Biliary Surgery PPT 2023 PDF

Biliary Surgery S425: RPN PERIOPERATIVE PROGRAM  Learning Outcomes Describe the anatomy of the gall bladder, pancreas, spleen and liver. Understand the purpose of biliary surgeries. Understand procedural considerations for specific biliary surgeries. Differentiate between various biliary su...

Biliary Surgery S425: RPN PERIOPERATIVE PROGRAM  Learning Outcomes Describe the anatomy of the gall bladder, pancreas, spleen and liver. Understand the purpose of biliary surgeries. Understand procedural considerations for specific biliary surgeries. Differentiate between various biliary surgeries including spleen, liver, and gallbladder. Understand the transplant process in Canada and Death in the Operating Room. Biliary Anatomy Includes: Liver Gallbladder Pancreas Spleen Biliary Ductal System Biliary Anatomy Triangle of Calot Landmark for surgical removal of gallbladder Procedure called: Cholecystectomy 3 C’s: Common Hepatic Duct (CHD) Cystic Duct Cystic Artery Biliary Anatomy Common hepatic duct = junction for Left and Right biliary ducts Blood supply – Cystic artery (from hepatic artery) Sphincter of Oddi – Ampulla of Vater in duodenum Protects the CBD and Pancreatic duct (Duct of Wirsung) Hepatic Tree Blood supply for the biliary tract Celiac Axis Major artery in the abdominal cavity Arises from abdominal aorta 3 main branches: Left Gastric : esophageal, < curvature of stomach Splenic: pancreatic, short gastric, left gastropiploic, splenic branches Common Hepatic: gastroduodenal, rt. Gastropiploic, lt. and rt. Hepatic, cystic Gallbladder Lies at the back of the liver Concentrates and stores bile Gallbladder’s average storage capacity is 40 to 70 mL Bile is released in the duodenum to aid in digestion Blood supply – cystic artery (branch of hepatic artery) Perioperative Nursing Considerations General anesthetic Open or Laparoscopic Supine position Blood loss preventative measures – scrub nurse role Surgical Count Open Laparoscopic Initial Count Major Major Closing Count Major Minor Final Count Minor Minor Surgical Interventions Gallbladder Spleen Cholecystectomy Splenectomy Endoscopic Retrograde Cholangeopancreatography (ERCP) Liver Pancreas Hepatic Resection Whipple Resection Liver Transplant Pancreatic Transplant ERCP Endoscopic Retrograde Cholangeopancreatography __________________ procedure Diagnose problems in the biliary tract ERCP scope inserted in mouth and passed into duodenum X-ray guided Catheter is passed through scope into the common bile duct ERCP Contrast Dye is passed through catheter to show the “Biliary Tree” Blockages identified Cholangiogram Test completed intraoperatively Catheter inserted into cystic duct and injected with contrast dye Blockages highlighted Stones = _________________ Choledocholithotomy: Incision of the Common Bile Duct to remove stone Instruments Instruments used in the Common Bile Duct to remove stones Laparoscopic Open Flexible Stone Forcep Randal Stone Forcep Cholecystectomy Open or Laparoscopic Removal of the gallbladder due to: 1) Chronic inflammation 2) Cholelithiasis (gall stones) 90% of cases are done laparoscopic Once entry to the abdomen is secure (open or laparoscopic) the steps to remove the gallbladder are essentially the same. Placement of Laparoscopic Ports Mayo Stand Set Up Instruments: Blade, Metz scissors, toothed forceps Hasson trocar 5mm trocar x3 Stay sutures MIS: Light cord Camera Camera Drape Insufflation tubing Hassan Trocar Placement Mini laparotomy: Skin, Subcutaneous, Fascia, Muscle, Peritoneum Hasson trocar Stay sutures Cholecystectomy A) Triangle of Calot is incised B) Cystic artery is double ligated (proximal and distal) and divided C) Cystic duct dissected Ligatures applied D) Dissection of gallbladder from liver bed Laparoscopic converted to Open What will you need as the scrub nurse? Pancreas - Anatomy Located behind the stomach Head of pancreas fixed to curve of duodenum Blood supply – celiac axis and SMA Approximately 25cm long Pancreas Two main functions: 1) Exocrine: The Duct of Wirsung secretes pancreatic enzymes into the duodenum. 2) Endocrine: The Islets of Langerhan secrete glucagon and insulin directly into the blood system These hormones metabolize _______________ Pancreatic Cancer 95% of tumors arise from _____________(head of pancreas) 80% of pancreatic cancers are Ductal Adenocarcinoma Obstruct the bile duct = jaundice Extends to the duodenum, intestines and spine Regional lymph nodes are affected Metastatic sites include liver and lung Late diagnosis and poor prognosis Laparoscopic Whipple Resection “Pancreaticoduodenectomy” Removal of: - Head of pancreas - Entire duodenum - Portion of jejunum - Distal 1/3rd of stomach - Lower half of common bile duct Pylorus Preserving Pancreaticoduodenectomy Purpose: Reestablish the continuity of the biliary, pancreatic and GI tract systems after removing tumor Better quality of life The stomach is left in its entirety, so the pyloric sphincter is preserved 3 anastomoses will be done Anastomoses 1. Pancreaticojejunostomy 2. Hepaticojejunostomy (Choledochojejunostomy) 3. Gastrojejunostomy (*or Duodenojejunostomy for Pylorus Preserving Whipple) Equipment 6-to-8-hour surgery Major abdominal set up GIA staplers Silk and Vicryl ties GI sutures - Silk, Vicryl, PDS – 3-0, 4-0 Double armed sutures for anastomosis Pancreatic Transplant Donor pancreas to recipient Patients with Type 1 Diabetes (NOT Cancer) Three Options: 1) (PTA) - Pancreas Transplant Alone -Patients with functioning kidneys 2) (SPK) - Simultaneous Pancreas-Kidney Transplant (SPK) -Patients with severe diabetes and chronic renal failure 3) (PAK) Pancreas After Kidney Transplant Pancreatic Transplant Does not have immediate results Done to prevent debilitating effects of diabetes Lifelong immunosuppressants postop Insulin dependent patients with successful transplant = eliminate need for glucose monitoring Most successful in patients with few or no secondary diabetic complications Pancreatic Transplant Pancreatic Transplant (SPK) SPK – Most common transplant Donor pancreas anastomosed to proximal jejunum to facilitate exocrine (enteric) drainage Donor kidney anastomosed to femoral vessels and ureteroneocystostomy Spleen - Anatomy Located in the ULQ behind the stomach Protected by 10, 11, 12th ribs Covered with peritoneum that forms supporting ligaments Main function: Filter blood cells (damaged) Produce white blood cells to fight infections Store blood and platelets = clotting factors Spleen – Blood Supply Aorta –> Celiac Axis –> Splenic Artery Splenic Vein – drains into the portal system *Both blood supplies must be ligated for a splenectomy Splenectomy Removal of the Spleen Indications: Trauma Malignant conditions (Hodgkin / non-Hodgkin lymphoma) Hemolytic jaundice Tumors Splenomegaly Accidental injury Viral or bacterial infections Procedure Considerations GA Count: Initial – Major, Closing – Major (if open), Final – Minor Blood replacement and hemostatic agents Equipment Open Approach Laparoscopic Approach (Emergency) Supine Position Right Lateral position Long instruments, clamps 12mm trocar Silk ties, Cautery, Hemoclips, GIA type stapler for ligaments, Vascular sutures Hemoclips large Spleen mobilized and put into endo bag Splenectomy Figure A - Splenectomy - First the splenic artery is clamped and tied off with suture. Blood within the spleen drains into the splenic vein thus reducing its size. Figure B - The short gastric arteries are then tied off followed by the splenic vein. The spleen is then removed  Splenectomy What are the 3 major ligaments that are cut and tied? Liver - Anatomy Right upper quadrant of the abdominal cavity Covered by the “______________” Function: Metabolizing carbohydrates, proteins, and fats into glycogen stores Glycogen = regulates blood glucose levels Lobules Functional units of liver Right and Left lobes divided by the _______________ 4 lobes – 2 on the anterior surface and 2 on the visceral surface Each lobe contains portal triad: Hepatic ducts Branch of hepatic portal vein Branch of hepatic artery Hepatic sinusoids contain Kupffer cells – immune cells that protect the liver from infection Lobules  Falciform Ligament Ascends from umbilicus Remain of the umbilical vein Right side forms the upper layer of the coronary ligament Left side form upper layer of left triangular ligament Liver- Blood Supply Arterial Supply: Aorta and Hepatic Artery Venous Supply: IVC and Portal Vein Venous blood form the stomach, intestines, spleen and pancreas travels to the liver and returns blood to the heart through the inferior vena cava Hepatic Resection Purpose – resection of tumors The portion of the liver that is removed is based on the affected part and lobe Procedure Considerations HEMOSTASIS! GA Supine position Forced-Air warming blanket CUSA, Hydrojet, Argon Laser, Ligasure – for hemostasis Intra op ultrasound – identify tumor Radio Frequency Ablation Equipment Hemostatic agents: Silk ties, surgicel, gelfoam, hemoclips Sutures: 4-0 or 5-0 Prolene Long instruments (louers and debakey forceps) CUSA, Hydrojet, Argon Beam, Ligasure – for hemostasis ESU – line of resection Drains (large Jackson Pratt) Specimen – segments for frozen and permanent Equipment CUSA CELL SAVER Ligasure Laparoscopic Resection Liver Transplant Implantation of donor liver into recipient 2 types of donors: Cadaveric Living Related Types of liver diseases requiring tx: Primary hepatic cancer Cirrhosis (Alcoholism) Biliary atresia in children Liver Anastomoses Implanting the donor liver through re-anastomosis of the hepatic arteries and veins Use: Permanent Vascular Suture (Prolene) Anastomoses: Vena Cava to Portal Vein Hepatic Artery to Hepatic Artery Portal Vein to Portal Vein Once blood flow is restored in new liver: Biliary (bile duct) anastomosis with recipient’s own bile duct or to the small intestine Liver Anastomoses Roux-en-Y biliary reconstruction Donor-to-Recipient anastomosis of CBD Equipment Liver perfusion time is approx. 12 hours Solutions: Preserved in UW solution (University of Wisconsin Solution potassium based) Frozen saline (slush machine) Papavarine (antispasmotic) Other: Vessel loops, Umbilical tapes Double armed Prolene sutures 3-0, 4-0, 6-0 Cell saver Trillium Gift of Life Network Government of Ontario agency responsible for delivering and coordinating organ and tissue donation and transplantation services. Support health care professionals in planning and coordinating transplants  Organ Donation Types of Donors: 1) Neurological Determination of Death (NDD) 2) After Circulatory Death (DCD) Prior to the arrival of the donor in the operating room: Brain death, and time, is declared and patient’s chart is signed by the surgeons. Signed consent for organ donation by the legal next of kin will be in the patient’s chart, including which organs are to be donated. The coroner’s signature will also be on the consent (if applicable) Organ Donation *Maintenance of Aseptic Technique is CRITICAL!!!!! The following are completed based on hospital policy: Surgical count Communication and planning Coordinating team members Accurate identification of the recipient and donor tissue/organ Completion of Surgical Safety Checklist Organ Retrieval Order of retrieval: 1. Heart 2. Lungs 3. Liver 4. Kidneys 5. Skin and eyes after the ventilator has been terminated Operating Room Deaths Support the patient to a dignified death Communicate to unit manager Follow hospital policy with management and care of the body Follow hospital policy for organ and tissue donation protocol with assistance of TGLN Incident Report Team debrief, counselling and supportive resources Liver Surgery Set Up Abdominal Clamps Thompson Retractor Sutures - Prolene References Rothrock, J. (2022). Alexander’s Care of the Patient in Surgery (17th ed.) Elsevier. Tighe, S. (2015). Instrumentation for the Operating Room (9th ed.) Elsevier. ORNAC Standards (2023) Trillium Gift of Life Network (2011). Tissue Donation Manual.