Hepato-biliary surgery involve the treatment of hepatic lesions and the treatment of gallbladder and biliary tree pathology.
The treatment of the hepatic lesions can be performed by hepatic resection with the respect of the anatomic description of functional segments or lobes (type left hepatectomy or segmental resection), non-anatomic hepatic resection or local thermoablation of the tumours (by radiofrequency or irreversible electroporation). The treatment of the malignant lesions is completed by chemotherapy regimen.
This type of surgery requires good level of echography skills from the surgeon for the lesion identification and peroperative hepatic resection planning.
–Gallbladder is an organ situated on the posterior side of the liver in the right hypochondrium. The role is to stock and concentrate the bile during the fasting periods of the day.
–Symptomatology of gallstones is usually represented by episodes of biliary colic which are pains in the right hypochondrium with nausea or vomiting. The biliary colic is produced when the gallstone migrate to the duodenum after the contraction of the gallbladder with a possible blockage of the cystic duct or common bile duct by the stone.
-The usual radiologic exam to investigate this pathology is represented by the abdominal echography.
-The surgery is performed by laparoscopy (with small incisions) under general anesthesia.
-It is possible to live normally without a gallbladder. After the procedure, the bile drains from the liver through the ducts, directly into the small intestine and a specific diet is usually not necessary. On the other hand, the more frequent flow of bile in the small intestine can cause diarrhea which is usually self-limiting. A low fat diet is recommended until the time of surgery, to avoid the risk of migration of the gallstones.
Classic postoperative course:
For elective cholecystectomy, the postoperative course is usually simple and the patient leaves the Unit on Day1.
•Day 0 – After the surgery, the patient can drink water and in the evening the oral intake is authorized. In case of One Day surgery, the patients can return home at the end of the day, if is in good general status.
•Day1 – After a night at the hospital, if the patient presents a correct clinical condition, parameters within physiological standards, oral refeeding and resumed intestinal transit, discharge is authorized.
-Infections on the postoperative wounds
-Bile leakage from the cystic duct
-Injury to the bile duct
-Injury to the colon, small bowel
Complications of gallstones:
-Acute cholecystitis (inflammation of the gallbladder- due to the mechanical irritation of the stones).
-Acute pancreatitis (inflammation of the pancreas- due to the gallstone migration)
-Angiocholitis (infection of the intra and extrahepatic bile ducts due to a blockage of a stone into the bile duct)
-Mirizzi syndrome (compression of the bile duct by a gallstone placed in the vesicular infundibulum)
-Gallstone ileus (creation of a fistula between the gallbladder and the duodenum with migration of a lithiasis who produce an mechanical occlusion of the small intestine)
-Hepatectomies can be performed by laparotomy or laparoscopy depending on the stage, number, size and location of the liver tumour.
-The oncological pathology is very wide and can consist in major hepatectomy (> 3 hepatic segments), minor hepatectomy and tumorectomy in the form of wedge resection. In selected cases, the treatment of the hepatic lesions can be performed by local destruction by thermoablation. All these gestures can be combined during the same intervention.
-The preoperative assessment is very important to achieve a good result, in the context of a complex surgery.
-Special attention should be paid to the administration of Paracetamol which is well known as hepatotoxic. The accepted safety doses after hepatic resection are <2g / day. Pain relief with opioids or morphine is desirable rather than increasing the dose of Paracetamol.
• Day1-the patient is allowed to have a TBB or even a light diet depending on his abdominal condition. A control blood test with liver function tests is essential. The drain is monitored as well as the parameters. The urinary catheter can be kept if the patient presents with abdominal pain during mobilization, for his comfort. If the hepatectomy has been performed by laparotomy, an abdominal belt is indicated to reduce wall pain upon mobilization. Be careful that the abdominal belt is too tight to limit respiratory movement and promote pulmonary atelectasis.
• Day2-A control blood sample is taken, the patient is stimulated to mobilize unless a PCA-type epidural is in place. In this case, the bladder catheter will be kept until the catheter is removed.
•> Day3– Clinico-biological monitoring
• Day4– The removal of the drain will be taken into consideration if it remains clean and the general condition of the patient is favourable.
• Day5-7– Depending on the patient’s progress and in the absence of complications, discharge may be considered during this period
• Bleeding – manifested by externalization of blood at the level of the drain and general signs (pallor, tachycardia, tachypnea, dizziness, and in a more advanced state confusion, state of shock). Depending on the extent of the bleeding, the patient will require a transfusion and / or reoperation.
• Liver failure – a very serious complication present in major hepatectomies, and related to the size and condition of the remaining liver (risk is higher if liver resection is performed on a cirrhotic liver). With limited resection, hepatic failure is usually transient and not very severe unless it persists beyond the fifth day.
• Biliary fistula – evidenced by the presence of bile in the drain. If the flow is low, conservative treatment is sufficient, usually will dry up spontaneously. In case of high flow> 200cc / 24h there is the possibility of endoscopy with the realization of a cholangiography to identify the leak, with the realization of a sphincterotomy to reduce the pressure in the biliary tree and/or the installation of a temporary stent.
• Intra-abdominal abscess – can appear in context of hematic or infected bilious collection. Clinically the patient is feverish, dyspnoeic, he presents an increase in abdominal pain or an intestinal ileus. The abdominal CT scan makes it possible to diagnose and even treat an abscess by percutaneous drinage under local anaesthesia. Antibiotic therapy should be considered.
• Pulmonary complications – acute respiratory distress syndrome (ARDS), acute lung oedema (OAP), pneumonia, pulmonary embolism or pleural effusion. Treatment consists of antibiotic therapy, oxygen therapy, respiratory physiotherapy, aerosols, or in more severe cases ventilatory support.