Cholecystectomy (laparoscopic /open) B.Van den Bossche
Normal situation 2
Normal situation 3
Normal situation 4
Normal situation and anatomy 5
Positionering 6
Trocar placement 7
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Triangle of Cal(l)ot 15
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Subtotal cholecystectomy 30
Subtotal cholecystectomy 31
Subtotal cholecystectomy 32
Subtotal cholecystectomy 33
Subtotal cholecystectomy 34
Subtotal cholecystectomy 35
Subtotal cholecystectomy 36
Subtotal cholecystectomy 37
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
Technique of cholangiography 39
Cholangiography 40
Cholangiography and Fogarty exploration 41
Anatomical variations 42
Anatomical variations 43
Anatomical variations 44
Anatomical variations 45
Anatomical variations 46
Sfincter spasme 47
Pitfalls in cholangiography 48
Open cholecystectomy 49
Open cholecystectomy 50
Open cholecystectomy open laparoscopic SILS 51
Open cholecystectomy 52
Open cholecystectomy 53
Open cholecystectomy 54
Open cholecystectomy 55
Open cholecystectomy 56
Open cholecystectomy 57
Open cholecystectomy 58
SILS 59
SILS 60
SILS 61
SILS 62
Thank you 63
Underfilling of the ductal system 64
Admixture defects 65
False level of obstruction 66
Confusing with lymfatics, perivascular and periductal patterns (only PTC) 67
Incomplete filling of intrahepatic ducts 68
Failure to evaluate sfincter mechanism adequately Spasm Contrast in duodenum Intermittent relaxation and contraction 69
Air bubbles mimicking stones + Anti-trendelenburg 70
Possible technical maneuvers A. Use of glucagon - Relaxation of sfincter 71
Possible technical maneuvers B. Combined cholangiography - duodenography - glucagon geen effect - distal bile duct ca van 9mm 72
Misinterpretation Dense contrast material obscuring stones Gridlines Motion artefacts Insufficient penetration of contrast Positioning of the patient 73
A. Distal duct Pseudocalculus defect - due to contraction of the sfincter of Oddi 74
B. Porta hepatis Pseudocalculus defect - secondary to compression from enlarged periportal nodes (metastatic adenopathy) - difference is easily made because : - uncommon place - known M+ 75
Vascular Impression mimicking stone Crossing of the right hepatic artery (10% of cholangiograms) 76
Stone simulating tumor 77
Tumor simulating stone DD. : - irregular - fixation versus mobility - sometimes local expansion of the duct at the site of eg a polypoid tumor 78
Tumor simulating stone PBD 79
Cystic duct overlying the common bile duct Rotate the patient Mostly with an unusual insertion(low) of the cystic duct 80
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
Pancreatic duct overlying the common bile duct Left intra hepatic duct? or Pancreatic duct? or Common bile duct? 82
Pancreatic duct overlying the common bile duct Long identical course of pancreatic duct and common bile duct 83
Pancreatic duct overlying the common bile duct 84
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
Exception 86
Good to know No stone! 87
Intraductal defects that may be confused with stones hepatoma cholangioca with intraductal polypoid growth 88
Intraductal defects that may be confused with stones Bloedklonter : meestal opgelost na 24h 89
Intraductal defects that may be confused with stones Foreign body : e.g. catheter after cholangiography 90
Distortion of extrahepatic ductal system Chronic pancreatitis or pancreatic carcinoma 91
Distortion of extrahepatic ductal system Right periportal hematoma 92
Distortion of intrahepatic ductal system cirrhose PBC 93
Possible (iatrogenic) nightmares 94