Mini-Laparoscopic Cholecystectomy with Intraoperative Cholangiogram for Symptomatic Cholelithiasis (Gallstones) - Standard
Authors: Brunt LM1, Singh R1, Yee A2
Published: September 26, 2017

AUTHOR INFORMATION
1 Department of Surgery, Washington University, St. Louis, Missouri
2 Division of Plastic and Reconstructive Surgery, Washington University, St. Louis, Missouri

DISCLOSURE
No authors have a financial interest in any of the products, devices, or drugs mentioned in this production or publication.

ABSTRACT
Minimal invasive laparoscopic cholecystectomy is the typical surgical treatment for cholelithiasis (gallstones), where patients present with a history of upper abdominal pain and episodes of biliary colic. The classic technique for minimal invasive laparoscopic cholecystectomy involves four ports: one umbilicus port, two subcostal ports, and a single epigastric port. The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) has instituted a six-step strategy to foster a universal culture of safety for cholecystectomy and minimize risk of bile duct injury. The technical steps are documented within the context of the surgical video for (1) achieving a critical view of safety for identification of the cystic duct and artery, (2) intraoperative time-out prior to management of the ductal structures, (3) recognizing the zone of significant risk of injury, and (4) routine intraoperative cholangiography for imaging of the biliary tree. In this case, the patient presented with symptomatic biliary colic due to a gallstone seen on the ultrasound in the gallbladder. The patient was managed a mini-laparoscopic cholecystectomy using 3mm ports for the epigastric and subcostal port sites with intraoperative fluoroscopic cholangiogram. Specifically, the senior author encountered a tight cystic duct preventing the insertion of the cholangiocatheter and the surgical video describes how the author managed the cystic duct for achieving a cholangiogram, in addition to the entire technical details of laparoscopic cholecystectomy.

Ellis Parker MSN, RN-BC, CNE, CHSE covers Incentive Spirometry. The Critical Nursing Skills - Shorts series is intended to help RN and PN nursing students study for nursing school exams, including the ATI, HESI and NCLEX.

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How to approach histology for Human Anatomy students. Using a key will help get you through it! Add some penguin fairy dust will help too!

Please note: I mis-spoke and said "striated" instead of "stratified epithelium" a couple of times... apologies!

There are lots of histology keys out there, but the one I showed in the video is here: http://www.penguinprof.com/upl....oads/8/4/3/1/8431323

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Details:

Tissue in the human body:

Epithelial: Is made of cells arranged in a continuous sheet with one or more layers, has apical & basal surfaces.

A basement membrane is the attachment between the basal surface of the cell & the underlying connective tissue.

Two types of epithelial tissues: (1) Covering & lining epithelia and (2) Glandular Epithelium.

The number of cell layers & the shape of the cells in the top layer can classify epithelium.

Simple Epithelium - one cell layer
Stratified epithelium - two or more cell layers
Pseudostratified Columnar Epithelium - When cells of an epithelial tissue are all anchored to the basement Membrane but not all cells reach the apical surface.
Glandular Epithelium -- (1) Endocrine: Release hormones directly into the blood stream and (2) Exocrine - Secrete into ducts.


Connective: contains many different cell types including: fibroblasts, macrophages, mast cells, and adipocytes. Connective Tissue Matrix is made of two materials: ground substance - proteins and polysaccharides, fiber -- reticular, collagen and elastic.

Classification of Connective Tissue:
Loose Connective - fibers & many cell types in gelatinous matrix, found in skin, & surrounding blood vessels, nerves, and organs.
Dense Connective - Bundles of parallel collagen fibers& fibroblasts, found in tendons& ligaments.
Cartilage - Cartilage is made of collagen & elastin fibers embedded in a matrix glycoprotein & cells called chondrocytes, which was found in small spaces.
Cartilage has three subtypes:
Hyaline cartilage -- Weakest, most abundant type, Found at end of long bones, & structures like the ear and nose,
Elastic cartilage- maintains shape, branching elastic fibers distinguish it from hyaline and
Fibrous Cartilage - Strongest type, has dense collagen & little matrix, found in pelvis, skull & vertebral discs.


Muscle: is divided into 3 categories, skeletal, cardiac and smooth.
Skeletal Muscle -- voluntary, striated, striations perpendicular to the muscle fibers and it is mainly found attached to bones.
Cardiac Muscle -- involuntary, striated, branched and has intercalated discs
Smooth Muscle -- involuntary, nonstriated, spindle shaped and is found in blood vessels & the GI tract.


Nervous: Consists of only two cell types in the central nervous system (CNS) & peripheral nervous system (PNS):
Neurons - Cells that convert stimuli into electrical impulses to the brain, and Neuroglia -- supportive cells.
Neurons -- are made up of cell body, axon and dendrites. There are 3 types of neurons:
Motor Neuron -- carry impulses from CNS to muscles and glands,
Interneuron - interpret input from sensory neurons and end responses to motor neurons
Sensory Neuron -- receive information from environment and transmit to CNS.
Neuroglia -- is made up of astrocytes, oligodendrocytes, ependymal cells and microglia in the CNS, and schwann cells and satellite cells in the PNS.

Appendicitis is one of the most common surgical problems. One out of every 2,000 people has an appendectomy sometime during their lifetime. Treatment requires an operation to remove the infected appendix. Traditionally, the appendix is removed through an incision in the right lower abdominal wall. In most laparoscopic appendectomies, surgeons operate through 3 small incisions (each ¼ to ½ inch) while watching an enlarged image of the patient’s internal organs on a television monitor. In some cases, one of the small openings may be lengthened to complete the procedure.

Examination of the cervical spines

Examination of the hip

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The bulb syringe is readily available, safe tool for clearing the airway of a newborn infant

A great video showing Total Abdominal Hysterectomy

different fetal lie and pre

First stage of labour with its signs and symptoms like uterine contractions and the show

A 30 YEAR WOMEN WITH INTRACTABLE BILIARY COLIC

CASE REPORT: This 30 year women developed severe pain right upper quadrant for last 10 days. She sought many consultations and was given intravenous analgesics both (nonnarcortic and narcotic). Pain did not subside and she sought my consultation. Examination revealed her to be in agony with severe upper abdominal pain. General physical examination was otherwise unremarkable. Abdominal examination revealed mild tenderness in right hypochondrium with doubtful Murphy's sign. Urgent abdominal ultrasound showed a linear structure in bile ducts making slow writhing movements. The structure had an anechoic tube (alimentary canal) inside suggestive of a large Ascarid. Urgent ERCP was performed and bile duct and pancreatic duct cannulated selectively. Pancreatic duct was normal. Bile ducts contained a long linear filling defect extending from lower end of common bile duct to right intrahepatic duct (see image gallery for ERCP plate). A basket was introduced in the duct (see video clip) and the linear structure was engaged with soft closure and extracted out of the bile duct. Accompanying the basket was a 25 cm thick highly motile Ascarid. To recover the worm, endoscope was withdrawn along with the basket and the friendly catch. While the endoscope was being withdrawn and the basket was in the duodenum with the worm out of bile duct, patient indicated of relief of abdominal pain. A relook cholangiogram showed no more structures in the duct. She was given antihelmintic therapy and passed hundreds of worms with the feces. The worms recovered form stools were both male and female population and varied in length and size. However the lone worm recovered form bile ducts was the longest and the thickest male worm. The phenomenal behavior of this ubiquitous infection remains unexplained.

Michael Marcus, MD Pediatric Pulmonary www.DrMDK.com Maimonides Medical Center Fellowship:Children’s Hospital of Philadelphia www.DrMDK.com

This is a educational video for the prostate cancer patient and their family. Depending on the individual patient, a radical prostatectomy, might a procedure that your urologist could recommend as treatment.

Examination of the lower limbs from Loyola medical school, Chicago

Ligation around a hemostatic Clamp

Esophagomyotomy for Achalasia

IM Injection instructions

A posterior Gastroenteral side to side anastomosis is presented. The procedure is made with circular stapler. After a good hemostasis of the suture has been obtained, the gastrotony is closed with linear stapler and running suture.