Dr Ross Elliot BVSc MMedVet (Surg) Bryanston Veterinary Hospital. 011 706 6023
The gall bladder is a pear shaped duct sitting in the right cranial quadrant of the abdomen in a fossa between the right medial and quadrate lobes of the liver. The gall bladder drains into the cystic duct, the cystic duct connects the gallbladder to the common bile duct. The hepatic ducts drain the liver lobes into the common bile duct. The common bile duct allows bile to be transported into the gall bladder for storage or allows bile to be transported into the duodenal lumen via the major duodenal papilla.(fig 1)
Surgery of the Biliary Tract
Many patients presented for surgery of the biliary tract are systemically compromised and require stabilisation prior to any surgery. These patients either have obstruction of the biliary tract, rupture of the biliary tract or gallbladder mucocoeles. Fluid therapy and initial stabilisation are crucial in most cases prior to surgical treatment.
Obstructive Biliary Tract Disease
Obstruction of the biliary tract from pancreatitis is a common cause and can often be managed medically on current evidence. However if the patient is deteriorating, showing progressive distention of the biliary tract and worsening of the hyperbilirubinaemia then surgical decompression is advised. Obstruction of the biliary tract from a choleolith should be addressed surgically as soon as possible. Obstruction due to neoplastic disease carries a poor prognosis but generally needs an exploratory celiotomy to investigate, diagnose and palliate the condition.
Obstructive Biliary Disease
There are 3 main techniques for dealing with obstructive biliary disease.
This is the most common technique used to re-establish bile flow into the intestine. The cholecystoduodenostomy is the ideal technique as it anatomically is the most correct at re-establishing bile flow.
This technique should be used if you are unable to catheterise the common bile duct at the duodenal papilla. This is performed through a small enterotomy on the anti-mesenteric surface of the duodenum in the area of the duodenal papilla. The papilla is visualised on the internal mesenteric surface of the duodenum. A small feeding tube is then introduced into the papilla and gently advanced into the gallbladder. If this tube is able to pass into the gallbladder and bile flows through the tube choledochal stenting should be performed. If the tube cannot be passed and the obstruction cannot be removed then a cholecystoduodenostomy should be performed.
On the rare occasion that there is a choleolith in the common bile duct this can be removed via a small incision into the bile duct over the obstruction and sutured closed with fine monofilament absorbable sutures. The common bile duct should be stented to divert bile from the incision site while it heals. To perform a cholecystoduodenostomy the gallbladder is bluntly dissected out of the fossa between the respective lobes of the liver usually using gentle digital manipulation. Care must be taken not to damage the first cystic ducts that run into the common bile duct. Severe haemorrhage can be controlled by application of a haemostatic agent such as Surgiceltm or Perclottm. The freed gallbladder is placed on the enterotomy previously performed to ensure there is no tension on the intended anastomosis site. This enterotomy should be in the region of around 3-5 cm as stoma smaller than 2,5cm are predisposed to recurrent obstructions from stricture formation. The gallbladder is now sutured to the far side of the enterotomy as the surgeon looks at the site with a continuous monofilament 3-0 or 4-0 absorbable. An incision is now made in the gallbladder to match the enterotomy. The near side of the gallbladder incision and enterotomy are now sutured in the same fashion. The area should be checked for leaks and a liver biopsy taken. Any abnormal lesions in the area of the bile duct, duodenal papilla should be biopsied to rule out neoplastic disease as a cause of the obstruction or confirm pancreatitis. Complications include haemorrhage, incisional breakdown and peritonitis, stricture of the stoma, ascending cholangitis and gastric ulceration.
2. Choledochal Stenting
This is a very simple technique that can be used if the common bile duct can be catheterised through the enterotomy. This is ideal for traumatic tears of the common bile duct, reversible obstructions or removal of choleoliths in the common bile duct. A small feeding tube is passed into the duodenal papilla. There should be good flow of bile through the tube. The largest size that will fit should be chosen but not too large to damage the papilla. The tip is cut leaving 3-4 cm of tube in the duodenum. Always place a stay suture in the end of the tube before cutting it as to not lose the end in the common bile duct. The duodenal end is now sutured to the submucosa of the duodenum to keep it in place. An absorbable monofilament should be used. The theory behind this is that once the cause has been reversed or the common bile duct has healed the suture will dissolve and pass out in the stool. The stent can be removed via endoscopy if it has not passed out in 2-3 months. The stent can lead to ascending cholangiohepatitis if not removed or passed out.
3. Cholecystostomy Tube
This diverts bile from the biliary system to an external collecting system. This can be done rapidly in compromised patients and does not alter the anatomy of the biliary system. It can only be used as a temporary solution in patients with permanent obstruction or in patients with a temporary obstructive disease. It should only be done when the gallbladder wall is considered to be healthy. A Foley’s catheter is placed through the right lateral wall of the abdomen. This Foley’s is then placed through a stab incision in the apex of the gallbladder. A purse string is placed around the incision and the cuff inflated of the Foley’s. This is connected to a collection system externally and bile is diverted.
Fig 2: Ruptured gallbladder mucocoele
Gallbladder mucocoele is the most common disease affecting the gallbladder. It appears to be caused by cystic mucosal hyperplasia. This can lead to extra hepatic biliary obstruction or bile peritonitis from rupture of the gallbladder. The procedure of choice is a cholecystectomy. This entails removal of the entire gallbladder. Before performing a cholecystectomy the patency of the common bile duct must be assessed. This is performed through an enterotomy as described in the previous section on cholecystoenterostomy. The gallbladder is then bluntly dissected as described until the junction of the cystic duct, gallbladder and common bile duct can be seen. The common bile duct is now ligated above the section where the cystic ducts enter and the gallbladder removed. The fossa where the gallbladder was removed is now assessed for haemorrhage, which can be controlled. The gallbladder should be submitted for histopathological examination.
There are few indications for cholecystostomy, they include removal of choleoliths, biopsy and any procedure requiring access to the lumen of the gallbladder. This should never be performed if the gallbladder wall is unhealthy. The gallbladder has a poor suture holding ability when diseased and trying to suture can lead to leakage and peritonitis. The gallbladder is packed off with sterile swabs and an incision is made in the gallbladder. The bile should be suctioned out and the choleolith removed. The gallbladder is then sutured with a monofilament absorbable suture and the area lavaged.
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