17 16 49 PorterWhitlowAcute appendicitis, perforated 3/13 - Laparoscopic appendectomy Abscess...

VA GENERAL SURGERY

Merry UchiyamaVictoria WhitlowJeremy PowersWoon Cho Kim

March 7 – April 3

Cases PGY-1 PGY-2 PGY-5

Total

17 16 16

49

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

Complication

Date: 3/20/2015

Fac/Res: Savas/Wesson

Procedure: Robotic cholecystectomy

Complication: Readmission, recurrent biloma

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.

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.

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.

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.

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

2.5 cm

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.

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

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

Type of Injurysd

Type of Injurysd

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

Management Stabilize the patient if needed Drain bilomas Establish biliary drainage Obtain a cholangiographic characterization of

the injury.

Recommendation

Role of robotic cholecystectomy Use of with Indocyanine green (ICG) to identify

the cystic duct When to convert to open