BILIARY SURGERY

PRESENTER: DR MUHUGA JR
FACILITATOR: DR MWASHAMBWA
 Overview
• Surgical anatomy of the Gallbladder and Extrahepatic
biliary tree
• Anomalies of the biliary tract

• Investigations of the biliary tract

• Common diseases of the biliary tract

• Operative/therapeutic procedures of the biliary tract

 Surgical anatomy of the gall-bladder and the
extrahepatic biliary tree
GALL BLADDER
• The gall bladder is a pear-shaped organ located in the inferior
surface of the liver, in the gallbladder fossa.
• The gall bladder has the following parts:-
Fundus: the dilated portion of the gallbladder adherent to the
undersurface of the liver from which it can be easily
separated.
The body extends from the fundus and tapers into a neck. It
is the main storage area
Neck: A funnel shaped area that connects to the cystic duct
the narrow angulated distal portion of the neck is called the
Hartmann’s pouch – common site where stones occur and
stay for a long time
• The organ holds about 30-50mls of bile. When distended, it can
distend markedly and contain ≈300mls
 Surgical anatomy…ctd
• The gall bladder is connected to the common bile duct
(CBD) through the cystic duct which is 2.5cm in length.
• The gall bladder is supplied by the cystic artery, a branch
of the right hepatic artery. The cystic vein drains
directly into the portal vein
• CHOLECYSTOHEPATIC TRIANGLE: (Calots
Triangle)- Bounded by the cystic duct and gall bladder
laterally, common hepatic duct medially and inferior
surface of the right lobe of the liver above. It consists
the right hepatic artery, the cystic artery and the cystic
lymph node of Lund.
Surgical anatomy…ctd
 Surgical anatomy…ctd
EXTRAHEPATIC BILIARY TREE
• Common hepatic duct (CHD) is formed by the union of the right
and left hepatic ducts. It is 3cm in length and continues as the
common bile duct (CBD).
• Common bile duct is about 7-11cm long and 5-10mm in
diameter. It has four parts; supraduodenal, retroduodenal,
infraduodenal and intraduodenal. Along with the pancreatic
duct, it forms the ampulla of Vater. Controlled by the sphincter
of Oddi, it ends by an opening into the second part of the
duodenum.
• Parts of the CBD
– SUPRADUODENAL
– RETRODUODENAL
– INFRADUODENAL
– INTRADUODENAL
Surgical anatomy…ctd
 Congenital Anomalies of the Gall bladder
• Absence of gall bladder – extremely rare
• Floating of the gall bladder – due to a long
mesentry. It is more vulnerable to torsion, a rare
cause of recurrent upper abdominal pain.
• Double gallbladder (the second always being
intrahepatic
• Absence of the cystic duct
 Congenital anomalies…ctd
• Low insertion of the cystic duct
• An accessory cholecystohepatic duct is present
in about 10% of patients.
• Anomalies of Blood supply:
– Cystic artery is given anteriorly from the right
hepatic artery
– Very tortuous hepatic artery (catepillar turn or
Moynihan’s hump
Congenital anomalies…ctd
Congenital anomalies…ctd
 Investigations of the biliary tract
Blood tests
– A raised WBC count may indicate or raise the suspicion
of cholecystitis.
– Alanine aminotransferase (ALT) and aspartate
aminotransferase (AST) levels are used to evaluate the
presence of hepatitis and may be elevated in
cholecystitis or with common bile duct obstruction.
– Bilirubin and alkaline phosphatase assays are used to
evaluate evidence of common duct obstruction.
– Amylase/lipase assays are used to evaluate the
presence of pancreatitis. Amylase may also be elevated
mildly in cholecystitis
 Investigations…ctd
 Oral cholangiogram (OCG)
 Studies the function of the gall bladder
 Patient is adviced to have a fat free diet for 3 days. Then on
the night before the test, the patient is given 6 tablets of
iopanoic acid
 On the day of the OCG, an erect plain abdominal X-ray is
taken to visualise the gall bladder
 Latter, a fatty meal is given and one more X-ray is taken to
visualise the change in size of the gall bladder (it should
decrease if functioning normally)
 IV Cholangiogram
 To visualise the bile duct and the EHBT
 Done by injecting IV Meglumine ioglycamate (biligram) and
taking an abdominal X-ray
 Can be combined with OCG
 Investigations…ctd
 Endoscopic Retrograde Cholangio-Pancreatography
(ERCP)
 Through a side-viewing gastroduodenoscope, the
sphincter of Oddi is cannulated, a dye injected and the
biliary and pancreatic trees visualised.
 Indications – Malignancies, chronic pancreatitis,
congenital anomalies, stones, stricture of the biliary tree,
choledocal cysts, sampling biliary and pacreatitic juices for
analysis and cytology, Brush biopsy from a tumor site and
for therapeutic use ((stone extraction or stenting)
 Magnetic resonance cholangio pacreatography (MRCP)
 Non contrast imaging method
 Safer than ERCP
 Cannot be used therapeutically
 Investigations…ctd
 Percutaneous Transhepatic Cholangiography (PTC)
 Under florouscopy, a 22G chiba needle is passed into the liver
through the right 8th intecostal space MCL.
 A water soluble dye is then injected to visualise the biliary tree
and assess the site and extent of obstruction e.g. tumor,
stricture
 Rarely required today
 Also allows biliary drainage and stenting
 Radio isotope scan studies (hepatobiliary scinigraphy)
 Using 131I or 99Tch labelled hepatoiminodiacetic acid (HIDA) or
diisopropyliminooacetic acid (DISIDA)
 Very useful in diagnosing acute cholecystitis and other
disorders like biliary atresia.
 Failure to fill gallbladder = acute cholecystitis
 Delay of flow into duodenum = biliary obstruction
 Investigations…ctd
 Ultrasound
 1st line investigation
 Can assess CBD diameter in case of dilatation due to
obstruction or GB wall thickness due to inflammation.
 Can visualize adjacent organs and tumors.
 CBD diameter increase with age and after previous
biliary surgery
 For obstructive jaundice ultrasound has a sensitivity of
95% and specificity 80 - 100%
 Investigations…ctd
 CT Scanning
 Sensitivity and specificity similar to good quality
ultrasound
 Useful in obese or excessive bowel gas
 Stages and assesses operability of tumours
 Common disorders of the GB and EHBT
1. Biliary Atresia
2. Gallstones (Cholelithiasis)
3. Choledocolithiasis
4. Cholecystitis – acute and chronic and
complications
5. Carcinoma of the gallbladder
6. Cholangiocarcinoma
7. Gall stone ileus
8. Others – Choledochal cyst, CBD strictures,
Sclerosing cholangitis, Hemobilia, Carcinoma
of the Head of Pancrease
 1. Biliary Atresia
• Due to either a viral infection or defective
embryogenesis
• Incidence 1 in 10,000
• May be correctable (10%) or non-correctable (90%)
• Classified as
– Type I: Atretic CBD
– Type II: Atretic CBD and common hepatic ducts
– Type III: Atretic CBD, common hepatic ducts and right and
left hepatic ducts
• May be associated with other congenital anomalies of
the GIT (malrotation, annular pancrease, duodenal
atresia) and congenital heart diseases.
Biliary Atresia...ctd
 Biliary Atresia...ctd
• Clinical features:
– Progressive jaundice in a newborn
– Steatorrhea
– Osteomalacia
– Biliary rickets
– Severe pruritis
• Diagnosis
– LFTs
– Ultrasound
– MRCP
– Radioisotope studies
• Treatment
– In correctable cases: Roux-en-Y jejunal anastomosis
– In non correctable cases hepaticoportojejunostomy (Kasai
Operation)
– Liver transplantation may be required
 2. Gall stones
• One of the most common problems affecting the GI Tract
• Prevalence 11-36%.
• Common in „Fat, Flatulent, Fertile, Female, Forty“
• Saint triad: Gall stones associated with diverticulosis of
colon and hiartus hernia.
• Most patients remain asymptomatic throughout life.
• Types
– Cholestrol stones: 6% common, often solitary
– Mixed: 90%. Contain cholestrol, Calcium salts
(phosphate, carbonate, palmitate) and proteins. Often
multiple and faceted.
– Pigment stones (4%): small,brittle, black and
sometimes spiculated
 Gall stones...
• Clinical features
• Silent stones
• Flatulent dyspepsia
• Biliary colic
• Acute or chronic cholecystitis
• Mucocele of the gallbladder
• Empyema of the gall bladder
• Mirrizi syndrome
• Pancreatitis
• Carcinoma of the GB
 Gall stones
• Investigations
– Ultrasound is the initial
investigation of choice
– Plain Abdominal X-ray
(Low yield – 10%
radioopaque)
– CT scan
 Gall stones...ctd
• Mirrizi Syndrome:
– Compression of the CHD by stones in the cystic duct,
usually in the Hartamann‘s pouch.
– Classified into
• Type I: CHD compression without lumen narrowing
• Type II: CHD compression causing lumen narrowing
• Type III: Compression causing CHD wall necrosis
• Type IV: Stone ulcerating into the CHD resulting into a
cholecysto-choledochal fistula
Gall stones...ctd
 Gall stones...ctd
Treatment
• Surgical
– Gall stones
• Open cholecystecomy
• Laparascopic Cholecystectomy
• Medical
– Oral dissolution: Chenodeoxycholic acid (CDCA) which
inhibits a rate limiting step in the synthesis of cholestrol,
thereby increasing the bile salts pool. It also decreases
cholestrol absorption in the GIT
– Contact dissolution: Methyl Terbutyl Ether (MTBE)
which is passed percutaneously through a catheter into
the gall bladder
• Mechanical
– Extracorporeal Shock Wave Lithotripsy (ESWL)
 3. Choledocholithiasis
• Stones in the CBD and the biliary tree
• May be Primary (formed in the CBD and EHBT) or
Secondary (formed in the GB and pass through the cystic
duct to the CBD)
• Clinical features:
– Pain and tenderness in the right hypochondrium and
epigastrium (colicky, similar to biliary colic)
– Obstructive jaundice (intermittent) – most common
clinical manifestation
– Ascending cholangitis – Charcot‘s triad (Pain,
Jaundice, Fever)
– Acute obstructive (suppurative) cholangitis-
Reynold‘s Pentad (Pain, Fever, jaundice, shock and
altered mental status)
– Steatorrhoea and pruritis
 Choledocholithiasis...ctd
• Investigations:
– Abd USS: CBD >1cm indicates biliary obstruction
– ERCP (goldstandard)
– MRCP
– LFTs
• Treatment:
– Vit K inj. 10mg od to correct PT
– IV antibiotics (e.g. Broad spectrum)
– IV fluids to correct dehydration
– IV fluids to prevent hepatorenal syndrome
– ERCP: a sphincterectomy is done during ERCP and the
stone extracted through a Dormia basket or a balloon
catheter or by fragmenting the stone and extraction
 Choledocholithiasis...ctd
• Complications
– Liver dysfunction and biliary cirrhosis
– White bile formation and liver failure
– Suppurative cholangitis
– Liver abscess
– Septicaemia
– Pancreatitis
 4. Acute cholecystitis
• Acute bacterial inflammation of the gall bladder with or
without stone
• Commonly occur in a patient with a pre-existing
chronic cholecystitis but can also occur at first
presentation
• Causative bacteria: E.coli, Klebsiella, Strept. Faecalis,
Salmonella spp.,and Clostridium welchii
• Classified as
– Acute calculous cholecystitis
– Acute acalculous cholecystitis
 Acute cholecystitis...ctd
• Acute calculous cholecystitis
– Obstructive, usually involving stones in the cystic duct
– Commonest (90% of cases)
– Risk factors for cholecystitis mirror those for cholelithiasis:
increasing age, female sex, certain ethnic groups, obesity,
drugs, and pregnancy.
• Acalculous cholecystitis is uncommon (10%) and is related to
conditions associated with biliary stasis, e.g.
– major surgery, severe trauma, sepsis, long-term total
parenteral nutrition (TPN), and prolonged fasting.
– Other causes of acalculous cholecystitis include cardiac
events; sickle cell disease; Salmonella infections; diabetes
mellitus; and cytomegalovirus, cryptosporidiosis, or
microsporidiosis infections in patients with AIDS
 Acute cholecystitis...ctd
• History
– Upper abdominal pain, often radiating to the tip of the right
scapula
– Fever, nausea and vomiting
– Risk factors (Fat, Fertile, Flatulent, Female of Forty)
• Clinical features
– Constant pain (usually greater than 12 hours duration) in
right upper quadrant
– Fever, tachycardia
– Tenderness in right upper quadrant
– Guarding in right upper quadrant on deep inspiration
(Murphy's sign)
– Jaundice may be present in 15% of patients. In such
patients, of the gall bladder is palpable, the cause is unlikely
to be due to stones (Courvoisier’s law)
 Acute cholecystitis...ctd
• Investigations
– Total WBC: neutrophilia
– Ultrasound is the initial investigation of choice
• Diagnostic features on ultrasound include: Presence
of gallstones, distended thick-walled gallbladder,
pericholecystic fluid , Murphy's sign demonstrated
with ultrasound probe
– If diagnostic doubt a HIDA scan may be useful
– Will show failure of isotope (hydroxyiminodiacetic
acid) uptake by gallbladder
– Plain Abdominal X-ray: 10% of stones are radioopaque.
show a calcified stone
 Acute cholecystitis...ctd
• Management
– Admission in the hospital
– Initially, conservative management
• Nil orally
• Nasogastric aspiration
• IV fluids
• Opiate analgesics and antispasmodics
• Intravenous antibiotics should be given to prevent
secondary infection
– Once fit, a cholecystectomy should be done. Timing of surgery
is controversial.
• Some centers do an early cholecystectomy (quick recovery,
shorter hospital stay and avoids complications of
conservative treatment faillure
• Other centres do a delayed cholecystectomy within 6-10
weeks after initial treatment. By this time the extensive
inflammatory oedema which masks the biliary tree has
resolved.
 Acute cholecystitis...ctd
Fate of acute cholecystitis
– Resolution and recurrence: in acute cholecystitis, the
entire gall bladder is inflammed, swollen and friable. The
exudate collects under the diaphragm resulting to irritation of
the phrenic nerve (C3,4) pain radiating to the tip of the
right shoulder. It may undergo complete resolution with
antibiotic therapy but recurrent attacks are common
– Perforation: Extensive ulceration may result to perforation
of the gall bladder
– If the obstruction is complete, the organ is converted to a
pyocele (empyema) or mucocele.
– Gangrene of the gallbladder can occur if the vessels get
thrombosed. This can lead to septicaemia
 Acute cholecystitis...ctd
Complications of acute cholecystitis
• Gangrenous cholecystitis
• Gallbladder perforation
• Cholecystoenteric fistula
• Gallstone ileus
• Pancreatitis
• Sepsis
 5. Chronic cholecystitis
• A chronically inflammed, thickened, contracted gall
bladder which is nonfunctioning and nondistending
• Due to recurrent attacks of acute cholecystitis
• Stones are invariably present
• Such patients have fatty food intolerance

Clinical features:
– Recurrent right hypochondriac pain (colicky or
persistent)
– Positive Murphy‘s sign
– Flatulent dyspepsia
 Chronic cholecystitis...ctd
• Diagnosis:
– History
– Clinical features
– Investigations
• USS: small contracted gall bladder
• OCG: to demonstrate the function of the gall bladder
• Treatment
– Cholecystectomy (Open or laparascopic)
 7. Carcinoma of the gall bladder
• Rare
• Predominantly in the elderly
• Aggressive with poor prognosis
• 5 years survival rate is 5%
• Female>Males. Peak incidence- 7th Decade
• Risk factors
– Gall stones with chronic cholecystitis
– Polypoid lesions of the gall bladder
– Choledochal cysts
– Sclerosing cholangitis
– Carcinogens: nitrosamines
 Carcinoma of the gall bladder...ctd
• 90% adenocarcinoma (papillary, nodular or tubular). Rarely
squamous
• Clinical features
– Weight loss
– Jaundice
– Rt hypochondrial pain
– Hard palpable mass Rt hypochondrium
– Incidentally diagnosed at cholecystectomy for another
indication
• Investigations
– Abd. USS
– CT scan
– Ultrasound guided FNAC
– LFTs
 Carcinoma of the gall bladder...ctd
• Cholecystectomy with portal lymph nodes clearance and
segmental resection of the liver (Extended Cholecystectomy)
• Hemihepatectomy
• No proven role of adjuvant radiotherapy/chemotherapy
• Palliation for patients with unresectable obstrucitve tumors by
stents
• Prognosis generally poor.
 8. Cholangiocarcinoma
• Rare
• Arises from the biliary epithelium
• Aggressive adenocarcinoma
• May be intrahepatic, perihilar or distal
• 2/3 occur at the hepatic duct bifurcation (Klatskin tumor)
• Associated with primary sclerosing cholangitis,
choledochal cysts, Ulcerative colitis, clonorchiasis infection
• Clinical features: Painless obstructive jaundice, anorexia,
fatigue, weight loss. 10% have cholangitis
• Investigations: ERCP, LFTs, PTC, Abd USS, MRI
• Rx: Surgery (Resection+Hemihepatectomy+Portal region
clearance. Chemotherapy has been attempted.
• Prognosis is poor
Operative/therapeutic procedures of the biliar
• Cholecystostomy
• Biliary enteric anastomoses
 Cholecystectomy
• Surgical removal of the gall bladder
• Indications
– Symptomatic gall stones
– Acute/Chronic cholecystitis
– Acalculous cholecystitis
– Empyema of the gall bladder
– Mucocele of the gall bladder
• Approach
– Open
• Rt Subcostal Incision (Kocher’s)
• Rt Paramedian Incision
– Laparascopic
 Cholecystectomy...ctd
• Technique
– After opening the abdomen, the colon is pushed
downwards and the stomach medially
• Duct first method: Here the Calot’s triangle is dissected.
The cystic artery is identified and ligated. The cystic duct
is ligated close to the gall bladder. The gall bladder is
removed from the gall bladder fossa and removed.
Haemostasis is maintained
• Fundus first method: It is done in a difficult gall bladder
with dense adhesions
• The fundus is separated from the liver bed. Dissection is
carried out proximally until the cystic duct and artery are
identified and ligated.
– A drain is usually placed and removed after
72hours
 Cholecystectomy...ctd
• Complications:
– Infection and subphrenic abscess
– Bleeding (from cystic artery or liver bed)
– Injury to the CBD or hepatic duct
– Bile leak and biliary fistula formation
– Biliary strictures
– Injuries to nearby viscera (colon,duodenum,
mesentry)
Cholecystectomy...ctd
 Biliary Enteric Anastomoses
• Drainage procedures
• Choledochoduodenostomy is the most commonly
employed drainage procedure and can be performed
either side-to-side or end-to-side.
– In the side-to-side procedure, sump syndrome is a feared
complication, in which food particles reflux into the CBD,
resulting in obstruction, cholangitis, and/or pancreatitis.
– This complication can be diminished if the size of the
anastomosis is limited to 14 mm.
• Choledochojejunostomy is performed either in
continuity or preferably as a Roux-en-Y loop that is
passed in a retrocolic fashion.
– The preferred anastomotic size is 2.5 cm.
– It is not associated with reflux of food particles
 References

 Schwartz Principles of Surgery

 SRB Manual of Surgery
 Manipal Manual of Surgery
 Sabiston Textbook of surgery; Sabiston D.C, Lyerly H.K; 15th
Edition; WB Saunders; 1997
 www.emedicine.com
THANKS