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Anatomical Variations of Cystic DuctOnly 14 pages are availabe for public view
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Abstract
Carl Langenbuch (1846-1901) developed the technique of cholecystectomy through cadeveric dissection and on July 15, 1882 he successfully removed the gall bladder of a 43-year-old man who was suffering from the disease for 16 years, In 1966, Kurt Semm introduced an automatic insufflator device capable of monitoring intra-abdominal pressure; he also developed thermo coagulation.
Hasson‟s introduction of trocar placement under direct vision in 1978 In 1985, Prof Dr Erich Mühe of Germany performed the first LC. He performed 94 such procedures before another surgeon, Phillipe Mouret of Lyon, France, performed his first laparoscopic cholecystectomy in 1987, followed by Francois Dubois of Paris, France, in 1988, In the last decades, the introduction of laparoscopic techniques to perform cholecystectomy has revolutionized this procedure. The revolutionary nature of this procedure has been unprecedented in surgical history.
Numerous reports have evidenced a lower incidence of postoperative pain, shorter recovery times, and significantly lower mortality and morbidity rates after laparoscopic cholecystectomy compared with open procedures.
The large number of variations in the anatomic structure of biliary tree imposes an imperative need for surgeons to have an adequate knowledge and understanding of those variations, in order to control the safety of the surgical procedure in this field. A large number of postoperative complications seen in this surgical area results from iatrogenic injuries incurred by a variation of anatomic elements.
Various operating strategies, techniques, and instrumentations such as the 0telescope, intraoperative cholangiogram, hydrodissection, and peanut gauze dissection have been proposed by various authors to minimize the risk of bile duct injury during cholecystectomy.However, the surgical fraternity agrees that there is no substitute for meticulous dissection and display of various vital structures near the common bile duct (CBD). In adherence to this dictum, few anatomic landmarks have been described for safe dissection that avoids bile duct injury such as damage to Rouviere‟s sulcus or Calot‟s triangle.
Indications of Laparoscopic cholecystectomy
A- Patients with Gallstones and Suggestive Symptoms.
b. Patients with Gallstones without Symptoms.
c. Patients without Gallstones but with Suggestive symptoms(Chronic acalculous cholecystitis).
LC is considered to be difficult when one of the followings is encountered:
1) Dense adhesions at the triangle of Calot (frozen triangle of Calot prohibiting proceeding laparoscopically without risk).
2) Contracted and fibrotic gallbladder.
3) Previous upper abdominal surgery.
4) Gangrenous gallbladder.
5) Acutely inflamed gallbladder,
6) Empyema gallbladder including Mirizzi‟s syndrome 7) Previously attempted cholecystostomy and
8) Cholecystogastric or cholecystoduodenal fistula.
The management of bile duct injuries can be categorized into nonoperative versus operative repairs and early versus delayed repairs. The method and timing of the repair depends on several factors which are the most important factors in achieving a successful repair.
1) The extent of the injury,
2) The expertise of the operating surgeon and team,
3) The amount of acute inflammation in the area, and
The hemodynamic stability of the patient
Management of Bile Duct Injuries:
1. Management of injuries recognized during operation
When a simple bile duct injury is detected intraoperatively, immediate repair is advised, When a partial transection of the common bile duct, primary repair with absorbable monofilament sutures over a T tube or endoscopic sphincterotomy and stenting. More complex injuries can be repaired with a hepaticojejunostomy if a hepatobiliary surgeon is available and conditions are suitable. In the absence of a hepatobiliary surgeon, the operative bed should be adequately drained and the patient referred to a tertiary center
2. Management of injuries recognized in the postoperative period
Unfortunately, most bile duct injuries are not recognized intraoperatively, and most patients are sent home immediately after or within 24 hours. The initial management of patients with suspected bile duct injury in the post-cholecystectomy period is directed at adequate resuscitation of the patient, controlling sepsis, drainage of bilomas or abscesses, establishing biliary drainage and establishing the diagnosis, type and extent of the bile duct injury. Broad-spectrum parenteral antibiotics covering the common biliary pathogens should be started.
There is virtually no indication to perform an urgent laparotomy, except for severe biliary peritonitis not responding to percutaneous drainage.
Delayed repair is advised in situations involving complex bile duct injuries, concomitant arterial injury, severe local inflammation, or in the presence of bile collection. Surgery should only be contemplated when the infection is controlled and the patient is stable, because reconstruction during peritonitis is associated with worse outcomes.
Currently, Roux-en-Y HJ is the most frequently performed surgical reconstruction of BDI. In this surgical technique, a proximal common hepatic duct is identified and prepared and the distal common bile duct is sutured. End-to-side or end-to-end HJ is performed in a single layer using interrupted absorbable polydioxanone (PDS) or polygalactine 3-0 or 4-0 or 5-0 sutures.