Thursday, June 14, 2007
An elective gallbladder yesterday that turned out to be a little complicated. Everything progressed well until I began my dissection in the distal infundibular area. I bluntly strip the peritoneum and fatty lymphatics off the cystic duct/infundibular interface using a Maryland dissector. First, there was an anterior cystic artery, intimately associated with the presumed cystic duct. I isolated this, identified it going up and arborizing on the gallbladder wall, and then clipped and cut it. The cystic duct, obviously terminating proximally in the infundibulum of the gallbladder, was very short and I could see it slightly tenting the common bile duct (CBD). I put a clip up on the proximal cystic duct and made a ductotomy with shears. I use the Ranfac cholangiocatheter for my cholangiograms, placed through a separate stab incision using a 14g angiocatheter. Unfortunately, the cystic duct was very narrow and fibrosed and I couldn't get the catheter introduced. In attempting to cut a little more, I actually transected the cystic duct. It was extremely thin and the lumen almost fibrosed. So I grasped the short stump and clipped it twice, being careful not to compromise the CBD. This released the gallbladder from its porta hepatis attachments and the infundibulum retracted nicely out of the way. Then i saw something I didn't like; another tubular structure emanating from the more proximal CBD that seemed to snake its way behind the gallbladder. I think my heart jumped into my pharynx at this point. Did I just cut a right hepatic duct? I completely liberated the gallbladder from its peritoneal attachments to the liver using cautery, essentially flopping it up over the anterior surface of the liver. This allowed me to dissect out where this thin structure wanted to go. It clearly did not connect to the gallbladder but, rather, inserted into the liver, just below the gallbladder fossa. I think this represented an accessory duct. A cholangiogram at this point would have involved doing a choledochotomy, which I felt was inadvisable. I simply left a drain in the RUQ and called it a day. Her liver function tests this morning are completely normal and the drain output is serous. So hopefully, I averted disaster.
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i recently had a similar experience. then i got all philosophical as is my tendency, and blogged it at http://other-things-amanzi.blogspot.com/2007/06/thinking-back.html
in the end the actual op wasn't the point.
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