c l i n i c a l f o l i o s : n a r r a t i v e





A D V E R T I S E M E N T

 

Biliary Pitfalls: 1

A D V E R T I S E M E N T

   

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A gallbladder may be tense due to wall thickening of acute cholecystitis, from enpyema or hydrops. The gallbladder must be decompressed to grasp for retraction. The fundus is held up with an open grasper, punctured with the large aspiration needle and the contents milked up as suction is applied. If the hepatocystic triangle can still not be visualized, top-down dissection is indicated. If the gallbladder is densely adherent to the liver bed, the back wall is left and the mucosa cauterized. Deep dissection in the bed risks bleeding and bile leak.   

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Biliary Pitfalls: 2

A D V E R T I S E M E N T

   

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Clear visualization of the triangle of Calot (cystic duct, cystic artery, common hepatic duct = critical view) requires lateral retraction of the infundibulum. Vertical retraction risks mistaking the common duct for the cystic. Calotís node helps identifying the underlying cystic artery, but manipulation of the vascular node risks obscuring the field with blood which absorbs light, decreases visibility and increases the chance for injury. If bleeding occurs and cannot be safely controlled, opening is indicated. Avoid blind placement of clips.   

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Biliary Pitfalls: 3

A D V E R T I S E M E N T

   
 

The cystic duct is very variable in length and junction with the common duct. A short cystic duct can be difficult to safely control and divide. Dissection is kept close to the infundibulum, there should be a low threshold for cholangiogram to identify structures and top-down dissection may be indicated. At the cystic duct, a cuff of gallbladder may be left and sutured. If closure is uncertain, a drain is left.      

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This page was last modified on 8/11/2009.