Gall bladder

Risk factors for Ca gall bladder

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Q) Risk factor for CA GB are all except
A. Multiple polyp
B large gall stone >3 cm
C PSC
D pigment stone same risk as cholesterol stone

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Radical Cholecystectomy

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 Q) Radical cholecystectomy includes all except

a) Segment IVb and Va

b) 2cm wedge resection

c) Rt Extended Hepatectomy

d) Paraaortic lymphnodes

Answer and Explanation here

History of Radical Cholecystectomy

  1. Early 20th century removal of gall bladder and wedge of liver ( No lymphadenectomy) 
  2. In 1954, Glenn et al - radical resection procedure with intended regional lymphadenectomy (portal lymph node dissection), designated as “radical cholecystectomy” (Glenn operation)
  3.  Fahim et al in 1962 advocated radical resection consisting of hepatectomy and portal lymph node dissection

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NOTES

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Q) Regarding minimal access cholecystectomy all are true except?

a) NOTES can be done transvaginally and transgastrically

b) Transgastric route is preferred

c) SILS is done through single port with multiple instruments avoiding multiple ports

d) SILS has difficulty with triangulation and retraction

Answer is B

Natural  orifice  transluminal  endoscopic  surgery (NOTES),  which  uses  natural  orifices  (transgastric, colonic,  urethral,  vagina)  to  introduce  an  endoscope,  has been  reported  since  early  2000  as  a  less  invasive  approach to  laparoscopy. 

The  first  human  NOTES  transvaginal  cholecystectomy  was  reported  in  2007,  and  later  the  report  of a  hybrid  combination  of  flexible  scope  by  a  transvaginal approach  in  combination  with  an  umbilical  needle  or port  for  laparoscopic  instruments  for  retraction,  dissection,  or  clips  application. 

This  hybrid  technique  allowed for  a  quicker  and  safer  procedure;  the  present  deficiency is  in  the  proper  endoscopic  instrumentation. For  the  trans vaginal  approach,  a  Foley  catheter is  placed,  a  dissection  is  performed  in  the  posterior vaginal  cul-de-sac  to  allow  a  port  placement,  and  when the  case  is  over,  the  closure  is  easier  than  a  transgastric or  transcolonic  approach,  which  continues  to  be  an  issue.

Shackelford

Post cholecystectomy injury

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Q   Post cholecystectomy Injury, which is true?

a.       Bile duct leak in approx 1%

b.      Open cholecystectomy bile duct injury 0.5 to 1 %

c.       Most common cause of bile leak is cystic stump blowout and duct of lushka injury

d.      Type E injury is due to clipping of CBD by mistake

 

Cholecystostomy

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Q.    Regarding percutaneous cholecystostomy A/E

a.       Technical success in 90 – 98 % of cases

b.      Indicated in Grade II cholecystitis with significant pericholecystic inflammation & GOO

c.       Indicated in Gr III cholecystitis with significant comorbidity

d.      In Grade III cholecystitis with biliary peritonitis, PCC results in significant improvement

Answer 

Cholelithiasis with Choledocholithiasis

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Q.  Patients with gallstones and choledocholithiasis in a centre with endoscopy, interventional radiology and tertiary care 

a.       Single setting lap chole + CBDE better than endoscopy followed by lap chole

b.      In choledocholithiasis endoscopic clearance alone without lap chole can be done without any long term complication

c.       For impacted ampullary stones with CBD dilatation that requires biliary enteric drainage is performed with a preferred open approach

Answer

 

Causes of Acalculus Cholecystitis

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Q) Which of the following is not a cause of acalculus cholecystitis? Questions on bile duct

a) Kinking of the neck of gall bladder

b) Acalculus cholecystitis Sphincter spasm

c) Thrombosis of cystic artery

d) Over eating

Ans d

Acalculus cholecystitis can be both acute and chronic in the absence of stones. Although it can present acutely, acalculous cholecystitis typically presents more insidiously.

Mostly the acute form is recognized and chronic form is called biliary dyskinesia.

The cause of acalculus cholecystitis are

  1. Kinking or fibrosis of neck of gall bladder.
  2. Thrombosis of cystic artery
  3. Sphincter of Oddi spasm
  4. Prolonged fasting
  5. Dehydration
  6. Sepsis
  7. Systemic diseases MODS

Ref: By Jarrell - NMS Surgery (National Medical Series for Independent) (Sixth Edition) (2015-07-30) [Paperback]

Jaundice in acalculus cholecystitis  is known to occur because of ischemia and inflammation cystic duct gets obstructed due to edema

Diagnosis

Chronic acalculus cholecystitis is a cholescintigraphy nuclear scan (HIDA) with the administration of cholecystokinin (CCK). After the . A calculated ejection fraction of 35% or less may be indicative of hypokinetic functioning of the gallbladder. An ultrasound of the gallbladder may also be useful. If this shows a thickened gallbladder wall of over 3.5 mm, this may be due to cholecystitis.

Acute acalculus cholecystitis - USG CT or HIDA

 

BEST BOOKSMCQ practise 

MRCS Part A: Essential Revision Notes: Book 1

MRCS Part A: Essential Revision Notes: Book 2