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Other: Gastrointestinal - Biliary Tract - Surgery - Cholecys
Other: Gastrointestinal - Biliary Tract - Surgery - Cholecystectomy [common bile duct strictures][hepatic duct strictures][biliary strictures][SR]
26
Medical
10/26/2009

Additional Medical Flashcards

 


 

Cards

Term
Laparoscopic cholecystectomy: Pneumoperitoneum
Definition

Laparoscopic cholecystectomy: Pneumoperitoneum

 

Open (Hasson trocar) vs closed (Veres needle)

 

mont reid p.498

Term
Laparoscopic cholecystectomy: Conversion to open procedure
Definition

Laparoscopic cholecystectomy: Conversion to open procedure

 

- Up to 20% of cases

- Unclear anatomy

- Suspected injury to major vessel, viscus, or duct

- Inability to remove CBD stone by minimally invasive techniques, including endoscopic retrograde cholangiopancreatography (ERCP)

 

mont reid p.499

Term
Laparoscopic cholecystectomy: Complications
Definition

Laparoscopic cholecystectomy: Complications

 

- Pneumoperitoneum -- Mildly elevated PCO2, decreased venous return, gas embolism, vagal reaction

 

- Trocar insertion -- bleeding, injury to bowel

 

- Cholecystectomy -- bile duct injury, wound infection

 

 

mont reid p.499

Term
Laparoscopic cholecystectomy: 1. Decompression
Definition

Laparoscopic cholecystectomy: 1. Decompression

 

 

The stomach is decompressed with a nasogastric tube to facilitate exposure.

 

CCS surgery p.87

Term
Incision and entrance into abdominal cavity
Definition

 

With the patient in the supine position, a 2-cm incision is made superior or inferior to the umbilicus.

 

Using S-shaped retractors, the fascia is identified and grasped with a small Kocher or Allis clamp.

 

The fascia is elevated and incised to allow for easy admission of a finger to confirm entrance into the abdominal cavity and sweep away any adhesions.

 

A U-stitch is placed using an absorbable suture.

 

The Hasson cannula is inserted and secured with the suture used for the U-stitch.

 

CCS surgery p.88

Term
Insufflation, insertion of endoscope, and inspection of abdominal cavity
Definition

 

 

- After setting the insufflator to an insufflation pressure of 12 mmHg, CO2 is instilled at a low flow (1L/min) into the abdominal cavity through the Hasson cannula.

 

- Approximately 1 L CO2 is instilled at a low flow rate, and then the flow rate is adjusted to the maximum (20L/min.)

 

- The endoscope is inserted, and the abdominal and pelvic cavities are inspected.

 

CCS surgery p.88

Term
Insertion of the cannulas and their function
Definition

 

The patient is placed in reverse Trendelenburg position to allow the colon and omentum to fall inferiorly.

 

After the pelvis and upper abdomen are visually inspected, a 10mm cannula is inserted two thirds of the way between the umbilicus and the xiphisternum just to the right of the midline.

 

A 5mm cannula is inserted 3cm inferior to the costal margin in the midclavicular line, and a second 5mm cannula is inserted 4cm inferior to the costal margin in the midaxillary line.

 

All three cannulas are inserted using a trocar under direct endoscopic vision.

 

The umbilical cannula is used for the endoscope and CO2 inflow, and the epigastric port is used for dissection.

 

Through the most lateral right subcostal cannula, a grasper retracts the dome of the gallbladder over the liver toward the right diaphragm.

 

Through the other subcostal cannula, a grasper retracts the neck of the gallbladder laterally and anteriorly..

 

CCS surgery p.88

Term
Dissection of the gallbladder
Definition

 

- Adhesions are dissected off the gallbladder, and dissection is begun at the neck of the gallbladder, and proceeds along the cystic duct.

 

- After the cystic duct and artery have been identified by removal of the peritoneum overlying these structures, a titanium clip is placed at the junction of the neck and cystic duct.

 

 

CCS surgery p.88

Term
Testing with cholangiogram
Definition

 

 

- A cholangiogram is performed by partially transecting the cystic duct using scissors.

 

- The cholangiocatheter is inserted into the cholecystodochomy, and a cholangiogram is performed using 30% Renografin.

 

- If the cholangiogram is normal, the catheter is removed and the cystic duct is secured just inferior to the ductotomy with two titanium clips and divided.

 

CCS surgery p.88

 

CCS surgery p.88

Term
next step
Definition

 

 

If the cholangiogram is normal, the catheter is removed and the cystic duct is secured just inferior to the ductotomy wtih two titanium clips and divided.

 

The cystic artery is clipped and divided.

 

The infundibulum and neck of the gallbladder are rotated medially or laterally, and the  peritoneal reflection onto the gallbladder is incised using the hook cautery.

 

The gallbladder is dissected from its bed, and before the last attachments at the dome are divided, the gallbladder bed is irrigated and inspected for bleeding and bile leaks.

 

The stumps of the cystic duct and artery are inspected for bleeding and bile leaks.

 

CCS surgery p.88

Term
next step
Definition

next step

 

- When hemostasis is attained, the remaining attachments between the gallbladder and the liver are divided and the gallbladder is positioned just superior to the liver.

 

- The laparoscope and CO2 insufflation tubing are transferred to the epigastric cannula, and the extraction sack is passed under direct visualization through the umbilical cannula.

 

The sack is opened, and the gallbladder placed in the bag and extracted.

 

CCS surgery p.88

Term
next step
Definition

 

 

- The umbilical incision is closed under direct visualization by tying the U-stitch.

 

- The subcostal cannulas are removed under direct visualization.

 

- The epigastric cannula is positioned over the liver away from the omentum, CO2 insufflation stopped, and residual CO2 allowed to escape from the abdomen through the cannula.

 

- The cannula is removed, and the incisions are closed with a subcuticular stich and sterile strips.

 

- Dressings are placed over the incisions, and the nasogastric tube and Foley catheter are removed.

 

- The patient may be discharged after observation.

 

-Most patients can be discharged within a few hours.

 

CCS surgery p.88-89

Term
Open: Step 1
Definition

Open: Step 1

 

 - After induction of anesthesia place a nasogastric tube to decompress the stomach.

 

- The most commonly used incision is Kocher's right subcostal.

 

- Place incision 4cm below and parallel to the costal margin, and extend it from the midline to the anterior axillary line.

 

- Open the anterior rectus sheath with a knife in the line of the incision.

 

- Divide the rectus muscle with cautery, and open the peritoneum between forceps.

 

CCS surgery p.89

Term
Open: Step 2
Definition

Open: Step 2

 

-Systematically explore the peritoneal cavity and note the appearance of the hiatus, stomach, duodenum, liver, pancreas, intestines, and kidneys.

 

- Palpate the gallbladder from the ampulla towards the fundus, the palpate the common duct, noting any dilation or foreign bodies.

 

- Carefully palpate the colon for neoplasms.

 

CCS surgery p.89

Term
Open: Step 3
Definition

Open: Step 3

 

- Grasp the gallbladder with a Rochester-Pean clamp near the fundus. Hold forceps in one hand, and introduce the right hand over the right lobe of the liver, permitting the liver to descend.

 

- Divide any adhesions to the omentum, colon or duodenum, and place a pack over these structures.

 

- Retract the structures inferiorly with a broad-bladed Deaver's retractor.

 

CCS surgery p.89

Term
Open: Step 4
Definition

Open: Step 4

 

- Inspect the anatomy of the biliary tree by carefully dividing the peritoneum covering the anterior aspect of the cystic duct, and continue dissecting into the anterior layer of the lesser omentum overlying the common bile duct.

 

- Bluntly dissect with a dissector (Kitner), exposing Charcot's triangle bounded by the cystic duct, common bile duct and infeior border of the liver.

 

- The cystic artery should be seen in this triangle.

 

- Carefully observe the arrangement of the duct system and arterial supply.

 

- Do not divide any structure until the anatomy has been identified, including the cystic duct and common bile duct.

 

CCS surgery p.89

Term
Open: Step 5
Definition

Open: Step 5

 

- Pass a ligature around the cystic duct with a right-angle clamp, and make a loose knot near the common duct.

 

- Partially divide the cystic duct below the infundibulum, and place a small polyethylene catheter attached to a syringe filled with saline into the cystict duct for 1-2cm.

 

- Tighten the ligature holding the catheter in position.

 

CCS surgery p.89

Term
Open: Step 6
Definition

Open: Step 6

 

- Attach a second syringe containing contrast material to the catheter, and remove all instruments.

 

- Place a sterile sheet, and slowly inject 10-15cc of diluted dye into the common duct.

 

- An operative cholangiogram should be performed to detect stones and evaluate the duct system.

 

CCS surgery p.89

Term
Open: Step 7
Definition

Open: Step 7

 

- Palpate the lower end of common bile duct, pancreas, and the foramen of Winslow.

 

- Palpate the ampulla, checking for stones or tumor.

 

- Hold the forceps on the gallbladder in the left hand, and clear the cystic artery of soft tissue with a pledget held in forceps.

 

- Follow the artery to the gallbladder, and clamp it with a right angle clamp.

 

-  Divide and ligate the artery close to the edge of the gallbladder, using clips or 000 silk.

 

-- Reaffirm the junction of the cystic duct, with the common bile, then compeltely divide the exposed cystic duct, leaving a stump of 5mm.

 

CCS surgey p.89

Term
Open: Step 8
Definition

Open: Step 8

 

- Incise the peritoneum anteriorly over the gallbladder with a scalpel.

 

- Elevate the peritoneum from the gallbladder, and separate the gallbladder gently with sharp and blunt dissection.

 

- Tissue strands containing vessels should be cauterized before division.

 

CCS surgery p.89

Term
Open: Step 9
Definition

Open: Step 9

 

- Inspect the gallbladder bed for bleeding and cauterize and/or ligate any bleeding areas.

 

- Control any persistent oozing from the bed with a small pack of hemostatic gauze.

 

CCS surgery p.90

Term
Open: Step 10
Definition

Open: Step 10

 

Irrigate the site with saline.

 

If there is excessive fluid present, place a soft rubber Penrose drain or closed suction drain in the area of the dissection, and bring it out through a separate stab wound in the right upper quadrant.

 

Inspect the operative field, including the ligatures on the arteries and the cystic duct. Approximate the peritoneum with continuous nonabsorbable suture.

 

CCS surgery p.90

Term
Open: Step 11
Definition

Open: Step 10

 

Irrigate the wound with saline and approximate the rectus fascia and fascia of the oblique muscles with interrupted, nonabsorbable sutures.

 

Irrigate the subcutaneous space with saline, and close the skin with staples, or absorbable subcuticular sutures.

 

CCS surgery p.90

Term
Definition
Term

Open cholecystectomy

sample Operative note

Definition

Open cholecystectomy

sample Operative note

 

 

PATIENT NAME: Brown, Robert

DATE OF OPERATION: 11/03/2009

 

PREOPERATIVE DIAGNOSIS: Acute cholecystitis.

POSTOPERATIVE DIAGNOSIS: Gangrenous cholecystitis.

OPERATION: Exploratory laparoscopy and open

cholecystectomy.

ANESTHESIA: General endotracheal anesthesia.

CLINICAL INDICATIONS: The patient is an 83-year-old gentleman who

is status post left cerebrovascular accident with a right hemiparesis

who presented with a complaint of approximately 3 days of abdominal pain

approximately 4 days ago. He was admitted, given IV antibiotics and is

now brought to the operating room having been consented by the patient

and agreed upon by his conservator. Our plan is to perform an

exploratory laparoscopy with probable laparoscopic cholecystectomy. The

patient's diagnosis was confirmed by both abdominal CT scan and

ultrasound.

The findings were that of a completely necrotic gallbladder that was

approximately 30% intrahepatic that could not be manipulated safely

laparoscopically. Consequently, we converted to an open procedure

which, in itself was quite difficult and required tedious dissection.

PROCEDURE: After the successful institution of a general

endotracheal anesthetic, the patient was positioned on the operating

table in the supine fashion. All pressure points were checked and

padded. The abdomen was prepped and draped in the usual sterile

fashion, excluding the patient's previously placed gastrostomy tube from

the operative field. A surgical time-out was performed and the patient

was maintained on his perioperative Zosyn for wound infection

prophylaxis. We began by insufflating the abdomen to a pressure of 15

mmHg utilizing an 11 mm Hasson trocar inserted in an 11 mm curvilinear

subumbilical incision. This was done without difficulty. On initial

insufflation of the abdominal cavity, the pathology appeared to be

localized to the right upper quadrant where there were multiple

adhesions between the gallbladder and the omentum. The gastrostomy tube

itself was well away from the operative field and did not visually

appear to be a technical obstacle. We introduced a second 5 mm trocar

in the right flank location and, as we began to peel the omentum down

from the gallbladder, we quickly realized that the gallbladder appeared

to be completely gangrenous and was approximately 30% intrahepatic, both

conditions of which made it technically challenging to proceed

laparoscopically. Consequently, the decision was made to convert to an

open operation. The trocars were removed and we explored the patient

through a midline laparotomy incision, extending from the xiphoid

process to approximately 3-4 cm above the umbilicus. A self-retaining

retractor device was inserted and we then ultimately were able to

mobilize the gallbladder, taking it down with division of the necrotic

visceral peritoneum. As we got to the neck of the gallbladder, the

perihilar inflammatory process was quite dense, rendering further

dissection unnecessarily dangerous; consequently the gallbladder was

divided at the neck, leaving approximately 1 cm of a gallbladder stump.

We retrieved approximately 10-15 gallstones from the gallbladder stump

itself, irrigated it liberally and then utilized the argon beam

coagulator to both obtain hemostasis in the gallbladder fossa and to

cauterize the exposed mucosa of the remaining gallbladder. Of note, the

gallbladder itself appeared to be completely necrotic with liquefactive

necrosis taking place. The gallbladder also contained in excess of 100

mixed gallstones measuring from 1 to 3 mm in diameter. Once hemostasis

was obtained, the retracting device was removed and the fascia was

closed with a running #1 Maxon suture. The subcutaneous tissue was

further irrigated and the skin was reapproximated with staples. The

patient tolerated the procedure quite well.

ESTIMATED BLOOD LOSS: Approximately 600 mL.

SPECIMEN TO PATHOLOGY: That of the necrotic gallbladder and

gallstones.

 

 

 

 

 

 

 

 

 

Term
Cholecystectomy: Multiple choice case
Definition

Multiple choice question

 

 

An in-hospital workup of a 78 year old hypertensive, mildly asthmatic man who is receiving chemotherapy for colon cancer reveals symptomatic gallstones. Preoperative laboratory results are notabe for a hematocrit of 24% and a urinalysis with 18 to 25 WBCs and gram-negative bacteria. On call to the operating room, the patient receives intravenous penicillin. His abdomen is shaved in the operating room. An open cholecystectomy is performed and, despite a lack of indications, the common bile duct is explored. The wound is closed primarily with a Penrose drain exiting a separate stab wound. On postoperative day 3, the patient develops a wound infection. Which of the following changes in the care of this patient could have decreased the chance of a postoperative wound infection?

 

 

a. Increasing the length of the preoperative hospital stay to prophylactically treat the asthma with steroids

 

b. Treating the urinary infection prior to surgery

 

c. Shaving the abdomen the night prior to surgery

 

d. Continuing the prophylactic antibiotics for three postoperative days

 

e. Using a closed drainage system brought out through the operative incision

 

 

 

 

 

 

 

 

 

The answer is b. (Brunicardi, pp. 118-120)

 

The determinants of a postoperative wound infection include those related to the bacteria, the environment (i.e. the wound), and the host's defense mechanisms.

 

Within this triad there are factors predetermined by the status of the patient (eg. age, obesity, steroid dependence, multiple diagnoses (more than three), immunosuppression) and by the type of procedure (eg. contaminated versus clean, emergent versus elective)

 

However, there are several factors that can be optimized by the surgeon.

 

Decreasing the bacterial inoculum and virulence by limiting the patient's prehospital stay, clipping the operative site in the operating room, administering perioperative antibiotics (within a 24 hour period surrounding operation) with an appropriate antimicrobial spectrum, treating remote infections, avoiding breaks in technique, using closed drainage systems (if needed at all) that exit the skin away from the surgical incision, and minimizing the duration of the operation have all been shown to decrease postoperative infection.

 

Making a wound less favorable to infection requires attention to basic Halstedian principles of hemostasis, anatomic dissection, and gentle handling of tissues as well as limiting the amount of foreign body and necrotic tissue in the wound.

 

Although they are the most difficult factors to influence, host defense mechanisms can be improved by optimizing nutritional status, tissue perfusion, and oxygen delivery.

 

pretest surgery p.12, 30-31; question #35