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The first 25 slides, exactly as they appear. The full deck has 175 content slides.
General Surgery
Choledochal Cyst and Benign Biliary Strictures
Built from Maingot's Abdominal Operations
What’s inside
14 sections · 175 slides
Overview
- Scope and terminology
- Two disease groups compared
Choledochal cyst
Focal or diffuse dilations of the biliary tree
- Definition and consequences of a biliary cyst
- 1 in 13,000
- Age and sex distribution
Classification
Alonso-Lej, Todani, and what the five types mean
- Development of the classification
- Alonso-Lej and Todani classification of choledochal cysts
- Classification of choledochal cysts as tabulated in the source
- Todani types IA, II and III illustrated
- Todani types IVA, IVB and V illustrated
- Type I and type II cysts
- Type III cyst, the choledochocele
- Type IV and type V cysts
- Controversy about the classification
Pathogenesis
Three theories, and the long common channel
- Ductal plate and obstruction theories
- Pancreaticobiliary maljunction
- Pancreaticobiliary maljunction on cholangiography
- Consequences of a long common channel
- Sphincter pressure and cyst wall pathology
Presentation and diagnosis
From the classic triad to MRCP
- Presentation in children and adults
- Differential diagnosis and first-line imaging
- Type IA cyst on computed tomography
- Type IVA cyst on computed tomography
- MRCP and the role of cholangiography
- Percutaneous cholangiogram of a large type I cyst
- Choosing between PTC and ERCP
- Type IVA cyst drained by bilateral percutaneous catheters
Cancer risk and operative management
Why every cyst is taken out, and how
- Preoperative priorities and malignancy risk
- 2.3%
- Cancer risk by cyst type
- Rationale for complete cyst excision
- Molecular changes, and long-term follow-up
- First steps and the plan for reconstruction
- Laparoscopic resection
- Exposure and distal dissection of a type I cyst
- Exposing the cyst and dividing it distally
- Posterior dissection up to normal duct
- Dissecting up to normal duct
- Completed excision and Roux-en-Y reconstruction
- Roux-en-Y hepaticojejunostomy
- Sequence of a type I cyst excision
- Type II excision and indications in type III
- Type III cyst: surgical technique
- Type IV cysts: operation and the liver
- Malignancy and type V (Caroli's disease)
Results after cyst excision
Complications, follow-up and summary
- 9-41%
- Complications and long-term outcome
- Summary of choledochal cyst disease
Benign biliary strictures
Diverse causes, one common consequence
- Definition and clinical importance
- Congenital and postoperative causes of benign biliary stricture
- Inflammatory and other causes of benign biliary stricture
- Main causes of a benign biliary stricture
Postoperative biliary stricture
Incidence, mechanism and prevention
- Modes of presentation after bile duct injury
- 0.2-0.3%
- Reported incidence data
- Persistence of the injury rate after the learning curve
- Patient and anatomic factors that raise the risk
- Technical factors in laparoscopy
- Classic laparoscopic bile duct injury
- Mechanism of the classic laparoscopic injury
- Frequency and cognitive basis of the classic injury
- Role of intraoperative cholangiography
- Intraoperative cholangiogram showing a clipped common bile duct
- Critical view of safety
- Blood supply of the bile duct, and ischaemia
- Fibrosis after bile duct injury
- Other operations that injure the duct
- Interval from first repair to recurrent stricture
- Timing of recurrent stricture
Classifying and recognising the injury
Bismuth levels, Strasberg classes and presentation
- Minor and major injuries
- Bismuth levels of bile duct stricture
- Bismuth classification of bile duct stricture
- Strasberg classes of biliary injury as tabulated in the source
- Strasberg classification of biliary injury and stricture
- Timing of recognition and intraoperative clues
- Early presentation: the bile leak
- Consequences of intraperitoneal bile
- Biloma on computed tomography after bile duct injury
- Missed leaks, and late presentation
- The laboratory picture
- First-line imaging
- MRCP after a cystic duct leak
- Cystic duct leak on endoscopic cholangiography
- Complete duct transection on endoscopic cholangiography
- Endoscopic and percutaneous cholangiography compared
- Percutaneous cholangiogram in complete duct transection
- Associated arterial injury
Repairing the injured duct
Control sepsis, define anatomy, then reconstruct
- Control sepsis first
- Pitfalls of early re-exploration
- Managing a postoperative bile leak
- Preoperative sequence, early and late
- Aim of the repair
- Injury found during the cholecystectomy
- Ligation versus repair of small ducts
- Primary repair over a T-tube
- End-to-end repair over a T-tube
- Limits of primary repair and the biliary-enteric alternative
- Injury found in the first days after surgery
- Planning a definitive stricture repair
- Tailoring the repair to the Bismuth level
- Debate about transanastomotic stents
- Hepaticojejunostomy over a transhepatic stent
- Completed Roux-en-Y hepaticojejunostomy
- Technique: exposure and duct preparation
- Technique: stents and anastomosis
- Cholangiogram after hepaticojejunostomy
- Postoperative stent care
- Hepp-Couinaud approach and hilar exposure
Non-operative treatment and results
Dilation, stents, and how repairs perform
- Percutaneous balloon dilation
- Balloon dilation of a mid-bile duct stricture
- Risks, limits and evidence for dilation
- A longer follow-up series
- Endoscopic dilation and stenting
- Choosing a stent, and endoscopy versus surgery
- 1.7%
- Mortality, surgeon experience and survival
- Morbidity after repair
- Detail from 200 reconstructions
- Reported results of surgical repair of postoperative strictures
- Results of surgical repair of postoperative bile duct strictures
- Determinants of a successful repair
- Effect of the repairing surgeon
- Results after repair of laparoscopic cholecystectomy injuries
- Surgical repair of laparoscopic cholecystectomy bile duct injuries
- Long-term results from the 1990s
- Quality of life after repair
- Summary of postoperative strictures
Inflammatory causes of stricture
Pancreatitis, stones, parasites and the sphincter
- Inflammatory strictures, and chronic pancreatitis
- Chronic pancreatitis: frequency and presentation
- Long tapering stricture of the intrapancreatic bile duct
- Chronic pancreatitis: imaging and treatment
- Chronic pancreatitis: ineffective options
- Mirizzi's syndrome
- Mirizzi's syndrome: pitfalls and management
- Strictures from stones in the duct
- Handling the distal duct at exploration
- Recurrent pyogenic cholangitis
- The cycle in recurrent pyogenic cholangitis
- Cholangiogram in cholangiohepatitis
- Imaging and treating recurrent pyogenic cholangitis
- Liver resection, hydatid disease and the sphincter
Primary sclerosing cholangitis
Progressive scarring of the whole biliary tree
- Definition of primary sclerosing cholangitis
- Link with inflammatory bowel disease
- Bacterial, immunological and genetic evidence
- Secondary sclerosing cholangitis
- Presentation of primary sclerosing cholangitis
- Diagnosis
- Beading of the intrahepatic ducts in primary sclerosing cholangitis
- Medical management
- Monitoring and dominant strictures
- Surgical resection with stenting
- Survival after resection of the hepatic bifurcation
- Survival curve and natural history
- Liver transplantation
- Transplantation, cancer and summary
- Key points: choledochal cyst
- Key points: benign biliary strictures
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- References (continued)
- Maingot's Abdominal Operations, 12th Edition