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