Slide 1

Our topic is cholecystitis.

Slide 2

First, divide up into 3 groups and take a minute to decide where the gallstone is located and the
various lab values you would expect to see associated with it.
o 1 = right bile duct
o 2 = left bile duct
o 3 = common hepatic duct
o 4 = gallbladder
o 5 = pyloric sphincter
o 6 = minor papilla
o 7 = main pancreatic duct
o 8 = major duodenal papilla (sphincter of oddi)
o 9 = duodenum
A = a gallstone in the cystic duct
o No increase in bilirubin, lipase, ALT/AST, or AP (only get AP if gallstone is at least as far
as the common bile duct)
B = gallstone in the common hepatic duct
o See increased direct bilirubin, no change in lipase, a slight elevation of ALT/AST, and
significant elevation of AP
C = gallstone at ampulla of Vater
o See increased direct bilirubin, lipase, slightly elevated ALT/AST and significantly elevated
AP

Slide 4

Slide 5

Slide 6

Given a diagnosis of acute calculous cholecystitis, it is necessary to send the patient into surgery
for treatment.
Given what you know about the anatomy of the gallbladder and the cadaver, identify what each
structure marked by a pin is and what vessels (whether they are marked here with a pin or not)
you would want to cut and clamp.
o White pin = portal vein
o Black pin = bile duct
o Red pins = common hepatic artery, proper hepatic artery, gastroduodenal artery
o Want to cut and clamp the cystic duct and cystic artery
What complications do you think may occur during a cholecystectomy?
o Go to slide 6

Hemorrhage
o Usually due to injuring the cystic artery
o Clipping the artery solves this problem usually
Perforation of gallbladder
o This is particularly problematic because any gallstones in the gallbladder may spill out
and need to be retrieved individually now. This can significantly prolong the operation.
Common bile duct injury
o If you do this, you will want to either suture it back closed if possible or insert a drain
and then suture it shut.
So in the picture on the left, you see the triangle of Calot. Based off this picture, why do you
think its important to know the triangle of Calot?
o Its an important landmark during the surgery.
o Its borders include the common hepatic duct medially, the cystic duct laterally, and the
inferior edge of the liver superiorly.
o This triangle also contains the site where the cystic artery branches off the right hepatic
artery.
o So, its important to carefully dissect this triangle so that you can identify, divide, and
ligate the cystic duct and artery without worrying about accidentally cutting the wrong
structure.
What complications can you guys think of that may occur after the surgery is completed?
o Go to slide 7

Slide 7

Bile leakage
o This may occur if you have injured the liver/gallbladder bed area
This can lead to a bile leak, hemorrhage, or subhepatic abscess
o This can also occur if any accessory bile ducts have been missed
For example, some people may have an accessory right hepatic duct or the
cystic duct may enter the right hepatic duct.
o This can also be the result of damage to the common bile duct.
This can sometimes occur if a surgeon has confused the common bile duct and
the cystic duct
Its more common in patients with inflammation making it more difficult
to properly identify the cystic duct or with surgeons lacking experience
Hemorrhage
o Hemorrhage usually occurs from 2 main places
If there is damage to the gallbladder bed/liver, there may be damage to the
middle hepatic vein and arteries which lay next to the gallbladder fossa in some
patients.
Another possible site is the cystic artery if it has not been properly clamped
shut.
Subhepatic abscess
o This can occur as a result of hemorrhage or bile leakage and is often seen 7-10 days
after the operation

In order to treat this, a tube can be inserted into the subhepatic recess to drain the
abscess (???)
Retained bile stones
o Sometimes bile stones can be left in one of the bile ducts. This usually isnt noticed right
away until they cause another complication like pancreatitis.
Bowel injury
o This is indicated by pain, distention, diarrhea, leukopenia, and sepsis within 96 hours of
the original surgery.
Death

Slide 8

Does someone want to read through the vignette?

Slide 9

This is what you see upon completing the X-ray. What do you guys see?
o There are gallstones located throughout the small intestine
How do you think that such large gallstones could have reached the small intestine?
o Sometimes, when a gallstone is particularly large a fistula can form between the biliary
tree and any part of the adjacent small intestine as the gallstone burrows through the
fundus of the gallbladder and intestinal wall
So this is called a gallstone ileus
If the gallstone is large enough, it can actually cause an obstruction within the small bowel.

Slide 10

If we have time, this is just pictures showing how they remove the gallbladder.