CASE 1:

▪A 29 yo female with a history of kidney stones is found to have a single mobile gallstone on ultrasound. She has no history of biliary colic, jaundice, pancreatitis.

Expectant Management of Asymptomatic Cholelithiasis

▪ 1 – 4% of patients per year develop symptoms

▪ 10 – 20% of patients develop symptoms at 5 and 20 years

▪ Almost all patients develop symptoms before complications

Asymptomatic Cholelithiasis: Is cholecystectomy really needed? A critical reappraisal 15 years after the introduction of laparoscopic cholecystectomy

Sakorafas, et al-Dig Dis Sci (2007)

CASE 2:

▪ A 32 yo male has frequent episodesof postprandial right upper quadrant pain radiating into the back. No history of pancreatitis or jaundice. Abdominal examination is benign. LFT’s are normal. Ultrasound reveals several gallstones with normal gallbladder wall thickness anda 3 mm common bile duct.

The Critical View of Safety

▪ The Triangle of Calot must be cleared of fat and fibrous tissue

▪ The lower part of the gallbladder must be separated from the cystic plate

▪ Two, and only two structures, should be entering the gallbladder.

Rationale and use of the critical view of safety in laparoscopic cholecystectomy

Strasberg, SM-JACS, Vol. 211, No. 1 (July 2010)

Critical View of Safety (CVS)

Strasberg, SM-JACS, Vol. 211, No. 1 (July 2010)

CASE 3:

▪A 41 yo female status post a laparoscopic cholecystectomy 5 days prior presents with abdominal pain, anorexia,and distention.

Protocol for the Minimally Invasive Management of Bile

Leaks Post Laparoscopic Cholecystectomy

Ahmad, et. al. Ann R Coll. Surg. Engl. 2007 January; 89(1): 51-56

CASE 4:

▪A 52 yo female presents witha history of classic attacks of biliary colic. Work up reveals a negative ultrasound and a normal liver function tests.

Evaluation of Surgical Outcomes and GallbladderCharacteristics in Patients with Biliary DyskinesiaSabbaghian, et. al. – Journal of Gastrointestinal Surgery (2008) 12:1324-1330

CASE 5:

▪ A 45 yo man with acute heart failure has an ejection fraction of 15%. He is to be listed for heart transplantation but discovered to have an asymptomatic porcelain gallbladder. The heart transplantation team is requesting cholecystectomy prior to transplantation.

▪ 25,900 gallbladders between 1962 and 1999

underwent pathology and chart reviews

▪ 150 gallbladder cancers (.6%)

▪ 44 patients with calcified gallbladders (.2%) :

17 complete intramural and 27 selective mucosal

▪ 2 patients with selective calcification had cancer

(7%) and 0 with complete intramural calcification

▪ 2 of 44 patients with calcification had cancer (5%)

Carcinoma in the porcelain gallbladder: a relationship revisitedStephen, et al- Surgery (2001) 129: 699 - 703

CASE 6:

▪ A 55 yo male presents with 12 hrsof right upper quadrant pain and a positive Murphy’s sign. WBC=17, T.Bili=2, SGOT/SGPT=80 and 55,Alk Phos=high normal. US + for thickened wall and multiple stones. HIDA + for cystic duct obstruction.

Acute Cholecystitis: Early Versus Delayed Cholecystectomy,A Multicenter Randomized Trial (ACDC Study, NCT00447304)Gutt, et. al. – Annals of Surgery (2013) 258(3):385-393

CASE 7:

▪ A 55 yo female presents with acute cholecystitis and elevated liver function test. An MRCP is obtained.