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STRATEGIES TO PREVENT BILIARY INJURIES

Dr.SURESH CHANDRA HARI.G MS FAIS FICS FMAS

HYDERABAD


OPEN TO LAP SURGERY


C U H K CLASSIFICATION 2007


CAUSES-BILE DUCT INJURY   

    

ACUTE CHOLECYSTITIS ANATOMICAL VARIATIONS BLEEDING FROM CYSTIC /HEPATIC UNCLEAR CALOT’S TRIANGLE ANATOMICAL ILLUSIONS MISIDENTIFICATION SHORT / ABSENT CYSTIC DUCT IMPACTED STONE


PRE OPERATIVE 

GOOD IMAGING

ASSESSMENT OF DIFFICULTY

PROPER COUNSELLING


DURING SURGERY 

IDENTIFY THE CALOT’S & CYSTIC DUCT  CRANIAL TRACTION OF FUNDUS  LATERAL TRACTION OF HARTMAN’S POUCH  ALWAYS START DISSECTION MEDIAL TO INFUNDIBULUM


LATERAL TRACTION OF CYSTIC DUCT


DURING SURGERY  

  

TRACE THE CYSTIC DUCT UNINTERRUPTED TO GB MAKE A BIG WINDOW BEHIND GB CLEAR ALL TISSUES BETWEEN CYSTIC DUCT AND GB AVOID BLIND DIATHERMY OR CLIPS TO CONTROL BLEEDING USE LIBERAL SUCTION IRRIGATION TO KEEP FIELD CLEAR


SAFE ZONE & DANGER ZONE


? CYSTIC DUCT / ??C B D     

INCOMPLETE ENCOMPASSMENT OF CLIP STRUCTURE COURSING TO BEHIND DUODENUM PRESENCE OF ANOTHER DUCTAL STRUCTURE LARGE ARTERY BEHIND / HEPATIC EXTRA LYMPHATIC & VASCULAR STRUCTURES ON DISSECTION


PEROPERATIVE CHOLANGIOGRAM 

ADHESIONS & INFLAMMATION  CONFUSING ANATOMY  SUSPECTED BILIARY ANOMALIES  DIFFICULTY IN DISSECTION


CLIP APPLICATION 

APPLY ONLY AFTER FULL MOBILISATION & CONFIRMATION  TIPS SHOULD BE VISUALISED  NO TISSUE BETWEEN CLOSED TIP  NEVER APPLY MORE THAN 8 CLIPS  MAINTAIN PROPER DISTANCE BETWEEN CLIPS


OBESE PATIENT WITH INVISIBLE CALOT’S • PLACE THE PATIENT IN STEEP REVERSE TRENDELENBERG

• INSERT AN EXTRA 5 MM TROCAR IN LEFT UPPER ABDOMEN • USE A FAN RETRACTOR / SUCTION CANNULA • PUSH DOWN THE DUODENUM & GREATER OMENTUM


INDICATIONS FOR CONVERSION TO OPEN 1. ADHESIONS 2. CIRRHOTIC LIVER

3. THICKENED CONTRACTED GALL BLADDER 4. ABNORMAL ANATOMY 5. SEVERE CHOLECYSTITIS WITH FRIABLE GB


WHAT NOT TO DO ? 

STARTING DISSECTION AT DANGER ZONE  EXCESS CAUTERY  BLIND AND INCOMPLETE CLIP APPLICATION  CUTTING BEFORE FULL DISSECTION AND IDENTIFICATION


WHAT NOT TO DO ?      

EXCESSIVE LATERAL TRACTION ON INFUNDIBULUM INCOMPLETE CLIPS ON LARGE CYSTIC DUCT DEEP DISSECTION OF LIVER BED DISSECTION OF SCARRED TISSUE IN INFLAMMATION DISSECTION OF CBD HANDLING CLIPS AFTER APPLICATION


LEGAL REQUIREMENTS 

30 DEGREE SCOPE Vs 0 DEGREE  CRANIAL TRACTION OF FUNDUS  LATERAL TRACTION INFUNDIBULUM  NO CLIP OR CUT BEFORE FULL DISSECTION  ROLE OF OPER CHOLANGIOGRAM


Strategies to prevent  
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