIENTS ON CLOFIBRATE
• BILE SALTS DECREASE BY INTERRUPTION OF
  ENTERO-HEPATIC CIRCULATION( ILEAL DISEASSE,
  RESECTION, BYPASS SURGERY, CHOLESTYRAMINE)
• ESTROGEN DECREASE CONCENTRATION OF BILE SALT IN
  THE BILE(CCP)

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CHOLESTEROL SOLUBILITY STATUS
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• 2. INFECTION- NIDUS
• 3. BILE STASIS- GALL BLADDER CONTRACTILITY
  DECREASE IN PREGNANCY, BY ESTROGEN(CCP), AFTER
  TRUNCAL VAGOTOMY, PATIENTS ON TPN ( LACK OF GOOD
  ORAL INTAKE) CAUSE DECREASE IN CHOLYCYSTOKININ
  SECRETION

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• 4. PIGMENT STONES OCCUR WITH HEMOLYSIS(
  HEREDITARY SPHEROCYTOSIS, SICKLE CELL ANEMIA,
  THALASSEMIA, MALARIA)
• WHERE BILIRUBIN PRODUCTION WILL INCREASE.
• PIGMENT STONES ALSO INCEASE WITH BENIGN AND
  MALIGNANT STRICTURES AND WITH PARASITE
  INFESTATION OF THE BILIARY DUCTS( ASCARIS
  LUMBRICOIDES, CHLONORCHIS SINENSIS)

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INCIDENCE OF GALL STONES

• FAT, FERTILE, FLATULENT, FEMALE, FIFTY- IS THE
  USUAL SUFFERER OF GALL STONES
• IT CAN OCCUR AT ANY AGE AND IN BOTH SEXES
• TOW THIRD ARE ASYMPTOMATIC
• SAINTS TRIAD- GALL STONES
• DIVERTICULOSIS
• HIATUS HERNIA

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COMPLICATIONS OF GALL STONES

• 1.IN THE GB- SILENT( NO INDICATION FOR OPERATION)
• CH CHOLECYSTITIS
• AC CHOLECYSTITIS
• GANGRENE
• PERFORATION
• EMPYEMA
• MUCOCELE
• CARCINOMA
• 2. IN THE BILE DUCTS-
• OBSTRUCTIVE JAUNDICE
• CHOLANGITIS
• ACUTE PANCREATITIS
• 3. IN THE INTESTINE-
• ACUTE INTESTINAL
  OBSTRUCTION (GALL STONE ILEUS)

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CHRONIC CALCULOUS CHOLECYSTITIS

• THICK, FIBROTIC WALL, BACTERIA ISOLATED IN LESS
  THAN 30 OF CASES FROM THE BILE AND SUGGESTS A
  CHEMICAL IRRITANTS IN THE BILE RATHER THAN
  BACTERIAL AS A CAUSE IN THE OTHER CASES

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CHRONIC CHOLECYSTITIS
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SIGNS AND SYMPTOMS

• Rt HYPOCHONDRIAL PAIN-
• DISCOMFORT TO EXCRUTIATING PAIN(BILIARY COLIC)
• RIADITES TO THE Rt SHOULDER
• PRESIPITATED BY FATTY MEAL
• ASSOCIATED BY NAUSEA AND VOMITING
• TENDERNESS IN THE Rt HYPOCHONDRIUM
• MURPHYS SIGN MAY BE POSITIVE
• (IF PAIN LASTS MORE THAN 12 HOURS, TEPERATURE
  INCREASE, AND WBC INCREASE, CONSIDER THE
  DIAGNOSIS OF AC CHOLECYSTITIS)

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DIAGNOSIS

• ULTRASONOGRAPHY IS USUALLY THE ONLY INVESTIGATION
  REQUIRED
• TREATMENT
• ANALGESICS INCLUDING OPIATES (SIMULTANEOUS
  INJECTION OF HYOSCINE BUTYLBROMIDE IS NEEDED TO
  ENCOUNTER THE EFFECT OF OPIATES ON THE SPHINCTER
  OF ODDI)
• ANTIEMETICS
• LOW FAT DIET UNTIL------
• CHOLECYSTECTOMY
• (DISSOLUTION OF GALL STONES HAS NO LONGER A ROLE
  IN THE TREATMENT OF GALL STONES)

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ACUTE CALCULOUS CHOLECYSTITIS

• THE GALL BLADDER OFTEN ALREADY AFFECTED BY
  CHRONIC CHOLECYSTITIS
• 95 OF CASES THE STON IS IMPACTED IN THE
  HARTMANNS POUCH OR OBSTRUCTING THE CYSTIC DUCT
• MICRO-ORGANISMS CAN BE ISOLATED IN MOST OF THE
  CASES FROM THE BILE OR GB WALL
• (E.COLI, STRTEP.FECALIS, BACTEROIDES, RARELY
  CLOSTRIDIA AND TYPHOID)

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ACUTE CHOLECYSTITIS
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SEQUELAE OF ACUTE CHOLECYSTITIS

• RESOLUTION- BY BACK SLIPPING OF THE STONE(MUCOUS
  MEMBRANE LIFTING), AND RELEASE OF MUCOID OR
  MUCOPURULENT CONTENT
• 2. EMPYEMA(PYOCELE)- WHEN THE OBSTRUCTION
  PERSISTS
• 3. PERFORATION- LEADS TO LOCAL ABSCESS OR
  GENERALIZED PERITONITIS
• (FUNDUS AND NECK)

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SIGNS AND SYMPTOMS

• PAIN
• NAUSEA AND VOMITING
• PYREXIA(38C OR MORE)
• TENDERNESS
• MURPHYS SIGN
• PALPABLE GB
• BOASS SIGN

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DIAGNOSIS

• ULTRASONOGRAPHY
• DIFFERENTIAL DIAGNOSIS
• APPENDICITIS
• PERFORATED PEPTIC ULCER
• ACUTE PANCREATITIS
• ACUTE PYELONEPHRITIS (Rt)
• MYOCARDIAL INFARCTION
• BASAL PNEUMONIA (Rt)

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TREATMENT

• 1.CONSERVATIVE TREATMENT FOLLOWED BY
  CHOLYCYSTECTOMY
• (90 OF CASES WILL SUBSIDE) BY
• A. NASOGASTRIC ASPIRATION
• B. I V FLUID
• C. ANALGESIA
• D. ANTIBIOTICS (AGAINST GRAM -NEGATIVE AEROBES)
• C. INTERVAL CHOLECYSTECTOMY (4-6 MONTHS)
• AFTER THE ACUTE EPISODE HAS RESOLVED

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• 2. EARLY CHOLECYSTECTOMY SHOULD BE DONE WITH IN
  72 HOURS FROM THE ONSET OF ACUTE SYMPTOMS (GOLDEN
  PEROID)
• 3. EMERGENCY CHOLECYSTECTOMY- DONE AT ANY TIME
  NEEDED, WHEN DIAGNOSIS IS DOUBTFUL(ACUTE HIGH
  RETROCAECAL APPENDICITIS)
• OR WHEN THERE IS PERFORATION

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MUCOCELE AND EMPYEMA

• MUCOCELE- THE BILE IS ABSORBED AND REPLACED BY
  MUCIN SECRETION(STERILE BLADDER NECK OBSTRUCTION
  BY A STONE OR MALIGNANCY)
• EMPYEMA- GALL BLADDER FILLED WITH PUS EITHER AS
  A SEQUELE OF AC CHOLECYSTITIS OR A MUCOCELE
  BECOME INFECTED

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MUCOCELE OF THE GB
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MUCOCELE OF THE GB WITH STONE IN THE HART. POUCH
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ACALCULOUS CHOLECYSTITIS

• CHOLECYSTOSIS
• NOT UNCOMMON GROUP OF CHRONIC INFLAMATION AND
  HYPERPLASIA OF ALL TISSUE ELEMENT-
• CHOLESTEROSIS(STRAWBERRY GB)- WITH A STRAWBERRY
  INTERIOR AND YELLOW SPECKS (SEEDS OF CHOLESTEROL
  CRYSTALS)
• CHOLESTEROL POLYPS- MUCH LESS NUMEROUS AND LARGER
  THAN THE YELLOW SEEDS
• CHOLYCYSTITIS GLANDULARIS PROLIFERANS-
• (POLYPS, ADENOMYOMATOSIS, INTRAMURAL
  DIVERTICULOSIS)

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NEW TECHNIQUES FOR GALL STONES

1. LITHOTRIPSY- EXTRACORPORIAL SHOCK WAVE
2. PERCUTANEOUS CHOLECYSTOLITHOTOMY- USING A
   NEPHROSCOPE UNDER US CONTROL
3. LAPAROSCOPIC CHOLECYSTECTOMY
4. MINICHOLECYSTECTOMY

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INDICATIONS FOR CHOLEDOCHOTOMY AT CHOLECYSTECTOMY

1. STONES FELT IN THE CBD
2. THERE IS JAUNDICE OR HISTORY OF JAUNDICE OR
   RIGOR(CHOLANGITIS)
3. DILATED CBD(10mm OR MORE)
4. ABNORMAL LFT IN PARTICULAR A RAISED ALKALINE
   PHOSPHATASE
5. PRESENCE OF SINGLE FACTED STONE IN THE GALL
   BLADDER

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POSTCHOLECYSTECTOMY SNDROME

• PERSISTENCE OF SYMPTOMS AFTER GALL BLADDER
  REMOVAL DUE TO-
• DISEASES OTHER THAN THE BILIARY TRACT(HIATUS
  HERNIA, PEPTIC ULCER, PANCREATITIS,
  DIVERTICULITIS OR IRRITABLE BOWWEL SYNDROME)
• 2. BILIARY CAUSES- A- RETAINED STONE IN THE
  CBD
• B- LONG CYSTIC
  DUCT STUMP IS LEFT
• C- CBD OPERATIVE
  DAMAGE (STRICTURE FORMATION)

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STONES IN THE COMMON BILE DUCT

• EITHER SECONDARY DUE TO PASSAGE OF STONES FROM
  THE GALL BLADDER OR RARELY PRIMARY STONES OCCUR
  WITH IFESTATION OF THE BILIARY TREE BY ASCARIS
  LUMBRICOIDES AND CLONORCHIS SINUNSIS.
• THESE STONES EITHER LEAD TO OBSTRUCTION OR
  INFECTION)CHOLANGITIS)

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SIGNS AND SYMPTOMS

• ASYMPTYMATIC
• PAIN
• JAUNDICE (INTERMITTENT OR PERSISTENT)(DARK
  URINE,PALE STOOL, PRURITIS)
• FEVER AND RIGOR (CHOLANGITIS)
• (CHARCOTS TRIAD)
• TENDERNESS
• IMPALPABLE GB (FIBROTIC AND INCOMPLETE
  OBSTRUCTION)
• COURVOISIERS LAW

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DIFFERENTIAL DIAGNOSIS

• PANCREATIC CA
• VIRAL HEPATITIS
• DRUG INDUCES
• PRIMARY BILIARY CIRRHOSIS
• DIAGNOSIS
• US, ERCP, PTC
• COMPLICTIONS
• BILIARY CIRRHOSIS
• SUPPURATIVE CHOLANGITIS (LIVER ABSCESSES,
  SEPTICAEMIA)

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PRE-OPERATIVE MANAGEMENT OF OBSTRUCTIVE JAUNDICE

• 1. HIGH INTAKE OF GLUCOSE (BUILD UP LIVER
  GLYCOGEN STORE)
• 2. VITAMIN K (FAT SOLUBLE), 10mg IV OR IM
• 3. ANTIBIOTICS (BROAD SPECTURUM)
• 4. HYDRATION (PEVENT RENAL FAILURE) (5 DEXTROSE
  TO ENSURE 30 ml/HOUR URINE FLOW)

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SURGICAL PROCDURES

• 1. ENDOSCOPIC PAPILLOTOMY (DORMIA BASKET, BALLOON
  CATHETER)(STENT TO RELIEVE SYMPTOMS)
• 2. PERCUTANEOUS REMOVAL OF STONES BY BURHENNE
  METHOD (T- TUBE LEFT FOR SIX WEEKS AND THEN
  REMOVED, DILATION OF THE MATURE TRACT, STEERABLE
  CATHETER, AND THEN STONE BASKET)
• 3. PERCUTANEOUS BILIARY DRAINAGE (PTC), IN THE
  VERY ILL
• 4. SUPRADUODENAL CHOLEDOCHOTOMY WITH OR WITH OUT
  TRANSDUODENAL SPHINCTEROTOMY OR
  CHOLEDOCHODUODENOSTOMY

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EXPLORATION OF THE CBD
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DILATED CBD
DORMIA BASKET
ERCP
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STRICTURE OF THE CBD

• BENIGN POSTOPERATIVE 80
• INFLAMMATORY
• MALIGNANT
• POSTOPERATIVE STRICTURE
• DUE TO TEQUNICHAL ERROR DURING CHOLECYSTECTOMY(
  15 ONLY RECOGNIZED DURING SURGERY)

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• CAUSES- 1. BLIND HAEMOSTAT APPLICATION IN AN
  EFFORT TO STOP UNEXPECTED BLEEDING ( PRINGLES
  MANOEUVRE )
• 2. TOO MUCH TRACTION ON THE GB
  3. FAILURE TO IDENTIFY CALOTS TRIANGLE(MUCH
  INFLAMMATION)
• 4. IGNORANCE OF THE ANATOMICAL
  ANOMALIES
• 5. LACERATION OF CBD (DURING
  EXPLORATION)
• PRESENTED EITHER AS A- PROFUSE BILIARY FISTULA OR
  BILIARY PERITONITIS (DRIN OR NO DRAIN)
  B- DEEPENING JAUNDICE (BY
  SUSEQUENT FIBROSIS)

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INVESTIGATION

• US, T-TUBE CHOLANGIOGRPHY, ERCP, PTC
• TREATMENT
• IMMEDIATE ROUX EN Y CHOLEDOCHOJEJUNOSTOMY IS THE
  BEST FOR BENIGN STRICTURES AND COMPLETE CBD
  TRANSECTION
• IN DEBILITATING PATIENTS, AN EXTERNAL DRAINAGE
  CATHETER OR BALLOON DILATION AND A STENT
• FOR MALIGNANT STRICTURES CHOLECYSTOJEJUNOSTOMY
• CHOLEDOCHOJEJUNOSTOMY
• STENTING

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CARCINOMA OF THE BG

• IT IS RARE AND FOUND IN LESS THAN 1 OF GB
  OPERATIONS, GALL STONES FOUND IN OVER 90 OF
  CASES, PATIENTS USUALLY IN THEIR 70S, FEMALEMALE
  RATIO OF 51
• THE USUAL TYPE IS SCIRRHOUS CA, BUT SEQUAMOUS OR
  MIXED SEQUAMOUS-ADENOCARCINOMA MAY BE FOUND
• SPREAD BY DIRECT INVASION OF THE LIVER AND TO THE
  PORTA HEPATIS
• DISTANT METASTASES ARE UNCOMMON

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SIGNS AND SYMOTOMS

• IT MAY BE FOUND DURING CHOLECYSTECTOMY
• MASS DUE TO THE TUMOUR OR OBSTRUCTION OF CYSTIC
  DUCT WHICH LEADS TO MUCOCELE
• CHOLECYSTITIS(OBSTRUCTION OF THE CYSTIC DUCT)
• JAUNDICE IN MORE THAN 50 OF CASES

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TREATMENT

• RESECTION OF THE GB WITH THE ADGACENT PART OF THE
  LIVER
• PALLATION TO RELIEVE JAUNDICE(STENT)
• 5 - YEAR SURVIVAL RATE IS 2-5, BUT IF THE TUMOUR
  FOUND DURING CHOLECYSTECTOMY, IT WILL REACH MORE
  THAN 50

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CHOLANGIOCARCINOMA(BILE DUCT CARCINOMA)

• IT IS MORE COMMON THAN GB CARCINOMA
• STONES PRESENT IN LESS THAN 30 OF CASES
• MALE ARE SLIGHTLY MORE THAN FEMALE
• USUALLY ADENOCARCINOMA
• THE PATIENTS ARE OLD AND PRESENTS LATER

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TRATMENT

• HILAR LESIONS RARELY RESECTABLE,
• AND MAY NEED EXTERNAL DRAINAGE FOLLOWED BY
  RADIOTHERAPY
• TUMOURS OF THE LOWER END MAY BE TREATED BY
  WHIPPLES OPERATION, OR STENTING

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BILIARY FISTULAS

• EXTERNAL AND INTERNAL
• 1 .EXTERNAL FISTULAS- NEARLY ALL FOLLOW BILIARY
  OPERATION ON THE BILIARY TRACT OR DUODENUM, FROM
  INJURY OR LEAKINK ANASTOMOSIS
• IT MAY PERSIST IF THERE IS DISTAL OBSTRUCTION
• CAN BE ASSESSED BY SINOGRAM OR ERCP
• 2. INTERNAL FISTULAS- WHEN A GALL STONE ULCERATE
  THROUGH THE GB INTO THE STOMACH, DUODENUM, OR
  COLON
• IT MAY CAUSE AIR TO BE SEEN IN PLAIN RADIOGRAPH
• IF LARGE ENOUGH, IT MAY LEAD TO SMALL BOWEL
  OBSTRUCTION
• OBSTRUCTION OF THE COLON GIVES THE SUSPITION OF
  UNDERLYING CARCINOMA CAUSING NARROWING OF THE
  LUMEN

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LAPAROSCOPIC CHOLECYSTECTOMY

• THE INDICTION ARE THE SAME AS FOR OPEN
  CHOLECYSTECTOMY
• ADVANTAGES
• 1. LESS POST-OPERATIVE PAIN
• 2. SMALLER INCISIONS
• 3. BETTER COSMESIS
• 4. SHORTER HOSPITALIZATION
• 5. EARLIER RETURN TO FULL ACTIVITY
• 6. DECREASED TOTAL COSTS

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DISADVANTAGES

• 1. LACK OF DEPTH PERCEPTION
• 2. VIEW IS CONTROLLED BY CAMERA
• 3. MORE DIFFICULT TO CNTROL BLEEDING
• 4. DECREASD TACTILE DISCRIMINATION
• 5. POTENTIAL CO2 INSUFFLATION COMPLICATIONS
• 6. ADHESIONS AND INFLAMMATION LIMIT ITS USE
• 7. SLIGHT INCREASE IN BILE DUCT INJURY

85
COMPLICATIONS OF LC

• A. GENERAL- 1. HEMORRHAGE
• 2. BILE DUCT INJURY
• 3. BILE LEAK
• 4. RETAINED STONES
• 5. PANCREATITIS
• 6. WOUND INFECTION

86

• B. PNEUMOPERITONEUM RELATED
• 1. C02 EMBOLISM
• 2. VASO-VAGAL RFLEX
• 3. CARDIAC ARRYTHMIAS
• 4. HYPERCARBIC ACIDOSIS
• C. TROCAR RELATED
• 1. ABDOMINAL WALL
  BLEEDING, HEMATOMA
• 2. VISCERAL INJURY
• 3. VASCULAR INJURY

87
LC THEATRE
88
VERES NEEDLE
89
TELESCOPE
90
DISSECTING CALOTS TRIANGLE
91
GB DISSEC. BY DIATHERMY
92
GB RETRIEVAL BAG