RU2145198C1 - Method for carrying out laparoscopic cholecystectomy - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves making laparotomy, intersecting gallbladder artery and gallbladder duct and removing concrements. The gallbladder cavity is longitudinally opened. The gallbladder is circumferentially intersected along the body and neck boundary. The body and neck are selected. When dissecting, parietal coagulation of gallbladder artery branches is carried out to reach hemostasis. The gallbladder duct lumen is tightened in proximal position with respect to the following intersection level. The gallbladder walls that are not fixed are to be removed. The fixed gallbladder walls mucoclasis is to be done. EFFECT: wider range of laparotomy applications.

Description

 The invention relates to medicine and can be used in the surgical treatment of calculous cholecystitis.

 A well-known fact is the widespread prevalence of cholelithiasis among the population with a persistent tendency to increase incidence. According to WHO, the number of patients is about 10% of the population, reaching 34% in some countries.

 It is generally recognized that currently the method of choice in the treatment of calculous cholecystitis is laparoscopic cholecystectomy.

 A known method of surgical treatment of calculous cholecystitis (A.A. Shalimov et al. Surgery of the liver and biliary tract, Kiev, 1993), which consists in performing laparotomy, opening the lumen of the gallbladder, removing its contents, excising unfixed sections of its walls while maintaining fixed in the area of the bed of the wall sections and the subsequent implementation of the destruction of the mucosa (mucoclasia) in the left areas.

The method has serious disadvantages:
a high degree of possibility of infection of the abdominal cavity and surgical wound, as well as the development of postoperative complications (abscesses of the abdominal cavity, suppuration of the postoperative wound).

 There is a method of performing laparoscopic cholecystectomy (LCE) (Mouret P., Dubois F., 1988; Reddick E., Olsen D., 1989), which we adopted as a prototype, which, after opening the parietal peritoneum, isolates the cystic artery and cystic duct in the Collot triangle, clipping and their intersection. Then, producing traction behind the crossed cystic duct towards the anterior abdominal wall, the gall bladder is cut off from the liver bed in the subserous layer. Careful control of hemostasis is performed and, if necessary, sanitation of the bed by washing with an antiseptic solution from blood clots, tissue fragments and coagulation products. After that, the gallbladder is removed through one of the punctures of the anterior abdominal wall.

The disadvantages of this method include:
- loss of orientation in the anatomical boundaries of organs and structures adjacent to the gallbladder with scar-inflammatory and fibrotic changes in tissues and, in this regard, the inability to continue the operation or create a high degree of risk of damage to nearby structures;
- the possibility of developing serious intra- and postoperative complications when trying to avoid conversion (bile leakage from the gallbladder bed, perforation of the extrahepatic bile ducts, etc.).

 The aim of the invention is to expand the boundaries of the possibilities of using laparoscopic cholecystectomy, prevention of a number of intra- and postoperative complications.

 Tasks.

 - Improving the exposure of the surgical field and the orientation of the surgeon during the operation.

 - Creating the possibility of treatment in a laparoscopic manner with scarred and fibrous tissues surrounding the gallbladder.

 - Reducing the risk of damage to nearby structures.

 - Exclusion of the possibility of bile leakage and bleeding from the bed of the gallbladder.

 The essence of the invention is that, subject to pronounced inflammatory changes and fusion of the gallbladder and surrounding organs, the cavity of the gallbladder is longitudinally opened, the liquid fraction is thoroughly removed, then the gallbladder is completely freed from calculi, the gallbladder crosses circularly along the border of the body and neck and, while continuing to hold the liver and gall bladder in a previously fixed position, the neck and cystic duct are secreted, while wall dissection produces parietal coagulation of the branches of the cystic ar se ries to achieve hemostasis and then sealed cystic duct lumen proximal to the subsequent level crossings, then removed unfixed gallbladder wall, or in the case of fixing them mukoklaziruyut.

 The method was tested in clinical conditions for 92 patients. At the same time, the immediate results showed that the conversion percentage decreased from 12% to 1.5%; bed day decreased by 2 times.

 The technical result of the new method is the elimination of intra- and postoperative complications (as a result of the prevention of damage to the intestinal loops, blood vessels and bile ducts; bleeding and bile leakage from the gallbladder bed), creating the possibility of performing the operation laparoscopically in difficult anatomical situations - refusing to switch to conversion.

 The method is as follows. An indication for the transition from conventional LCE is the occurrence of technical difficulties in the allocation of the gallbladder, due to the presence of pronounced scar-inflammatory changes and fusion of the gallbladder and surrounding organs.

 The operation involves the following steps. First, along the midline at the border of the bottom and body of the gallbladder, using the L-electrode, longitudinally open its cavity. The initial cut length is 6 - 7 mm. Through this hole, an aquapurator tube is inserted into the lumen of the bubble and thorough reorganization of its cavity is carried out by washing out the finely dispersed contents with a pulsating jet of antiseptic solution with periodic aspiration.

 Then an endomesh is introduced into the abdominal cavity, it is opened and placed (depending on individual anatomical features) either in the space between the lower surface of the liver and the hepatic angle of the colon, or on the diaphragmatic surface of the liver. Additionally, the length of the incision is increased towards the neck until stones appear that are captured by the clamp and transferred to the prepared bag. The procedure is repeated until all the stones have been removed.

 Second phase. Transverse (circular) intersection of the gallbladder is carried out at the level of the border of the body and neck of the gallbladder. Particular attention should be paid to the careful implementation of hemostasis from the edge of the incision.

 The third stage. After crossing the gallbladder, optimal conditions arise for improving the visibility and instrumental accesses when freeing from the structures that fix the neck of the gallbladder and cystic duct. At the same time, during the antitracking instruments (from the 4th point behind the bottom of the bladder and from the 3rd beyond the edge of the neck), the distance between the wall of the neck of the bladder or cystic duct and the “dangerous” anatomical structures (right hepatic artery, right hepatic duct) increases significantly and better conditions are created for the identification of the cystic duct, especially in cases of difficult interaction between the cystic duct and the surrounding anatomical structures, as well as various structural anomalies. With this technique of surgery, as a rule, the preparation of the cystic duct ends successfully. The duct is clipped with 2 clips or an endolope is applied, above which the duct is crossed. The removed parts are placed in the endo bag.

 The fourth stage. Excision of the walls and bottom of the gallbladder. The free edge of the body wall of the gallbladder is captured by a clamp from the 3rd point and, manipulating it and a clamp from the 4th point, fixed to the bottom of the bladder, create an optimal exposure of the surgical field. The walls of the gallbladder, if possible, are cut off in the subserous layer from the surface of the liver using monopolar electrocoagulation. At the same time, thorough hemostasis is performed in the gallbladder bed. Cut off fragments are placed in a container.

 The fifth stage. The operation is completed using standard principles. The only difference is the technique for removing the container with the contents and parts of the gallbladder. Usually additionally increase the diameter of the puncture at the supra umbilical point in the cranial direction by 7 - 10 mm. Through this opening, the neck of the bag is removed from the abdominal cavity, from which all large fragments are removed with a terminal clamp, and then the bag itself with the rest of the contents.

 Partial cholecystectomy with mucoclasia.

 The essence of the operation option is that if there are technical difficulties in isolating the gallbladder from the surrounding tissues due to cicatricial inflammatory changes, it is not possible to completely mobilize the walls in the places of fixation and intimate adhesions. Free (unfixed) sections of the wall of the bladder are excised along the visible border of the adhesions, and mucosal destruction (mucoclasia) is performed on the left sections of the walls.

 Example 1. B. Noah, born in 1965. I.b. N 709. He was admitted to the hospital with a diagnosis of Gallstone disease. Chronic calculous cholecystitis. Choledocholithiasis. Obstructive jaundice. Acute purulent cholangitis.

 The patient underwent endoscopic papillosphincterotomy and mechanical extraction of calculi from the common bile duct. The bile outflow into the duodenum 12 (duodenum) is restored. However, on the third day after the intervention - recurrence of obstructive jaundice due to migration of calculi in the choledoch from the gallbladder along the expanded, having a low flow into the hepatic choledochus, cystic duct. It was decided to perform LCE with choledochoscopy and choledocholithoextraction.

 According to the technique adopted in the clinic, pneumoperitoneum was applied, trocars were introduced at typical points. The gallbladder is in the infiltrate, and when it was isolated, technical difficulties arose due to the presence of pronounced scar-inflammatory changes in the wall of the gallbladder and its surrounding organs. It was decided to switch to open cholecystectomy.

 A longitudinal incision was made along the posterior wall of the gallbladder up to 8 mm long. Through this hole, an aquapurator tube was introduced into the lumen of the bubble and sanitation of its cavity was made. An endo-bag (plastic bag) is placed in the abdominal cavity, in which all stones extracted from the gallbladder are placed, for which the length of the incision is gradually increased to the beginning of the cystic duct. The gallbladder wall at the level of the border of the body and neck is circularly crossed and the neck and cystic duct are prepared. The cystic duct is wide, up to 8 mm in diameter. A choledochoscope was inserted into the duct, 3 calculi up to 7 mm in diameter were detected and extracted. The choledochoscope passes freely in the duodenum. On the cystic duct 4-5 mm from the wall of the common bile duct, 2 endolopes are placed, above which the duct is crossed and the removed part of the bladder is placed in the endomesh. The body and bottom of the bladder are cut off from the bed, placed in the endomesh bag and removed from the abdominal cavity through the supra umbilical puncture. The intervention zone was sanitized and a control drainage tube was installed in the bed of the bladder, which was removed by the end of 1 day. Discharged for outpatient treatment in satisfactory condition on the 3rd day. There were no complications associated with the performed LCE. A follow-up examination after 1 year showed that the patient was feeling well, had no complaints, there were no clinical symptoms, and instrumental examinations (ultrasound, ERCP) did not reveal any obstruction to the bile duct.

 Example 2. B-naya 3. 1927 year of birth. I.b. N 718. Was admitted to the hospital with a diagnosis of Gallstone disease. Chronic calculous cholecystitis.

 When performing LCE, the gall bladder in commissures is swollen, infiltrated, tissue differentiation is impaired. The performed puncture of the bladder had no effect and the attempt to isolate the cystic duct by a typical technique ended in failure. It was decided to switch to open cholecystectomy.

 A longitudinal incision was made along the posterior wall of the gallbladder up to 8 mm long. Through this hole, an aquapurator tube was introduced into the lumen of the bubble and sanitation of its cavity was made. An endo-bag (plastic bag) is placed in the abdominal cavity, in which all stones extracted from the gallbladder are placed, for which the length of the incision is gradually increased to the beginning of the cystic duct. The gallbladder wall at the level of the border of the body and neck is circularly crossed and the neck and cystic duct are prepared. The cystic duct, up to 6 mm, 2 endolopes are superimposed on it 4-5 mm from the choledoch wall, above which the duct is crossed and the resected part of the bladder is placed in the endomesh. When trying to separate the body and bottom of the bladder from the bed, due to severe fibrosis, clipping in the subserous layer failed. It was decided to leave the wall of the bladder adjacent to the liver in place. The non-fixed walls of the bladder are cut off and placed in the endo bag. The mucosa in the left areas was removed by electrocoagulation (mucoclasia). An endomesh bag with contents removed from the abdominal cavity through the supra umbilical puncture. The intervention zone was sanitized and a control drainage tube was installed in the bed of the bladder, which was removed by the end of 1 day. There were no complications associated with the operation of LCE. Discharged from the hospital by the end of 2 days.

Using the proposed method allows you to:
- perform a cholecystectomy in a laparoscopic manner in difficult intraoperative situations (in case of loss of orientation in the anatomical boundaries of organs and structures adjacent to the gallbladder due to scar-inflammatory and fibrous tissue changes) and to avoid conversion;
- improve the exposure of the surgical field and the orientation of the surgeon during the operation LCE;
- reduce the risk of damage to nearby anatomical structures and structures;
- eliminate the possibility of bile leakage and bleeding from the gallbladder bed.

Claims (1)

 A method of laparoscopic cholecystectomy, including laparotomy, intersection of the cystic artery and cystic duct and removal of calculi, characterized in that, under the conditions of pronounced inflammatory changes and fusion of the gallbladder and surrounding organs, the gallbladder cavity is longitudinally opened, the liquid fraction is carefully removed, then the gall bladder is completely released from calculi, cross the gallbladder circularly along the border of the body and neck and, while continuing to hold the liver and gallbladder in a previously recorded dix, isolated cervix and cystic duct, while simultaneously coagulating dissection producing parietal branches cystic artery to achieve hemostasis and then sealed cystic duct lumen proximal to the subsequent level crossings, after which the unfixed gallbladder wall removed, gallbladder mukoklaziruyut fixed wall.