Surgery Multiple Choice
Questions for Post graduate Students
Q16 Which of the following Biliary injuries do not present immediately after surgery
a) Type A
b) Type B
c) Type C
d) Type D
Q17.Which of the following is not true regarding ERCP in benign injuries of biliary tract
a) ERCP should be the initial investigation in all cases of injuries to the ble duct to define the extent of injury
b) ERCP is of value if there is a incomplete stricture
c) ERCP is helpful if it is a Type A or Type D injury
d) ERCP is of no use if clinically or radiologically the bile leak has stopped
Q18 What is not true regarding the role of (IOC) Intra Operative Cholangiography in Bile duct injury
a) IOC should be done in all cases of cholecystectomy as it prevents inadvertent injury
b) Cholangiography only serves to limit the extent of injury
c) It allows for immediate recognition of injury and repair
Answers
16. b
According to Strasberg's classification of biliary injuries, Type B injury is the one in which there is no bile leak. It is a occulson of Right sectoral duct.
For Bismuth classification of bile duct injuries see here
17) a
ERCP is not the initial investigation if there is a suspicion of complete ductal occlusion. This is because ERCP would not demonstrate the proximal extent of injury.In these cases PTC (Percutaneous Transhepatic Chonalgiography) would be more useful.
18. a
Routine intraoperative cholangiography does not decrease the rate of injuries associated with Lap Cholecystectomy. Cholangiography is clearly not preventive if the injury occurs after a normal study or if the study serves only to identify an injury that already has been inflicted
Notes
Successful management of biliary strictures depend on
1. Defining the type and extent of injury
2. Treat sepsis,cholangitis, ongoing biliary leaks, abscess
3. Achieving a tension free duct to mucosa anastomoses
Questions Bile duct injuries
Notes on Laparoscopic CBD management
Normally 6% of all asymptomatic patients with gall stones will have stones in the common bile duct (CBD) (Majeed et al 1999)
In patients with CBD stones who are asymptomatic 26% will have stones spontaneously passing.
Indications of Choledochoduodenostomy
Multiple stones and debris
Primary Duct stones
Evidence of obstruction at the lower end
Uncertainity if the duct is clear
There are two types of laparoscopic surgeries for CBD stones
1. Transcystic
2. Choledocholithotomy
Indications for Transcystic extraction
1. Stones less than 8 in number
2. stone size less than 9 mm
3. Distal to cystic duct
Contraindication to Transcystic extraction is
Friable cystic duct
Intra hepatic stones
Multiple large stones
SUCCESSFUL EXTRACTION IN 67-96%
Infection and pancreatitis in 5-10 % with a mortality rate of 1%
In Laparoscopic choledochotmy
success rate is 90%
Complications 5-10%
Mortality 1-2%
Complications include- laceration of the CBD, bile leakage, sewn-in T-tubes, and postoperative CBD strictures
Stewart Way Classification of Biliary injury- Bases on cognitive factors
Class I - CBD mistaken for cystic duct recognised cholangiogram incision in cystic duct extended to CBD
Class II- Lateral damage to CHD, bleeding with poor visibility
Class III- CBD mistaken for cystic duct, not recognised
Class IV- RHD mistaken for cystic duct, RHA mistaken for cystic artery
