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.
After, and when it goes wrong
Post-op & Emergencies
The expected course, the ward reads, and the calls that cannot wait.
The expected course and the ward reads, then the complications and the calls that cannot wait.
On the ward
Three boards, three reads
POD 3 · Whipple
Drain amylase 4200
Drain volume 180 mL, turbid
Temp 37.6
CRP 190
Eating small amounts
What is the drain saying?
The read
That the pancreatic anastomosis is leaking: drain amylase several times the serum level defines a postoperative pancreatic fistula. Most are managed exactly as found, drain stays, nutrition optimised, sepsis hunted, but the team now watches for the two escalations: an undrained collection needing another drain, and the sentinel bleed that sends this patient to angiography.
Day 2 · gallstone pancreatitis
O2 4L to keep sats 94%
RR 24
Creatinine 130 from 90
CRP 280
Abdomen distended, quiet
Mild attack or something else forming?
The read
Something else: persistent organ dysfunction past 48 hours reclassifies this as severe pancreatitis, and the rising oxygen requirement and creatinine are two organ systems voting. The move is critical care review today, fluids titrated to perfusion rather than by reflex, feeding maintained if tolerated, and no CT panic yet: imaging for necrosis reads best after the first week.
Evening after ERCP
New epigastric pain 6/10
Amylase pending
HR 96
Low-grade fever
Expected discomfort or a complication list opening?
The read
The list is short and worth saying aloud: post-ERCP pancreatitis (the commonest), perforation, bleeding after sphincterotomy, and cholangitis. New significant pain after ERCP earns bloods including amylase or lipase, serial examination, and a low threshold for imaging: retroperitoneal perforation in particular punishes the team that reassured too early.
Common problems
Complications to know
early
Postoperative bleeding
Tachycardia first, hypotension late; falling urine output; a distending abdomen or rising drain output.
late
Surgical-site infection
Wound erythema, warmth, discharge, and pain out of proportion, typically from postoperative day 4–7.
early
Bile leak
Right upper quadrant pain, fever, and bilious drain output, or a patient who is simply failing to thrive after cholecystectomy.
late
Venous thromboembolism
Unilateral leg swelling, or sudden dyspnoea, pleuritic pain, tachycardia, sometimes the only sign is unexplained hypoxia.
Emergencies
The calls that cannot wait
Ascending cholangitis
Recognise: Fever, rigors, jaundice and right upper quadrant pain; hypotension and confusion complete Reynolds' pentad and announce septic shock.
First move: Cultures, antibiotics, resuscitation, and the drainage call made early: the duct is decompressed within hours, not days, in the sick patient.
Severe acute pancreatitis
Recognise: An attack with persistent organ failure: creatinine climbing, oxygen requirement rising, pressure sagging beyond 48 hours.
First move: This patient belongs in critical care for support, not in theatre: fluids to perfusion, organ support, feeding, and the necrosis conversations deferred and staged.
Bile leak after cholecystectomy
Recognise: Days after a lap chole: pain, fever, bile in a drain or a collection on imaging, and a patient failing to follow the day-case script.
First move: Define the leak's anatomy (usually cystic stump or a duct of Luschka), drain the collection, and let ERCP depressurise the tree so the leak can close.
Haemorrhage after pancreatic surgery
Recognise: A sentinel bleed from a drain days after a Whipple, especially with a known pancreatic leak: an artery bathed in enzymes is warning you once.
First move: Take the sentinel seriously: crossmatch, CT angiography and interventional radiology now, because the second bleed is the one that arrests.
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.