Biliary Study Material ABSITE PDF

Gallbladder Anatomy - 20-45cc. - From the ventral bud (hepatic diverticulum) of the foregut. - Gallbladder arises from a separate bud. - The ampulla is not present in 95% of cases (i.e., no dilated portion). - Distal CBD has sporadic longitudinal weak muscles -- cannot be the...

Gallbladder Anatomy - 20-45cc. - From the ventral bud (hepatic diverticulum) of the foregut. - Gallbladder arises from a separate bud. - The ampulla is not present in 95% of cases (i.e., no dilated portion). - Distal CBD has sporadic longitudinal weak muscles -- cannot be the cause of biliary pain. - The sphincters of CBD, pancreatic duct and common channel exist. Common channel exists in 80%. - The cystic duct and common hepatic duct run parallel. - CBD has exclusively arterial blood supply. - Distal CBD -- posterior superior pancreaticoduodenal artery. - Proximal CBD -- right hepatic and cystic artery. - Retropancreatic portion of the CBD -- GDA. - Retroportal artery (from celiac axis or SMA) may supply distal CBD in the posterior aspect (to avoid injury to this region, leave the thin fibrous capsule of the head of the pancreas alone while mobilizing the duodenum). - Valves of Heister (7-10) are not true valves, but merely mucosal folds. - Gallbladder has no submucosa. - CBD Blood supply -- afferent vessels, marginal arteries (x3), and epicholedochal plexus. Physiology - Long-chain fatty acids (LCFA) are the only nutrient that escapes first-pass liver metabolism. They get absorbed by the chylomicrons and reach the systemic circulation via the lymphatics. - Sludge -- cholesterol crystals, calcium bilirubinate and mucin gel matrix. Bile duct injury - After vascular injury, collateral flow starts at 10 hours and approaches stabilized levels around 4 days. - Biliary obstruction leads to decrease in portal venous supply. Ligation of hepatic artery and bile duct leads to hepatic necrosis, but not the hepatic artery alone. - RHA is the most commonly injured -- 10% of RHA-VBI develop clinically relevant ischemia. - 7% of cadavers with prior cholecystectomy show RHA injury. - 'Classical injury pattern' -- 1. Ligation of CBD, 2. Mobilization of CHD, and 3. Transection of CHD. - Late repair is recommended -- 3 months. - Concomitant portal vein injury associated with high mortality (\~50%). Biliary pain - Epigastric/ RUQ pain - Builds steady and last \>=30 minutes - Occurring at different intervals - \0.3% in emergency LC -- institutional review must be held. - CVS introduced I 1995, has 3 components. - If CVS is not seen -- 'bailout procedures' -- Subtotal, top-down approach. - STS -- more infection rate. - Opening does not reduce incidence of BDI. - IOC is useful, if known how to do it, and can be interpreted correctly, and known how to act upon it. - What can be done to reduce BDI - Operate early (\< 48 hours), not later than 10 days. - CVS -- is a must. - Use bailout procedures - Gallbladder parts -- fundus, body, infundibulum, neck, cystic duct. - Infundibulum -- Hartman\'s pouch is the part where the neck emerges. It emerges from the side, so we pull above, outward, and laterally. - Cystic duct drains to the right side. - Cystic duct runs parallel to the CHD. - The commonest abnormality is the Phrygian cap -- 4-10%. No treatment is required. - Cystic artery tethers the gallbladder -- so divide cystic artery first. - Cystic node is Lund's node -- is the sentinel node. - Cystic duct is long! -- 4cm, S-shaped - CHD is also 4cm. CBD is longer -- 8cm. - Failure to see CVS - Males - Acute on chronic cholecystitis (OR \~5.5) - Symptoms \> 9 days (OR \~5.3) - History of chronic liver disease (OR \~8) - Thickness of gallbladder wall in the neck (OR \~10) - Obscured GB neck in MRI (OR \~10)