SURGICAL MANAGEMENT OF

BENIGN CAUSES OF OBSTRUCTIVE

JAUNDICE

Raghavi R
Final year MBBS
BENIGN DISORDERS
•Stones
Cholelithiasis
Choledocholithiasis
•Strictures
•Choledochal cyst
 SURGICAL MANAGEMENT OF
CHOLELITHIASIS
Open Cholecystectomy
Laproscopic Cholecystectomy
OPEN CHOLECYSTECTOMY
PRE OPERATIVE WORKUP:
 Complete blood count
Renal profile and liver function tests
Prothrombin time
Chest X ray and electrocardiogram(if over 45 years or medically indicated)
Antibiotic prophylaxis
Deep vein thrombosis prophylaxis
Informed consent
Fasting for 8 hours
OPERATIVE STEPS
1)INCISION:
Right subcostal incision (8-12 cm)
Midline incision done when
- costal angle is narrow
- need to visualize abdomen
- can be extended superior and inferiorly
Holman’s incision
Right subcostal incision + upper midline/paramedian incision
2)Retraction of the subcostal margin
3)Reverse Trendelenberg position to bring the liver down under the costal margin
Moist gauze packs are placed behind the hepatic lobule
Division of falciform ligament
Place retractor to lift the inferior aspect of liver up
Moist packs to pack adjacent structures
Orogastric or nasogastric tube is placed to decompress stomach
4) Dissection
Done close to the gall bladder wall
Presence of cholecystemic fistula is checked
5)Gall bladder fundus is grasped with a clamp
6) Removal of Gall bladder:
 Neck towards fundus
- Incision on the peritoneum
- Another clamp on the neck of gall bladder
- Blunt dissection of the calot’s triangle – to identify the cystic duct
- Palpate the duct, identify the stones and milk them back
- Cystic duct is cut between the clamps close to the gall bladder
- Cystic duct stump is tied and reinforced with a clip
- Cystic artery clamped and ligated
- Neck is free. Dissection of gall bladder from hepatic fossa is done all the way upto fundus
- Ducts of Luschka clipped and ligated
- Gall bladder bed checked for hemostasis
 Fundus down:
- Done in infections
- Incision in the serosa at the tip of fundus
- Sub serosal plane is created between gall bladder and liver
- Fundus is grasped and taken out by sharp and blunt dissection
- Neck is reached. Cystic artery is divided between clamps close to the
gall bladder
- Cystic duct, common bile duct and common hepatic duct are identified
- Cystic duct clamped , ligated and closed down
- Drain removed
- Abdominal incision closed in one or two layers
OTHER TYPES OF OPEN CHOLECYSTECTOMY:
- MINI CHOLECYSTECTOMY:
5cm transverse incision is made.
Useful in conditions where laproscopic machines are not available or conversion from
laproscopy to open cholecystomy surgeries.
- PARTIAL CHOLECYSTECTOMY:
Indicated in excessive bleeding, patient’s instability,inability to identify gall bladder and
calots triangle.
Complications of Open
Cholecystectomy:
Hemorrhage
Bile duct injury
Bile leak
Retained stones
Pancreatitis
Wound infection
Incisional Hernia
LAPROSCOPIC
CHOLECYSTECTOMY
Preoperative care similar to open cholecystectomy
OPERATIVE STEPS
Pneumoperitoneum :
 To see and operate within the abdominal cavity
 Entry - midline near the umbilicus
-supraumbilical /infraumbilical – vertical/horizontal/curvilinear incision
 Closed technique: Veress needle replaced with lap port placed blindly in abdominal cavity
 Open technique: Port inserted under direct vision into peritoneal cavity via small incision
Port placement and exposure:
 5/10 mm laproscope is inserted through periumbilical port to visualize abdomen
 Patient is placed in reverse trendelenberg position
 Two accessory subcostal ports are placed for insertion of grasping forceps in order to
secure gall bladder
- 5mm trocar- along anterior axillary line between 12th rib and iliac crest
- 5mm port- along midclavicular line in the right subcostal areas
 4th port inserted through incision in midline of epigastrium (approximately
5cm below xiphoid process)
Directing forceps are inserted and directed towards gall bladder
 Laproscope should be parallel to cystic ducts
 Other ports should be right angle to the plane
Dissection:
 Top down technique – starts 4-5 cm proximal to gall bladder
proceeds distally to free the gall bladder from its bed
 Hepatocyte triangle is maximally opened
 Cystic duct is then visualized and skeletonized
 Cystic artery is separated by blunt dissection
 Neck of gall bladder is dissected away from liver leaving a large window through which liver parenchyma is
seen
 Critical view of safety is thus developed to avoid bile duct injury
 (only cystic duct and cystic artery crosses the window)
Completion of cholecystectomy:
 Cystic duct and cystic artery clipped and divided
 Ligated stump should be checked for any leak
 Suction irrigation catheter is placed
 Separation of gall bladder is done then
 Gall bladder can be extracted at the umbilical port site
 Skin of subxiphoid and umbilical incision is closed with subcuticular absorbable
suture
 5mm port sites closed with skin closure adhesions
 Orogastric tube is removed
 Patient evaluated 1 week following surgery and sutures if present are removed.
 Complications of Laproscopic Cholocystectomy:
Similar to open cholecystectomy
Pneumoperitoneum related gas embolism,vagal reaction
Troca related visceral injury,vascular injury and abdominal wall bleeding

Newer Techniques:
-Single port laproscopic surgery
-Natural orifice transluminal endoscopic surgery
 SURGICAL MANAGEMENT OF
CHOLEDOCHOLITHIASIS
PREOPERATIVE:
Investigations:
Transcutaneous USG , MRCT, CT, ERCP
Therapeutic use of ERCP in Stone extract removal:
 Sphincteromy
 Dormia basket
 Balloon sphincterectomy
Other Techniques of Stone removal:
• Mechanical lithology
• Intraductal shock wave lithology
• Electrohydraulic lithotripsy
• Laser lithology
• Extra corporeal shock wave lithotripsy
Intraoperative:
Intraoperative Cholangiography(IOC)
- Length of cystic duct and location of its junction with common bile duct
- Size of common bile duct
- Presence of intraluminal filling defects
Intraoperative Ultrasonography(IOUSG)
- Decrease the risk of bile duct injury
Laproscopic Common bile duct Exploration:
- Transcystic( via the cystic duct)
- Laproscopic choledochotomy (incising and opening common bile duct)
Open Common bile duct Exploration:
If patient presents with dilated common bile duct or multiple CBD stones
Surgical biliary drainage procedure:
 In case of multiple stones
 Incomplete removal of all stones
 Impacted unremovable distal bile duct stones
Methods: Transdermal sphincteroplasty
Choledochoduodenotomy
Choledochojejunostomy
 SURGICAL MANAGEMENT OF POST
OPERATIVE STRICTURES
INJURY RECOGNIZED IN INTRA OPERATIVE PERIOD:
If laproscopic cholecystectomy  open cholecystectomy is to be done.
Intraoperative cholangiography should be done

Bile duct

Less than 3mm More than 4mm

Ducts are ligated Operative repair

 OPERATIVE REPAIR

Partial common duct transection Complete common duct transection

less than 180 degree circumference greater than 180 degree circumference

Closed using T Tube

Less than 1cm Significant loss
in length of length or high in biliary
tree

-Reconstruction-Roux- en –Y
END TO END
hepaticojejunostomy
ANASTOMOSIS
-Trans hepatic silastic biliary
WITH T TUBE
stent
-Perianastomotic drain
INJURY RECOGNIZED IN IMMEDIATE POSTOPERATIVE PERIOD:

Broad spectrum antibiotics

Percutaneous or Endoscopic biliary drainage
Correction of fluid electrolyte abnormality, anemia, nutritional deficits
Reconstruction
Dissection of porta hepatis
Clearance of adhesions
Identification of proximal biliary segment above the stricture
Anastomosis Roux -en- Y hepaticojejunostomy
Roux- en –Y hepaticojejunostomy
 CHOLEDOCHAL CYSTS
MODIFIED ALONSO-LEJ/TODANI CLASSIFICATION

DILATATION OF CBD DIVERTICULUM DILATATION OF CBD IN

INTRADUODENAL
INTRA & EXTRA HEPATIC EXTRAHEPATIC INTRAHEPATIC
DILATATION OF CBD DILATATION OF CBD DILATATION OF CBD
 SURGICAL MANAGEMENT OF CHOLEDOCHAL CYST
Goal:
To prevent malignant change of the cyst
Procedure:
◦ Resection of extrahepatic biliary tree
◦ Removal of choledochal cyst along with cholecystectomy
◦ Roux – en – Y hepaticojejunostomy – Type 1,2,4b
◦ Type – I : Excision of the cyst with its mucosa and reconstruction by Roux – en – Y
hepaticojejunostomy
◦ Type -2 : Excision of the diverticulum and suturing of CBD
◦ Type -3 : Endoscopic sphincterotomy and excision of the cyst
◦ Type- 4 : Cyst adherent to portal vein – mucosa of that part removed (lily’s operation )
◦ Type- 5 : Liver transplantation
Frozen section biopsy – Look for Cholangiocarcinoma
If positive – Hepatic resection along with bile duct resection