SurgSpace / Specialties / Hepatobiliary Surgery
Hepatobiliary Surgery
Liver, biliary tree and pancreas: the most anatomy-dense corner of general surgery, where the operation is planned segment by segment on imaging before the incision, and where variant ducts and vessels are the rule rather than the exception.
Apply it
Cases & Practice
Patients to decide on, images to interpret, and the first day on the rotation.
Patients to decide on, images to interpret, and the briefing for the first day on the rotation.
Decisions, one patient at a time
Cases
Imaging practice
Read the image, then decide
Surgical decision-making
Does this patient need surgery?
Cholangitis with a BP of 95/60 after two litres of fluid, lactate 3.1, on antibiotics. When does the duct get drained?
Urgent ERCP (within hours)
The septic, obstructed tree is an undrained abscess with a postcode: decompression is the source control, and antibiotics alone are a holding measure.
Next-day ERCP after stabilisation
Reasonable for the responder who defervesces and holds pressure: the schedule can breathe when the physiology does.
Grade the cholangitis by the physiology: the sicker the patient, the sooner the drain. The classic error is escalating antibiotics for a deteriorating patient whose actual problem is pressure in a blocked duct, and the fix is a phone call to endoscopy, not a third agent.
A pancreatic head tumour abutting the portal vein over 90 degrees, no arterial contact, no metastases. Resect now, treat first, or palliate?
Surgery first
For the clearly resectable tumour with clean vessel planes: the Whipple while the window is open.
Neoadjuvant therapy then restage
The borderline tumour's pathway: chemotherapy first, and the operation for those whose disease holds or retreats.
Palliation
For locally advanced arterial encasement or metastatic disease: stents, symptom control and oncology, with honesty about what surgery cannot add.
The vein and artery lines on the CT are the decision: resectable, borderline and locally advanced are radiologic categories with different pathways attached. The MDT's discipline is refusing an operation the imaging has already declared futile.
A 3 cm HCC in segment VI, Child-Pugh A cirrhosis, platelets 95, no varices on endoscopy. Resect, ablate, or list for transplant?
Resection
For the compensated cirrhotic without significant portal hypertension: removes the tumour, leaves the disease (the cirrhosis) behind under surveillance.
Ablation
For small tumours in poor-access sites or poorer livers: local control without an operation's toll.
Transplantation
The only treatment for both tumour and cirrhosis, inside criteria: bought with a waiting list and lifelong immunosuppression.
In cirrhosis every treatment decision is two decisions: what does the tumour permit, and what does the liver forgive. Platelets and portal pressure often veto what the tumour's size would allow, and the transplant option reframes the whole conversation.
The rotation
Your first day here
- Learn the biliary tree's map first: cystic duct, common hepatic, common bile duct, ampulla. Every emergency in the specialty is an address on it.
- Read the liver segments module and then find segments on one CT: the specialty plans on imaging, and this is its alphabet.
- Obstruction plus infection equals drainage: cholangitis is the reference case, and the principle will serve you in three other specialties.
- Before a Whipple or liver resection, read the operation's why: these are long cases, and they teach far more when you know what each phase is for.
- Drain fluid is data: colour, volume and amylase tell the story of a pancreatic or biliary anastomosis better than any examination.
- In cirrhotic patients, check the synthetic function before anything else: the INR, albumin and platelets are the liver telling you what it can afford.
Hub shaped by the Surgical Specialties Lead with the Hepatobiliary surgery reviewer (open seat). Images and videos carry their source; educational use for supervised learning, not clinical guidance.