SURGERY
Surgical Management of Biliary Tract Disease
Dr Ross Elliot BVSc MMedVet ( Surg ) Bryanston Veterinry Hospital . 011 706 6023
Surgical Anatomy
The gall bladder is a pear shaped duct sitting in the right cranial quadrant of the abdomen in a fossa between the right medial and quadrate lobes of the liver . The gall bladder drains into the cystic duct , the cystic duct connects the gallbladder to the common bile duct . The hepatic ducts drain the liver lobes into the common bile duct . The common bile duct allows bile to be transported into the gall bladder for storage or allows bile to be transported into the duodenal lumen via the major duodenal papilla .( fig 1 )
Fig 1 : Anatomy of the biliary tract of the dog .
Surgery of the Biliary Tract
Many patients presented for surgery of the biliary tract are systemically compromised and require stabilisation prior to any surgery . These patients either have obstruction of the biliary tract , rupture of the biliary tract or gallbladder mucocoeles . Fluid therapy and initial stabilisation are crucial in most cases prior to surgical treatment .
Obstructive Biliary Tract Disease
Obstruction of the biliary tract from pancreatitis is a common cause and can often be managed medically on current evidence . However if the patient is deteriorating , showing progressive dissention of the biliary tract and worsening of the hyperbilirubinaemia then surgical decompression is advised . Obstruction of the biliary tract from a choleolith should be addressed surgically as soon as possible . Obstruction due to neoplastic disease car- ries a poor prognosis but generally needs an exploratory celiotomy to investigate , diagnose and palliate the condition .
Obstructive Biliary Disease
There are 3 main techniques for dealing with obstructive biliary disease .
1 . Cholecystoenterostomy This is the most common technique used to re-establish bile flow into the intestine . The cholecystoduodenostomy is the ideal technique as it anatomically is the most correct at re-establishing bile flow .
This technique should be used if you are unable to catheterise the common bile duct at the duodenal papilla . This is performed through a small enterotomy on the anti-mesenteric surface of the duodenum in the area of the duodenal papilla . The papilla is visualised on the internal mesenteric surface of the duodenum . A small feeding tube is then introduced into the papilla and gently advanced into the gallbladder . If this tube is able to pass into the gallbladder and bile flows through the tube choledochal stenting should be performed . If the tube cannot be passed and the obstruction cannot be removed then a cholecystoduodenostomy should be performed .
On the rare occasion that there is a choleolith in the common bile duct this can be removed via a small incision into the bile duct over the obstruction and sutured closed with fine monofilament absorbable sutures . The common bile duct should be stented to divert bile from the incision site while it heals . To perform a cholecystoduodenostomy the gallbladder is bluntly dissected out of the fossa between the respective lobes of the liver usually using gentle digital manipulation . Care must be taken not to damage the first cystic ducts that run into the common bile duct . Severe haemorrhage can be controlled by application of a haemostatic agent such as Surgiceltm or Perclottm . The freed gallbladder is placed on the enterotomy previously performed to ensure there is no tension on the intended anastomosis site . This enterotomy should be in the region of around 3-5 cm as stoma smaller than 2,5cm are predisposed to recurrent
Issue 03 | JUNE 2016 | 33