Hepatobiliary Surgery

The liver, the biliary tree and the pancreas: anatomy-dense, imaging-led, unforgiving of guesswork.

• Hepatobiliary surgery works the right upper quadrant's plumbing: the liver and its segments, the biliary tree and its stones and strictures, and the pancreas, whose cancers demand surgery's biggest elective operation.
• Its defining habit is planning on imaging: liver resections are designed segment by segment on the CT before the incision, because the liver's anatomy is vascular, not surface.
• One triad organises the emergencies: obstruction plus infection in the biliary tree is cholangitis, and an obstructed infected system, here as everywhere, must be drained.
• Variant anatomy is the rule: ducts and arteries branch differently in a large minority of patients, which is why the specialty's operations are built around proving anatomy before dividing it.

MRI

What should I notice?

• Jaundice with pain and fever

  “Rigors, right upper quadrant pain and a bilirubin of 90 in a patient with known gallstones: Charcot's triad, textbook and febrile.”

  • Pain, jaundice and fever is cholangitis: a stone has blocked the common bile duct and the stagnant column above it is infected under pressure.
  • Add hypotension and confusion (Reynolds' pentad) and this is septic shock from a blocked duct: resuscitation and urgent decompression, not observation.
  • The drainage route is usually endoscopic: ERCP with sphincterotomy and stone extraction or a stent, with percutaneous drainage as the fallback.

  Live it as a case ERCP with sphincterotomy

• Painless jaundice

  “Six weeks of darkening urine, pale stools and itch in a 68-year-old, no pain, gallbladder palpable: a mass in the head of the pancreas.”

  • Painless obstructive jaundice with a distended gallbladder points above the gallbladder's own disease: Courvoisier's insight is that stones rarely do this, tumours do.
  • The workup is staging from the start: CT designed for the pancreas, asking about the vessels behind it, because resectability lives in the relationship of tumour to vein and artery.
  • Only a minority are resectable at diagnosis, and the Whipple is the only curative road for the head-of-pancreas tumour: the MDT sorts candidates honestly.

  Live it as a case Pancreaticoduodenectomy (Whipple)

• Gallstone pancreatitis

  “Epigastric pain boring to the back, amylase in the thousands, and an ultrasound full of stones: the pancreas is paying for the gallbladder's debts.”

  • A migrating stone has irritated the pancreatic duct's outflow: most attacks are mild and settle with fluids and analgesia, but the first 48 hours declare which ones will not.
  • Severity scores and the CRP trend separate the mild attack from the necrotising one: organ failure, not amylase height, is the measure of severity.
  • Cholangitis or a persistently obstructed duct changes the pathway: that patient needs urgent ERCP, while the uncomplicated attack does not.

  Live it as a case ERCP with sphincterotomyLaparoscopic cholecystectomy

• The liver lesion

  “Surveillance CT after a colorectal cancer finds two new segment VI and VII lesions: the liver question, asked the modern way.”

  • Context is the first diagnostic test: a new lesion in a cancer survivor is metastasis until proven otherwise; the same lesion in a cirrhotic is hepatocellular carcinoma until proven otherwise; in a well young woman it is probably benign.
  • Colorectal liver metastases are the treatable exception among stage IV cancers: resection cures a real fraction, so the question is always 'could this be resected?' before 'is this palliative?'.
  • Resectability is arithmetic about what remains: the future liver remnant needs adequate volume, inflow, outflow and drainage, and in cirrhosis the arithmetic changes entirely.

  Live it as a case Liver resection (segmentectomy)

• The cirrhotic with a new mass

  “An ultrasound surveillance scan in hepatitis-C cirrhosis shows a 3 cm arterialised lesion: hepatocellular carcinoma in a liver that cannot spare much.”

  • In cirrhosis, imaging can make the diagnosis without a biopsy: the arterial enhancement and washout pattern is HCC's signature.
  • Two diseases share this patient: the tumour and the cirrhosis, and the treatment must respect both. A resection the tumour permits may still kill via the liver that remains.
  • Child-Pugh status and portal hypertension gate everything: the compensated cirrhotic may tolerate resection; the decompensated one is a transplant conversation, where criteria allow.

  Live it as a case Liver resection (segmentectomy)