Manual of Surgery of the Gallbladder, Bile Ducts, and Exocrine Pancreas

308 Pages·1979·56.486 MB·English

by  Robert E. Hermann M.D. (auth.)

Comprehensive Manuals of Surgical Specialties
~
lZJZJ
Richard H. Egdahl, editor
Robert E. Hermann
Manual of Surgery
of the Gallbladder,
Bile Ducts,
and Exocrine Pancreas
With contributions by Avram M. Cooperman, Caldwell B. Esselstyn, Jr.,
Ezra Steiger, and R. Thomas Holzbach
Includes 197 color illustrations and 123 illustrations in black and white
Springer-Verlag
New York Heidelberg Berlin
Comprehensive Manuals of Surgical Specialties, Volume 3
SERIES EDITOR
Richard H. Egdahl M.D., Ph.D., Professor of Surgery, Boston University Medi
cal Center, Boston. Massachusetts 02118
AUTHOR
Robert E. Hermann M.D .. Head. Department of General Surgery. The Cleveland
Clinic Foundation. Cleveland, Ohio 44106
CONTRIBUTORS
Avram M. Cooperman M.D., Caldwell B. Esselstyn. Jr.. M.D .. Ezra Steiger
M.D., Department of General Surgery, The Cleveland Clinic Foundation. Cleve
land, Ohio 44106
R. Thomas Holzbach M.D., Gastrointestinal Research Unit. Department of Gas
troenterology, The Cleveland Clinic Foundation. Cleveland. Ohio 44106
MEDICAL ILLUSTRATOR
Robert M. Reed A.M.I., Head, Department of Medical Illustrations. The Cleve
land Clinic Foundation. Cleveland. Ohio 44106
Library of Congress Cataloging in Publication Data
Hermann, Robert E.
Manual of surgery of the gallbladder, bile ducts,
and exocrine pancreas.
(Comprehensive manuals of surgical specialties; v. 3)
Includes index.
I. Gall-bladder-Surgery-Handbooks, manuals, etc.
2. Bile-ducts-Surgery-Handbooks. manuals, etc.
3. Pancreas-Surgery-Handbooks. manuals, etc.
I. Cooperman, Avram M. II. Title. [DNLM: I. Gall
bladder-Surgery. 2. Bile ducts-Surgery. 3. Pancreas
-Surgery. WI750 H552ml
RD546.H36 617' .556 78-23697
All rights reserved.
No part of this book may be translated or reproduced in any form without written
permission from Springer-Verlag.
Copyright © 1979 by Springer-Verlag New York Inc.
Softcover reprint of the hardcover 1st edition 1979
987654321
ISBN-13: 978-1-4612-6152-0 e-ISBN-13: 978-1-4612-6150-6
DOl: 10.1007/978-1-4612-6150-6
To all those who have taught me surgery,
especially,
Ewald E. Hermann, M.D.
Carl A. Moyer, M.D.
William D. Holden, M.D.
George Crile, Jr., M.D.
Stanley O. Hoerr, M.D.
Editor' s Note
Comprchcnsivc Manuals of SurRical Specialties is a series of surgical
manuals designed to present current operative techniques and to explore
various aspects of diagnosis and treatment. The series features a unique
format with emphasis on large, detailed, full-color illustrations, schematic
charts and photographs to demonstrate integral steps in surgical proce
dures.
Each manual focuses on a specific region or topic and describes
surgical anatomy, physiology, pathology, diagnosis and operative treat
ment. Operative techniques and stratagems for dealing with surgically cor
rectable disorders are described in detail. Illustrations are primarily
depicted from the surgeon's viewpoint to enhance clarity and compre
hension.
Other volumes in preparation:
Manual of GynecoloRic SurRery
Manual oj Lower Gastrointestinal SurRery
Manual oj UroloRic SurRery
Manual oj Vascular SurRery
Manual of Cardiac SUrRel}'
Manual oj Lil'er SurRery
Manual of Sojt Tissue Tumor SurRery
Manual oj Orthopaedic SurRay
Manual oj Upper Gastrointestinal SU"Rel}'
Manual of Plastic SurRery
Manual oj Amhulatol}' SUrRel}'
Richard H. ERdahl
Foreword
It is appropriate that a surgical teacher. Robert E. Hermann. M.D .. with
a large experience in a specialized field should author the beautifully il
lustrated Manual of StlrRery of the Gallbladder. Bile Ducts. and Exocrine
Pancreas. This manual. which takes its place in the distinguished series
sponsored by RiChard H. Egdahl, M.D .. is designed for the working sur
geon. resident or practitioner. who wishes to refresh his memory or to
bring himself abreast of current thinking and technics. The carefully
planned format and the elegant color illustrations of Mr. Robert Reed per
mit this with the expenditure of a minimum of time and effort. and sur
geons who must operate on the organs and structures it covers will wish to
have it available for reference.
Stanley O. Hoerr. M.D.
former Chairman. Division of Surgery
Cleveland Clinic
Chairman. Department of Surgery
Fairview General Hospital
Cleveland. Ohio
Preface
Operations on the gallbladder and bile ducts are among the surgical proce
dures most commonly performed by general surgeons. In most hospitals,
cholecystectomy is the most frequently performed operation within the ab
domen; approximately 6()(),OOO are performed each year in the United
States. In addition, an estimated 120,000 bile duct operations are performed
yearly.
Pancreatic surgery is less frequent, but because of the close relation
between the biliary system and the pancreas, knowledge of pancreatic
problems is equally essential to the surgeon. Acute and chronic pancrea
titis and cancer of the pancreas are often encountered by surgeons, with
apparently increasing frequency; their treatment remains difficult and per
plexing. This book correlates the association between the biliary system
and pancreas in a way not done by previous books.
For the gallbladder, bile ducts, and exocrine pancreas, this manual
provides an understanding of their anatomy and physiology, their dis
eases, and most important, methods of operative management. It is
written from a personal viewpoint, emphasizing my practice and that of
my associates in the operative principles and technics presented.
As in previous manuals in this series, every effort has been made to
orient the illustrations to the operative field as seen by the surgeon. We are
especially pleased with the many full-color illustrations prepared by Mr.
Robert M. Reed and with the publisher's cooperation in the production of
this volume.
Rohert E. Hermann
Acknowledgments
In the creation of any book. many people contribute to the development
of the final manuscript and the illustrations. I would like to especially thank
Miss Mary Rita Feran. M.S .• Head of the Department of Scientific Publica
tions at the Cleveland Clinic Foundation. for her help in reviewing and
editing the manuscript and for checking on innumerable references;
Mrs. Margot Lacy and Mrs. Shirley Prokuski of the Department of Word
Processing for typing and processing the text; Mr. James T. Suchy and
Mr. Jeffrey J. Loerch of the Department of Medical Illustrations for
providing additional art work and illustrations for Mr. Robert M. Reed.
A.M.I.. the principal artist; and to the members of the Department of Med
ical Photography at the Cleveland Clinic for their help in providing full
color photographs and high quality reproductions of roentgenograms.
Robert E. Hermann
Contents
I Gallbladder and Bile Ducts
1
General Introduction 3
Surgical Anatomy 3
Bile Ducts 3
Gallbladder and Cystic Duct 7
Distal Common Bile Duct 9
Hepatic and Cystic Arteries II
Portal Vein 14
Biliary Lymphatics 15
Physiology of Bile Production and Storage 16
Interdigestive Phase 16
Formation and Excretion of Bile 16
Enterohepatic Circulation 19
Storage of Bile 20
Disturbances of Enterohepatic Circulation 22
Formation of Gallstones 23
Physiological Effects of Cholecystectomy 24
Current Status of Oral Gallstone
Dissolution Therapy 24
References 26
2
Congenital Anomalies 29
Introduction 29
Biliary Atresia 29
Pathology 31
Diagnosis 34
Treatment 35
Choledochal Cyst 38
Pathology 38
Diagnosis 39
Treatment 40
References 42
Contents
3
Inflammatory Disease 45
Cholecystitis and Cholangitis 45
Pathology 45
Diagnosis 48
Treatment 52
Gallstone Ileus 56
Post-Cholecystectomy Syndrome and Biliary
Dyskinesia (A vram M. Cooperman) 60
Incidence 60
Pathology 60
Diagnosis 60
Treatment 64
Biliary Stricture 66
Pathology 66
Diagnosis 66
Treatment 68
References 71
4
Neoplasms 77
Benign Tumors 77
Pathology 77
Diagnosis 79
Treatment 80
Carcinoma of the Gallbladder
(Caldwell B. Esselstyn, Jr) 82
Pathology 82
Diagnosis 82
Treatment 83
Carcinoma of the Bile Ducts
(A vram M. Cooperman) 85
Pathology 85
Diagnosis 86
Treatment 87
References 93
5
Injuries of the Gallbladder and
Bile Ducts 97
(Ezra Steiger)
Introduction 97
Pathology 97
Diagnosis 97
Treatment 99
References 101
6
Operative Technics 103
Biliary Exploration 103
Operative Cholangiography 106
Portoenterostomy for Biliary Atresia III
Choledochal Cyst 113
Cholecystectomy 116
Retrograde Method of Cholecystectomy 120
Drains 123
Cholecystostomy 123