Gall bladder (GB) & Biliary tract Surgery😍

Surgical Anatomy of Gallbladder (GB)

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ㅤ	Calot Triangle (Cystohepatic Triangle)	Hepatobiliary Triangle
Right	Cystic duct	Cystic duct
Left	Common hepatic duct	Common hepatic duct
Superiorly	Cystic artery	Inferior surface of liver
Content	Cystic node of Lund ↳ Sentinel node of gallbladder	• Cystic artery (From R Hepatic A) • Cystic nodes

Moynihan’s Hump (Caterpillar Hump)

• Tortuous right hepatic artery.

• Lies in front/within Calot’s triangle.

• mimic cystic artery

• Injury leads to torrential bleeding.

Cystic Plate:

• Flat, ovoid fibrous sheet,

• Continuous with liver capsule of segments 4b & 5.

• Location: GB bed.

• Exposure critical view of safety during laparoscopic cholecystectomy.

Rouviere’s Sulcus: (Bailey update)

• Under surface of right lobe of liver, right of hepatic hilum.

• Marks position of right posterior sectoral pedicle.

R4U Line:

• Line joining Rouviere’s sulcus (R), Segment 4B & Umbilical fissure.

• Above this line: Cystic artery + Cystic duct.

• Below this line: Common Bile Duct (CBD).

• B SAFE Approach → To prevent Bile duct injury

• Dissection should be done above R4U line during cholecystectomy.

Gall Bladder

• Gall bladder
• Appears black due to bile

• Echogenic structure
• Gall stones → posterior acoustic shadowing (+)

Phrygian Cap:

• Folding inside gallbladder

• Considered normal

• Physiological variant.

• Not an indication for cholecystectomy or risk for cancer.

Gallstones

Types:

• Mixed stones: 
• M/c overall (Cholesterol + pigment).

• Pure cholesterol stones.

• Pigment stones: 
• M/c in Asia (<30% cholesterol).
• Brown:
• Calcium bilirubinate, Ca Palmitate, Ca Stearate
• Associated with infected bile
• Clonorchis, Cholangitis
• Black:
• Insoluble bilirubin pigment + CaPO4 + CaHCO3
• Associated with hemolytic conditions
• Sickle cell anemia, Hereditary spherocytosis

Investigations:

• IOC: 
• USG Abdomen: Posterior acoustic shadow.

Presentation:

Asymptomatic:

• Indications for surgery: 
• Porcelain GB (calcification of GB wall) → ↑ Risk of malignancy by 10%
• Polyp > 1 cm
• Salmonella typhi carrier
• DM
• Stone size >2 cm

• Note: Cholesterosis (Strawberry GB) is not a risk factor for GB cancer

Porcelain GB

• Premalignant - 10%

Strawberry Gallbladder:

• Cholesterolosis of the gallbladder 

• aka Adenomyomatosis of gall bladder

• Note: Cholesterosis (Strawberry GB) is not a risk factor for GB cancer

• Gross specimen: 
• Strawberry GB appearance

• White lines → Comet tail appearance

• Special Stains: 

Stains	Sections For	Features
Oil Red O (reddish)	Frozen/Fresh section	For fat identification Advantage Tissue frozen → no chemicals added → fat preserved. (Routine processing alcohol washes off fat).
Sudan Black B (black)	Fixed	ㅤ
Sudan 4 (orange)	ㅤ	ㅤ

Gallbladder Poly

• Appears attached to gallbladder wall and echogenic

• No posterior acoustic shadowing

• Non‑mobile

• GB polyps → >1 cm in size, multiple
• Risk factor for GB cancer
• If single and < 1cm → Regular follow up (?every 2 months)

Gall Stone

• Posterior acoustic shadowing

• Mobile

• GB stone in CT
• Usually not seen
• When seen → Mercedes Benz sign
• Stone with trapped air inside

Acute Cholecystitis:

Tokyo Guidelines for Diagnosis:

• a. Local signs of inflammation:
• Murphy’s sign
• RUQ pain/tenderness/mass + N/V

ㅤ	C/F	Conditions
Murphys sign	RUQ pain/tenderness	Acute Cholecystitis
Murphys triad	• Pain in the right illiac fossa • Vomiting • Fever	Acute appendicitis
Murphys punch sign	Pain in costovertebral traingle on punch	Acute pyelonephritis Obstruction of kidney

• b. Systemic signs of inflammation:
• Fever
• ↑ CRP
• ↑ WBC

• c. Imaging findings: IOC → US
• Overdistended gall bladder
• Probe tenderness
• Thick wall (> 3 mm)
• Pericholecystic fluid.
• Gallbladder stone in the neck causing obstruction

• Suspected diagnosis:
• 1 item in A & B but not C.

• Definitive diagnosis:
• 1 item in A + B + C.

• Gold standard investigation
• For acalculous cholecystitis.
• HIDA scan

HIDA Scan

• Tests for the biliary tract

• HIDA shows uptake/excretion in biliary tract
• HIDA enters biliary tract
• Blocked gallbladder → HIDA will not enter
• Leads to non-visualisation of gall bladder
• HIDA = nuclear scan for biliary tract

Inference

• Presence in gallbladder, biliary tract, duodenum, intestine
• Patent biliary tract

• Biliary atresia:
• HIDA not seen in biliary tract

Grading (Tokyo consensus guidelines):

Grade	Severity	Characteristics
Grade I	Mild	No organ dysfunction & mild inflammatory changes
Grade II	Moderate	Any 1 of: • WBC >18,000, • palpable tender mass, • >72 hours duration, • marked local inflammation (emphysematous/gangrenous, abscess, biliary peritonitis)
Grade III	Severe	Organ dysfunction

Management (Based on Tokyo guidelines):

• Note: Chronic cholecystitis → Mx: Cholecystectomy.

• Grade I: 
• Antibiotics + General supportive care.
• Early laparoscopic cholecystectomy (LC).

• Grade II & III: 

• Antibiotics + General supportive care.
• No negative predictive factors & good facilities:
• Urgent LC.
• Negative predictive factors
• Poor Performance Status:
• Urgent GB drainage (Tube cholecystostomy).
  ↓
• Good Performance Status:
• Delayed/Elective LC.

Emphysematous cholecystitis

 

• Black on CT is air.

• Air means Emphysema.

• This is emphysematous cholecystitis.

Mucocele:

• Aseptic dilatation of GB with mucus.

• Due to impacted stone at neck of GB (Hartman’s pouch).

• If infected: Empyema.

• Mx: Cholecystectomy.

Gallstones in Pregnancy:

• Hormonal changes:
• ↑ cholesterol secretion, ↓ bile acid secretion, ↓ GB emptying (progesterone) → ↓Ability of bile to solubilise cholesterol → Promotes formation of stones

• First trimester: Conservative Mx (avoid NSAIDs).

• Third trimester: Conservative Mx.

• Second trimester:
• Moderate/Severe disease → Lap cholecystectomy.

Mirizzi’s Syndrome:

• GB adherent to CBD → Stone pushes against CBD → Obstruction → Fistula (CBD & GB).

• Clinical Features: Obstructive jaundice + ↑ALP.

• Csends classification

• IOC: MRCP.

• Mx: Ideal:
• Cholecystectomy + Fistula repair.
• If GB adherent: Subtotal cholecystectomy.

Emphysematous cholecystitis

 

• Black on CT is air.

• Air means Emphysema.

• This is emphysematous cholecystitis.

Gallstone Ileus:

• Secondary to cholecystoduodenal fistula →
• Dynamic bowel obstruction
• Risk factors
• Any previous abdominal surgery
• Abdminal Hysterectomy

• Bouveret syndrome
• Gallstone causing gastric outlet obstruction
• Bouveret: BO (Bowel Obstruction) varattu

• M/c site: Last 60 cm of ileum

a. X-ray abdomen: Riggler’s triad:

1. Pneumobilia
• Air in biliary tree

2. Features of small intestine (SI) obstruction.

3. Radiopaque shadow in Right lower quadrant (RLQ).

b. CECT: IOC.

Management:

• a. Mx of intestinal obstruction.

• b. Second surgery (Cholecystectomy + Fistula repair).

Hemobilia

• Bleeding into the biliary tree

• Due to abnormal communication between a blood vessel and bile duct

• Causes
• Iatrogenic trauma
• Most common cause
• Liver
• Bile ducts
• Intraductal rupture
• Hepatic abscess
• Hepatic artery aneurysm
• Tumor hemorrhage
• Biliary
• Hepatic
• Mechanical causes
• Choledocholithiasis
• Hepatobiliary parasitism
• Diagnostic procedures
• Liver biopsy
• Percutaneous transhepatic cholangiography (PTC)
• Transhepatic biliary drainage catheter
• Vascular disorders

• Clinical presentation
• Quincke’s triad (Sandblom triad):
• Biliary pain
• Obstructive jaundice
• Melena or occult blood in stools
• Quick Sand → biliary tree climb

• Investigation of choice
• CT angiography

• Management
• Minor hemobilia
• Conservative management
• Major hemobilia
• Transarterial embolization
• Required if blood transfusion needed
• Ligation of bleeding vessel may be required

Choledocolithiasis:

• Stones in the CBD.

• Patient come with complaints of abd pain, USG showed CBD dilatation
• Check if jaundice is present or CBD>10mm
• If present → High grade
• If not → check CBD diameter → if 8-10mm → Moderate grade
• For both → Do MRCP → +/- ERCP + stone removal → Cholecystectomy

Presentation: 

• Asymptomatic, Obstructive Jaundice (↑ALP), Cholangitis (Charcot’s triad).
• Charcot’s Triad:
• Pain + Fever + Jaundice.
• Intermittent
• Reynolds Pentad:
• Charcot’s triad +
• Septic shock +
• Altered mental status.

Investigations:

1. Endoscopic Ultrasound (EUS):
• 1st Inv
• IOC for CBD microliths.
• Protocol
• US show CBD dilatation (without CBD stone)→ Do MRCP → ERCP
• US show CBD dilatation + Gall stone → Do MRCP → ERCP
• US show CBD stone → Do ERCP

2. MRCP: IOC.

3. ERCP
• Gold standard for CBD stone

• Image 1
• Investigation: ERCP
• Endoscope & CBD visible
• Pancreatic duct seen

• Image 2
• Investigation: MRCP
• No endoscope, No dye

Feature	Image 1	Image 2
Procedure	T tube cholangiogram	PTC (Percutaneous Transhepatic Cholangiogram)
Entry route	Tube from outside → CBD	Catheter through liver
Shape	T-shaped	Not T-shaped (straight catheter)
Placement context	Post cholecystectomy	Direct puncture into liver
Position inside	Lies in CBD	Enters peripheral intrahepatic radicle
Purpose	Divert bile drainage	Imaging via transhepatic route

Management:

CBD/GB stone detected before cholecystectomy:

1. ERCP followed by Cholecystectomy.
1. Side viewing endoscope used
2. Endoscope visualised



• S/E: : Pancreatitis

CBD Stones detected during surgery:

1. Lap cholecystectomy + CBD exploration.

2. T-Tube insertion or Kehr tube.

• Dye injected after 5-7 days
• No residual stones :
• Remove T-Tube
• Mnemonic: T tube keetti (Kehrs) idum, 2-3 weeks muruki (burhenne) idum
• Stones +
1. Burhenne’s technique : Retain T-Tube
2. 2-3 wks → Remove stones using choledochoscope.

CBD Stones detected after surgery:

• At or Within 2 years: Residual/Retained stones → ERCP.

• After 2 years: Recurrent/Primary CBD stones → ERCP.

Laparoscopic Cholecystectomy (LC)

Be Safe Method: 

• Visualize:
• Bile duct,
• Sulcus of Rouviere,
• Hepatic artery,
• Umbilical fissure,
• Duodenum.
• Cystic artery,
• Cystic duct.

Bailout Strategies: 

• If standard LC fails/not feasible
• Abort procedure.
• Convert to open procedure.
• Tube cholecystostomy (14F Foley’s).
• Subtotal cholecystectomy.
• Fundus first procedure.

Complications:

• Right shoulder tip pain (M/c):
• Due to retained CO2.

• Bleeding.

• Steatorrhea
• Due to continuous bile leak into intestine → affect absorption

• CBD injury
• Bile leak
• M/c site injured → Lateral wall of common hepatic duct

• Residual/recurrent stones
• Present at or within 2 years

• Post-cholecystectomy syndrome:
• Pain due to
• Sphincter of Oddi dysfunction,
• retained stones.

Bile Duct Injury:

• Bile leak during surgery: Surgical repair.

• Bile leak after surgery:



• MOST SENSITIVE INV → HIDA
• Not done because it does not detect the site, and does not treat
• Minor:
• Stable patient, no fever, conservative Mx.
• Major: Fever +, Jaundice +, Pain +,
• USG: Collection +.
• Within 24-48 hours:
• Re-explore & Repair.
• >48 hrs:
• Abs + Pigtail → MRCP (IOC)
• ERCP f/b stenting

Bismuth & Strasberg Classification

• (Strasberg uses E for major injuries):

• Note: Hannover classification → bile duct + Vascular injury.
• Vascular injury in type C and D

• Mnemonic: Handover (Hannover) Bile (Bismuth) through straw (Strasburg)

Extrahepatic biliary atresia

• Jaundice at birth

• Periductal fibrosis and proliferation

• Japanese & Anglo-Saxon:



• Type 1: Atresia restricted to CBD.
• Type II: Atresia of Common Hepatic Duct (CHD).
• Type III: Atresia of right, left hepatic ducts & entire extrahepatic biliary tree.

• D/ds
• Neonatal hepatitis
• Alagille syndrome:
• Biliary atresia
• Congenital heart disease
• Skeletal abnormalities
• Mnemonic: Alanjappo → slipped on Bile, got Skeletal fracture + Heart attack

• A/w
• Cardiac lesions
• Polysplenia
• Situs inversus
• Absent vena cava
• Preduodenal portal vein

• Initial: Fasting USG (Gold standard): Shows atretic biliary tree.
• Triangular Cord sign
• fibrosed bile duct seen anterior to portal vein

• Ghost GB triad
• GB become small and atretic

• Screen: HIDA scan ??
• Highest Negative Predictive Value → rule out

• MRCP: Sensitive and specific.

• Liver Biopsy: Confirmatory.

• Tx:
• Kasai procedure (H - J)
• within first 60 days OR
• NO cirrhosis



• Otherwise → Liver Transplant
• M/c indication for liver transplant in children.

Choledochal Cysts

PATHOPHYSIOLOGY

• ABNORMAL PANCREATICO BILIARY JUNCTION

Todani/Modified Alonso-Lej Classification:

Type I (M/c): 

• Diffuse dilatation of CBD.

• Treatment: 
• Cyst resection +
• Roux-en-Y hepaticojejunostomy.
• Single → Cyst

Type II: 

• Diverticulum of CBD.

• Treatment: Diverticulum resection & repair.

• 2 → Di → Diverticulum

Type III: 

• Dilatation of intraduodenal portion of CBD (Choledochocele).
• Treatment: 
• ERCP +
• Sphincterotomy +
• Removal of abnormal mucosa.

• 3 → 3C → CholedoChoCele

Type IV A: 

• Intrahepatic + Extrahepatic biliary tree dilatation.
• Treatment: Liver transplant.

• 4 A → A → All involved

Type IV B: 

• Only extrahepatic biliary tree dilatation.
• Treatment: Kasai procedure
• Portoenterostomy

Type 5: 

• Dilatation of only intrahepatic biliary tree (CarolI’s disease).
• DUCT DILATED WITH A DOT (VENOUS RADICLE ) IN CENTRE

• Treatment: Liver transplant.

• 5 carolI teams → I → Intrahepatic

IOC:

• MRCP

Caroli disease

• Rare congenital disorder

• Saccular dilatation of intrahepatic bile ducts

• Autosomal recessive

• Non-obstructive

A/W

• Congenital hepatic fibrosis

• Often with polycystic kidney disease

Imaging sign

• Central dot sign on CT

• MRI
• IOC