1. consultant general and laparoscopic surgeon..
Dr. Mumtaz Khudhur
Hanna Alnaser
Assistant professor
consultant general and laparoscopic surgeon..
- Fellow of Arab board of general surgery
Fellow of royal college of physicians and surgeon of glasgow
MBchB , C.A.B.S. , FRCS (glasgow)

2. GALL BLADDER AND BILE DUCTS

3. ANATOMY
The extrahepatic billiary system begins with hepatic ducts and ends at the stoma of common bile duct in the duodenum(CBD).
CBD is 8-11 in length and 6-10 in diameter
It lies in the free edge of the lesser omentum to the right of hepatic artery and anterior to portal vein.
GALL BLADDER is pear shaped 7-12 cm long, it is divided into fundus body and neck terminate into a narrow infundibulum.
cystic duct is 3-4cm long ,1-3mm in diameter.
It is supplied by cystic artery ,branch of right hepatic artery.

4. PHYSIOLOGY The gall bladder is a reservior for bile .
Concentration of bile by 5-10 times by active absorption of water sodium chloride and bicarbonate by mucous membrane of g.b.
Secration of mucous 20ml/day.

5. CONGENITAL anomalies of GALL BLADDER
CALL BLADDER
Absence of gall bladder
Phrygian gap
Double gall bladder
Floating gall bladder
OF cystic duct
Low insertion of the cystic duct
Short or absent cystic duct
Accessory cystic duct passing directly from the liver ,or from the right hepatic duct to the g.b.

6. Extrahepatic biliary atresia
It occur at any level of CBD even intrahepatic
30% of cases are jaundiced at birth m and should be differentiated from physiological jaundice .
Stool become pale ,urine is dark ,prolonged steatorrhea .
20% associated with another congenital anomalies.
If Untreated child die before age of 3 years ,due to liver failure or haemorrhage.
Diagnosis should be early and treatment is surgical
Hepaticojejunostomy.

7. Choledochal cyst
It is due to weakness in part or whole of the wall of CBD
It is presented at early childood , usually with jaundice,cholangitis and abdominal mass
It is either fusiform or saccular.
Diagnosis by U\S and MRI
Treatment is by radical excision of the cyst with reconstruction by Roux-en Y loop of jejunum.

8. Gall stone (cholelithiasis)
It is a common condition and the classical sufferer is a fat , fertile, flatulent,female, of fifty (5f).
In men the disease tend to occur in the older age group.
Classification of stone s according to their chemical composition
Cholesterol stones(20%) often it is solitary ,pure one is uncommon,usually large with smooth surfaces.
Mixed stones (75%)cholesterol is the major component other include calcium bilirubinate ,calcium phosphate ,calcium carbonate ,calcium palmitate and protein,usually multiple and often facated
Pigment stone (5%) composed almost entirely of calcium bilirubinate ,mostly small and multiple .

9. Etiology of gall stone formation
Idiopathic
Metabolic usually cholesterol is insoluble in water and held in solution by the detergent action of bile salt and phospholipid with which it form micelles ,it occur with increasing age in female ,pills,and obesity.
Infection ex. Helicobacter pylori
Bile stasis gall bladder contractility decrease by oestrogen in pregnancy and after truncal vagotomy ,patient on long term TPN and lack good oral intake
Pigment stone is also seen in patients with haemolysis, benign and malignant strictures ,infestation with clonorchis sinesis ascaris lumbricoid.

10. The Effect And Complications Of Gall Stones
85%-90% of gall stones are asymptomatic
In the gall bladder
Silent stones
Chronic cholecystitis
Acute cholecystitis
Gangrene
Perforation
Empyema
Mucocele
Carcinoma
In the bile ducts
obstructive jaundice
Cholangitis
Acute pancreatitis
In the intestine
Acute intestinal obstruction.(gall stone ileus).

11. Chronic calculus cholecystitis
Generally associated with cholelithiasis and consist of round cell infilteration and fibrosis and thickening of the wall
Flatulent dyspepsia
Right hypochondrial pain of varying severity in association with nausea and occasional vomiting.
During the attack tenderness and even Murphy sign is positive and may be palpable gall bladder
Picture may be complicated by bouts of acute cholecystitis or stone passing into CBD.
Diagnosis ultrasonography,cholecystogram,abdominal x- ray in 10% of cases
Treatment cholecystectomy.

12. Acute calculus cholecystitis
It is usually associated with obstruction of the neck of the gall bladder or cystic duct due to stones impacted in the hartmanns pouch
The gall bladder become inflammed producing chemical cholecystitis the gall bladder fills with pus which is frequently sterile on culture but in most instances superadded bacterial infection usually gram negative aerobes E. coli,proteus,klebsiella
Clinical features
Sudden onset of moderate to sever pain is experient in the right upper quadrant or epigastric region may radiate to the back or interscapular region ,usually this attack come after fatty meal ,fever with marked toxaemia and leukocytosis,tenderness and quarding in right upper abdomen ,often palpable mass
The swollen gall bladder may press against the CBD ,and may produce a tinge of jaundice (Mirrizi syndrome)
Diagnosis ultrasonograghy ,HIDA , plain abdominal x-ray

13. Complication of acute cal. cholecystitis
Mucocele
Empyema
Perforation lead to peritonitis
gangrene

14. Treatmentof acute cal. cholecystitis
There are three main ways
Conservative treatment:
At least 90% relieved and acute attack resolved by
Bed rest
restriction of fluid and food intake and continous naso-gastric suction and iv fluid.
Analgesic and anti-cholinergic drugs.
Antibiotics mainly for E.coli and bacteriod
Then elective cholecystectomy is usually performed about six weeks later.

15. Dis advantage of conservative treatment
Failure of the acute attack to resolve in about 10 percent of cases.with deveolpment of complication of acute cholecystitis.
During the 6-8 wks while waiting for elective cholecystectomy he may develop another attacks and he should wait again for another 8 wks so its not practical.

16. Advantage of the conservative treatment
Most cases of acute cholecystitis subside on conservative management without significant complication.
Operation performed in the presence of inflammation with vascular congestion may be injurious as aresult of spreading infection.
The acute inflammation obscure the anatomy and lead to technical error.
Many of the patients with acute cholycystitis have associated disease and do not represent optimal risk for surgical intervention.

17. 2.Early operation within 72 hrs after the onset of the acute process.
3.Intermediate operation is one carried out between 72 hours and cessation of clinical manifestations.
We first admit the patient to the hospital.
Proper antibiotics.
i.v. fluid.
And then early cholecystectomy..
we prefer this mode of treatment.

18. A calculus cholecystitis
It is less common than the calculus one.
It can be acute or chronic.
Acute a calculus cholycystitis:
Frequently is a complication of burn,sepsis multiple system failure, cardiovascular disease. Diabetes, prolonged illness or major operation.
Causes of chronic a caculus cholecystitis
Anatomic condition due to fibrosis, kinking ,obstruction of the cysti duct due to tumer or abnormal vessels.
Thrombosis of major vessel.
Spasm and fibrosis of sphincter of oddi .
Systemic disease such as diabetes and collagen disease.
Specific infection like typhoid fever ,actinomycosis and parasitic infestation.
Diagnosis by u/s
Treatment by chlecystectomy.

19. Empyema and gangrene of the gall bladder
When the conservative treatment failed and the condition progress to empyema and gangrene which is very dangerous condition and the operation of cholecystecomy become risky due to obscured anatomy and frozen area so cholecystostomy is enough just to drain and evacuate the pus and the stone and to put tube through the skin to the gall bladder and later on arrange for cholecystectomy electively this to avoid injury to the CBD and hepatic artery because the are obscured by the inflammatory oedema and adhesion.

20. The advantage of early or intermediate cholecystectomy
5-10% fail to respond to the medical management and more than half of those who respond initially experience an exacervation.
Unless there is medical contraindicaion eventual surgical intervention is indicated for almost all patients with cholecystitis and chle lithiasis.
Low mortality rate and it is comparable with elective procedure.
usually there is little difficulty in displaying the duct system in spite of acute inflammatory process.
If early operation is performed and the inflammatory process has progressed to obsecure the structure,chlecystostomy done with low mortality and speeds the patient recovery. this is done especially if the patient with extreme toxicity or otherwise complicating medical illness.

21. Indication of exploration of CBD (choledochotomy)
Palpable duct stone
Jaundice or history of jaundice or cholingitis.
CBD is dilated more than 10 cm.
Liver function test are abnormal, in particular the serum alkaline phosphatase.