Hepatobiliary and Pancreatic Surgery
The hepatobiliary and pancreatic domain tests gallstone disease and its complications, the acute pancreatitis pathway, and the work-up of a liver or pancreatic mass. The exam favours severity classification, timing of intervention, and biliary anatomy.
Gallstones and the biliary tree
- Tokyo Guidelines grade acute cholecystitis: I mild, II moderate (WBC >18,000, palpable mass, symptoms >72 hours), III severe with organ dysfunction. Early laparoscopic cholecystectomy within 72 hours in fit patients.
- Choledocholithiasis: MRCP or EUS, then ERCP; laparoscopic bile duct exploration is an expert alternative.
- Cholangitis (Charcot triad, Reynolds pentad) is an emergency: antibiotics and biliary drainage by ERCP, then cholecystectomy.
- Strasberg injury classification: A cystic duct leak, D lateral duct injury, E complete transection. Type E needs Roux-en-Y hepaticojejunostomy by a specialist.
Pancreatitis
- Diagnosis needs two of: characteristic pain, lipase >3× upper limit of normal, imaging. Atlanta classification: mild, moderately severe (local complication or organ failure <48 hours), severe (organ failure >48 hours).
- BISAP and CRP at 48 hours predict severity; early crystalloid, analgesia, and enteral nutrition when tolerated.
- No prophylactic antibiotics. Infected necrosis at 3-4 weeks is managed by a step-up approach: percutaneous drainage first, necrosectomy only if needed.
Liver
- Couinaud segments are defined by hepatic veins and portal pedicles; segment I is the caudate lobe.
- Hydatid cyst: albendazole, meticulous avoidance of spillage, PAIR for selected cases.
- Hepatocellular carcinoma in cirrhosis: Milan criteria for transplantation - single lesion ≤5 cm, or up to three lesions each ≤3 cm.
Worked example
A 55-year-old with four days of epigastric pain, lipase six times normal, and CT showing 20% pancreatic necrosis but no organ failure. Reasoning: moderately severe acute pancreatitis with sterile necrosis. Give no antibiotics, plan no early surgery, feed enterally; intervene only if gas appears within the necrosis or sepsis develops at 3-4 weeks, starting with percutaneous drainage.
Traps
- Early open necrosectomy - mortality is high; wait for a walled-off collection.
- Forgetting that a duct of 8-9 mm can be normal after cholecystectomy.
- Missing Mirizzi syndrome: a stone in the cystic duct compressing the common hepatic duct.
- Ignoring rising bilirubin or pain after cholecystectomy instead of investigating for a leak or clip injury.