Transcript Pathogenesis - Back to Medical School
Anatomy
Anomalies of the cystic artery
Calot’s triangle
Anomalies of the gall bladder
Surgical physiology • Concentration of bile • Reservoir of bile • Changing pH of bile • Cholesterol excretion • Secretion of mucin
Pathogenesis • Lithogenic bile • Sepsis • Anatomical abnormalities • Abnormal gall bladder epithelium
Types of Gallstones • Cholesterol stone - usually solitary, yellow • Pigment stone - calcium bilirubinate, black • Mixed stones - multiple, faceted, laminated
Symptoms • Pain - biliary colic • Nausea & vomiting
Sir Walter Scott’s biliary colic • “called his family, and bidding them farewell, turned his face to the wall to await death” master of the romantic historical novel
Signs • Tenderness over gall bladder • Guarding & rigidity • Palpable mass • Murphy’s sign
Sir Zachary Cope • Exceptionally, palpation may reval an enlarged gall bladder during an attack of biliary colic
Courvoisier’s Law • In a jaundiced patient, if the gall bladder is palpable, it is probably not due to a stone impacted in the CBD Prof of Surgery, Basle, Switzerland
Investigations • FBC, U & Es, LFTs CRP, amylase • AXR & CXR • Ultrasound • CT • (HIDA scan)
Gallstones on plain abdominal radiograph
Gallstones on ultrasound
Gallstones on CT scan
Cholangiogram
Differental diagnosis • Appendicits • Peptic ulcer • Acute pancreatitis • Pyelonephritis • MI • R sided basal chest infection
• Pain • Jaundice • Fever Charcot’s triad
Jean-martin Charcot Physician, Paris
Charcot’s triad • Pain - 90% of patients • Jaundice - 50% of patients • Fever - 30% of patients
Saint’s triad • Gallstones • Hiatal hernia • Diverticular disease
Consequences of gallstones - in the gall bladder • Silent stones • Flatulent dyspepsia • Gall-stone colic • Mucocele • Acute cholecystitis • Carcinoma
Consequences of acute cholecystitis • Perforation - peritonitis • Gangrene • Penetration - fistula • Empyema
Consequences of gall-stones - in the bile ducts • Obstructive jaundice, liver failure, white bile • Acute or recurrent pancreatitis • Cholangitis
Consequences of gallstones - in the intestine • Acute intestinal obstruction
Case history Mr A.E.
• Presented with jaundice and abdominal pain • Ix - gallstones • Open cholecystectomy • Op note - “uneventful”
Post-op course • Eventful • External biliary fistula • Jaundice • Re-explored - sub-hepatic collection, drained • T-tube inserted - no drainage of bile • Sinogram performed …
1
. Fistulogram suggesting partial filling of the hepatic ducts but not of the distal bile duct or duodenum .
Second opinion • Dr Richard Cattell (Lahey clinic) • Insisted on taking patient to Boston (against the wishes of patient’s boss (a Mr WC) • Reoperated - end-to-side hepatico jejunostomy
Subsequent course • One year later … fever and chills • Two years later … significant promotion • Later the same year … unwell with fevers, chills, hospitalised once • Unwilling to have further surgery because of pressure of work • Much later ….
2
. Barium upper gastrointestinal series obtained in 1965 - suggests an enlarged left lobe of the liver and a smaller right lobe.
3
. Barium cholangiogram of 1969 with no visualization of the right anterior segment ducts
4
. Intraoperative retrograde right anterior segment duct study showing leakage of dye into liver lobules and a cavity in the liver substance
Case history Mr A. Eden.
• Presented 1953 with jaundice and abdominal pain • Ix - gallstones • Open cholecystectomy • Op note - “uneventful”
Second opinion • Dr Richard Cattell (Lahey clinic) • Insisted on taking patient to Boston (against the wishes of patient’s boss (a Mr WC) • Reoperated - end-to-side hepatico-jejunostomy
Subsequent course • 1954 … fever and chills • 1955 … PM • 1956 … unwell with fevers, chills, hospitalised once
Choledochal cyst
Cholecystostomy
Open cholecystectomy
Kocher’s incision
Kocher’s incision
Hand over the liver
Exposure The left hand of my assistant. Moynihan
Exclude a stone
Divide the cystic duct
Dissect the gall bladder off the liver bed
Clipping the cystic artery
Dividing the cystic duct
On-table cholangiogram
Gall bladder placed into a bag
Lap simulators
Davinci robot
Laparoscopic cholecystectomy Phillipe Mouret Lyon 1987
Exploration of the common bile duct
Surgery for hiatal hernia
Inguinal hernia
Laparoscopic surgery for colon and rectal disease
Proportion of lap : open cases Laparoscopic fellowship appointment MRC CLASSIC trial 100% 80% 60% 40% 20% Open Converted 0% 2003 Jul Dec Laparoscopic 35 0 9 2004 Jan-Jun 28 0 13 2004 Jul-Dec 38 0 17 2005 Jan -Jun 33 1 8 2005 Jul-Dec 41 1 15 2006 Jan-Jun 30 0 39 2006 Jul -Dec 17 1 30 2007 Jan -Jun 5 0 55 2007 Jul -Dec 0 5 62 2008 Jan -Jun 0 5 65 2008 Jul -Dec 0 1 58
Effector arms of the da Vinci surgical robot
Natural Orifice Transluminal Endoscopic Surgery
Operation Anubis