Cholecystectomy: Open and Laparoscopic

#!/usr/bin/env python3
"""
Cholecystectomy Surgical Procedure Guide - Intraoperative Reference PDF
Generated with ReportLab
"""

from reportlab.lib.pagesizes import A4
from reportlab.lib import colors
from reportlab.lib.units import mm, cm
from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle
from reportlab.lib.enums import TA_LEFT, TA_CENTER, TA_JUSTIFY
from reportlab.platypus import (
    SimpleDocTemplate, Paragraph, Spacer, Table, TableStyle,
    HRFlowable, KeepTogether, PageBreak
)
from reportlab.platypus.flowables import BalancedColumns
from reportlab.lib.colors import HexColor
import os

OUTPUT_PATH = "/home/daytona/workspace/cholecystectomy-guide/Cholecystectomy_Surgical_Guide.pdf"

# ── Color palette ──────────────────────────────────────────────────────────
C_NAVY      = HexColor("#1a2e4a")
C_BLUE      = HexColor("#1e5fa8")
C_LIGHT_BLUE= HexColor("#dbeafe")
C_TEAL      = HexColor("#0f766e")
C_TEAL_LT   = HexColor("#ccfbf1")
C_RED       = HexColor("#b91c1c")
C_RED_LT    = HexColor("#fee2e2")
C_AMBER     = HexColor("#d97706")
C_AMBER_LT  = HexColor("#fef3c7")
C_GREEN     = HexColor("#15803d")
C_GREEN_LT  = HexColor("#dcfce7")
C_GRAY_DARK = HexColor("#374151")
C_GRAY      = HexColor("#6b7280")
C_GRAY_LT   = HexColor("#f3f4f6")
C_WHITE     = colors.white
C_BLACK     = colors.black
C_HEADER_BG = HexColor("#1a2e4a")
C_DIVIDER   = HexColor("#e5e7eb")

W, H = A4  # 210 x 297 mm

# ── Document setup ─────────────────────────────────────────────────────────
doc = SimpleDocTemplate(
    OUTPUT_PATH,
    pagesize=A4,
    topMargin=18*mm, bottomMargin=18*mm,
    leftMargin=16*mm, rightMargin=16*mm,
    title="Cholecystectomy Surgical Procedure Guide",
    author="Orris Medical AI",
    subject="Intraoperative Reference"
)

# ── Styles ─────────────────────────────────────────────────────────────────
base = getSampleStyleSheet()

def S(name, **kw):
    return ParagraphStyle(name, **kw)

sTitle = S("sTitle",
    fontName="Helvetica-Bold", fontSize=22,
    textColor=C_WHITE, alignment=TA_CENTER,
    spaceAfter=2*mm, leading=26)

sSubtitle = S("sSubtitle",
    fontName="Helvetica", fontSize=11,
    textColor=HexColor("#cbd5e1"), alignment=TA_CENTER,
    spaceAfter=2*mm)

sDisclaimer = S("sDisclaimer",
    fontName="Helvetica-Oblique", fontSize=7.5,
    textColor=HexColor("#94a3b8"), alignment=TA_CENTER)

sSectionHeader = S("sSectionHeader",
    fontName="Helvetica-Bold", fontSize=11,
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sSubSection = S("sSubSection",
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sBody = S("sBody",
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sBold = S("sBold",
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sBullet = S("sBullet",
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    textColor=C_GRAY_DARK, leading=12, leftIndent=8*mm,
    bulletIndent=2*mm, spaceAfter=1*mm)

sWarning = S("sWarning",
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sStep = S("sStep",
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sStepBody = S("sStepBody",
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sTableHeader = S("sTableHeader",
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sTableCell = S("sTableCell",
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sTableCellB = S("sTableCellB",
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sSmall = S("sSmall",
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sAlert = S("sAlert",
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sGreen = S("sGreen",
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# ── Helpers ────────────────────────────────────────────────────────────────
def section_header(title, color=C_HEADER_BG):
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    tbl.setStyle(TableStyle([
        ("BACKGROUND", (0,0), (-1,-1), color),
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        ("ROUNDEDCORNERS", [4,4,4,4]),
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    return KeepTogether([Spacer(1, 4*mm), tbl, Spacer(1, 2*mm)])

def hr(color=C_DIVIDER):
    return HRFlowable(width="100%", thickness=0.5, color=color, spaceAfter=2*mm, spaceBefore=1*mm)

def two_col_table(rows, col1_w=55*mm, col2_w=None, header_color=C_NAVY):
    """Generic 2-column table with styled header row."""
    col2_w = col2_w or (W - 32*mm - col1_w)
    header_row = rows[0]
    data = [
        [Paragraph(str(header_row[0]), sTableHeader), Paragraph(str(header_row[1]), sTableHeader)]
    ] + [
        [Paragraph(str(r[0]), sTableCellB), Paragraph(str(r[1]), sTableCell)]
        for r in rows[1:]
    ]
    tbl = Table(data, colWidths=[col1_w, col2_w])
    style = TableStyle([
        ("BACKGROUND",    (0,0), (-1,0), header_color),
        ("BACKGROUND",    (0,1), (-1,-1), C_WHITE),
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        ("RIGHTPADDING",  (0,0), (-1,-1), 5),
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    tbl.setStyle(style)
    return tbl

def three_col_table(rows, widths, header_color=C_NAVY):
    data = [
        [Paragraph(str(r), sTableHeader) for r in rows[0]]
    ] + [
        [Paragraph(str(r[0]), sTableCellB), Paragraph(str(r[1]), sTableCell), Paragraph(str(r[2]), sTableCell)]
        for r in rows[1:]
    ]
    tbl = Table(data, colWidths=widths)
    tbl.setStyle(TableStyle([
        ("BACKGROUND",    (0,0), (-1,0), header_color),
        ("ROWBACKGROUNDS",(0,1), (-1,-1), [C_WHITE, C_GRAY_LT]),
        ("GRID",          (0,0), (-1,-1), 0.4, C_DIVIDER),
        ("TOPPADDING",    (0,0), (-1,-1), 4),
        ("BOTTOMPADDING", (0,0), (-1,-1), 4),
        ("LEFTPADDING",   (0,0), (-1,-1), 5),
        ("RIGHTPADDING",  (0,0), (-1,-1), 5),
        ("VALIGN",        (0,0), (-1,-1), "TOP"),
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    return tbl

def alert_box(text, bg=C_RED_LT, border=C_RED, text_style=None):
    ts = text_style or sAlert
    tbl = Table([[Paragraph(text, ts)]], colWidths=[W - 32*mm])
    tbl.setStyle(TableStyle([
        ("BACKGROUND",   (0,0), (-1,-1), bg),
        ("LINEABOVE",    (0,0), (-1,-1), 2, border),
        ("LINELEFT",     (0,0), (0,-1), 3, border),
        ("TOPPADDING",   (0,0), (-1,-1), 5),
        ("BOTTOMPADDING",(0,0), (-1,-1), 5),
        ("LEFTPADDING",  (0,0), (-1,-1), 8),
        ("RIGHTPADDING", (0,0), (-1,-1), 6),
    ]))
    return KeepTogether([tbl, Spacer(1, 2*mm)])

def step_box(num, title, body_lines):
    """Numbered step box."""
    num_cell = Paragraph(f"<b>{num}</b>", S("n",
        fontName="Helvetica-Bold", fontSize=13,
        textColor=C_WHITE, alignment=TA_CENTER, leading=16))
    title_p = Paragraph(title, S("st",
        fontName="Helvetica-Bold", fontSize=9,
        textColor=C_NAVY, leading=13))
    body_content = [title_p] + [Paragraph(f"• {l}", sStepBody) for l in body_lines]
    tbl = Table([[num_cell, body_content]], colWidths=[10*mm, W - 32*mm - 12*mm])
    tbl.setStyle(TableStyle([
        ("BACKGROUND",   (0,0), (0,-1), C_TEAL),
        ("BACKGROUND",   (1,0), (1,-1), C_WHITE),
        ("LINEBELOW",    (0,0), (-1,-1), 0.5, C_DIVIDER),
        ("TOPPADDING",   (0,0), (-1,-1), 5),
        ("BOTTOMPADDING",(0,0), (-1,-1), 5),
        ("LEFTPADDING",  (0,0), (0,-1), 2),
        ("RIGHTPADDING", (0,0), (0,-1), 2),
        ("LEFTPADDING",  (1,0), (1,-1), 6),
        ("VALIGN",       (0,0), (-1,-1), "TOP"),
        ("ROUNDEDCORNERS", [3,3,3,3]),
    ]))
    return KeepTogether([tbl, Spacer(1, 1.5*mm)])

# ══════════════════════════════════════════════════════════════════════════
# BUILD CONTENT
# ══════════════════════════════════════════════════════════════════════════
story = []

# ── COVER HEADER ──────────────────────────────────────────────────────────
cover = Table(
    [[
        Paragraph("CHOLECYSTECTOMY", sTitle),
        Paragraph("Surgical Procedure Guide", sSubtitle),
        Paragraph("Open &amp; Laparoscopic | Intraoperative Reference", sSubtitle),
        Spacer(1, 3*mm),
        Paragraph("For use by qualified surgical teams in an operative setting.", sDisclaimer),
        Paragraph("Schwartz's 11e · Bailey &amp; Love 28e · Maingot's · Fischer's Mastery 8e", sDisclaimer),
    ]],
    colWidths=[W - 32*mm]
)
cover.setStyle(TableStyle([
    ("BACKGROUND",   (0,0), (-1,-1), C_NAVY),
    ("TOPPADDING",   (0,0), (-1,-1), 12),
    ("BOTTOMPADDING",(0,0), (-1,-1), 10),
    ("LEFTPADDING",  (0,0), (-1,-1), 14),
    ("RIGHTPADDING", (0,0), (-1,-1), 14),
    ("ROUNDEDCORNERS", [6,6,6,6]),
]))
story.append(cover)
story.append(Spacer(1, 4*mm))

# ── 1. INDICATIONS ────────────────────────────────────────────────────────
story.append(section_header("1. Indications for Cholecystectomy", C_BLUE))

ind_rows = [
    ["Indication", "Notes"],
    ["Biliary colic / Symptomatic cholelithiasis", "Most common. >80% recurrence/complication risk once symptomatic."],
    ["Acute cholecystitis", "Early (same-admission) laparoscopic preferred."],
    ["Chronic cholecystitis", "Recurrent symptomatic attacks."],
    ["Choledocholithiasis", "With or without cholangitis."],
    ["Gallstone pancreatitis", "Same admission or within 2 weeks."],
    ["Cholangitis / Obstructive jaundice", "After biliary decompression (ERCP/PTC)."],
    ["Acalculous cholecystitis / Biliary dyskinesia", "Typical biliary symptoms + HIDA EF <35%."],
    ["Mirizzi syndrome / Cholecystoenteric fistula", "Complex – higher conversion risk."],
]
story.append(two_col_table(ind_rows, col1_w=65*mm))
story.append(Spacer(1, 2*mm))

story.append(Paragraph("Prophylactic Indications (Asymptomatic Gallstones)", sSubSection))
story.append(Paragraph(
    "Asymptomatic gallstones carry &lt;20% lifetime risk of symptoms. "
    "Prophylactic cholecystectomy is justified in:", sBody))
bullets_prop = [
    "Sickle cell disease (vaso-occlusive crisis mimics acute cholecystitis)",
    "Gallbladder polyp ≥10 mm (malignant potential)",
    "Open bariatric surgery (concurrent; laparoscopic bariatric – avoid due to added risk)",
    "Porcelain gallbladder / Gallstones >2.5 cm in high-risk populations (Native Americans)",
    "Long-term total parenteral nutrition",
    "Chronic immunosuppression post solid-organ transplant",
    "Congenital hemolytic anemias (hereditary spherocytosis, thalassaemia)",
    "No access to healthcare (military, missionaries)",
]
for b in bullets_prop:
    story.append(Paragraph(f"• {b}", sBullet))
story.append(Spacer(1, 2*mm))

# ── 2. CONTRAINDICATIONS / CONVERSION ────────────────────────────────────
story.append(section_header("2. Contraindications & Conversion Criteria", C_RED))

story.append(Paragraph("Absolute Contraindications to Laparoscopic Approach", sSubSection))
abs_ci = [
    ["Condition", "Rationale"],
    ["Hemodynamic instability", "Cannot tolerate pneumoperitoneum; open preferred"],
    ["Uncontrolled coagulopathy", "Bleeding risk precludes laparoscopy"],
    ["Frank peritonitis", "Requires open exploration"],
    ["Severe COPD / CHF (EF <20%)", "Cannot tolerate CO₂ pneumoperitoneum"],
]
story.append(two_col_table(abs_ci, col1_w=65*mm, header_color=C_RED))
story.append(Spacer(1, 2*mm))

story.append(Paragraph("Indications to Convert to Open (Intraoperatively)", sSubSection))
conv = [
    ["Trigger", "Action"],
    ["Unable to tolerate pneumoperitoneum", "Convert immediately"],
    ["Cannot achieve Critical View of Safety (CVS)", "Bailout strategy → convert if needed"],
    ["Intraoperative complication not manageable laparoscopically", "Convert + repair"],
    ["No progress after a set time period", "Convert; do not persist"],
    ["Suspected or confirmed bile duct injury", "Convert for open repair at HPB center"],
]
story.append(two_col_table(conv, col1_w=70*mm, header_color=C_AMBER))
story.append(Spacer(1, 1*mm))
story.append(Paragraph(
    "Conversion rate: ~5% elective | 10–30% emergency/complicated cases. "
    "Conversion is NOT a failure; discuss preoperatively with patient.", sSmall))
story.append(Spacer(1, 2*mm))

# ── 3. PREOPERATIVE PREPARATION ───────────────────────────────────────────
story.append(section_header("3. Preoperative Checklist", C_TEAL))

pre_data = [
    ["Checklist Item", "Detail"],
    ["Bloods", "FBC, U&E, LFTs, coagulation (PT/INR)"],
    ["Imaging", "RUQ ultrasound (confirm stones, CBD diameter, anatomy)"],
    ["ECG / CXR", "If medically indicated (age >40, cardiac/respiratory history)"],
    ["Antibiotic prophylaxis", "2nd-generation cephalosporin (e.g., cefuroxime 1.5g IV) at induction"],
    ["DVT prophylaxis", "LMWH (e.g., enoxaparin 40mg SC) + TED stockings"],
    ["Bladder", "Patient to void before OR; avoid urinary catheterization"],
    ["Orogastric tube", "Insert if stomach distended; remove at end of procedure"],
    ["Consent", "Procedure, alternatives, BDI risk (~0.3–0.6%), conversion to open"],
    ["Team briefing / WHO checklist", "Confirm site marking, allergies, antibiotic given"],
]
story.append(two_col_table(pre_data, col1_w=52*mm))
story.append(Spacer(1, 2*mm))

story.append(Paragraph("Predictors of Difficult Cholecystectomy", sSubSection))
diff_data = [
    ["Domain", "Risk Factors"],
    ["History", "Male sex, age >65 yrs, onset >72–96 hrs (acute cholecystitis), prior upper abdominal surgery, prior cholecystostomy"],
    ["Examination", "Morbid obesity, high ASA score, palpable gallbladder mass"],
    ["Laboratory", "Elevated WCC, abnormal LFTs, elevated bilirubin"],
    ["Imaging (USS/CT/MRCP)", "Wall thickness >4–5 mm, pericholecystic fluid, impacted stone in neck, contracted gallbladder, Mirizzi syndrome, suspected fistula"],
]
story.append(two_col_table(diff_data, col1_w=42*mm, header_color=C_AMBER))
story.append(Spacer(1, 2*mm))

# ── 4. LAPAROSCOPIC CHOLECYSTECTOMY ───────────────────────────────────────
story.append(PageBreak())
story.append(section_header("4. Laparoscopic Cholecystectomy", C_NAVY))

story.append(Paragraph("Patient Position", sSubSection))
pos_lap = [
    ["Position", "Details"],
    ["Primary position", "Supine; surgeon on patient's LEFT side"],
    ["Alternative", "Split-leg (French) position; surgeon between patient's legs – ergonomic for RUQ"],
    ["Table tilt", "Reverse Trendelenburg (15–20°) + left lateral tilt – bowel falls away from operative field"],
    ["Arm", "Tuck one arm (ipsilateral) if cholangiogram planned – allows fluoroscopy machine access"],
    ["Monitor", "Placed at patient's right shoulder/head end"],
]
story.append(two_col_table(pos_lap, col1_w=45*mm))
story.append(Spacer(1, 2*mm))

story.append(Paragraph("Port Placement (Standard 4-Port)", sSubSection))
port_data = [
    ["Port", "Size", "Location", "Purpose"],
    ["Port 1 – Camera", "5 or 10 mm", "Supra-umbilical (umbilicus)", "30° laparoscope (camera port)"],
    ["Port 2 – Main working", "10 or 12 mm", "Epigastrium (subxiphoid, midline)", "Clips, scissors, dissector, cholangiogram"],
    ["Port 3 – Infundibulum", "5 mm", "Right mid-clavicular line (RUQ)", "Grasper – retract infundibulum inferolaterally"],
    ["Port 4 – Fundus", "5 mm", "Right flank / anterior axillary line", "Locking grasper – retract fundus to right shoulder"],
]
port_tbl = Table(
    [[Paragraph(r, sTableHeader) for r in port_data[0]]] +
    [[Paragraph(str(c), sTableCellB if i==0 else sTableCell) for i,c in enumerate(row)]
     for row in port_data[1:]],
    colWidths=[35*mm, 20*mm, 55*mm, 62*mm]
)
port_tbl.setStyle(TableStyle([
    ("BACKGROUND",    (0,0), (-1,0), C_NAVY),
    ("ROWBACKGROUNDS",(0,1), (-1,-1), [C_WHITE, C_GRAY_LT]),
    ("GRID",          (0,0), (-1,-1), 0.4, C_DIVIDER),
    ("TOPPADDING",    (0,0), (-1,-1), 4),
    ("BOTTOMPADDING", (0,0), (-1,-1), 4),
    ("LEFTPADDING",   (0,0), (-1,-1), 5),
    ("RIGHTPADDING",  (0,0), (-1,-1), 5),
    ("VALIGN",        (0,0), (-1,-1), "TOP"),
]))
story.append(port_tbl)
story.append(Paragraph(
    "Additional ports may be placed as needed for retraction in difficult cases. "
    "Hasson (open) technique preferred if previous surgery/scars at umbilicus. "
    "Fascial defects >10 mm must be closed at end.", sSmall))
story.append(Spacer(1, 3*mm))

story.append(Paragraph("Operative Steps", sSubSection))

steps_lap = [
    ("1", "Establish Pneumoperitoneum",
     ["CO₂ to 12–15 mmHg",
      "Technique: Closed Veress needle (supraumbilical), OR Open Hasson cut-down, OR Optical viewing trocar",
      "Confirm intraperitoneal position before insufflation (aspiration test, saline hanging drop)",
      "Insert camera port first; inspect for entry injuries before other ports"]),
    ("2", "Insert Remaining Ports",
     ["Under direct vision (not blind)",
      "Port 2 (epigastric) → working port",
      "Port 3 (RMC line) → infundibulum grasper",
      "Port 4 (right flank) → fundus grasper"]),
    ("3", "Retraction – Open Hepatocystic Triangle",
     ["Port 4 (assistant): Grasp fundus → retract CEPHALAD over liver edge toward patient's RIGHT SHOULDER",
      "Port 3 (surgeon): Grasp infundibulum → retract INFEROLATERALLY (toward patient's right side)",
      "This opens the hepatocystic triangle, increases cystic duct–CBD angle, limits dissection to safe zone",
      "B-SAFE landmarks: Bile duct | Sulcus of Rouvière | hepatic Artery | umbilical Fissure | Enteric (duodenum)"]),
    ("4", "Dissect Hepatocystic Triangle",
     ["Hook electrocautery (monopolar ~30 W, low setting, intermittent short bursts – avoid thermal spread)",
      "Clear ALL fat, fibrous, and areolar tissue from BOTH anterior AND posterior aspects of the triangle",
      "Safe zone: cephalad to R4U line (Rouvière's sulcus → umbilical fissure across base of segment IV)",
      "Do NOT use blind/deep cautery; divide small amounts of tissue at a time"]),
    ("5", "Achieve Critical View of Safety (CVS) ← MANDATORY",
     ["THREE criteria ALL must be met before ANY clipping:",
      "① Hepatocystic triangle CLEARED of all fat/fibrous tissue",
      "② Lower ⅓ of gallbladder SEPARATED from cystic plate/liver bed",
      "③ ONLY TWO structures seen entering the gallbladder (cystic duct + cystic artery)",
      "DOCUMENT CVS by photograph or video clip in the operative record",
      "If CVS cannot be achieved → STOP → employ bailout strategy"]),
    ("6", "Divide Cystic Artery and Cystic Duct",
     ["Clip cystic artery: 2 clips proximally + 1 clip on gallbladder side → divide",
      "Clip cystic duct: 2 clips at base (proximal) + 1 clip on gallbladder side → divide",
      "Dilated cystic duct (too wide for clips): use endoloop, laparoscopic stapler, or suture ligation",
      "CONFIRM: only cystic structures divided – NOT the CBD or right hepatic artery"]),
    ("7", "Intraoperative Cholangiogram (Selective)",
     ["Indications: abnormal LFTs, prior pancreatitis/jaundice, dilated CBD on USS, unclear anatomy",
      "Technique: proximal clip on cystic duct → small anterior incision → insert cholangiogram catheter",
      "Ideal IOC: fills right + left hepatic ducts, drains into duodenum, no filling defects, no air bubbles",
      "Routine IOC detects CBD stones in ~7% of patients"]),
    ("8", "Dissect Gallbladder from Liver Bed",
     ["Electrocautery dissection on the cystic plate (staying on the gallbladder side)",
      "Watch for aberrant posterior bile ducts or arteries",
      "Before final detachment: use gallbladder as retractor for a final field evaluation",
      "Check: bleeding points, bile staining, clip positions on cystic duct and artery"]),
    ("9", "Remove Gallbladder & Close",
     ["Remove via epigastric or umbilical port (retrieval bag recommended – prevents stone spillage)",
      "Enlarge fascial incision if needed for large or inflamed gallbladder",
      "Retrieve ALL spilled stones (risk of delayed abscess, fistula)",
      "Drain: NOT routine; use if gangrenous, bile spill, or anticipated accumulation",
      "Close fascial defects ≥10 mm to prevent port-site hernia",
      "Skin closure with absorbable sutures or skin glue"]),
]

for num, title, body in steps_lap:
    story.append(step_box(num, title, body))

story.append(Spacer(1, 2*mm))

# CVS alert box
story.append(alert_box(
    "⚠  CRITICAL VIEW OF SAFETY (CVS): No structure is to be clipped or divided until ALL THREE CVS criteria "
    "are satisfied and documented. This is the single most important safety principle in cholecystectomy.",
    bg=C_RED_LT, border=C_RED
))

# Bailout strategies
story.append(Paragraph("Bailout Strategies (When CVS Cannot Be Achieved)", sSubSection))
bail_data = [
    ["Strategy", "When to Use"],
    ["1. Abort + return electively", "Acute inflammation too severe; stable patient – plan interval cholecystectomy"],
    ["2. Convert to open cholecystectomy", "Ongoing difficulty, suspected injury, anatomical uncertainty"],
    ["3. Tube cholecystostomy (14 Fr Foley)", "Decompression only; bridge to definitive procedure in unstable patient"],
    ["4. Subtotal cholecystectomy (fenestrating or reconstituting)", "Safer than risky dissection; leave cystic duct/part of wall if adherent"],
    ["5. Fundus-first (retrograde) approach", "Severe adhesions/inflammation at Calot's – dissect from fundus downward"],
]
story.append(two_col_table(bail_data, col1_w=70*mm, header_color=C_AMBER))
story.append(Spacer(1, 2*mm))

# ── 5. OPEN CHOLECYSTECTOMY ───────────────────────────────────────────────
story.append(PageBreak())
story.append(section_header("5. Open Cholecystectomy", C_TEAL))

story.append(Paragraph("Patient Position & Incision", sSubSection))
open_pos = [
    ["Parameter", "Detail"],
    ["Position", "Supine; optional right-sided bolster/roll under flank to extend RUQ"],
    ["Incision options", "① Right subcostal (Kocher) – most common; 2–3 cm below costal margin, over lateral rectus border\n② Upper midline – faster, better for exploration\n③ Right upper transverse – alternative"],
    ["Retraction", "Self-retaining retractor (Finochietto, Thompson) OR assistant's left hand – \"the left hand of the assistant does all the work\" (Moynihan)"],
    ["Exposure", "Packs on hepatic flexure of colon, duodenum, lesser omentum"],
]
story.append(two_col_table(open_pos, col1_w=42*mm))
story.append(Spacer(1, 2*mm))

story.append(Paragraph("Operative Steps – Open Cholecystectomy", sSubSection))

steps_open = [
    ("1", "Incision & Entry",
     ["Kocher incision: skin → subcut fat → anterior rectus sheath → split/divide rectus → posterior sheath → peritoneum",
      "Confirm gallbladder position; run fingers along undersurface of liver"]),
    ("2", "Exposure",
     ["Place moist packs: hepatic flexure of colon, duodenum, lesser omentum",
      "Retract liver superiorly with liver retractor",
      "Place Duval/Allis forceps on infundibulum for traction"]),
    ("3", "Identify Triangle of Calot",
     ["Dissect peritoneum over hepatoduodenal ligament",
      "Palpate CBD (usually right-sided, rounded cord) to confirm location BEFORE any dissection",
      "Clear fat/areolar tissue from Calot's triangle (cystic duct + cystic artery + liver margin)"]),
    ("4", "Ligate Cystic Artery",
     ["Trace artery from Calot's triangle to gallbladder wall",
      "Pass 2-0 absorbable ligatures (or clips) proximal and distal",
      "Divide between ligatures",
      "Beware: right hepatic artery can be mistaken for cystic artery – confirm origin"]),
    ("5", "Ligate Cystic Duct",
     ["Dissect cystic duct free from CBD junction under direct vision",
      "Confirm NOT dividing CBD (palpate, intraoperative cholangiogram if uncertain)",
      "Ligate with 2-0 absorbable sutures (proximal + distal) and divide",
      "Leave adequate cystic duct stump (≥5 mm) to prevent stump leak"]),
    ("6", "Intraoperative Cholangiogram (Selective)",
     ["Same indications as laparoscopic (see Section 4)",
      "Proximal tie on cystic duct → small anterior ductal incision → insert cholangiogram catheter → contrast under fluoroscopy"]),
    ("7", "Dissect Gallbladder from Liver Bed",
     ["Retrograde (fundus-first) OR antegrade (infundibulum-first) dissection",
      "Electrocautery or sharp dissection on cystic plate",
      "Secure hemostasis from liver bed with diathermy / hemostatic agents",
      "If gallbladder perforates: retrieve all stones; bile irrigation"]),
    ("8", "Partial/Subtotal Cholecystectomy (If Anatomy Unclear)",
     ["Remove as much gallbladder mucosa as possible (ablate remaining mucosa with diathermy)",
      "Oversew or close cystic duct stump with absorbable sutures",
      "Wide drainage of the area – mandatory"]),
    ("9", "Closure",
     ["Check for bile leak (bile staining, bilious fluid) and bleeding",
      "Drain placement (sub-hepatic closed-suction drain) if: severe inflammation, uncertain duct stump, bile spill",
      "Close peritoneum (1-0 absorbable continuous) → posterior sheath → rectus → anterior sheath (1-0 absorbable loop or PDS)",
      "Skin: subcuticular absorbable or staples"]),
]

for num, title, body in steps_open:
    story.append(step_box(num, title, body))

story.append(Spacer(1, 2*mm))

# ── 6. INTRAOPERATIVE CHOLANGIOGRAM ──────────────────────────────────────
story.append(section_header("6. Intraoperative Cholangiogram (IOC)", C_BLUE))

ioc_data = [
    ["IOC: Selective Indications", "Technique Summary"],
    ["History of jaundice or abnormal LFTs", "1. Clip proximal cystic duct"],
    ["Prior biliary pancreatitis", "2. Small anterior incision on cystic duct"],
    ["Dilated CBD on preoperative ultrasound", "3. Insert and secure cholangiogram catheter"],
    ["Large duct + small stones on imaging", "4. Inject dilute contrast (50%) under fluoroscopy (live)"],
    ["Failed or unavailable preoperative ERCP", "5. Avoid air bubbles (mimic filling defects)"],
    ["Intraoperative anatomical uncertainty", "Ideal result: R+L hepatic ducts filled, drainage into duodenum, no defects"],
]
story.append(two_col_table(ioc_data, col1_w=75*mm))
story.append(Paragraph(
    "Routine IOC detects CBD stones in ~7% of patients. "
    "No consensus on routine vs selective use; all surgeons performing cholecystectomy "
    "should be proficient with the technique. (Schwartz's 11e)", sSmall))
story.append(Spacer(1, 2*mm))

# ── 7. COMPLICATIONS ──────────────────────────────────────────────────────
story.append(PageBreak())
story.append(section_header("7. Complications", C_RED))

story.append(Paragraph("Intraoperative Complications", sSubSection))
intraop_comp = [
    ["Complication", "Incidence / Notes", "Immediate Action"],
    ["Bile duct injury (BDI)", "Lap: 0.3–0.6% | Open: 0.2–0.3%\nMost feared; major cause of litigation", "Stop dissection. Convert to open. Refer to HPB centre if complex repair needed."],
    ["Right hepatic artery injury", "Often accompanies BDI (close anatomic proximity)", "Control bleeding. Vascular repair or ligation if necessary."],
    ["Major vascular injury (aorta/IVC/portal vein)", "Trocar/Veress insertion – rare but life-threatening", "Direct pressure immediately. Call for vascular surgeon. Open laparotomy."],
    ["Bowel injury (stomach/duodenum/colon)", "Veress or trocar insertion", "Repair immediately (primary or with loop if contaminated)."],
    ["Gallbladder perforation / Stone spillage", "5–40% of laparoscopic cases", "Irrigate thoroughly. Retrieve ALL stones. Document in operative note."],
    ["Bleeding from cystic artery / liver bed", "Common", "Clip, tie or cauterise. Do not clip blindly."],
]
comp_tbl = Table(
    [[Paragraph(r, sTableHeader) for r in intraop_comp[0]]] +
    [[Paragraph(str(c), sTableCellB if i==0 else sTableCell) for i,c in enumerate(row)]
     for row in intraop_comp[1:]],
    colWidths=[45*mm, 55*mm, 72*mm]
)
comp_tbl.setStyle(TableStyle([
    ("BACKGROUND",    (0,0), (-1,0), C_RED),
    ("ROWBACKGROUNDS",(0,1), (-1,-1), [C_WHITE, C_RED_LT]),
    ("GRID",          (0,0), (-1,-1), 0.4, C_DIVIDER),
    ("TOPPADDING",    (0,0), (-1,-1), 4),
    ("BOTTOMPADDING", (0,0), (-1,-1), 4),
    ("LEFTPADDING",   (0,0), (-1,-1), 5),
    ("RIGHTPADDING",  (0,0), (-1,-1), 5),
    ("VALIGN",        (0,0), (-1,-1), "TOP"),
]))
story.append(comp_tbl)
story.append(Spacer(1, 3*mm))

story.append(Paragraph("Postoperative Complications", sSubSection))
postop_comp = [
    ["Complication", "Presentation", "Investigation / Management"],
    ["Bile leak", "RUQ pain, fever, bilioma on USS", "USS → MRCP/ERCP (stent if cystic stump leak). Drain if collection."],
    ["Bile duct stricture / injury", "Jaundice, cholangitis (early or late)", "USS → MRCP. ERCP/stent or surgical hepaticojejunostomy at HPB centre."],
    ["Retained CBD stones", "Jaundice, cholangitis (Charcot's triad)", "MRCP → ERCP with sphincterotomy + stone extraction."],
    ["Intra-abdominal abscess", "Fever, RUQ pain, sepsis (esp. if stones spilled)", "CT abdomen → radiological drainage ± antibiotics."],
    ["Port-site / wound hernia", "Bulge at port site; can obstruct", "Repair electively (or urgently if obstructed)."],
    ["Acute pancreatitis", "Epigastric pain, raised amylase", "Conservative management; ERCP if CBD stone."],
    ["Post-cholecystectomy syndrome", "Residual/recurrent RUQ symptoms (~10–15%)", "Exclude retained stone (MRCP), sphincter of Oddi dysfunction (ERCP manometry)."],
    ["Pulmonary complications", "Atelectasis, pneumonia (more common – open)", "Physiotherapy, analgesia, early mobilisation."],
]
postop_tbl = Table(
    [[Paragraph(r, sTableHeader) for r in postop_comp[0]]] +
    [[Paragraph(str(c), sTableCellB if i==0 else sTableCell) for i,c in enumerate(row)]
     for row in postop_comp[1:]],
    colWidths=[42*mm, 48*mm, 82*mm]
)
postop_tbl.setStyle(TableStyle([
    ("BACKGROUND",    (0,0), (-1,0), C_NAVY),
    ("ROWBACKGROUNDS",(0,1), (-1,-1), [C_WHITE, C_GRAY_LT]),
    ("GRID",          (0,0), (-1,-1), 0.4, C_DIVIDER),
    ("TOPPADDING",    (0,0), (-1,-1), 4),
    ("BOTTOMPADDING", (0,0), (-1,-1), 4),
    ("LEFTPADDING",   (0,0), (-1,-1), 5),
    ("RIGHTPADDING",  (0,0), (-1,-1), 5),
    ("VALIGN",        (0,0), (-1,-1), "TOP"),
]))
story.append(postop_tbl)
story.append(Spacer(1, 3*mm))

# Strasberg classification table
story.append(Paragraph("Strasberg Classification of Bile Duct Injuries", sSubSection))
stras_data = [
    ["Type", "Description", "Management Principle"],
    ["A", "Bile leak from cystic duct stump or duct of Luschka (minor radical in GB fossa)", "ERCP + stent; drain collection"],
    ["B", "Occluded (clipped) right posterior sectoral duct – no leak", "Depends on symptoms; often conservative vs Roux-en-Y"],
    ["C", "Bile leak from divided (unoccluded) right posterior sectoral duct", "ERCP if amenable; otherwise Roux-en-Y hepaticojejunostomy"],
    ["D", "Lateral laceration/leak from main bile duct without tissue loss", "ERCP + stent (minor); primary repair or hepaticojejunostomy (major)"],
    ["E1", "Transected main bile duct; stricture >2 cm from hilum", "Hepaticojejunostomy at HPB centre"],
    ["E2", "Transected main bile duct; stricture <2 cm from hilum", "Hepaticojejunostomy at HPB centre"],
    ["E3", "Stricture at hilum; R + L ducts in communication", "High hepaticojejunostomy"],
    ["E4", "Stricture at hilum; R + L ducts separated", "Complex biliary reconstruction"],
    ["E5", "Right aberrant sectoral duct + main duct involved", "Complex biliary reconstruction"],
]
stras_tbl = Table(
    [[Paragraph(r, sTableHeader) for r in stras_data[0]]] +
    [[Paragraph(str(c), sTableCellB if i==0 else sTableCell) for i,c in enumerate(row)]
     for row in stras_data[1:]],
    colWidths=[15*mm, 80*mm, 77*mm]
)
stras_tbl.setStyle(TableStyle([
    ("BACKGROUND",    (0,0), (-1,0), C_RED),
    ("ROWBACKGROUNDS",(0,1), (-1,-1), [C_WHITE, C_RED_LT]),
    ("GRID",          (0,0), (-1,-1), 0.4, C_DIVIDER),
    ("TOPPADDING",    (0,0), (-1,-1), 4),
    ("BOTTOMPADDING", (0,0), (-1,-1), 4),
    ("LEFTPADDING",   (0,0), (-1,-1), 5),
    ("RIGHTPADDING",  (0,0), (-1,-1), 5),
    ("VALIGN",        (0,0), (-1,-1), "TOP"),
]))
story.append(stras_tbl)
story.append(Spacer(1, 2*mm))

story.append(alert_box(
    "SUSPECTED POSTOPERATIVE BDI PROTOCOL: Resuscitate → IV antibiotics → Urgent RUQ USS → "
    "MRCP (anatomy) → ERCP if therapeutic intervention needed → Surgical repair (hepaticojejunostomy) "
    "for major injuries AT AN HPB CENTRE. Do NOT attempt repair without expertise.",
    bg=C_RED_LT, border=C_RED
))

# ── 8. OPEN vs LAPAROSCOPIC COMPARISON ───────────────────────────────────
story.append(PageBreak())
story.append(section_header("8. Open vs Laparoscopic – Comparison", C_NAVY))

comp_table_data = [
    ["Parameter", "Laparoscopic", "Open"],
    ["Gold standard?", "YES – treatment of choice", "When lap not feasible/safe"],
    ["Incision", "4 × 5–12 mm ports", "Kocher / midline (10–15 cm)"],
    ["Pneumoperitoneum", "CO₂, 12–15 mmHg required", "Not required"],
    ["Pain (postop)", "Significantly less", "More; requires adequate analgesia"],
    ["Hospital stay", "Day case to 1–2 days", "3–5 days"],
    ["Return to work", "1–2 weeks", "4–6 weeks"],
    ["Wound infection", "Lower", "Higher"],
    ["Bile duct injury rate", "0.3–0.6% (historically higher; converging)", "0.2–0.3%"],
    ["Stone spillage risk", "5–40%", "Less common; direct retrieval"],
    ["Mortality", "~0.1%", "<1%"],
    ["Visualization", "Magnified laparoscopic view (10–30°)", "Direct (wide field)"],
    ["Conversion", "~5% elective; 10–30% emergency", "N/A (already open)"],
]

comp_tbl2 = Table(
    [[Paragraph(r, sTableHeader) for r in comp_table_data[0]]] +
    [[Paragraph(str(c), sTableCellB if i==0 else
      (S("g", fontName="Helvetica-Bold", fontSize=7.8, textColor=C_GREEN, leading=10.5) if i==1 else sTableCell)
      ) for i,c in enumerate(row)]
     for row in comp_table_data[1:]],
    colWidths=[45*mm, 72*mm, 55*mm]
)
comp_tbl2.setStyle(TableStyle([
    ("BACKGROUND",    (0,0), (-1,0), C_NAVY),
    ("ROWBACKGROUNDS",(0,1), (-1,-1), [C_WHITE, C_GRAY_LT]),
    ("GRID",          (0,0), (-1,-1), 0.4, C_DIVIDER),
    ("TOPPADDING",    (0,0), (-1,-1), 4),
    ("BOTTOMPADDING", (0,0), (-1,-1), 4),
    ("LEFTPADDING",   (0,0), (-1,-1), 5),
    ("RIGHTPADDING",  (0,0), (-1,-1), 5),
    ("VALIGN",        (0,0), (-1,-1), "TOP"),
]))
story.append(comp_tbl2)
story.append(Spacer(1, 2*mm))

# ── 9. KEY ANATOMICAL LANDMARKS ───────────────────────────────────────────
story.append(section_header("9. Key Anatomical Landmarks & Safety Principles", C_TEAL))

story.append(Paragraph("Triangle of Calot (Hepatocystic Triangle)", sSubSection))
story.append(Paragraph(
    "Bounded by: <b>cystic duct</b> (inferiorly), <b>common hepatic duct</b> (medially), and "
    "<b>inferior surface of the liver / cystic plate</b> (superiorly). "
    "Contains the cystic artery and lymph node of Calot (Lund's node). "
    "Note: 'Triangle of Calot' strictly includes the cystic artery; the broader 'hepatocystic triangle' "
    "is the modern preferred term used in CVS criteria.", sBody))

anat_data = [
    ["Landmark", "Significance"],
    ["Rouvière's sulcus", "Constant hepatic fissure on right liver surface. Safe dissection zone is CEPHALAD to a line from its roof to the umbilical fissure (R4U line)."],
    ["Cystic plate", "Peritoneal reflection where GB attaches to liver. Exposing the medial ⅓ of the cystic plate is the 3rd CVS criterion."],
    ["Lund's node (Node of Calot)", "Lymph node at junction of cystic duct and hepatic duct; landmark for cystic artery."],
    ["Hartmann's pouch", "Infundibulum of GB; the grasping point for inferolateral retraction."],
    ["Duct of Luschka", "Small bile duct from liver directly into GB bed; if injured → Type A bile leak."],
    ["Right hepatic artery", "Typically passes behind CHD into Calot's triangle; caterpillar hump variant mimics cystic artery."],
    ["B-SAFE method", "5 landmarks: Bile duct | Sulcus of Rouvière | hepatic Artery | umbilical Fissure | Enteric (duodenum). Use to orient cognitive map during difficult dissection."],
]
story.append(two_col_table(anat_data, col1_w=50*mm))
story.append(Spacer(1, 2*mm))

story.append(alert_box(
    "SAFE ENERGY USE (Hook Cautery): Low setting ~30 W | Intermittent short bursts | "
    "Small tissue bites at a time | AVOID blind cautery near hepatocystic triangle | "
    "Ultrasonic energy = less lateral spread (but cumbersome in tight triangle).",
    bg=C_AMBER_LT, border=C_AMBER,
    text_style=S("amb", fontName="Helvetica-Bold", fontSize=8.2, textColor=C_AMBER, leading=12)
))

# ── 10. QUICK REFERENCE / SAFETY CHECKLIST ───────────────────────────────
story.append(section_header("10. Intraoperative Safety Checklist", C_GREEN))

checklist_data = [
    ["☐ Pre-incision WHO surgical safety check completed"],
    ["☐ Antibiotic given within 60 minutes of incision"],
    ["☐ DVT prophylaxis in place"],
    ["☐ Patient positioned correctly (supine / split-leg); table tilted"],
    ["☐ 4 ports placed under direct vision"],
    ["☐ B-SAFE landmarks identified"],
    ["☐ Correct retraction: fundus → right shoulder; infundibulum → inferolateral"],
    ["☐ Hepatocystic triangle dissected ANTERIORLY and POSTERIORLY"],
    ["☐ CVS criteria ALL met – confirmed by surgeon"],
    ["☐ CVS DOCUMENTED (photo or video)"],
    ["☐ Only 2 structures entering gallbladder before clipping"],
    ["☐ Cystic duct clipped: 2 proximal + 1 distal → divided"],
    ["☐ Cystic artery clipped: 2 proximal + 1 distal → divided"],
    ["☐ IOC performed if indicated; results reviewed"],
    ["☐ Gallbladder dissected off cystic plate (not avulsed)"],
    ["☐ Final field check: bleeding? bile staining? clip positions?"],
    ["☐ ALL spilled stones retrieved"],
    ["☐ Retrieval bag used for specimen"],
    ["☐ Drain placed if indicated (gangrenous GB / bile spill)"],
    ["☐ Fascial defects ≥10 mm closed"],
    ["☐ Instrument and swab count confirmed correct"],
    ["☐ Post-procedure briefing with team completed"],
]

check_tbl = Table(
    [[Paragraph(r[0], sBody)] for r in checklist_data],
    colWidths=[W - 32*mm]
)
check_tbl.setStyle(TableStyle([
    ("ROWBACKGROUNDS", (0,0), (-1,-1), [C_GREEN_LT, C_WHITE]),
    ("GRID",           (0,0), (-1,-1), 0.3, C_DIVIDER),
    ("TOPPADDING",     (0,0), (-1,-1), 3),
    ("BOTTOMPADDING",  (0,0), (-1,-1), 3),
    ("LEFTPADDING",    (0,0), (-1,-1), 8),
    ("RIGHTPADDING",   (0,0), (-1,-1), 6),
]))
story.append(check_tbl)
story.append(Spacer(1, 3*mm))

# ── FOOTER / REFERENCES ───────────────────────────────────────────────────
story.append(hr(C_DIVIDER))
story.append(Paragraph(
    "<b>References:</b> Schwartz's Principles of Surgery 11e (pp. 1438–1443) · "
    "Bailey &amp; Love's Short Practice of Surgery 28e (pp. 1270–1274) · "
    "Maingot's Abdominal Operations (pp. 1014–1016) · "
    "Mulholland &amp; Greenfield's Surgery 7e (pp. 3065–3066) · "
    "Fischer's Mastery of Surgery 8e · "
    "Current Surgical Therapy 14e",
    sSmall))
story.append(Paragraph(
    "<b>Disclaimer:</b> This guide is intended as a quick intraoperative reference for qualified surgical teams and "
    "does not replace surgical judgment, institutional protocols, or applicable training. "
    "Generated by Orris Medical AI · June 2026.",
    sSmall))

# ── BUILD ──────────────────────────────────────────────────────────────────
os.makedirs(os.path.dirname(OUTPUT_PATH), exist_ok=True)
doc.build(story)
print(f"PDF generated successfully: {OUTPUT_PATH}")