Hepatobiliary Surgery

Each disease with the image that defines it: what it looks like, what the scan shows, and which operation answers it.

Biliary obstruction & cholangitis

A blocked duct is a problem; a blocked infected duct is an emergency.

The plumbing

Bile flows from segmental ducts to the common hepatic duct, meets the cystic duct, and descends as the common bile duct through the pancreatic head to the ampulla: every obstruction has an address on this map.

Causes by address

Stones from the gallbladder are the everyday cause; strictures, pancreatic head tumours and cholangiocarcinoma are the sinister ones; and the pattern of the liver tests plus the ducts' calibre on imaging usually names the level.

Cholangitis

Stagnant bile above an obstruction gets infected and pressurised, pushing organisms into the bloodstream: Charcot's triad clinically, and a duct that needs decompression, not just antibiotics.

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Drainage routes

ERCP from below (sphincterotomy, extraction, stent), percutaneous transhepatic drainage from above, or surgery: the first two do most of the work, and the choice follows the level and the local expertise.

After the drain

Decompression treats the episode; the cause still needs its own plan, cholecystectomy for stones, staging for strictures, because a drained tree with an untreated cause re-obstructs.

ERCP with sphincterotomyLaparoscopic cholecystectomyCase: Fever, jaundice and rigors

Ultrasound

What should I notice?

• Pancreatic cancer

  Found late, staged on vessels, and cured only by the biggest operation in the elective book.

  The disease

  Adenocarcinoma, mostly of the head, presenting as painless jaundice, new diabetes, weight loss or vague epigastric pain: symptoms arrive late because the retroperitoneum is a quiet neighbourhood.

  Staging is vascular

  Resectability is defined by the tumour's relationship to the superior mesenteric and portal veins and the mesenteric and hepatic arteries: the pancreatic-protocol CT is read vessel by vessel, and 'borderline' is a formal category with its own pathway.

  The Whipple

  Pancreaticoduodenectomy removes the pancreatic head, duodenum, distal bile duct and gallbladder, then rebuilds three joins: it exists because the head shares its blood supply with the duodenum and cannot leave alone.

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  Around the operation

  Chemotherapy before or after is now standard territory; the feared complication is the pancreatic anastomotic leak, drain amylase is the sentinel; and even resected disease demands honest survival conversations.

  Pancreaticoduodenectomy (Whipple)Case: Painless jaundice

• Acute pancreatitis

  A chemical burn inside the retroperitoneum, mostly mild, occasionally catastrophic.

  Causes

  Gallstones and alcohol lead; the rest of the list (hypertriglyceridaemia, ERCP, drugs, and rarer causes) matters because the cause directs the prevention of the next attack.

  Severity

  Amylase makes the diagnosis but not the prognosis: organ failure and its persistence define severe disease, and the first 48 hours of physiology outperform any single number.

  Treatment is support

  Fluids titrated to perfusion, analgesia, early feeding as tolerated, and no routine antibiotics: the pancreas is not operated on for being inflamed, and early surgery makes things worse.

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  The late game

  Necrosis that gets infected declares itself in week two onward: the modern approach is delay, drain, and escalate step by step (percutaneous, endoscopic, minimally invasive), a complete reversal of the old open necrosectomy reflex.

  The gallbladder clause

  Mild gallstone pancreatitis earns a same-admission cholecystectomy: discharge with the gallbladder in place is a rebooking with a recurrence risk attached.

  Laparoscopic cholecystectomyERCP with sphincterotomyCase: Epigastric pain boring to the back

• Liver tumours

  Metastases, primaries, and the arithmetic of what liver remains.

  The cast

  Colorectal metastases (common, and uniquely often curable by resection), hepatocellular carcinoma (in cirrhosis, usually), cholangiocarcinoma, and the benign trio (haemangioma, focal nodular hyperplasia, adenoma) that mostly need recognition rather than resection.

  Segmental anatomy

  Couinaud's eight segments, each with its own inflow and drainage, are the operation's vocabulary: resections remove segments, not shapes, and the plan is drawn on the CT.

  Resectability arithmetic

  What remains must be enough: adequate future liver remnant with intact inflow, outflow and biliary drainage. Volumes can be grown (portal vein embolisation) and operations staged; cirrhosis rewrites all the margins.

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  The wider menu

  Ablation for small deep lesions, embolisation for the unresectable, transplantation for the cirrhotic within criteria, and chemotherapy sequencing throughout: liver tumour care is a rotation through an MDT's whole toolbox.

  Liver resection (segmentectomy)Case: Four spots in the liver Case: A nodule in a cirrhotic liver