24 Questions
What are the potential long-term complications associated with spilled or retained gallstones?
Abscess and fistula formation
What are some factors that increase the rate of conversion to an open procedure during laparoscopic cholecystectomy?
Emergent cholecystectomy, male sex, age >60 years, obesity, severe GB inflammation, choledocholithiasis, and prior upper abdominal surgery
In which situations is open cholecystectomy typically performed?
When patients have contraindications to LC, require conversion from LC, or are undergoing laparotomy for another operation
Why should conversion to an open operation during laparoscopic cholecystectomy not be viewed as a failure or complication?
Because it is a way to avoid potential injury to the patient
What is the purpose of partial cholecystectomy in the setting of severe acute inflammation?
To safely identify ductal and vascular structures in the triangle of Calot
What conditions are associated with the development of benign strictures?
Chronic pancreatitis, choledocholithiasis, primary sclerosing cholangitis, prior hepatic transplantation, trauma, or iatrogenic injury
What is the significance of primary sclerosing cholangitis in the context of benign strictures?
It is one of the underlying conditions that can cause benign strictures
How does hepatic transplantation relate to the development of benign strictures?
Prior hepatic transplantation is a risk factor for benign strictures
What is the incidence of major bile duct injury associated with LC?
2.5/1,000
What is the importance of dissecting the triangle of Calot free of fat, fibrous, and areolar tissue?
To demonstrate only two structures (cystic duct and cystic artery) entering the gallbladder, ensuring a critical view of safety.
What is the role of IOC in laparoscopic cholecystectomy?
To assist with anatomical definition, especially when the critical view is not achieved.
What is the commonest cause of biliary injury during laparoscopic cholecystectomy?
Mis-identification of the cystic duct
What is the contraindication for laparoscopic cholecystectomy in young patients?
Relative indication, not an absolute contraindication
What is the boundary of the hepatocystic triangle?
Upper boundary is the inferior border of the liver, lateral boundary is the cystic duct and neck of the gallbladder, and medial boundary is the common hepatic duct.
What is the significance of the critical view of safety in laparoscopic cholecystectomy?
It ensures that only two structures (cystic duct and cystic artery) enter the gallbladder, reducing the risk of biliary injury.
What is the risk of injury to other structures during laparoscopic cholecystectomy?
Injury to the hepatic artery and the bowel.
What is the main cause of acute cholangitis, a potentially life-threatening bacterial infection of the biliary tree?
Obstruction of the ductal system, often associated with choledocho-lithiasis, benign and malignant strictures of the bile ducts or at biliary-enteric anastomoses, parasites, and indwelling tubes or stents.
Why is it essential to pre-treat patients with antibiotics before ERCP in the presence of a stricture?
To prevent cholangitis above the stricture in case a stent cannot be placed.
What is Charcot's triad, and how common is it in patients presenting with acute cholangitis?
Charcot's triad is fever, jaundice, and right upper quadrant pain, and it is present in 50-70% of patients.
What is the primary event that incites gallstone pancreatitis?
Pancreatic ductal obstruction caused by the passage of gallstones through the cystic duct and into the distal common bile duct (CBD).
What type of gallstones are more likely to cause gallstone pancreatitis?
Small gallstones, or microlithiasis, which are more likely to escape the gallbladder and transit the cystic duct to reach the CBD.
What is the name of the condition where gallstones pass through the cystic duct and into the distal CBD, causing pancreatic ductal obstruction?
Gallstone pancreatitis or biliary pancreatitis.
What is the risk of not decompressing the bile duct, especially in the presence of a stricture?
Incomplete biliary decompression can lead to acute cholangitis.
What is the significance of routine antibiotic pre-treatment before ERCP in patients with strictures?
It reduces the risk of cholangitis in case a stent cannot be placed.
Study Notes
Complications of Gallstones
- Spilled and retained gallstones can lead to infrequent but serious long-term complications such as abscess and fistula formation.
- Factors associated with an increased rate of conversion to an open procedure include emergent cholecystectomy, male sex, age >60 years, obesity, severe GB inflammation, choledocholithiasis, and prior upper abdominal surgery.
Open Cholecystectomy
- Open cholecystectomy is performed in patients who have contraindications to laparoscopic cholecystectomy (LC), who require conversion from LC, or who are undergoing laparotomy for another operation.
- Conversion to an open operation should never be viewed as a surgical failure or complication, but rather as a way to avoid potential injury to the patient.
- A partial cholecystectomy is advocated when the ductal and vascular structures in the triangle of Calot cannot be safely identified in the setting of severe acute inflammation.
Benign Strictures and Bile Duct Injuries
- Benign strictures occur in association with chronic pancreatitis, choledocholithiasis, primary sclerosing cholangitis (PSC), prior hepatic transplantation, trauma, or iatrogenic injury after instrumentation or surgery.
- Clinical presentation includes acute cholangitis, a potentially life-threatening bacterial infection of the biliary tree typically associated with obstruction of the ductal system.
Diagnosis of Acute Cholangitis
- Patients present with a spectrum of disease severity, ranging from subclinical illness to acute toxic cholangitis.
- Fever is present in >90% of patients, and Charcot triad (fever, jaundice, and right upper quadrant pain) is present in only 50-70% of patients.
Gallstones and Biliary Pancreatitis
- Biliary pancreatitis, synonymous with gallstone pancreatitis, is a form of acute pancreatitis caused by the passage of gallstones through the cystic duct and into the distal common bile duct (CBD) where they can obstruct the biliary and pancreatic ducts.
- Pancreatic ductal obstruction is felt to be the inciting event in gallstone pancreatitis.
Contraindications of Laparoscopic Cholecystectomy
- Concomitant diseases that prevent use of a general anesthetic.
- Patient's refusal of open cholecystectomy should urgent conversion be required.
Technique of Laparoscopic Cholecystectomy
- The surgeon must use a technique to provide conclusive identification of the cystic duct and artery in Calot's triangle and hepatocystic triangle.
- In the critical view of safety technique, the triangle of Calot is dissected free of fat, fibrous, and areolar tissue.
This quiz covers the complications and factors associated with open cholecystectomy, a surgical procedure to remove the gallbladder. It includes information on conversion to an open procedure and when it's necessary.
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