The laparoscopic cholecystectomy is a commonly performed operation for removal of gallstones/gall bladder. The radiographer's role is usually to provide imaging with an image intensifier during the surgery. This page considers all aspects of the radiographers role in laparoscopic cholecystectomy.

Biliary System Anatomy http://gallbladder-symptoms.biz/wp-content/uploads/2010/10/GallBladder-Pancreas-02.jpg (28/2/2011)

The biliary system consists of the organs and ducts (bile ducts, gallbladder, and associated structures) that are involved in the production and transportation of bile. The transportation of bile follows this sequence: 1. When the liver cells secrete bile, it is collected by a system of ducts that flow from the liver through the right and left hepatic ducts. 2. These ducts ultimately drain into the common hepatic duct. 3. The common hepatic duct then joins with the cystic duct from the gallbladder to form the common bile duct, which runs from the liver to the duodenum (the first section of the small intestine). 4. However, not all bile runs directly into the duodenum. About 50 percent of the bile produced by the liver is first stored in the gallbladder, a pear-shaped organ located directly below the liver. 5. Then, when food is eaten, the gallbladder contracts and releases stored bile into the duodenum to help break down the fats. Functions of the biliary system: The biliary system's main function includes the following: * to drain waste products from the liver into the duodenum * to help in digestion with the controlled release of bile Bile is the greenish-yellow fluid (consisting of waste products, cholesterol, and bile salts) that is secreted by the liver cells to perform two primary functions, including the following: * to carry away waste * to break down fats during digestion Bile salt is the actual component which helps break down and absorb fats. Bile, which is excreted from the body in the form of faeces, is what gives faeces its dark brown color. Quoted from The Ohio State University Medical Center (28/2/2011)

This 78 year old female underwent Laparoscopic cholecystectomy for removal of gallstones. The procedure included laparoscopic cholangiography. The image left is a screen capture from the image intensifier which was employed for the laparoscopic cholangiography. The arrowed structure is a filling defect in the common bile duct. There is very little that can be gleaned from this image apart from the presence of the filling defect and its general shape and position. Therein lies the problem with a static image. Enter the image intensifier that is able to undertake a sequence acquisition producing what is essentially a dynamic study of the contrast injection.

This is the full sequence acquisition. Note that the filling defect changes shape and appears to break up and pass down the common bile duct towards the deuodenum. This material is commonly referred to as biliary sludge (or biliary sand or sediment) and will not cause biliary obstruction in this state. It is the dynamic nature of sequence acquisition that provides the additional important information. If your image intensifier has the capability to perform a sequence acquisition, you should suggest to the surgeon that it be employed (even if he/she doesn't ask for it). It wont be long before the surgeons will expect a sequence acquisition for all operative cholangiogram procedures. If you click on the you tube logo you can watch this video at full resolution. You will need to select 720p and the fit-to-screen buttons to see the video in full resolution. Select the Esc key on your keyboard to return to normal viewing.

	This 69 year old female consented to a laparascopic cholecystectomy for treatment of cholycystitis. The radiographer was called to the operating theatre to provide laparoscopic cholecystogram imaging with the image intensifier. The initial low dose image is shown left. You will be required to quickly re-orientate the image into the anatomical position. The position of the pedicles in relation to the vertebral bodies, the liver shadow, and the ilac crest (?) all suggest that the image is up-side-down and back-the-front. If you click on the YouTube logo you can watch this video at full resolution. You will need to select 720p and the fit-to-screen buttons to see the video in full resolution. Select the Esc key on your keyboard to return to normal viewing.
	The initial sequence acquisition was performed at 2 frames per second and maximum field size. The radiographer noted that the common bile duct was overlying the spine and asked the surgeon if he would like the CBD projected off the spine. The appropriate tube angulation was undertaken. The radiographer noted that the intrahepatic ducts were well defined with contrast medium at the expense of the common bile duct. The radiographer asked the surgeon if the table could be tilted head up but the request was declined. If you click on the YouTube logo you can watch this video at full resolution. You will need to select 720p and the fit-to-screen buttons to see the video in full resolution. Select the Esc key on your keyboard to return to normal viewing.
	A second sequence acquisition was performed with improved demonstration of the common bile duct (CBD) but no contrast medium was see to pass into the deuodenum. Glucagon was administered to the patient and the bile duct was flushed with saline. There was some question of a filling defect in the common bile duct. Note that the tube angulation has projected the CBD off the spine. If you click on the YouTube logo you can watch this video at full resolution. You will need to select 720p and the fit-to-screen buttons to see the video in full resolution. Select the Esc key on your keyboard to return to normal viewing.
	The radiographer decreased the field size (effectively magnification) and another sequence acquisition was performed. Some contrast refluxed into the pancreatic duct and there was an impression of a filling defect in the CBD. A common bile duct exploration set was opened but access to the CBD with this catheter was unsuccessful. The imaging was stopped at this point. If you click on the YouTube logo you can watch this video at full resolution. You will need to select 720p and the fit-to-screen buttons to see the video in full resolution. Select the Esc key on your keyboard to return to normal viewing.