17 16 49 porterwhitlowacute appendicitis, perforated 3/13 - laparoscopic appendectomy abscess...
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VA GENERAL SURGERY
Merry UchiyamaVictoria WhitlowJeremy PowersWoon Cho Kim
March 7 – April 3
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Cases PGY-1 PGY-2 PGY-5
Total
17 16 16
49
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ComplicationsPorter
Whitlow Acute appendicitis, perforated
3/13 - Laparoscopic appendectomy
Abscess
Vu Whitlow Colon cancer
3/9 - Right hemicolectomy
Leak, sepsis, AKI
Savas
Stromberg Sigmoid volvulus, intestinal malrotation
3/27 - Sigmoidectomy, Ladd procedure
LGIB
Savas
Wesson Acute gangrenous cholecystitis
9/14/14 - Robotic cholecystectomy
Biloma, abdominal wall abscess
Malik Uchiyama Small bowel mass, R/O lymphoma
3/20/14 Right inguinal lymph node biopsy
Wound infection
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Complication
Date: 3/20/2015
Fac/Res: Savas/Wesson
Procedure: Robotic cholecystectomy
Complication: Readmission, recurrent biloma
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Background 34-year-old man s/p bicuspid aortic valve
replacement at UVA in 2011. Admitted to RVAMC August 2014 for bacterial
endocarditis and required replacement of aortic valve.
Developed septic emboli and presented with acalculous cholecysitis, which was treated with placement of a percutaneous cholecystostomy tube.
Despite this, had persistent right upper quadrant pain consistent with acute cholecystitis.
Taken to the operating room September 2014 for robotic cholecystectomy.
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Background Intra-operatively, found to have a gangrenous
gallbladder with evidence of thrombosed cystic artery. Identified the cystic duct with fluorescence
guidance using Indocyanine Green (ICG). The cystic duct was friable and leaking.
A drain was placed and continued to leak bile in the post-operative setting. It was removed one month later.
Underwent ERCP and biliary stent placement in September with stent removal in October.
Underwent CT-guided drainage of biloma with placement of drain in December 2014. Drain removed as outpatient in January 2015.
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Background “No show” to subsequent clinic follow-up. Presented to ED at RVAMC in March with complaint
of persistent, sharp RIGHT-sided abdominal pain, nausea, NBNB vomiting, and subjective fever.
On exam, afebrile, in distress with tachycardia and tachypnea, normotensive. Abdomen mildly distended with exceptional TTP over
RIGHT side with voluntary guarding.
No wounds, erythema, or induration; incisional scars healed.
On laboratory, WBC 9.7, lactate 1.3, Alk Phos 529, Tbili 1.1
CT A/P obtained.
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Readmission Admitted to SICU, made NPO, resuscitated,
and broad-spectrum IV antibiotic therapy started that night.
HD2-3: New findings of abdominal wall erythema and
induration.
WBC 10.6, then 14.5.
Repeat CT A/P with attempted percutaneous drainage.
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Readmission Taken to OR on HD4 for incision and drainage.
Bilirubin of fluid 27.7.
Subsequently underwent MRCP with Eovist in attempt to localize biliary leak. Tract inferior to porta hepatis confluence leading away
from bile duct along inferior liver to abdominal wall consistent with leak
2.5 cm irregular narrowing of suprapancreatic bile duct due to extrinsic compression and/or scarring
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2.5 cm
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Readmission Then underwent ERCP.
Filling defect present in mid-common bile duct with upstream dilatation to 10 mm.
Biliary sphincterotomy, balloon sweep and sphincteroplasty performed with return of “stones, sludge, and debris”.
10 mm x 3 cm fully covered metal stent placed in bile duct “to reduce risk of post-sphincteroplasty bleeding and aid passage of residual stone material”.
Bile the noted to flow freely across the stent.
No biliary leak present.
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Fishbone
PRE-OP Etiology of cholecystitis
POST-OP Initial ERCP with stent but
without sphincterotomy Percutaneous drainage
INTRA-OP Use of ICG to identify cystic duct Recognizing cystic duct as necrotic or friable and
therefore risk for leak Placement of drain
OUTCOME Recurrent biloma
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Bilomas after Cholecystectomy
Bile duct injuries 0.2% open cholecystectomy
0.5% laparoscopic cholecystectomy
Successful management depends on Type of injury
Timing of the injury recognition
Presence of complications
Condition of the patient
Availability of hepatobiliary surgeons, if needed
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Type of Injurysd
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Type of Injurysd
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Timing of injury recognition 25-32% of bile duct injuries are recognized at
the time of surgery Injuries not recognized intraoperatively can
manifest days to months later
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Management Stabilize the patient if needed Drain bilomas Establish biliary drainage Obtain a cholangiographic characterization of
the injury.
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Recommendation
Role of robotic cholecystectomy Use of with Indocyanine green (ICG) to identify
the cystic duct When to convert to open