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Cholecystectomy With Intraoperative Cholangiogram
Cholecystectomy With Intraoperative Cholangiogram
I. INTRODUCTION
common bile duct (CBD) during cholecystectomy occurs infrequently, but it is an important
source of patient morbidity. Serious injuries often require at least 1 surgical repair, and these
repairs have variable long-term outcomes. Furthermore, CBD injury is the leading cause of
medical malpractice claims against general surgeons.
DEFINITION
The gallbladder serves as a reservoir for bile, a yellow-green fluid produced in your
liver. Bile flows from your liver into your gallbladder where it's held until needed during the
digestion of food. When you eat, your gallbladder releases bile into the bile duct, where it's
carried to the upper part of the small intestine (duodenum) to help break down fat in food.
Cholecystectomy is used to treat gallstones and the complications they cause. Your doctor
may recommend cholecystectomy if you have:
CHOLELITHIASIS
DEFINITION
• Calculi, or gallstones, usually form in the gallbladder from the solid constituents of
bile and vary greatly in size, shape, and composition.
- Smeltzer, S.C., Bare, B.G. Brunner & suddarth’s Textbook of Mecial-Surgical Nursing
!0th Edition.
• Stones on the gallbladder or biliary tree are referred to collectively as cholelithiasis.
Most patients have multiple stones, sometimes several dozen. Most gallstones (80%)
are cholesterol gallstones, which form when bile becomes oversaturated with
cholesterol. Pigment gallstones, accounting for the remaining 20% of gallstones are
composed of bilirubin and bile substances other than cholesterol.
- McConnell, T. H., The Nature of Disease Pathology for the Health Professions. 2007
• Gallstones are hard, pebble-like deposits that form inside the gallbladder. Gallstones
may be as small as a grain of sand or as large as a golf ball, depending on how long
they have been forming.
- http://www.nlm.nih.gov/medlineplus/ency/article/000273.htm
Gastroinstestinal Tract
The gastrointestinal tract (GIT) consists of a hollow muscular tube starting from the
oral cavity, where food enters the mouth, continuing through the pharynx, esophagus,
stomach and intestines to the rectum and anus, where food is expelled. There are various
accessory organs that assist the tract by secreting enzymes to help break down food into its
component nutrients. Thus the salivary glands, liver, pancreas and gall bladder have
important functions in the digestive system. Food is propelled along the length of the GIT by
peristaltic movements of the muscular walls. The primary purpose of the gastrointestinal
tract is to break down food into nutrients, which can be absorbed into the body to provide
energy.
Focus: GALLBLADDER
The gallbladder (or cholecyst, sometimes gall bladder) is a small organ whose
function in the body is to harbor bile and aid in the digestive process.
Anatomy
• The cystic duct connects the gall bladder to the common hepatic duct to form the
common bile duct.
• The common bile romero duct then joins the pancreatic duct, and enters through the
hepatopancreatic ampulla at the major duodenal papilla.
• The fundus of the gallbladder is the part farthest from the duct, located by the lower
border of the liver. It is at the same level as the transpyloric plane.
Microscopic anatomy
The gallbladder is a hollow, pear-shaped sac from 7 to 10 cm (3-4 inches) long and 3
cm broad at its widest point. It consists of a fundus, body and neck. It can hold 30 to 50 ml
of bile. It lies on the undersurface of the liver’s right lobe and is attached there by areolar
connective tissue.
Serous, muscular, and mucous layers compose the wall of the gallbladder. The
mucosal lining is arranged in folds called rugae, similar in structure to those of the stomach.
The gallbladder stores bile that enters it by way of the hepatic and cystic ducts.
During this time the gallbladder concentrates bile fivefold to tenfold. Then later, when
digestion occurs in the stomach and intestines, the gallbladder contracts, ejecting the
concentrated bile into the duodenum. Jaundice a yellow discoloration of the skin and
mucosa, results when obstruction of bile flow into the duodenum occurs. Bile is thereby
denied its normal exit from the body in the feces. Instead, it is absorbed into the blood, and
an excess of bile pigments with a yellow hue enters the blood and is deposited in the
tissues.
The gallbladder stores about 50 mL (1.7 US fluid ounces / 1.8 Imperial fluid ounces)
of bile, which is released when food containing fat enters the digestive tract, stimulating the
secretion of cholecystokinin (CCK). The bile, produced in the liver, emulsifies fats and
neutralizes acids in partly digested food.
After being stored in the gallbladder the bile becomes more concentrated than when
it left the liver, increasing its potency and intensifying its effect on fats. Most digestion
occurs in the duodenum.
II. ETIOLOGY
Age (40 and above) Most internal functions decline as one ages. Inevitably resulting in
organ degeneration which also affects the body's metabolism of
lipids.
Race Cholesterol stones are common in Northern Europe and in North and
South America.
Hemolytic Disease In cirrhosis, at least two fifths of patients have gallstones. One
and Hepatic possible mechanism behind the appearance of pigment softness, so
Cirrhosis far unproven, is the excretion of unconjugated bilirubin directly into
the bile, something that might happen in patient with hemolysis or
in the cirrhotic with his high incidence of pigment stones, currently
estimated at 27 %.
Bile stasis Brown pigment gallstones form when there is stasis of bile
(decreased flow), for example, when there are narrow, obstructed
bile ducts.
Pregnancy Altered physiology of the biliary system during pregnancy may play
a role in accelerating the formation of stones in susceptible women.
Treatment with The contraceptive pill not only promotes thromobphlebitis but points
estrogen/ to an endocrine background of gallstones by the risk of gallstones in
contraceptives young women taking the pill. This is largely as a result of increased
cholesterol secretion into the bile and a decrease in
chenodeoxycholic acid content, along with impaired emptying of the
gallbladder brought about by estrogen.
Clofibrate use and Drugs that lower the serum level of cholesterol, notably clofibrate,
other Antilipemic are associated with an increased incidence of gallstones. Clofibrate
drugs presumably increases the secretion of cholesterol into the bile and
apparently also decreases bile acid synthesis, so increasing the
cholesterol saturation of the bile. Clinical reflection of these
physiologic abnormalities has been found in the overwhelming
association between clofibrate therapy and gallstones.
Laboratory Studies
• The workup of cholelithiasis in pediatric patients is similar to that in adults. The goal
is to demonstrate evidence of gall bladder or biliary tract disease.
• Liver function test (LFT) and CBC results are typically within reference ranges.
Abnormalities suggest infection or obstruction, or both.
• All laboratory results in simple cholelithiasis should be within reference ranges. They
are of use in identifying a more complex disease process, including biliary obstruction
and cholecystitis.
Imaging Studies
• Use of kidney-ureter-bladder (KUB) plain radiography in these patients is often
fruitless because many stones are not visible. However, it may be beneficial in
identifying small-bowel obstruction or free air under the diaphragm.
• Ultrasonography of the right upper quadrant (RUQ) is the study of choice for these
patients. Ultrasonography can be used to identify the location of the stone,
gallbladder wall thickening, and pericholecystic fluid, and a sonographic Murphy sign
aids in diagnosis of the disease process.