Concepts in Hepatobiliary Surgery

This chapter introduces the most common disorders of the hepatobiliary tract and provides the concepts necessary for safe surgery in this region. The diagnosis, evaluation, and treatment of cholecystitis and its variants are described, including a discussion of the merits of intraoperative cholangiography and drain placement during cholecystectomy. Indications for cholecystostomy tube placement as an alternative to cholecystectomy are also discussed. Iatrogenic common bile duct injury is described in detail, with attention to common mechanisms of injury, management of bile leak, and timing of definitive repair. The etiology of cholangitis and the options for ductal drainage procedures are explored, along with a discussion on the indications and management of T-tubes. The evaluation and management of gallbladder carcinoma and cholangiocarcinoma are also introduced. Within the section on hepatic surgery, liver tumors including hepatocellular carcinoma and colorectal liver metastases are presented along with their classic imaging characteristics. Important concepts such as how to determine tumor resectability and estimating liver remnant function are explained. Techniques for hemostasis during hepatectomy are described, including central venous pressure management, clamping of the hepatoduodenal ligament, and application of topical coagulants. Hepatic trauma is briefly presented with a discussion of its operative and nonoperative management. Finally, the management of postoperative complications of hepatectomy is explained.