LESION DE VIA BILIAR
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LESION DE VIA BILIAR
- 1. lesiones de vías biliares Diagnostic Humberto Juárez Rosario medico residente cirugía general
- 2. IntroducciónAnatomía Juicio, técnica y atención a los detalles Incidencia: • Abierta 0.1 a 0.2 % • Laparoscopica 0.4 a 0.6 % • 750 000 Colecistectomias laparoscopicas • Trauma hepatico 0.5% Iatrogenic Biliary Injuries: Classification, Identification, and Management Kenneth J. McPartland, MDa,b, James J. Pomposelli, MD, PhD Clin N Am 88 (2008) 1329–1343
- 3. Anatomía Lesiones de vias Biliares. Miguel Mercado 2005
- 4. Anatomía Lesiones de vias Biliares. Miguel Mercado. 2005
- 5. Anatomía Lesiones de vias Biliares. Miguel Mercado. 2005
- 7. Anatomia
- 8. Impacto Iatrogenic bile duct injury-a cost analysis ROLAND ANDERSSON, KARIN ERIKSSON, PER-JONAS BLIND & BOBBY TINGSTEDT HPB, 2008; 10: 416-419 Costos segun el tipo de lesión
- 9. Transplante Hepático 10 a 12% fugas biliares estrecheses en la anastomosis y fuera de ella mas prevalencia en receptores pediatricos
- 10. Fisiopatología
- 11. Factores de riesgo colecistitis Adherencias del cistico y coledoco hemorragia Variantes anatomicas
- 12. Factores de Riesgo Factor OR sexo masculino 1.92 hospital escuela 2.16 Pancreatitis 2.5 Colangiografia 0.5 Fletcher et al. annals of surgery 1999
- 13. Mecanismos Mala interpretacion de las estructuras anatomicas (97%) errores tecnicos (3%) Incapacidad o resistencia de realizar colangiografia excesiva retraccion cefalica del fondo Poca retraccion lateral del infindubulo Prevention of Biliary Leaks. Nathaniel J. SopeJ Gastrointest Surg (2011) 15:1005–1006 Causes and Prevention of Laparoscopic Bile Duct Injuries Analysis of 252 Cases From a Human Factors and Cognitive Psychology PerspectiveLawrence W. Way, MD,* Lygia Stewart, MD ANNALS OF SURGERY Vol. 237, No. 4, 460–469
- 14. Mecanismos Uso excesivo del cauterio excesiva retraccion lateral del infindibulo radical derecho de insercion baja Prevention of Biliary Leaks. Nathaniel J. SopeJ Gastrointest Surg (2011) 15:1005–1006 Causes and Prevention of Laparoscopic Bile Duct Injuries Analysis of 252 Cases From a Human Factors and Cognitive Psychology PerspectiveLawrence W. Way, MD,* Lygia Stewart, MD ANNALS OF SURGERY Vol. 237, No. 4, 460–469
- 15. Esquema mental Causes and Prevention of Laparoscopic Bile Duct Injuries Analysis of 252 Cases From a Human Factors and Cognitive Psychology PerspectiveLawrence W. Way, MD,* Lygia Stewart, MD ANNALS OF SURGERY Vol. 237, No. 4, 460–469
- 16. Visiones heuristica Causes and Prevention of Laparoscopic Bile Duct Injuries Analysis of 252 Cases From a Human Factors and Cognitive Psychology PerspectiveLawrence W. Way, MD,* Lygia Stewart, MD ANNALS OF SURGERY Vol. 237, No. 4, 460–469 ■ Si no consigues entender un problema, dibuja un esquema. ■ Si no encuentras la solució n, haz como si ya la tuvieras y mira qué puedes deducir de ella (razonando a la inversa). ■ Si el problema es abstracto, prueba a examinar un ejemplo concreto.
- 17. Mecanismos - Trasplante Trombosis de la arteria hepatica lesion durante la preservacion barro biliar
- 18. Prevencion
- 19. Prevencion Maniobra critica uso de lente angulado mantenerse cerca a la vesicula Minimizar el uso del cauterio Ver las puntas de los clips colangiografia transoperatoria?¿
- 20. Prevencion diseccion del tejido sobre el cistico y el infindibulo uso de mas de ocho clips
- 21. Maniobra critica
- 22. Prevencion Prevention of iatrogenic bile duct injuries in difficult laparoscopic cholecystectomies: is the naso-biliary drain the answer? Chandika A. H. Liyanage Æ Yoshihiko colangiografia por el dreanje nasobiliar
- 23. tecnicas visualizar estructuras Intraoperative assessment of biliary anatomy for prevention of bile duct injury: a review of current and future patient safety interventions K. Tim Buddingh • Vincent B. Nieuwenhuijs Surgical Endoscopy 2011
- 24. colangiografia fluorescenia infra-roja Intraoperative assessment of biliary anatomy for prevention of bile duct injury: a review of current and future patient safety interventions K. Tim Buddingh • Vincent B. Nieuwenhuijs
- 25. Clasificaciones
- 28. Clasificacion de Stewart-way Class I refers to the incomplete sectionof bile duct with no loss of tissue. It has a prevalence rate of 7%. The first mechanism of injury is a misleading recognition of the common hepatic duct with the cystic duct but is rectified and results in only a small loss of tissue with no complete section of the bile duct. The second mecha- nism refers to the lateral injury of the common hepatic duct which results from the cystic duct opening extension during cholangiography. The former represents 72% and the latter 28% of class I cases. Class I refers to the incomplete sectionof bile duct with no loss of tissue. It has a prevalence rate of 7%. The first mechanism of injury is a misleading recognition of the common hepatic duct with the cystic duct but is rectified and results in only a small loss of tissue with no complete section of the bile duct. The second mecha- nism refers to the lateral injury of the common hepatic duct which results from the cystic duct opening extension during cholangiography. The former represents 72% and the latter 28% of class I cases. Class II is a lateral injury of the common hepatic duct that leads to stenosis or bile leak. It is the consequence of thermal damage and clamping the duct with surgical staples. It has a prevalence of 2% with a concomitant he- patic artery injury in 18% of cases. T-tube related injuries are included within this class. Class II is a lateral injury of the common hepatic duct that leads to stenosis or bile leak. It is the consequence of thermal damage and clamping the duct with surgical staples. It has a prevalence of 2% with a concomitant he- patic artery injury in 18% of cases. T-tube related injuries are included within this class. Class III is the most common (61% of cases) and rep- resents the complete section of the common hepatic duct. It is subdivided in to type IIIa, remnant common hepatic duct; type IIIb, section at the confluence; type IIIc, loss of confluence; and type IIId, injuries higher than confluence with section of secondary bile ducts. It occurs when the common hepatic duct is confounded with the cystic duct, leading to a complete section of the common hepatic duct when resecting the gallbladder. A concomitant injury of right hepatic artery occurs in 27% of cases Class III is the most common (61% of cases) and rep- resents the complete section of the common hepatic duct. It is subdivided in to type IIIa, remnant common hepatic duct; type IIIb, section at the confluence; type IIIc, loss of confluence; and type IIId, injuries higher than confluence with section of secondary bile ducts. It occurs when the common hepatic duct is confounded with the cystic duct, leading to a complete section of the common hepatic duct when resecting the gallbladder. A concomitant injury of right hepatic artery occurs in 27% of cases Class IV describes the right (68%) and accessory right (28%) hepatic duct injuries with concomitant injury of the right hepatic artery (60%). Occasionally it includes the common hepatic duct injury at the confluence (4%) besides the accessory right hepatic duct lesion. Class IV has a prevalence of 10%[11,12]. Class IV describes the right (68%) and accessory right (28%) hepatic duct injuries with concomitant injury of the right hepatic artery (60%). Occasionally it includes the common hepatic duct injury at the confluence (4%) besides the accessory right hepatic duct lesion. Class IV has a prevalence of 10%[11,12].
- 29. Diagnostico
- 30. Diagnostico Transoperatorio salida de bilis del higado o porta hepatis observar un segundo conducto o arteria cistica USG Doppler estrechez de la via biliar Salida de bilis de una estructura tubular u otro sitio distinto a la vesicula ecause 12% to 32% of patients who have laparoscopic cholecystectomy– associated bile duct injury have a concomitant arterial injury and vascular injury significantly increases morbidity and mortality and may increase the incidence of later stricture formation ecause 12% to 32% of patients who have laparoscopic cholecystectomy– associated bile duct injury have a concomitant arterial injury and vascular injury significantly increases morbidity and mortality and may increase the incidence of later stricture formation
- 31. Diagnostico Trans- operatorio Tejido fibroso en la el lecho vesicular linfaticos rodeando al conducto cistico conducto cistico que no se puede ligar un cistico que se va sin interrupcion hasta el duodeno 75% inadvertidas 22% tuvieron protocolos que expusieron la dificultad Causes and Prevention of Laparoscopic Bile Duct Injuries Analysis of 252 Cases From a Human Factors and Cognitive Psychology PerspectiveLawrence W. Way, MD,* Lygia Stewart, MD ANNALS OF SURGERY Vol. 237, No. 4, 460–469
- 32. Porcentaje de deteccion intraoperatoria Bile Duct Injury during Laparoscopic Cholecystectomy : Risk Factors, Mechanisms, Type, Severity and Immediate Detection J.-Fr. Gigot Acta chir belg, 2003, 103, 154-160
- 33. Diagnostico Post- Operatorio Fuga Biliar Obstruccion biliar Cuadro Clinico Nauseas, vomitos, peritonitis Colangitis Patron bilirrubina Mixto Directo
- 34. errores en diagnostico Ileo, distension y dolor abdominal Falla en reconocer el drenaje bilioso persistente Regreso al cuarto de urgencia No realizar colangiografia previo a la LPE no encontrar el sitio de lesion Surgical manajement of hepatobiliary and pancreatic disorders. L bumgart 2nd edition
- 35. diagnostico y fines conocer la anatomia reestablecer la comunicacion bilio-enterica
- 36. CPRE Fuga del muñon del cistico vs lesion intra/extrehepatica Coledocolitiasis Limitacion en oclusiones y ligaduras e missed on ERCP (6). Aberrant right posterior segmental duct injuries are often suspected in the setting of clinical or imaging evidence of a bile leak (perihepatic fluid collection on postcholecystectomy cross-sectional imaging or copious bil- ious output from surgical drains) but “normal” ERCP e missed on ERCP (6). Aberrant right posterior segmental duct injuries are often suspected in the setting of clinical or imaging evidence of a bile leak (perihepatic fluid collection on postcholecystectomy cross-sectional imaging or copious bil- ious output from surgical drains) but “normal” ERCP
- 37. Colangiografía Transhepática identifacion de la anatomia busqueda de fugas, estrecheces tutor y drenaje Cholangiography is used to distinguish between a transected duct, a completely occluded duct, and a duct that has been partially obstructed. Cholangiography is used to distinguish between a transected duct, a completely occluded duct, and a duct that has been partially obstructed. Accuracy of Percutaneous Transhepatic Cholangiography in Predicting the Location and Nature of Major Bile Duct Injuries Nicholas Fidelman, MD, Robert K. Kerlan, Jr., MD, Jeanne M. LaBerge, MD, and Roy L. Gordon, MDJ Vasc Interv Radiol 2011;10.1016/j.jvir.2011.02.007
- 38. Colangiografía Transhepática Deteccion del punto lesion 85% 100% 92% 55% 83% 82%
- 39. Resonancia magnetica Se ve todo el arbol biliar desventaja costo no terapeutica
- 40. Ultrasonido busqueda de colecciones dilatacion de via biliar
- 41. Tomografía Computada deteccion de Colecciones patencia de la circulación Planeamiento de Drenaje de Colecciones
- 42. HIDA Sospecha de fuga No detecta el sitio
- 43. algoritmo Diagnostico Sospecha de Lesión CPRE Fuga Lesión Parcial Seccion CPTHProtesis Centelleo Hepatobiliar negativa
- 44. Tratamiento
- 45. Tratamiento Reduccion de la presion distal Endoscopico o Tubo en T fuga de alto y bajo grado Strasberg A Evaluation and Treatment of Biliary Leaks after Gastrointestinal Surgery Gary C. Vitale & Brian R. DavisJ Gastrointest Surg DOI 10.1007/s11605-011-1513
- 46. Tratamiento Manejo Conservador Casos refractarios: drenaje percutaneo resecciones segmentarios Strasberg b Segmentary bile duct occlusion is the etiological factor in this type of injury. If mild pain and elevation of liver function tests are present with no clinical impairment, conservative management is followed. The presence of moderate and severe cholangitis makes the drainage of the occluded liver segment necessary. Segmentary bile duct occlusion is the etiological factor in this type of injury. If mild pain and elevation of liver function tests are present with no clinical impairment, conservative management is followed. The presence of moderate and severe cholangitis makes the drainage of the occluded liver segment necessary.
- 47. Tratamiento de fugas Postoperative Bile Duct Injuries Kourosh F. Ghassemi, MD, and Janak N. Shah, MDTech Gastrointest Endosc 8:81-91 2006
- 48. Seguimientos estenosis Postoperative Bile Duct Injuries Kourosh F. Ghassemi, MD, and Janak N. Shah, MDTech Gastrointest Endosc 8:81-91 2006
- 49. Tratamiento Manejo Conservador Drenajes externos Hepatectomia Derivacion biliodigestiva/ Drenaje percutaneo Strasberg c As in Strasberg B injury, an accessory right duct is sec- tioned but the proximal stump is not detected and oc- cluded, with an unnoticed bile leak as a consequence. No continuity exists with the rest of the bile duct system, leaving endoscopy out of the therapeutic options. Subhepatic collections are frequent in the postopera- tive setting. These must be drained in order to avoid bili- ary peritonitis and septic shock. It is common that the bile leak is occluded spontane- ously with no other intervention maintaining a controlled bile leak through external drains. If this does not happen, therapeutic options are the same that Strasberg B injury, biliodigestive derivation to segmentary ducts (also with poor long term prognosis), percutaneous drainage and hepatectomy. As in Strasberg B injury, an accessory right duct is sec- tioned but the proximal stump is not detected and oc- cluded, with an unnoticed bile leak as a consequence. No continuity exists with the rest of the bile duct system, leaving endoscopy out of the therapeutic options. Subhepatic collections are frequent in the postopera- tive setting. These must be drained in order to avoid bili- ary peritonitis and septic shock. It is common that the bile leak is occluded spontane- ously with no other intervention maintaining a controlled bile leak through external drains. If this does not happen, therapeutic options are the same that Strasberg B injury, biliodigestive derivation to segmentary ducts (also with poor long term prognosis), percutaneous drainage and hepatectomy.
- 50. Tratamiento Rafia Primaria - Drenaje percutanea - endoscopia con Esfinterotomia/Protesis Desvacularización Tratamiento quirúrgico ultima opción Strasberg D In the setting of a devascularized duct, even if small 5-0 absorbable stitches are used, a bile leak will develop during the first postoperative week with concomitant bile collections. Management of these cases requires a mul- tidisciplinary approach with endoscopy and radiological- guided drainage as the first therapeutic options. Surgery is the last resource of treatment when a loss of bile duct tissue is present and migration of a Strasberg D to E in- jury has taken place. In the setting of a devascularized duct, even if small 5-0 absorbable stitches are used, a bile leak will develop during the first postoperative week with concomitant bile collections. Management of these cases requires a mul- tidisciplinary approach with endoscopy and radiological- guided drainage as the first therapeutic options. Surgery is the last resource of treatment when a loss of bile duct tissue is present and migration of a Strasberg D to E in- jury has taken place.
- 52. dilataciones/Protesis vs Cirugia cirugia Promedio (Rango) Dilataciones Promedio (Rango) Exitos temprano ( 0 a 4 años) % 89 (81-98) 74 (27-95) Exitos Tardio( > 4 años) % 85 (74-99) 55 Dias de Tratamiento (dias) 14 (7-27) 365 ( 146-550) Hospitalización (dias) 14 (7-27) 24 (10-38) Morbilidad % 19 ( 4-39) 28 (5-72) Mortalidad % 1.6 (0-9) 1.3 (0-22) Surgical manajement of hepatobiliary and pancreatic disorders. L bumgart 2nd edition
- 53. Cirugía
- 54. Hepato-yeyunostomia en y de roux •parte anterior de la placa •extension al radical izquierdo •resecciones parciales segmento IV
- 55. Segmento IV
- 56. Hepp-couinaud
- 57. Hepp-couinaud
- 58. Hepp-couinaud
- 59. Hepp-couinaud
- 60. Hepp-couinaud The Hepp-Couinaud Approachto StricturesoftheBileDucts AlbertusMyburgh. Annals of Surgery Vol 218 No 5 1993
- 61. Claves anatomicas Circulacion 3 y 9 horas 60% de la circulacion tiene una direccion cefalocaudal las anastomosis altas no dependen de la arteria hepatica derecha
- 62. Perlas del exitoerradicar la sepsis e inflamacion usar tejido viable una capa mucosa-mucosa monofilamento absorbible sin tension protesis no son mandatarias cirujano con experiencia
- 63. Resumen del Cohorte de los tres periodos Classification and management of bile duct injuries Miguel Angel Mercado, Ismael Domínguez J
- 64. Recomendaciones Lesion de via biliar laparoscopica No convertir dejar drenajes y referir Hacer hemostasia anastomosis Amplias diferir procedimientos en casos de sepsis o falla organica multipleClassification and management of bile duct injuries Miguel Angel Mercado, Ismael Domínguez J Gastrointest Surg 2011 April 27; 3(4): 43-48
- 65. recomendaciones Centro terceriario buscar ayuda convertir establecer el daño Colangiografia
- 66. ¿cuando operamos? Durante el evento, si la realiza un cirujano experimentado Estabilizar, drenajes y Referir
- 67. Reparacion temprana vs Tardia No hay estudios aleatorizados strasberg recomienda esperar 12 semanas* Mercado no hubo diferencias entre el manejo temprano y tardio (75 pacientes) *Strasberg SM, Picus DD, Drebin JA (2001) Results of a new strategy for reconstruction of biliary injuries having an isolated right-sided component. J Gastrointest Surg 5: 266–274
- 68. Cirugía Hepatectomía Daño irreversible del radical Daño de la arteria Hepatica Classification and management of bile duct injuries Miguel Angel Mercado, Ismael Domínguez J Gastrointest Surg 2011 April 27; 3(4): 43-48
- 69. Trasplante cirrosis biliar secundaria no se puede reconstruir
- 70. Pronostico
- 71. Contribución de los tratamientos al periodo de enfermedad Surgical manajement of hepatobiliary and pancreatic disorders. L bumgart 2nd edition
- 72. Pronostico 43 % de morbilidad luego de una reconstruccion 6 a 22% desarrollan enfermedad hepatica cronica 1.7 a 9% de mortalidad Dilataciones y Stents 33% de las lesiones proximales a confluencia desarrollan estrecheces 90% de éxito
- 73. The Good Surgeon believes what he sees, The Bad Surgeon sees wha he believes. Richard I Cook Cognitive Technologies Laboratory Chicago
- 74. Bibliografia 1. Iatrogenic bile duct injury-a cost analysis ROLAND ANDERSSON, KARIN ERIKSSON, PER-JONAS BLIND &BOBBY TINGSTEDT HPB, 2008; 10: 416-419 2. Prevention of Biliary Leaks. Nathaniel J. SopeJ Gastrointest Surg (2011) 15:1005–1006r 3. Accuracy of Percutaneous Transhepatic Cholangiography in Predicting the Location and Nature of Major Bile Duct Injuries Nicholas Fidelman, MD, Robert K. Kerlan, Jr., MD, Jeanne M. LaBerge, MD, and Roy L. Gordon, MDJ Vasc Interv Radiol 2011;10.1016/j.jvir.2011.02.00 4. Evaluation and Treatment of Biliary Leaks after Gastrointestinal SurgeryGary C. Vitale & Brian R. DavisJ Gastrointest Surg DOI 10.1007/s11605-011-1513 5. Classification and management of bile duct injuries Miguel Angel Mercado, Ismael Domínguez J Gastrointest Surg 2011 April 27; 3(4): 43-4 6. Surgical manajement of hepatobiliary and pancreatic disorders. L bumgart 2nd editio 7. Strasberg SM, Picus DD, Drebin JA (2001) Results of a new strategy for reconstruction of biliary injuries having an isolated right-sided component. J Gastrointest Surg 5: 266–274
- 75. Bibliografia 9. Bile Duct Injuries in the Era of Laparoscopic Cholecystectomies Yuhsin V. Wu, MDa, David C. Linehan, MDb,* Clin N Am 90 (2010) 787–802 • Causes and Prevention of Laparoscopic Bile Duct Injuries Analysis of 252 Cases From a Human Factors and Cognitive Psychology PerspectiveLawrence W. Way, MD,* Lygia Stewart, MD ANNALS OF SURGERY Vol. 237, No. 4, 460–469 • Prevention of iatrogenic bile duct injuries in difficult laparoscopic cholecystectomies: is the naso-biliary drain the answer? • Chandika A. H. Liyanage Æ Yoshihiko J Hepatobiliary Pancreat Surg (2009) 16:458–462 Postoperative Bile Duct Injuries Kourosh F. Ghassemi, MD, and Janak N. Shah, MDTech Gastrointest Endosc 8:81-91 2006 • Intraoperative assessment of biliary anatomy for prevention of bile duct injury: a review of current and future patient safety interventions K. Tim Buddingh • Vincent B. Nieuwenhuijs Surgical Endoscopy 2011 • The Hepp-Couinaud Approachto StricturesoftheBileDucts AlbertusMyburgh. Annals of Surgery Vol 218 No 5 1993 • Lesiones de vias Biliares. Miguel Mercado. 2005 • Surgical manajement of hepatobiliary and pancreatic disorders. L bumgart 2nd edition
Notas do Editor
- las diferencias entre lesiones ocurren antes de las 30 o 50 colecistectomia 1 lesion por cada mil colecistectomias
- 90% arteria cistica areria hepatica derecha en 80% los conductos biliares accesorio s 91% y arteria hepatica accesoria 95% cistico angulado 70%, pararelos 15% y esperiales 8% 2.5 a 4 cm
- sick leave licencia por enfermedad
- Feller et al(Sydney) ␣ 12.5% of 154 ␣ 16 non anastomotic, 4 anastomotic
- segmento derecho al coledoco radical derecho aberrante de implantacion baja
- 1) misidentification of the anatomy of the biliary tract as being the dominant factor in around 70% of the injuries and (2) technical errors leading to bleeding and subsequent clipping of the bile duct/artery or leading to bile leakage by inadequate clipping or traction and sub- sequent lateral wall injuries. Prevention of injuries is most important and different measurements have been advo- cated as for example the use of routine operative cholan- giographyn class I, class III, and some class IV injuries the mistake involved misidentifying the common duct (or right hepatic duct) for the cystic duct, followed by deliberate cutting of the misidentified duct. In the class II and some class IV injuries, the mistake consisted of performing the dissection in the triangle of Calot unintentionally too close to the bordering common hepatic or right hepatic duct. The ducts Operative cholangiogram demonstrating narrowing of the common bile duct. The cholangiocatheter is located in the common duct rather than the cystic duct. This patient went on to have a class III injury. were not seen because they were covered by connective tissue or inflammation. The underlying nature of the error in either case was misperception.
- se piensa q el resto de las estructuras son adheerencia o accesorios la percepcion de agarre y del espacio manipulacion de los objetos
- haptic informacion vs pasiva heuristic information informacion probabilitica baja para resolver problemas poco comun son de subconsciente
- recipiente con dx de PSC
- colangio de rutina no es concluyente si mejora el porcentaje de prevencio,... sin embargo la detectan mas elective • Timeandcost • RarityofBDI • Willnotpreventallinjury • Needtobecorrectlyinterpreted Slater, Strong et al (Queensland) 2001
- Table 3. RULES OF THUMB TO HELP PREVENT BILE DUCT INJURIES Optimize Imaging Use high-quality imaging equipment. Initial Steps and Objectives Before starting the dissection, use the triangle of Calot for orientation; find the cystic duct starting at the triangle. Pull the gallbladder infundibulum laterally to open the triangle of Calot. Clear the medial wall of the gallbladder infundibulum. Make sure the cystic duct can be traced uninterrupted into the base of the gallbladder. Open any subtle tissue plane between the gallbladder and presumed cystic duct; the real cystic duct may be hidden in there. Factors that Suggest One May Be Dissecting the Common Duct Instead of Cystic Duct The duct when clipped is not fully encompassed by a standard M/L clip (9 mm). Any duct that can be traced without interruption to course behind the duodenum is probably the CBD. The presence of another unexpected ductal structure. A large artery behind the duct—the right hepatic artery runs posterior to the CBD. Extra lymphatic and vascular structures encountered in the dissection. The proximal hepatic ducts fail to opacify on operative cholangiograms. Obtain Operative Cholangiograms Liberally Whenever the anatomy is confusing When inflammation and adhesions result in a difficult dissection Whenever a biliary anomaly is suspected; assume that what appears to be anomalous anatomy is really normal and confusing until proved otherwise by cholangiograms. Avoid Unintended Injury to Ductal Structures Only place clips on structures that are fully mobilized; the tip of a closed clip should not contain tissue. The need for more than eight clips suggests the operation may be bloody enough to warrant conversion to an open procedure. Consideration of a need for blood transfusion suggests the operation should be converted to an open procedure. Open when inflammation or bleeding obscures the anatomy. Illusions Compelling anatomic illusions to which everyone is susceptible are the primary cause of bile duct injuries; experience, knowledge, and technical skill by themselves are insufficient protection against this complication.
- fter the laparoscopic era. The Bismuth-Corlette classi- fication was introduced before laparoscopy. It is difficult to apply in laparoscopic cholecystectomy as most of the technical factors and lesion mechanisms are completely different to open surgery. It considers the complete sec- tion of the common bile duct and the length of the proximal bile duct stump[10]. Nevertheless, most cases have late stenosis or bile duct obstruction which may be included in this classification, representing a subtype Strasberg E and Stewart-Way III-IV lesions. is based on the most distal level at which healthy biliary mucosa is available for anastomosis during repair of a stricture or leak. This system was intended to help the surgeon choose the appropriate site for repair, and the degree of injury on this scale has been shown to correlate with outcomes after surgical repair
- arteria cistica es la la arteria hepatica derecha el cistico un luchka un ducto abaarrente
- Tejido fibroso es ceerca de la hepatico comun lifnagicos es la porta Neverthe- less, the injury was discovered in only six (18%) of these patients. durante la conversion gallbladder, 6 class I injuries when bile was seen to be leaking from the CBD, and 26 by operative identification of injured hepatic ducts. In the other 33 cases, the biliary anatomy was misinterpreted. In three class II injuries, the surgeon concluded that the bile duct injury had occurred because the gallbladder was connected directly to the CBD without an intervening cystic duct. In 30 cases, bile leakage (5 cases) and accessory ducts were reported.
- 3 dias despues de colecistectomia Bile leak – Jaundice – Peritonitis – Biliary fistula
- todo esto hace un dx retardado la tendencia es pensar que es el muñon cistico y sutural 30%sin colangiografia . solo el 4% se repara exitosamente, el 30% no se realiza, y el 67% no es exitoso. colangiografia incompleta solo es exitos en 31% y 69% no es exitosoa. c Colangiografia completa se lleva a 84% exitoso
- E1-E3
- 65% de las lesiones Sandha et al.4 created a grading system for post- cholecystectomy bile leaks diagnosed by ERCP. Low-grade leaks were described as identification of a leak after opacification of intrahepatic radicals and high grade as leakage that was detected before radical opacification. Low- grade leaks were treated with sphincterotomy alone, while high-grade leaks mandated biliary stenting, with resolutionoccurring in 91% of low-grade leaks and 100% of high-grade leaks. Sphincterotomy alone for the treatment of bile leaks has been found to be less effective than stenting it, but reduces the overall number of ERCPs.
- hepatectomia colangitis a repeticion
- 10 12 fr sello no floter 72 H DRENAJE GRACIAS
- lesiones combinadas arteria hepatica derecha 50% This injury is defined by a complete loss of common and/or hepatic bile duct continuity. Devascularization and loss of bile duct tissue obliges the surgeon to per- form a high-quality hepatojejunal anastomosis. The lat- ter procedure guarantees well-perfused bile ducts and a low tension anastomosis. The opposite is obtained when choledoco-choledoco or hepato-duodenum anastomosis are performed as devascularized ducts are used for the reconstruction and the duodenum tends to move down- wards, increasing anastomotic tension, even if a Kocher maneuver is performed well in advance[17]. The best postoperative outcomes are obtained when the hepatic confluence is preserved, allowing a high- quality, wide, well vascularized hepatojejunal anastomosis. Partial resection of IV and V segments facilitates iden- tification of bile ducts and proper settling of the jejunal loop[17,18]. In the unfortunate situation of inadequate ducts to perform a hepatojejunoanastomosis, the jejunal loop must be sutured to the liver parenchyma including feru- lized bile ducts within the anastomosis similarly to a Ka- zai portoenterostomy[19]. Most of these cases are consid- ered for liver transplant as postoperative outcomes after portoenterostomy are disappointing
- la dilatacion ayuda a diferir o evitar una segunda cirugia hecha por n cirujano con experiencia
- en cirujanos expertos es de 80 a 99% de exito y menos expertos 60 a 70% 3mmde via biliar la y no es buena la termino-terminal no va a funcionar si el muñon proximal es mayor de 3cm
- este tipo de circulacion contribuye a isquemia dle aparte proximalRepairing these injuries can be difficult due to the loss of substance on the artery and the deep inflammatory reaction on the stumps. It has been shown that this accident has no repercussion in terms of biliary reconstruction results if the repair was done by an experienced surgeon [11]. This is the reason why no routine angiographic study is done by most groups in the preoperative period. Nevertheless, the surgeon must keep in mind that after a right arterial injury and caudocephalic loss of the ductÕs arterial circulation (secondary to the ablation and loss of substance of the duct), the ducts are dependent on only the left hepatic artery. This is why we do high repairs to guarantee a good-quality, nonischemic, bilioenteric anastomosis as a routine. 60 porciento de arterias mayores y el 38% viene de laarteria hepatica deeraca a
- 60% d exitos si se usa esto 19% de exito en sirs 9% usa tejido sin debridar 17% de exito el cirujano que lesiona y 94% con cirujano distinto- especialitsta
- The opportunity to obtain a wide, non ischemic anas- tomosis at the hilar level began to restrict the usage of stents. A wide anastomosis allows free flow of the pro- ducing low duct pressure and less opportunity of leak. It also minimizes the risk of stricture and the need of sub- sequent instrumentation. Nevertheless, some cases with loss of confluence and complete destruction of the iso- lated right and left hepatic duct need a portoenterostomy, with no probability of obtaining a wide, tension free non ischemic anastomosis that need ferulization of the ducts, they obtain long term patency.
- No optimal period of waiting for performance of an elective repair has been established, but Strasberg advises a wait of 3 months. Resolution of bilomas, collections, and concomitant inflammation is expected after this period. Once the injury has reached its maxi- mum level of ischemia, the lesion is set to be stable. Elective surgical treatment then is recommended. Quality of life and cost (in some countries) are an obstacle to the delayed biliary repair. For this reason, it should be reserved for patients with complex injuries in which systemic and local repercussion is noticed. Stras- berg et al. [13] have shown excellent results for complex injuries by delaying the surgery and using temporary stents for percutaneous drainage. The long-term results reported for their series are excellent. Falta de recursos
- 5% amertian reoperacion