الفهرس 
Surgical Anatomy of the Gallbladder andOnly 14 pages are availabe for public view
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Abstract
Minimal access surgical techniques are now considered to be the gold standard for biliary, anti-reflux and bariatric surgery. This is mainly due to improved patient recovery with reduced pain, shorter hospital stay and a quicker return to normal daily activities.
The biliary tract is a complex organ system that performs the simple though vital task of collecting, storing, and delivering bile to the gastrointestinal tract. Diseases of the biliary system can be extremely painful, debilitating, and occasionally life threatening. The complex development of the liver and biliary system in utero can result in multiple anatomic variations. An absolute knowledge of these anatomic variations with careful dissection and identification of structures at the time of surgery is a minimal requirement for the safe performance of any hepatobiliary operation. Because of the unforgiving nature of the biliary system, errors in technique or judgment can be disastrous to the patient, resulting in lifelong disability or death. For this reason, a high premium exists on performing the correct procedure, without technical misadventure, the first time. Equally important is the ability to recognize iatrogenic injury so that prompt repair or referral to a surgeon who has expertise in hepatobiliary surgery can be instituted. Positive outcome requires a balance between sound judgment, technical acumen, and attention to detail. Additionally, the hepatobiliary surgeon of today must be able to integrate surgical options with the broadening array of radiologic and endoscopic treatment options available in the management of patients who have hepatobiliary disorders.
Despite the clear benefits of laparoscopic cholecystectomy, the rate of iatrogenic bile duct injury has increased from a rate of 0.1% to 0.2% during the era of open cholecystectomy to between 0.4% and 0.6% during the era of laparoscopic cholecystectomy. Unfortunately, iatrogenic bile duct injuries result in increased patient morbidity and mortality and impart a huge increased financial burden in hospital resource use and excessive malpractice litigation.
The reason for the high rate of initial complications was the failure to recognize that the adoption of minimally invasive techniques for cholecystectomy required the surgeon to learn new skills. Indeed, the skills acquired in open surgery have not led to an improved performance in the laparoscopic arena.
To be able to diagnose and manage a biliary injury, it is necessary to be aware of the strategies for classification. The Bismuth classification was developed prior to the advent of laparoscopic surgery and is still used. More recently, the Strasberg, McMahon, Neuhaus and Siewert systems have been proposed. They vary in complexity and whether clinical and therapeutic aspects are incorporated, but essentially there is a gradation from accessory duct damage through to occlusion of the common bile duct .It is generally accepted that the repair of a bile duct injury should be performed by an experienced biliary surgeon for the best results. This implies that the patients operated upon by general surgeons should be transferred to a biliary centre for further management. The procedure of choice for transection of the common bile duct is a biliary-enteric anastomosis such as a Roux-en-Y choledochojejunostomy, though a minor laceration may be sutured after insertion of a T-tube drain beside the anastomosis . If the complication is noted postoperatively, the initial procedure of choice is an endoscopic retrograde cholangiogram (ERC) to define the problem. Bile duct injury is a serious complication of laparoscopic cholecystectomy, and inadequate repair may lead to further complications such as secondary biliary cirrhosis, liver failure and death.
Successful management of bile duct injuries depends on the type of injury, prompt recognition of a problem, complete definition of the anatomy, and multidisciplinary expert intervention. When an injury is recognized in the operating room, several principles should be followed: (1) conversion to an open procedure, (2) hepatobiliary consultation, (3) close attention to anastomotic tension and blood supply, and (4) drainage or exclusion of the repair