SAGES Gallbladder CBD
Transcript of SAGES Gallbladder CBD
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Gallbladder and Bile Duct Surgery(Cholecystectomy and Common DuctExploration)
A simple guide to help answer yourquestions
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What is a gallbladder?
The gallbladder isthe organ in thebody which isresponsible for
concentrating andstoring bile. Itsits just under theliver in the upperright side of the
abdomen (belly).
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What is bile?
Bile is a digestive juice that is made by
the liver. It is responsible for helpingthe body to digest fats and the fatty
foods in our diet. Normally, bile isgolden in color. Our body makes about - 1 quart of bile each day.
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What are the bile ducts?
Since bile is used in the digestiveprocess, it must be taken from the liver
where it is made to the intestine(bowel) where it is used. The tubes orpipes in the body which deliver the bilefrom the liver to the small intestines arecalled bile ducts. They are the size of a
small straw or pencil. The bile ductslink the liver to the gallbladder as well,so that some of the bile which is made
can be stored for future use.
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This is a diagram showing the relationship
between the liver, gallbladder, bile duct,stomach and small intestine
Small Intestine (Duodenum)
Bile Duct
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The area around the gallbladder and bile
ducts is very complicated
The bile ducts are further categorized
(named) for their relationship to theliver. The pancreas and the pancreaticduct (the tube that drains the
pancreatic juices) are in very closeproximity and association to the bileducts and the small intestine. Lookclosely at the next slide to betterunderstand how these relate to each
other.
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Gallbladder, Pancreas andGallbladder, Pancreas and
their ductstheir ducts
(Where the bile and pancreatic
juices enter the small
intestine)
Beginning of the
small intestine
Muscle which controls emptying of the
stomach into the small intestine
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What is a gallstone?
A gallstone occurs whenthe bodys chemistrygets out of balance.
The bile gets too thickin the gallbladder, andcrystallizes (forms) intostones. These can be
single or many, and canvary greatly in size.The size is generallydetermined by the
amount of time that thestones have beenpresent. To the eye,gallstones mayresemble gravel, peas,or even olives.
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Gallstones in the gallbladder
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Who gets gallstones?
Certain factors seem to be more commonin people who develop gallstones
Overweight
Women more than men especially
those with more than one child
People over the age of forty
People who have gained or lost a largeamount of weight in a relatively short
period of time
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Who gets gallstones?
Certain ethnic races/nationalities
Native Americans Inuit
Northern Europeans People with certain other illnesses
Sickle cell anemia
Hemolytic anemia
Inflammatory bowel disease
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What symptoms do gallstones cause?
Many people have no symptoms (up to50%)
Those who do may notice the followingafter eating a meal which contains fat
Crampy pain in the upper right or middlepart of the belly. This pain usually radiatesto the shoulder blade.
Nausea or vomiting
Bloating or gassiness
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What symptoms do gallstones cause?
In more severe cases, fever, chills, a yellowtint to the whites of the eyes or dark colored
urine may be present. Occasionally sludge or very thick bile can
cause these symptoms even if there are nogallstones in the gallbladder.
These symptoms should prompt a visit either toyour doctor or in severe cases to theemergency room.
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How are gallstones detected or diagnosed?
The most accurate (>90%) way is withan ultrasound exam (radiology test
which uses sound waves). Other tests such as a CAT scan may
detect gallstones, but are not as likelyas an ultrasound to see the gallstones ifthey are there.
Rarely (15%), gallstones can be seenon an ordinary X-Ray of the abdomen(belly).
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Ultrasound showing 2 large gallstones
within the gallbladder. Notice how theycreate a shadow below.
Arrows pointing
to 2 gallstones
inside of thegallbladder
Dotted arrows
pointing to the
wall of the
gallbladder
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Ultrasound showing thick sludge within the
gallbladder
Liver
Gallbladder
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Gallstones seen on an ordinary X-Ray of the
abdomen (belly)
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How are gallstones treated if they are
found? Standard treatment is to remove the
gallbladder along with the stones insurgery.
In patients who are too old or sick toundergo surgery, an attempt atdissolving them with medications or
pulverizing them with ultrasound wavesmay be tried.
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How are gallstones treated if they are
found?
Sometimes, some of the gallstones get out
of the gallbladder and make their waydown the bile duct into the intestine. Aslong as these stones do not get caught in
the bile duct this is not a problem. Ifthese stones do get caught in one of thebile ducts, this can cause a very severeinfection or severe inflammation of thepancreas. This will be discussed later in
this presentation.
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A CAT Scan showing an enlarged and inflamed infectedgallbladder. This is what can happen if a stone blocks the
drainage duct to the gallbladder
Gallbladder with an infection
shown by arrows
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How is the gallbladder removed?
There are 2 major techniques to remove thegallbladder and stones:
1. Open involves making
a large incision (6 15
inches) just under the rib-
cage on the right side so
that the surgeon can placehis hands inside the body
to remove the gallbladder
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How is the gallbladder removed?
2. Laparoscopic several small incisions( inch) aremade through which atelescope connected to
a TV camera and smallinstruments are placedto perform the surgery.
The surgeon watcheson a TV monitor whileperforming the
surgery.
Small incisions (circled)
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Can I live without my gallbladder?
The gallbladder is where bile is stored until itis needed to help with the digestion of fatty
foods. Bile is made in the liver If the gallbladder is removed, the bile goes
directly into the intestine
The gallbladder is not a necessary organ andtherefore there arent any problems
associated with removing it(SIMPLY PUT YES, WITHOUT ANY PROBLEM!)
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These diagrams illustrate where the most commonlocations for the incisions for gallbladder surgery are
made and what each one is used for.
Telescope
and Camera
Grasping andDissecting
Instruments
Lap Assoc
of SF
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Laparoscopic Cholecystectomy (removal
of the gallbladder and stones)
The image that isobtained by the telescopeis enlarged and projectedon a TV screen
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Laparoscopic Cholecystectomy (removal of
the gallbladder and stones)
This picture shows how the
laparoscopic operation isperformed. The camerathat is connected to thetelescope which is inside of
the abdomen (belly)projects the picture ontothe large TV. The surgeonthen uses this picture in
combination with smallinstruments to remove thegallbladder
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Instruments used during a laparoscopic gallbladder surgery. The sizedepends on your symptoms and the surgeons preference. These are
placed through the abdominal (belly) wall and enable the surgeon tooperate through small incisions.
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A close-up view of the smallest of these instruments which allows anincision so small that you can barely see it. The smaller the incision,
the less pain that the patient feels after the operation.
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When very small instruments are used for surgery, thescars left after surgery are very difficult to see and cause
very little pain.
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Yellow cholesterol gallstones removed beforethe gallbladder became infected
ll d f fl d d f d
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Gallstones inside of an inflamed and infectedgallbladder
Ad t f L i
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Advantages of Laparoscopic
Cholecystectomy
Less scaring Less pain
Quicker recovery
Shorter hospitalization Faster return to work
Fewer problems with the incisions
P ibl li ti f llbl dd
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Possible complications of gallbladder
surgery Injury to the bile duct
Injury to the intestine of one of theadjacent organs
Narrowing of the bile duct
Bleeding
Infection
Hernia
Leakage of bile into the abdominal
cavity
P ibl li ti f llbl dd
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Possible complications of gallbladder
surgery
Spillage of stones into the abdominal
cavity Missing stones in the bile duct
Bowel obstruction (blockage) from scartissue
Blood clot in the veins of the leg or inthe lung
Wh t h h ll t l th
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What happens when gallstones leave the
gallbladder and get into the bile duct?
This makes the problem of
gallstones much morecomplicated for yourdoctor and can increase
the severity of symptomsthat the patientexperiences. Thesestones can either partiallyor completely block theflow of bile from the liverinto the intestine
LaparoscopicAssociates of SF
Wh t h h ll t l th
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What happens when gallstones leave the
gallbladder and get into the bile duct?If the flow of bile is blocked, the
potential for a serious and severeinfection known as Cholangitis(infection of the bile ducts) is very high.
This problem can be life-threateningand should be treated immediately.
Symptoms include: shaking chills, highfever, severe abdominal pain, nausea,vomiting, and jaundice (turning yellow).
How do we know if a patient has stones in
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How do we know if a patient has stones in
their bile ducts? Most of the time, patients will have
symptoms that will alert the doctor tothis this may include dark coloredurine, light colored stool (feces), or a
yellow tint in the whites of their eyes Sometimes, patients will not havesymptoms. Most doctors will perform
lab tests to help them identify patientswho have stones in their bile duct buthave no symptoms
How do we know if a patient has stones in
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How do we know if a patient has stones in
their bile ducts?Surgeons can alsoperform special tests atthe same time thegallbladder is removedto detect these stones.
The most common testis an X-ray called aCholangiogram.Special dye is injected
into the bile duct andstones will appear assmall bubbles withinthe duct.
Bile
Duct
How do we know if a patient has stones in
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How do we know if a patient has stones in
their bile ducts?
Another test is an ultrasound exam atthe time of surgery. A small probe isplaced directly on the bile duct todetect stones.
How are patients treated who have stones
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How are patients treated who have stones
in their bile ducts?There are 3 ways to treat patients
who have stones in their bile duct:
1. Laparoscopic bile duct exploration andstone removal
2. Open bile duct exploration and stone
removal
3. Endoscopic stone extraction (ERCP)
Laparoscopic Bile Duct Exploration
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Laparoscopic Bile Duct Exploration
The surgeon uses small baskets and
flexible scopes to remove the stone atthe same time that the gallbladder isremoved. They may also use a
Lithotripter which is an instrument thatpulverizes the stone into dust so that
you body can pass it. This is donethrough the same small incisions whichare used to remove the gallbladder.
Laparoscopic Bile Duct Exploration
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Laparoscopic Bile Duct Exploration
ADVANTAGES
Only one procedureneeded (gallbladderand stones in theduct removed at thesame time)
DISADVANTAGES
Requires thesurgeon to havespecial training
Can be a technicallydifficult surgery
Laparoscopic Bile Duct Exploration
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Laparoscopic Bile Duct Exploration
X-ray showingstone in duct
Stone
Basket beingused to remove
stone
Flexible scope andbasket being used
to remove stone
Open Bile Duct Exploration
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Open Bile Duct Exploration
Occasionally (5-10% of the time), thestones cannot be removed using a
laparoscopic approach (or your doctorhas not been trained in this technique),and it is necessary to revert to an open
operation. In this instance, a largerincision is made (just like in the opengallbladder removal) and your surgeonuses the same techniques as describedin the previous slides to remove the
stones.
Open Bile Duct Exploration
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Open Bile Duct Exploration
ADVANTAGES
Only one procedureneeded (gallbladder andstones in the ductremoved at the sametime)
Technically, less difficultthan a laparoscopic
procedure
DISADVANTAGES
Large incision, andtherefore more pain alonger hospital stay,and much more time tofully recover
Much more complicatedsurgery than just
removing thegallbladder
ERCP (endoscopic retrograde
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ERCP (endoscopic retrograde
cholangiopancreatography)
A procedure performed with a flexible,lighted telescope which allows thedoctor to take X-rays of the bile ducts
and remove stones from the bile ductsthrough the small intestine.
ERCP (endoscopic retrograde
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ERCP (endoscopic retrograde
cholangiopancreatography)Since the opening of the bile duct is in
the small intestine, this scope can beplaced through the mouth, downthrough the stomach, and into the
intestine where the duct is located. Theduct can then be opened (a procedure
known as sphincterotomy) so that thestones that are in the bile duct can beremoved.
ERCP (endoscopic retrograde
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ERCP (endoscopic retrograde
cholangiopancreatography)
These pictures illustrate how the
flexible scope is able to removestones from the duct. Cathetersand instruments can be fedthrough the scope enabling the
doctor to inject dye into the duct,enlarge the opening of the duct(with special devices that cut withelectrical current) to allow passage
of the stones, and even to place aballoon catheter up into the duct toassist with removal of the stones.
ERCP showing the presence of gallstones
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g p gin the main bile duct
Stones in
the Bile
Duct
Flexible
scopewhich is
in the
small
intestine
ERCP
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with sphincterotomy and stone extraction
This shows the process of finding the end
of the bile duct and opening it to removetrapped stones
Openingof the
bile ductinto theintestine
Greatly enlarged
opening aftersphincterotomyto allow passage
of stones
ERCP (endoscopic retrograde
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( p g
cholangiopancreatography)ADVANTAGES
Does not requiregeneral anesthesiaand admission to
the hospital is notrequired
DISADVANTAGES
Requires anadditional procedurebefore or after the
gallbladder isremoved
If the stones cannotbe removed, anadditional operationmay be necessary
Possible complications of ERCP
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Possible complications of ERCP
Pancreatitis
Injury to the bile duct
Failure to remove all of the stones inthe bile duct
Bleeding
Perforation of the intestinal tract
Infection
Which is method of stone removal is best
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for me??
Your doctor will decide taking intoconsideration how severe your conditionis, how healthy you are, and the
individual skill and training of thedoctors involved in your care.
If you would like more information on this
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If you would like more information on this
topic, or to find surgeons in your area whomay be experience in laparoscopicsurgery.
Contact your physician or go to the SAGESwebsite for more help
www.SAGES.org
THANK YOU