The GALLBLADDER and the BILIARY TRACT

Attached to the liver by loose (areolar) connective tissue

Dr. Bangaoet
Gallbladder operations more common than appendectomy
Fundus slants inferiorly, to the right
Scope of Lecture
Anatomy
Peritoneum covers free surfaces
Methods of Investigation
Diseases of the Gallbladder

KEY POINTS
1. The physiology of the gallbladder and sphincter of Oddi are regu-
lated by a complex interplay of hormones and neuronal inputs de-
signed to coordinate bile release with food consumption. Dysfunc-
tions related to this activity are linked to the development of
gallbladder pathologies described in this chapter.

2. In Western countries, the most common type of gallstones are

cholesterol stones. The pathogenesis of these stones relates to su-
persaturation of bile with cholesterol and subsequent precipitation.

3. The main risk factor for gallbladder disease in Western

countries is cholelithiasis. The main complications include
cholecystitis, cho-ledocholithiasis, cholangitis, and biliary Fundus
pancreatitis. In addition, cholelithiasis plays the role as the major Common bile duct meets pancreatic duct
risk factor for the devel-opment of gallbladder cancer. Normal Measurements:
o 7-10 cm long o
4. Laparoscopic cholecystectomy has been demonstrated to be a 6 cm diameter
safe and effective alternative to open cholecystectomy and has o 30-35 cc volume
become the treatment of choice for symptomatic gallstones. Body and neck directed towards porta hepatis
Knowledge of the various anatomic anomalies of the cystic duct and Neck is continuous with cystic duct
artery is helpful in guiding the dissection of these structures as well Cystic duct:
as avoiding injury to the common bile duct during cholecystectomy. o joins common hepatic duct
o superior and posterior to pylorus of stomach
5. Common bile duct injuries, although uncommon, can be devastat-ing
to patients. Proper exposure of Calot's triangle and careful iden-
tification of the anatomic structures are keys to avoiding these inju-ries.
Once a bile duct injury is diagnosed, the best outcomes are seen at large
referral centers with experienced biliary surgeons.

6. Carcinoma of the gallbladder and bile duct generally have a

poor prognosis because patients usually present late in the disease
pro-cess and have poor response to chemo and radiation therapies.
Surgery offers the best chance for survival and has good long-term
survival in patients with early-stage disease.
 Common Bile Duct
INTRODUCTION o 10-15 cm long
Location o Courses through lesser omentum
o Epigastric region o Deep to pyloric sphincter Narrow tube, 1-2 mm diamete
o Right hypochondriac region o Should be no more than 6 mm in diameter
o On inferior surface of liver  May be 8-10 mm in post-cholecystectomy patients
o Between quadrate and right lobes o Normally has smooth walls
Pear shaped, hollow structure o Joins with pancreatic duct o
On L.S., convergence is seen
 anterior to portal vein
 posterior to head of pancreas
Combined duct empties into duodenum at ampulla of Vater
Sphincter of Oddi guards duct, regulates bile flow
o Closed: bile goes into gallbladder
o Open: bile goes into duodenum

Triangle of Calot boundaries:

- Medial: Common hepatic duct:

- Lateral: Cystic duct
- Superior: inferior margin of liver
 The GALLBLADDER and the BILIARY TRACT
continuous with cystic duct
E. NECK OF GALLBLADDER
characterized by a spiral valve (of Heister)
makes catheterization difficult

Ampulla of Vater with CBD and Pancreatic Duct

Spiral Valve (of Heister) in Cystic Duct
DETAILED ANATOMY
A. FUNDUS OF GB: F. HARTMANN’S POUCH
may be palpated Infundibulum of gallbladder
in angle between lateral border of right rectus Lies between body and neck of gallbladder
abdominis and costal margin A normal variation
At level of elbow May obscure cystic duct
Most anterior visceral structure If very large, may see cystic duct arising from pouch

B. BODY OF GALLBLADDER
Visceral surface of liver
Deep to transverse colon or hepatic flexure of colon
Descending portion of duodenum is medial

Hartmann’s Pouch of the Gallbladder

G. CYSTIC DUCT
3-4 cm long
Extends from neck of gallbladder to common hepatic duct
Joins with common hepatic duct inferior to porta hepatis
Spiral valve may extend into neck of gallbladder

Gallbladder; Lesser Omentum; Common Bile Duct; IVC

C. INFECTIONS
may spread to:
o duodenum, liver, colon, anterior abdominal wall, peri-
toneal cavity
o Direct or via lymphatics H. EPIPLOIC FORAMEN (OF WINSLOW):
o Regions on the right half of the abdomen an opening deep to lesser omentum
o Fistulas may develop: leads to lesser peritoneal cavity
 abnormal opening between two organs
NG
BA

AO
ET

 with duodenum
separates Right portal vein and IVC
 Anastomoses with jejunum
important clinically,
surgically, foramen can be used to palpate CBD to check for
stones
Clinically significant because abscesses may spread via this fo-
ramen into lesser peritoneal cavity
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METHODS OF d
INVESTIGATI i
o
ON g
Ultrasonograph r
y a
CT, Computed p
Tomographic h
Mag s
neti I
c n
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ona r
nce a
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ang n
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atog o
raph g
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eous h
Tran y
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Chol n
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 countr
ULTRASO yside.
9
NOGRAPH 5
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Proper ti v
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Normal

sludge
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stone
present
 SURGERY II
CT SCAN
Gallstones can be seen on CT, but it is not used primarily for
this purpose.
 CT can be used in situations where ultrasound is difficult --
such as in obese patients. It can also be used if the ultrasound
is not definitive.

Stones was detected in the bile duct by MRCP.

ERCP [ENDOSCOPIC RETROGRADE

Plain CT shows multiple gallstones. CHOLANGOPANCREATOGRAPHY]
ERCP is the primary method of direct cholangiography, and
has therapeutic potential. It also allows for examination of the
upper GI tract, the papilla of Vater, and the pancreatic duct.

Multiple stones were found in the left intrahepatic bile duct.

MRCP [MAGNETIC RESONANCE

CHOLANGIOPANCREATOGRAPHY]
MRCP becoming a more viable imaging technique, as MRI LEFT RIGHT
technology improves. However, CT and ultrasound are Left picture showed anatomy of upper GI: The endoscope was
faster, easier, and more readily available, so they are used introduced to the papilla of Vater and contrast medium was in-
more fre-quently than MRCP. jected into common bile duct.
MRCP is emerging as a new tool for non-invasive evaluation of Right picture shows the radiographic result after the contrast
the pancreatic and biliary ductal systems. medium was injected into the CBD.
MRCP is gradually replacing PTC and ERCP for diagnostic pur-
poses.

ERCP: Instruments can also be inserted through the scope to re-

move stones, insert stent, tissue biopsy, and other treatments.

PTC [PERCUTANEOUS TRANSHEPATIC

CHOLANGIOGRAPHY]
The catheter was placed into intrahepatic bile duct through

MRCP showed slight dilation of CBD patient’s skin guiding by B-ultrasound. PTC is indicated when
ERCP is not suitable or has failed. It can be used to drain biliary
obstructions.
 DISEASES OF THE BILIARY TRACT

PTC

BEFORE AFTER
Left : After injection of dye, showing a large
gallstone trapped in the duct.
Right: After removal of the stone through the
drainage catheter.
T-TUBE CHOLANGIOGRAPHY
Postoperatively
Injection of contrast medium through a T-tube
catheter placed in the CBD
Easy way to show whether there are
remaining stones or any stricture
RADIOGRAPHS
This was an imaging technique used in the
past, but has been widely replaced by the
ultrasound.
Can be used to visualize calcified stones,
emphysematous chol-ecystitis (gas within the
wall of the gallbladder), biliary fistula (gas
within the biliary system), or a porcelain
gallbladder.
Abdominal x-ray demonstrating stones in the
gallbladder
CHOLELITHIASIS (GALLSTONES)
Gallstone disease, or cholelithiasis, is one of
the most common surgical problems
worldwide.
Gallstones are abnormal, inorganic masses
formed in the gallbladder and, less
commonly, in the common bile or hepatic
ducts
They are a frequent cause of abdominal pain and
dyspepsia.
Although gallstones can form anywhere in
the biliary tree, the most common point of
origin is within the gallbladder.
Three types
of gallstones
exist: o pure
cholesterol
o pure pigment
o mixed
Gallstones are classified according to their
predominant chem-ical composition as either:
o cholesterol
o calcium bilirubinate stones

< 20% of stone type in Europe & US

30-40% of stones in Japan
Three compounds comprise 80-95% of the total solids dis-
solved in bile;
o conjugated bile salts
o lecithin
o cholesterol
Under normal conditions, a delicate balance occurs among the
levels of bile acids, cholesterol, and phospholipids.

A disparity in this balance, especially with the supersaturation
of cholesterol, predisposes patients to the formation of litho-
genic bile and the subsequent development of cholesterol-type
gallstones.
Pigmented gallstones are composed of calcium bilirubinate
and appear in 2 major forms: black and brown.
Hemolysis and liver disease are associated with the
black stones;
the brown, earthy stones more frequently are formed
outside the gallbladder and often are associated with bacterial
infec-tions of the biliary tract.
MORTALITY / MORBIDITY
Related directly to the complications of the disease and it surgi-
cal treatment
Approximately 10% patients with gallstones have common bile
duct stones
Gallstones can cause obstruction of the common bile
duct, causing jaundice
Cholangitis, a potentially life-threatening infection, can follow
biliary obstruction
Obstruction of the neck of the gallbladder causes bile stasis,
which can lead to inflammation and edema of the gallbladder
wall.
Sequelae of this condition include acute cholecystitis
secondary to compromised lymphatic, venous, and, ultimately,
arterial supply to the gallbladder.
The latter can lead to gangrene or abscess formation.
Women are more likely to develop gallstones than men, with a
ratio of 2:1.
Classically, gallstones occur in obese, middle-aged women,
which leads to the popular mnemonic, fat fertile forties.
HISTORY
Nausea, with or without vomiting, might be present.
Certain foods, especially those with high fat content, can pro-
voke symptoms.
The patient might experience episodes of acute abdominal
pain, called biliary colic.
PHYSICAL EXAM
Murphy sign
o pain on palpation of the right upper quadrant when the
patient inhales might indicate acute cholecystitis
Other signs of cholecystitis
o fever
o tachycardia
COMPLICATIONS OF CHOLELITHIASIS
The physical examination might indicate complications
of cholelithiasis.
o Passage of gallstones from the gallbladder into the com-
mon bile duct can result in a complete or partial obstruc-
tion of the common bile duct.
o Frequently, this manifests as jaundice.
o In all races, jaundice is detected most reliably by exami-
nation of the sclera in natural for yellow discoloration.
Pancreatitis, another complication of gallstone disease, pre-
sents with more diffuse abdominal pain, including pain in
the epigastrium and left upper quadrant of the abdomen.
Severe hemorrhagic pancreatitis occurs in 15% patients
and carries a high mortality rate because of multisystem
organ failure.
The GALLBLADDER and the BILIARY TRACT
IISURGERY
icus (Cullen sign) or the flank (Grey-Turner sign).
In a few patients, the hemorrhagic pancreatic process and ret-
roperitoneal bleeding induce discoloration around the umbil-
Charcot triad
o (right upper quadrant pain, fever, and jaundice)
o associated with common bile duct obstruction and chol-
angitis
Additional symptoms:
o alterations in mental status and hypotension, indicate
Raynaud pentad, a harbinger of worsening, ascending
cholangitis.
CAUSES OF CHOLELITHIASIS
Prolonged fasting (5-10 days) can result in the formation of
biliary sludge (microlithiasis) which resolves by itself when
feeding is reestablished - but it can lead to biliary symptoms
or gallstone formation
LAB STUDIES
For patients with uncomplicated cholelithiasis, blood work re-
sults usually are normal.
However, labs can detect complications of gallstone
disease; complications might alter the course of treatment.
CBC
chemistry panel, including electrolytes, liver enzymes, and
bili-rubin.
o Choledocholithiasis can manifest with only elevation of
serum alkaline phosphatase or bilirubin.
o Nearly 50% of patients with symptomatic gallstone dis-
ease will have abnormal transaminases
Serum lipase and amylase levels are helpful in cases of diag-
nostic uncertainty or suspected concurrent pancreatitis
IMAGING STUDIES
X-rays
o Approximately 15% of gallstones are radiopaque and
can be visualized on plain x-ray.
o A porcelain gallbladder (heavily calcified) should be re-
moved surgically because of increased risk of gallblad-
der cancer.
o Other causes of abdominal pain diagnosed with the as-
sistance of x-rays include perforated viscus, bowel ob-
struction, calcific pancreatitis, and renal stones.
Ultrasound (US) is the most sensitive and specific test for the
detection of gallstones.
US provides information about the size of the common bile
duct and hepatic duct and the status of liver parenchyma and
the pancreas.
Thickening of the gallbladder wall and the presence of peri-
cholecystic fluid are radiographic signs of acute cholecystitis
CT scanning often is used in workup of abdominal pain with-
out specific localizing signs or symptoms.
CT scanning is not a first-line study for detection of gallstones
because of greater cost and the invasive nature of the test.
When present, gallstones usually are observed on CT scan.
HIDA scan does not detect gallstones
HIDA scan identifies an obstructed gallbladder (eg, gallstone
impacted in the neck of the gallbladder).
o HIDA scan is the most sensitive and specific test for
acute cholecystitis.
o A poorly contracting gallbladder (biliary dyskinesia)
might cause the patient's symptoms, and HIDA scan
makes the diagnosis.

o Acute acalculous cholecystitis is diagnosed most accu-
rately with HIDA scan.
IISURGERY
the diagnosis of acute cholecystitis
The localization of pain and tenderness in the right hypochon-
drium with radiation to the infrascapular area strongly favors

TREATMENT
Removal of the gallbladder laparoscopic cholecystectomy is the TREATMENT
treatment of choice for symptomatic gallbladder disease
Conservative tx regimen of
Only gallstones that cause symptoms or complications o TPN
require treatment
o analgesics (Meperidine preferred drug- less spasm of
There is generally no reason for prophylactic sphincter of Oddi)
cholecystectomy in an asymptomatic person unless
o antibiotics
o the gallbladder is calcified
Due to high rate of recurrence
o gallstones are > 3cm in diameter
- cholecystectomy advised
o cholecystectomy must be performed when evidence
ACUTE CHOLECYSTITIS of gangrene or perforation is present
Cholecystitis is associated with gallstones in > 90% of cases
o Inflammation develops behind a stone impacted in the CHOLEDOCHOLITHIASIS & CHOLANGITIS
cystic duct
May be caused by infectious agents (cytomegalovirus, cryp- CHOLEDOCHOLITHIASIS
tosporidiosis, or microsporidiosis) common in AIDS patients
Acalculous cholecystitis Choledocholithiasis - common bile duct stones
Occur in 15% of patients with gallstones
o should be considered in patient with FUO, RUQ pain oc-
curring 2-4 weeks after major surgery Increases with age - in elderly w/gallstones occurrence as
high as 50%
Usually condition goes unknown until obstruction occurs
HISTORY
Acute attack often follows a large, fatty meal
HISTORY
sudden, steady pain in epigastrium or right hypochondrium
- pain may steadily subside over a period of 12-18 hours History suggestive of biliary colic or jaudice
vomiting - 75% Of cases frequent/recurrent attacks of severe RUQ pain- duration of
several hours
RUQ tenderness associated with muscle guarding and
severe colic - chills/fever
re-bound pain
Charcot’s Triad- classic picture of cholangitis
Palpable gallbladder 15% of
o Pain
cases Jaundice 25% of cases
o Fever
o also suggestive of choledocholithiasis
o Chills
Fever

IMAGING
LABS The most direct and accurate way to determine the cause, lo-
WBC - elevated (12-15,000 usuallly) cation, and extent of obstruction:
Total serum bilirubin 1-4mg/dL o ERCP
Often elevated levels of: o percutaneous transhepatic cholangiography
o serum aminotransferase
o alkaline phosphatase
TREATMENT
o serum amylase
Common duct stone in patient with cholelithiasis and chole-
cystitis is usually treated with endoscopic papillotomy and
IMAGING STUDIES stone extraction - followed by laparoscopic cholcystectomy
X-ray Ciprofloxacin, 250mg IV q 12 hours effective tx for cholangitis
o may show radiopaque gallstones 15% of cases alternative tx - mezlocillin, 3g IV q 4 hours with either metro-
HIDA Scan nidazole or gentamicin or both
o useful for obstructed cystic duct Aminoglycosides should not be used for more than several
o reliable if bilirubin < 5mg/dL days due to increased risk of aminoglycoside nephrotoxicity in
Ultrasound cholestasis
o useful for gallstone visulization
PRIMARY SCLEROSING CHOLANGITIS
OTHER CONDITIONS Rare disorder
Some disorders that may be confused with acute Characterized by diffuse inflammation of the biliary tract lead-
cholecystitis: o perforated peptic ulcer ing to fibrosis and strictures of the biliary system
o acute pancreatitis Most common - men aged 20-40
o appendicitis (high lying appendix)
o liver abscess
Associated with histocompatible antigens HLA-B8 and -DR3 or
o hepatitis
-DR4 - suggestive of genetic etiologic role
o pneumonia w/pleurisy on right side Sclerosing cholangitis may occur in AIDs patients from infec-
o myocardial ischemia

tions caused by CMV, cryptosporidium, or microsporum

 SURGER II
Symptoms - LABS
o progressive obstructive jaundice frequently Conjugated hyperbilirubinemia
associated with:

Y
elevated alkaline phophatase
 malaise, pruritus,anorexia and indigestion

 Early detection in presymptomatic phase may oc-cur

due to elevated alkaline phosphatase level
Complications of chronic cholestasis such as osteoporosis
and malabsorption of fat-soluble vitamins may occur
Diagnosis generally made by:
o ERCP
o magnetic resonance cholangiography
Tx w/corticosteroids and broad spectrum antimicrobial
agents yields inconsistent and unpredictable results
Episodes of acute bacterial cholangitis may be treated with
ciprofloxacin
high dose ursodeoxycholic acid (20mg/kg/d) may reduce
chol-angiographic progression and liver fibrosis
In patients with ulcerative colitis, primary sclerosing cholangi-
tis is an independent risk factor for development of colorectal
dysplasia and cancer- routine colonoscopic surveillance is ad-
vised
For patients with cirrhosis and clinical decompensation, liver
transplantation is the procedure of choice
Survival of patients with primary sclerosing cholangitis
aver-ages 10 years once symptoms appear
Adverse prognostic factors:
o increased age
o increased serum bilirubin
o increased aspartate aminotransferase levels
o low albumin levels
o history of variceal bleeding
CARCINOMA OF THE BILIARY TRACT
CARCINOMA OF BILIARY TRACT
Occurs in 2% of people surgically treated for biliary
disease Insidious onset - usually discovered during surgery
Cholelithiasis usually present
Other risk factors:
o Chronic gallbladder infectionwith salmonella typhi
o gallbladder polyps over 1cm
o mucosal calcification of the gallbladder (porcelain
gallbladder)
o anomalous pancreaticobiliary ductal junction
Carcinoma of the bile ducts (cholangiocarcinoma) accounts
for 3% of all US cancer deaths
Effects both sexes equally
More prevalent 50-70 age group
2/3 Klatskin tumors - arise at the confluence of hepatic
ducts 1/4 in the distal extrahepatic bile duct
remainder are intrahepatic
Signs/symptoms:
o Progressive jaundice
o pain RUQ w/ pain radiating to back present in gallblad-
der CA but occurs later in course of bile duct carcinoma
o anorexia, weight loss
o fever, chills (due to cholangitis)
o A palpable gallbladder w/obstructive jaundice usually is
said to signify malignant disease (Courvoisier’s Law):
however this has only proved to be accurate 50% of the
time
o Hepatomegaly, liver tenderness
o Pruritus
elevated serum cholesterol
AST may be slightly elevated
CA19-9 (elevated level can help distinguish cholangiocarcino-
ma from benign biliary stricture)
IMAGING STUDIES
Ultrasound
CT
MRI
MRCP
TREATMENT
Laparoscopic cholecystectomy
o 5 year survival for localized carcinoma of the gallbladder
is as high as 80%
o survival rates drop dramatically with more extensive
disease
o Carcinoma of the bile ducts is curable by surgery in <
10% of cases
CASES AND DISCUSSION
Gold standard for cholecystectomy: Laparoscopic Cholecystectomy.
Advantage: recorded.
Absolute Contraindication: those patients who are contraindicated to
undergo General Anesthesia.
Complication of Lap: conversion to open in cases of bleeders.
BOTTOMLINE: get consent for Lap and if possible include consent for
open cholecystectomy.
Tests to do for obstructive jaundice:
1. Ultrasound- dilated ducts are seen
2. MRCP- magnetic resonance cholangiopancreatography
*ERCP is not diagnostic but a therapeutic intervention
- putting a T tube
- best way to clear CBD stones
- only the ampulla is cut
MC complication: Pancreatitis
Intraoperatively, do IOC (Intraoperative cholangiography)
- dye from cystic duct. To see if there is a filling defect.
Can we do IOC laparoscopically? Yes.
Usually, ERCP first then Lap Cholecystectomy
If with history of jaundice: do hepatitis profile
If the patient is female: obtain Gyne Clearance
Single port Lap cholecystectomy is done for very big stones.
Obstruction presents with colicky pain.
Pain after post-lap chole: may indicate injury to the bile duct causing
biliary leak.
BILIARY LEAK- management: drainage insertion
-diagnostic/ mgmt: ERCP, then put a stent.
1 month s/p Cholecystectomy with Jaundice: do ERCP to evaluate
problem
You cannot extract stones via ERCP if they are in the cystic duct.
If there is a stricture, put a stent or dilate it.
The specimen is taken out via the camera port in lap. Cholecystectomy.
CASE 1: CASE 6:
A 45 year old, female, comes into your clinic complaining of A patient was sent home after undergoing an open cholecystectomy. 1
epigastric to right upper quadrant pain, radiating to the back for month post op, patient was noted to have jaundice. What is your plan
about 1 month duration. No associated vomiting, weight loss nor of action?
change in bowel habits. What is your plan for the patient? Rule out presence of jaundice.
PE: Palpate RUQ, ask patient to inhale -> pain (Murphy’s sign) Possibility: there is stricture on the Bile Duct or
Diagnostics: Ultrasound obstruction which can be a stone (either retained or recurrent)
CP clearance, platelet function test **we cannot extract stone from a cystic duct using ERCP
CBC, Liver enzymes + serum bilirubin + Hepatitis profile
Endoscopy to rule out extra cause of s/s Best condition to remove Gallbladder:
If Female: must be OB cleared 1. Patient is asymptomatic
 Diabetic patients will require surgery sooner than non-DM 2. Patient is healthy
patients because they are at risk for cholecystitis 3. Patient is doing very well
Treatment: **Blood absorbs light, so the more blood in the surgical site the darker
 Laparoscopic cholecystectomy- Gold standard the field.
Advantage: recorded (video) **Critical View/Part in performing cholecystectomy:
Absolute contraindication: General anesthesia 1. Cystic plate
**Must secure consent for possible Open Surgery before 2. Cystic duct
the operation 3. Cystic artery

CASE 2:
A 27 year old, male, call center agent, complains of epigastric pain
with occasional right upper quadrant pain, burning in character.
An EGD was done revealing esophagitis, gastritis and H. pylori
infection. Patient has completed H. pylori eradication and is on PPI
maintenance and still complains of right upper quadrant pain.
What is your plan for the patient?
Diagnostics: Request Ultrasound

CASE 3:
A 42 year old male, triathlete complains of abdominal pain with
yellowish discoloration of his skin for 2 weeks duration. Patient
claims to also have tea-colored urine. What is your plan?
Differential: Pancreatitis
Rule Out Medical Jaundice or a Surgical Jaundice
Diagnostics: Amylase, Lipase
**Do all Acute Abdomen Surgically operated? (Patient presented as
having direct and rebound tenderness which can be a sign involving
the peritoneum). ANSWER: NO.
**All pancreatitis will manifest with acute abdomen but not all are
treated surgically but can be medically manage only.
MRCP: a diagnostic procedure
ERCP: Should be therapeutic in nature

CASE 4:
An 18 year old female comes into your clinic with a chief complaint
of abdominal pain. Had a previous appendectomy 10 years prior to
admission. She had an ultrasound done revealing multiple
gallstone with the largest at 7 mm. CBD was noted to be dilated at
1.5 cms but no noted choledocholithiasis. Slight yellowish tinge of
her sclera was noted. What is your plan for the patient?
**Stone measuring 3 cm on UTZ, what will you perform? Open
surgery or Laparotomy?
Can perform Laparotomy. Crush the stone before taking it
out. The surgeon may opt to use a single port.

CASE 5:
A post laparoscopic cholecystectomy patient was noted to have
persistent abdominal pain, described to be continuous, 7-8/10,
located in the right upper quadrant area. What would you request
for at this time? .
*Adhesion leading to obstruction is the most common complication
of post-surgical patients. Manifests as colicky pain (on and off)
*If with Biliary leak. Would you go back in?
Surgeon may leave JP (Jackson-Pratt) drain then observe
drainage for color.