A, Percutaneous transluminal cholangiography.
Note the remnant of the duct draining into the common bile duct solid arrow and cystic stump open arrow. Note the low entry of this duct into the common bile duct. B, Tube fistulography. The biliary ductal system of the cut sectoral duct is outlined. In a population-based study by Flum and colleagues , the rate of bile duct injury was found to be significantly higher when IOC was not used 0.
In a national survey of American surgeons performing laparoscopic cholecystectomy, Archer and colleagues found that IOC was helpful for intraoperative detection of bile duct injury. Interestingly, of the surgeons surveyed in the United States, one third had experienced this complication. A single institutional study by Kohn and associates examined the use of routine versus selective cholangiography among surgeons performing laparoscopic cholecystectomy.
This study found that surgeons performing selective cholangiography were less likely to attempt IOC, even if indications arose resulting in significantly worse adverse events. Regardless of surgeon preference for routine or selective IOC, we recommend a low threshold for early conversion to laparotomy, if the ductal anatomy remains unclear or for any other concern. IOC remains the gold standard to define biliary anatomy, but it cannot prevent all bile duct injuries; and in some rare cases, it may even be the cause.
Eimear Brannigan, It has an extremely low rate of postoperative infection 0. Two meta-analyses have revealed no beneficial effects of antibiotic prophylaxis in low-risk patients those without cholecystitis, choledocholithiasis and cholangitis undergoing elective laparoscopic cholecystectomy in reducing postoperative infection rates. However, antibiotic prophylaxis remains appropriate in complicated patients and patients requiring open cholecystectomy. Bacterial colonization of bile occurs as a result of either obstruction of the biliary tree or biliary stasis.
In the former, it is commonly due to gallstones but can be as a result of benign or malignant obstruction to the common bile duct. Biliary stasis is seen in critically ill patients as a consequence of increased bile viscosity due to fever and dehydration. Patients on long-term total parenteral nutrition TPN , prolonged fasting, gallbladder dysmotility and occasionally diabetes are at increased risk of biliary stasis, which can lead to acalculous cholecystitis.
Bacterial infection is thought to be a consequence, not a cause, of cholecystitis. In early acute cholecystitis, bile is sterile. Bacteria can enter bile by ascending the common bile duct from the duodenum across an incompetent sphincter of Oddi or following instrumentation ; entering directly from the small bowel after choledochoenterostomy; or by translocation from the gut into the portal vein, resulting in cholangitis. Anaerobes are rare. Recurrent pyogenic cholangitis oriental cholangiohepatitis is common in South East Asia and is characterized by recurrent attacks of primary bacterial cholangitis.
The cause is unknown, although Clonorchis sinensis , ascariasis and nutritional insufficiency have been suggested. Antimicrobial treatment of biliary tract infections usually requires single-agent therapy, or combination treatment with broad-spectrum cover for more serious infections. High biliary concentration of antimicrobials is vital, but the range of antimicrobial activity is a more important factor.
When there is biliary obstruction, it is doubtful whether any antibiotic is excreted effectively into the bile.
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Cephalosporins have the required spectrum of activity and suitable pharmacokinetics, while quinolones achieve high concentrations in the biliary tract and are active against biliary pathogens. Suitable single-agent regimens include the following:. Mild to moderate cholecystitis: ampicillin—sulbactam, ticarcillin—clavulanate, ertapenem, quinolones, cefuroxime, ceftriaxone or cefoxitin. Severe cholecystitis, nosocomially acquired or prior antibiotic exposure: piperacillin—tazobactam, imipenem or meropenem. Combination regimens include penicillin including piperacillin, ampicillin, or penicillin and metronidazole; penicillin with an aminoglycoside gentamicin or tobramycin ; or an aminoglycoside and third-generation cephalosporin.
In cholangitis or biliary obstruction, biliary secretion of antibiotics may be impaired. Treatment may therefore require decompression and drainage of the biliary system depending on the cause of the infection and the severity of illness.
Do I Need Surgery?
Early laparoscopic cholecystectomy for acute cholecystitis is controversial as there is a higher complication rate with conversion to open surgery. However, a meta-analysis has shown that early laparoscopic cholecystectomy is safe and shortens hospital stay. Srinivas R.
Puli, David L. Laparoscopic cholecystectomy see Chapter 34 has replaced open cholecystectomy as the procedure of choice for gallbladder removal in most patients with symptomatic cholelithiasis. Optimal management of patients with suspected or documented CBD stones varies according to the expertise available in a particular institution.
Laparoscopic transcystic choledochoscopy is hindered by the small size and tortuosity of the cystic duct, making instrument passage and stone lithotripsy and removal potentially difficult. Small asymptomatic stones may be of minor clinical relevance, because their natural history is unknown, and conceivably many if not most of these calculi would pass spontaneously without ever coming to clinical attention. We have favored selective evaluation of the CBD only for patients with risk factors for choledocholithiasis. Table Cholangiography Stratification for Risk of Choledocholithiasis.
Algorithm 1 offers the advantage of complete surgical management at a single procedure without the need for additional postoperative stone extraction.
Medical University of South Carolina Digestive Disease Center
This strategy has not gained widespread acceptance, but it would be a reasonable approach in centers incapable of providing adequate endoscopic therapy, or when techniques are achieved for performing laparoscopic CBD exploration. Algorithm 2 focuses on endoscopic cholangiography and stone clearance before performance of laparoscopic cholecystectomy. Algorithm 3 uses laparoscopic transcystic cholangiography to detect CBD stones and postoperative ERCP to remove stones in patients with positive cholangiograms. This strategy relies heavily on ERCP expertise, because failed stone removal necessitates referral to a more experienced endoscopist or a second open operative procedure.
The choice between these strategies should be strongly influenced by the surgical and endoscopic expertise available. At our institution, in a prospective series of consecutive laparoscopic cholecystectomies Table ERCP was successful in All stones were removed after sphincterotomy, with nine complications: six cases of pancreatitis three mild, three moderate , two of hemorrhage one mild, one moderate , and one fever with negative blood cultures.
ERCP, endscopic retrograde cholangiopancreatography. We suggest performance of precholecystectomy ERCP 24 to 48 hours before the planned surgery whenever logistically feasible to avoid the infrequent occurrence of stone migration from the gallbladder into the CBD during the ERCP-laparoscopy interval, resulting in the possibility of a retained CBD stone. This sequence of events occurred early in our series in one patient who passed a stone from the gallbladder into the CBD during a 3-week interval between the preoperative ERCP and laparoscopy, but it has not recurred with subsequent performance of preoperative ERCP at the recommended to hour interval.
Patients without preoperative indicators patients and considered low risk did not undergo cholangiography, and 21 1. George W. Laparoscopic cholecystectomy is becoming a common operation for pediatric surgeons. Also, children presenting with biliary dyskinesia are being seen more frequently. Most pediatric patients undergoing laparoscopic cholecystectomy are in the adolescent age group.
However, an occasional elementary school-age child will need this procedure, and, rarely, a preschool infant will be symptomatic from cholelithiasis. When positioning the instruments and cannulas for the operation, it is important to space the cannulas widely for optimal working room Fig. This is especially true in the younger patient. The two right-sided instruments are usually for retracting purposes, with the most inferior instrument being used by the assistant and the most cephalad manipulated by the surgeon. These can often be inserted by using the stab incision technique see Fig.
For the preschool patient a 5-mm umbilical port is placed, but for older patients a mm port is usually necessary. The gallbladder will be extracted through this cannula or the umbilical fascial defect. Figure For laparoscopic cholecystectomy in infants and children, it is important to space the cannulas widely to create an adequate working space and not have the instruments inhibiting one another.
A, A suggested diagram for location of the ports for an infant.
B, The cannulas can be arranged as shown for a child between ages 3 and 10 years. C, Instruments can be positioned as they are for an adult. Any omental or peritoneal attachments to the gallbladder are bluntly divided, and the tip of the gallbladder is rotated ventrally over the liver, which exposes the infundibulum and cystic duct.
It is very important to retract the infundibulum laterally, which orients the cystic duct at a right angle to the common bile duct Fig. If the infundibulum is retracted cephalad, the cystic duct approaches a more vertical orientation and the cystic duct and common duct can be misidentified. This may lead either to injury or to ligation of the common duct. With the infundibulum retracted laterally, the cystic duct is well visualized and then easily skeletonized.
Laparoscopic Cholecystectomy - an overview | ScienceDirect Topics
Cholangiography often is not necessary. However, if the surgeon desires cholangiography, several techniques are available. In older children, a lateral incision in the cystic duct can be made, with insertion of a cholangiocatheter into the cystic duct, followed by cholangiography.