Cholecystectomy (laparoscopic /open)

Transcription

1 Cholecystectomy (laparoscopic /open) B.Van den Bossche

2 Normal situation 2

3 Normal situation 3

4 Normal situation 4

5 Normal situation and anatomy 5

6 Positionering 6

7 Trocar placement 7

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15 Triangle of Cal(l)ot 15

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30 Subtotal cholecystectomy 30

31 Subtotal cholecystectomy 31

32 Subtotal cholecystectomy 32

33 Subtotal cholecystectomy 33

34 Subtotal cholecystectomy 34

35 Subtotal cholecystectomy 35

36 Subtotal cholecystectomy 36

37 Subtotal cholecystectomy 37

38 Reason for cholangiography Identify stones in the biliary tract Define biliary anatomy Reduce the risk of bile duct injury Failed ERCP and proven biliary stones 38

39 Technique of cholangiography 39

40 Cholangiography 40

41 Cholangiography and Fogarty exploration 41

42 Anatomical variations 42

43 Anatomical variations 43

44 Anatomical variations 44

45 Anatomical variations 45

46 Anatomical variations 46

47 Sfincter spasme 47

48 Pitfalls in cholangiography 48

49 Open cholecystectomy 49

50 Open cholecystectomy 50

51 Open cholecystectomy open laparoscopic SILS 51

52 Open cholecystectomy 52

53 Open cholecystectomy 53

54 Open cholecystectomy 54

55 Open cholecystectomy 55

56 Open cholecystectomy 56

57 Open cholecystectomy 57

58 Open cholecystectomy 58

59 SILS 59

60 SILS 60

61 SILS 61

62 SILS 62

63 Thank you 63

64 Underfilling of the ductal system 64

65 Admixture defects 65

66 False level of obstruction 66

67 Confusing with lymfatics, perivascular and periductal patterns (only PTC) 67

68 Incomplete filling of intrahepatic ducts 68

69 Failure to evaluate sfincter mechanism adequately Spasm Contrast in duodenum Intermittent relaxation and contraction 69

70 Air bubbles mimicking stones + Anti-trendelenburg 70

71 Possible technical maneuvers A. Use of glucagon - Relaxation of sfincter 71

72 Possible technical maneuvers B. Combined cholangiography - duodenography - glucagon geen effect - distal bile duct ca van 9mm 72

73 Misinterpretation Dense contrast material obscuring stones Gridlines Motion artefacts Insufficient penetration of contrast Positioning of the patient 73

74 A. Distal duct Pseudocalculus defect - due to contraction of the sfincter of Oddi 74

75 B. Porta hepatis Pseudocalculus defect - secondary to compression from enlarged periportal nodes (metastatic adenopathy) - difference is easily made because : - uncommon place - known M+ 75

76 Vascular Impression mimicking stone Crossing of the right hepatic artery (10% of cholangiograms) 76

77 Stone simulating tumor 77

78 Tumor simulating stone DD. : - irregular - fixation versus mobility - sometimes local expansion of the duct at the site of eg a polypoid tumor 78

79 Tumor simulating stone PBD 79

80 Cystic duct overlying the common bile duct Rotate the patient Mostly with an unusual insertion(low) of the cystic duct 80

81 Cystic duct overlying the common bile duct Mirizzi syndrome,with a long cystic duct parallel to the common bile duct cystic duct stone impacted and compressing the common bile duct 81

82 Pancreatic duct overlying the common bile duct Left intra hepatic duct? or Pancreatic duct? or Common bile duct? 82

83 Pancreatic duct overlying the common bile duct Long identical course of pancreatic duct and common bile duct 83

84 Pancreatic duct overlying the common bile duct 84

85 Transverse bands mimicking strictures or webs Mostly due to dilatation of the biliary ducts and therefor not the cause of obstruction but the result 85

86 Exception 86

87 Good to know No stone! 87

88 Intraductal defects that may be confused with stones hepatoma cholangioca with intraductal polypoid growth 88

89 Intraductal defects that may be confused with stones Bloedklonter : meestal opgelost na 24h 89

90 Intraductal defects that may be confused with stones Foreign body : e.g. catheter after cholangiography 90

91 Distortion of extrahepatic ductal system Chronic pancreatitis or pancreatic carcinoma 91

92 Distortion of extrahepatic ductal system Right periportal hematoma 92

93 Distortion of intrahepatic ductal system cirrhose PBC 93

94 Possible (iatrogenic) nightmares 94