肝膽外科膽囊炎說課

1、Cholecystitis,,Jing Gao Department Of Hepatobiliary Surgery The 2nd Affiliated Hospital of WMC Email: GJ_5000@126.com,Teaching Design Presentation,,,,,,Fat,E,,,,,,Food,,,,,,,Family,Cholecystitis,≥Forty,Fe

2、male,,,,,,,01,,02,,03,,04,Textbook,Study Enviroment,Study Objectives,Teaching Methods,,,contents,,05,Teaching Procedure,Textbook,About this book-4th EditionExtremely detailed and usefulstandards for trainees in hepatob

3、iliary and upper gastrointestinal surgerya reference for practicing hepatobiliary surgeonsPage1033,Chapter 32-Cholecystitis,,,,,,,Clinical Practice,,,,Medical Theory,Study Enviroment,INTERNS,,,,EXCITED,,EASY!CALM!,,,

4、,,,,Master keypoints of Cholecystitis,How to deal with a clinical case?,,,,Study Objectives,,,Surgical skills:FA&CA-Teamwork,Humanistic Education-Comminication,two forms of cholecystitis, clinical manifestations,

5、 complications, diagnosis & treatment.,Etiology, pathogenesis, laboratoryfindings & differential diagnosis,,How to deal with cases &scrub in surgeries AMAP,Teaching Requirements,Master,Understand,,Epidemi

6、ology & pathology,,Familiar,,Practice,STUDENTS are the KITES, not homeless because the STRING is HELD by TEACHERS.,Teachers,Students,CBL-Case-based learning,PBL-problem-based learning,Rehearsal-Preview,Case-Role-Play

7、ing,Study Groups,Teaching Methods,Multimedia teaching,,,Teaching Procesures,,,,,,,,,,,,Case,Question,Cholecystitis,Case based learning,Problem-based learning,Discussion,,,,,Medical Practice-A Case for Real,,,,,,,,,,Teach

8、ing Procesures,,Step 1 Warming-UpCASE,Mr Pan,25 yr old,No past history.He got abdominal pain for 1 hour,which was located in right epigastric area.Also he described the pain as intermittent, very sharp with a ra

9、diation to the subscapulara.,What is your diagnosis? How to diagnose?,,Classification,Calculous Cholecystitis,1,Acalculous Cholecystitis,2,Teaching Procesures,Step 2Let's roll,95%,5%,,,,,,F,,F,F,F,≥40 yr old,femal

10、e mostly,fatty people,family genetic factors,F,food junky-yummy,Incidence & Epidemiology,Step 2Let's roll,Etiology&Pathogenesis,,,,Gallstones,,Obstruction,,,Retroinfection,,Distention &Edema,,Venous Sta

11、sis,,,Ischemia&Necrosis,,,,,,,,Cholecystitis,,,,Symptom,,1,Clinical Manifestations,,,2,Digestive systems :abdominal painnausia, vomitting, diahrra,etc.General:Jaundice fever,anorexia,fatig-ue,exhausted,etc.,,Phys

12、ical Examination,Right epigastric tenderness,Rebound tenderness,Murphy's sign(+),Total vital signs.,3,,,Accessory Examination,Laboratory test: CRP↑WBC ↑ NEU↑,,Image Exa:B UltrosoundCT scan, MIR,,boring! ! !,,,

13、,,,,,,,,Clinical Manifestations,LG,,Life is so Good,Local,symptoms,General,symptoms,,,abdomianl pain,,,,Right epigastric area,,Radiation,where?,,,why?,&,,,infection,,,,,Fever,,Jaundice,,For ? reasons,,,,,Mirizz Syndr

14、ome,a Special manifestication,Definition,Stones,Ductuli hepaticus communis,Common bile duct,Jaundice,,,,,Mirizz Syndrome,a Special manifestication,Csendes's Classification,Type I lesions are those with external compr

15、ession of the CBD.Type II lesions a cholecystobiliary fistula is present with erosion of less than one-third of the circumference of the bile duct.Type III lesions the fistula involves up to two-thirds of the duct ci

16、rcumferenceType IV lesions there is complete destruction of the bile duct.,OUT,<1/3,1/3-2/3,,IN,TOTAL,,Clinical Manifestations,,Tenderness,,Vital Signs,,Pathological typing,,,,Rightepigastric area,,,Suppurative cho

17、lecystitis,,Rebound,Acute cholecystitis,Gangrenous cholecystitis,,Perforation,,Tightness,,,,,LocalOR,,Total,Murphy's sign,,,,,,,,,,,,,,,,,,,,Accessory Examnation,CRP↑,WBC↑,NEU↑,ALT↑,AST↑,AM↑,,Lab,,Lab Findings,Acces

18、sory Examnation,,Radiaology-B Ult & CT Scan,,GB,,Size:?CM*?CM*?CM,Morphology:Enlargment Atrophy Absence,OUT,,,Wall:>0.3CM;Thicken-ing，Eedema，Rough,Cavity:components (stones)Hyperechogenicity,Inside,

19、,,,,ST,,,How to diagnose?,1.So what will you do next?,Step 3PracticeBYGroup,About this case???,,History of Inquiry,,Physical Examination,,Anatomy Location,,Basical Diagnosis,2.Then how to make sure your final diagnosi

20、s?,,,,Questions,How will you deal with the treatment if you are in charge of this case?How will youcommunicate with the patient and his families?,About this case,,,A,ModifyLifestyle,,,B,Medicine,,,C,Surgey,Treatment,

21、Patient's Concern,Indications,,,C,Surgey,Surgeon's Concern,Time:24-72h Complication:Suppurative Gangrenous Perforation,Recurrent symptoms despite medical therapy,Selective,2,,,,,Attacting neighbors

22、,Malignance transformation,Emergency,1,Surgerical Techniques,,Damage,Control,Patients,,Surgery,Classy from 1882 by Langenbuch,Cholecystectomy,?LC Laparoscopic Cholecystectomy,,Open for yrs,1980's,,gold standard,,No

23、w,?PTGD Percutaneous Transhepatic Gallbladder Drainge,?Cholecystostomy,CT&B-sound,Summary of Cholecystitis,What kind of management next ?What clinical features? 5F+Abdominal pain+ImageWhat make you do

24、 the final diagnosis?Diagnosis & Differential Diagnosis Symptoms+Physical Examination&Image (perforation of digestive tract;pancreatitis;appendicitis;liver diseases; lung disease)How will you treat

25、this patient?,Back to this case,Interactive Discussion,3W+1H,Surgerical Skills(LC),Postion: (Patient & Doctor) Revers Trendelenberg, right side up 30°Trocar spots:A,B,D A-subxyphoid

26、 B-right costal margin D-supraumbilical,,,Step1 :Camera Assistant (CA),Trocar's location,LOREM,1,Disection of Calot's trangle,2,Resection of gallbladder,3,Hemostasis of the liver bed,4,Specimen retraction,5,

27、Surgery Procesures,Surgerical Details,,,,,Fundus of gallbladder,,,Right abdominal wall,Liver horizental line,Superior abdominal wall,Surgerical Details,,,,,TrocarSubxyphoid,,Ligamenta teres,Surgerical Details,,,,,,,,Retr