RU2365349C2 - Method of laparoskopic cholecystolithoextraction - Google Patents

Abstract

FIELD: medicine; surgery.

SUBSTANCE: lumen of a gall bladder is opened, concrements are removed, a gall bladder is drained. Sanation of a gall bladder cavity is carried out in the early postoperative period using a solution of the following structure: Furacilinum of 0.02% - 2 mg, Chymotrypsin - 0.2% - 20 mg, Hidrocortizonum of 0.5% - 50 mg, water - the rest up to 10 ml.

EFFECT: fast restoration of gall bladder functions, elimination of risk factors of cholecystolithiasis relapse development.

1 dwg, 1 ex

Description

The present invention relates to medicine, namely to surgery, and can be used for minimally invasive treatment of patients with uncomplicated cholelithiasis (cholecystolithiasis) by opening the lumen of the gallbladder, extracting the calculus, external drainage of the gallbladder and debridement of its cavity in the early postoperative period.

Surgical tactics for the treatment of cholelithiasis (cholelithiasis) continues to be relevant for a long time, due to the continued high frequency of this disease in the vast majority of countries. About 250-300 thousand cholecystectomies per year are performed in Russia, and annual referral in Russia for cholelithiasis is 5-6 people per 1 thousand population, about 1 million per year (N.A. Maistrenko, A.I. Nechay, 1999). The main treatment for cholelithiasis is the operation of cholecystectomy (CE), which until now continues to be considered the "gold standard" of treatment.

However, treatment, limited to the removal of the gallbladder (GI) without correction of etiological factors, appears to be incomplete and does not lead to the cure of cholelithiasis (E.V. Lutsevich, R.A. Megrabyan, 1986, S.G. Burkov, 2004) . When performing this intervention, along with the removal of the gallbladder, a number of its functions also fall out - deposition, evacuation, concentration, suction, secretory, valve, hormonal and others, ensuring the synchronization of the sphincter apparatus of the biliopancreatoduodenal zone. According to surgeons, 20%, and according to therapists, 40% of patients after surgery performed in the early stages of the disease, have problems associated with the loss of a functioning gallbladder (Sh.I. Karimov et al., 2000, Sayfutdinov R.G. et al., 2005).

The loss of a functioning organ and its physiological role takes time to adapt the body to new conditions associated with the exclusion of cystic bile from the digestive processes and a change in the exocrine function of the liver due to cholecystectomy. Removal of the gastrointestinal tract leads to the inevitable functional restructuring of the biliary system, affecting a complex set of neurohumoral relationships arising from the loss of the physiological function of the gallbladder.

In the majority of operated patients, the polymorphism of clinical manifestations and complaints after CE are, as a rule, not the result of errors in the operation, but are caused by functional or organic disorders of the biliary zone that arise after the removal of the gastrointestinal tract, which is usually generalized by the term postcholecystectomy syndrome (PCES), the frequency of which, according to various authors, it reaches 17.8-35% (P.Malle-Guy, 1973; V.V. Vinogradov, 1977; G.A. Buromskaya, 1984; BC Saveliev, 1986; S.A. Dadvani, 2000 and other).

Based on the foregoing, to tactically more correct, with uncomplicated calculous cholecystitis with preserved gallbladder function, is the implementation of organ-preserving operations. There is a method of treating cholelithiasis (AS USSR, No. 1491472, Mcl. A61B 17/00, A61M 25/00), intended for minimally invasive treatment of patients with calculous cholecystitis. A laparoscopic cholecystostomy is performed with the introduction of a double-lumen drainage with an inflatable cuff at the working end into the bladder cavity. Fractional introduction of monooctanoin is carried out along one of the drainage channels. A swollen cuff at the working end obstructs the cystic duct, preventing the ingress of monoctanoin into the intestine, which reduces the toxic resorptive effect on the patient.

Disadvantages:

- 100% dissolution of stones is not ensured due to their different chemical structure,

- dissolution is carried out for a sufficiently long time,

- the operation requires constant medical supervision of the patient due to the known toxicity of monooctanoin,

- inadequate removal of degradation products of gallstones through a small diameter of the drainage.

As the closest analogue, the operation of laparoscopic cholecystolithotomy is accepted. The essence of this operation is to dissect the bladder, remove stones and deafly suture its walls (A.Zaprudnov, L.Kharitonova. “Medical newspaper”, No. 5, 2001, http://gallbladder.surgery.ru/cholelithiasis treatment / new operation /).

The main advantage of this operation is that the functionally active organ is preserved, and the use of the laparoscopic surgery technique gives a good cosmetic effect.

Disadvantages of the operation:

- a greater number of complications after surgery due to the lack of decompression of the biliary tract,

- the impossibility of postoperative rehabilitation of the cavity of the gallbladder,

- the impossibility of sampling cystic bile in the postoperative period in order to study its lithogenic properties,

- A large number of relapses of stone formation.

Tasks:

- reduce the number of complications in the early postoperative period,

- reduce the number of relapses of stone formation in the late postoperative period,

- to provide the possibility of postoperative rehabilitation of the cavity of the gallbladder,

- to provide the possibility of sampling cystic bile in the postoperative period in order to study its lithogenic properties.

The essence of the invention is that after opening the lumen of the gallbladder and removing the calculus, the operation of laparoscopic cholecystolite extraction is completed by drainage of the gallbladder to conduct in the early postoperative period the sanation of the cavity of the gallbladder with a solution containing antiseptic, enzymatic and anti-inflammatory drugs.

The technical result is:

- decompression of the gallbladder in the early postoperative period,

- sanitation with the aim of antimicrobial action, removal of fibrinous deposits and other inclusions that are foci of precipitation, accelerate the healing process of the gallbladder wound, more quickly restore its functions, control the effectiveness of treatment.

The method is as follows.

The operation is performed under general anesthesia. After triple processing of the surgical field, an upper paraumbilical incision is made. Stupidly, with the help of Billroth's clamp, an aponeurosis is secreted, on which two filament-holders are applied at a distance of 1.0 cm from each other. Using these holders carry out the initial traction of the anterior abdominal wall. Perpendicular to the aponeurosis, in order to prevent damage to the organs, a Verisch needle is inserted into the abdominal cavity with subsequent carboxypneuroperitoneum. The supply of carbon dioxide to the abdominal cavity is carried out using an automatic insufflator. The recommended gas pressure in the abdominal cavity is 8-10 mm Hg. After the carboxypneumoperitoneum, the Verisch needle is removed and a trocar is introduced through the resulting soft tissue defect by translational movement. Further, through this port, an initial examination of the abdominal cavity with a laparoscope is performed. The introduction of three other trocars is carried out already under the control of a laparoscope and produced individually in each case (depending on the patient’s constitution, changes in internal organs, adhesions, etc.). Roughly, these trocars are introduced along the edge of the costal arch according to the levels: the right parasternal line, the right midclavicular line, the right anterior axillary line.

The first stage of the operation is cholecystotomy, cholecystoscopy and cholecystolithoextraction. In the area of the bottom of the gallbladder using endoscissors, a section of the wall up to 1.0 cm long is made. Through this section, using the choledochoscope inserted into the abdominal cavity through the parasternal port, the cavity of the gallbladder and its mucous membrane are examined. After inspection, lithoextraction is performed. Extraction of stones is carried out through a choledochoscope (using, for example, a basket probe of the Dormia type).

The second stage of the operation is suturing and drainage of the gallbladder. The drawing shows a diagram of the formation of drainage, where cholecystostomy is applied using the invention according to patent No. 2273496, A61M 1/00, indirectly protecting the method. The drainage device consists of a tube system (2) - in a tube (1) with a common base fixed to the skin, and the protruding proximal end of the inner tube (2), inserted into the gall bladder, is equipped with a loop (3) attached to the tube attached to outer tube (1). At the base of the loop (3), the endo suture fixes the drainage to the gallbladder wall. The operation is completed by a control examination of the abdominal cavity, drainage and omening of the right subhepatic space, layer-by-layer wound closure.

Drainage from the subhepatic space is removed the day after surgery. Starting from 2 days after the operation, when signs of intestinal motility appear, sanitation of the gallbladder cavity is carried out. Remediation is carried out as follows. 2-3 hours after a light breakfast (the gallbladder ceases to participate in digestion), the residual volume of bile is evacuated through a cholecystostomy from the gallbladder with a syringe. At the same time, the gallbladder drops to the maximum. Next, a drug mixture is introduced into the bladder cavity, consisting of an antiseptic, an enzyme preparation and an anti-inflammatory drug, with a total volume of about 10 ml (hydrocortisone - 50 mg (0.5% solution), chymotrypsin - 20 mg (0.2% solution), furatsilina - 2 mg (0.02% solution), distilled water - up to 10 ml). An important requirement for the drugs used is the safety of their ingestion (oral administration), since the possibility of their penetration into the gastrointestinal tract is not ruled out. A clamp is placed on the cholecystostomy, which prevents backflow, and the drug mixture remains in the cavity of the bladder for 30-40 minutes. After the specified time, the clamp is removed and a re-aspiration from the gall bladder is carried out using a syringe with the maximum removal of the residual mixture. In the event of a cloudy or inhomogeneous content, the bladder cavity is washed with a 0.02% (1: 5000) solution of furatsilina.

The internal thin drainage tube (2) (cholecystostomy) is removed on the 7-8th day after surgery. In the absence of leakage of bile through the external drainage tube (1) (“watchman”), the absence of fluid accumulations in the gallbladder during ultrasound examination (ultrasound), it is removed on the 8-9th day. The day after extracting the "watchman" the patient is discharged.

The advantage of the proposed method of laparoscopic cholecystolithoextraction is the drainage of the gallbladder using an original drainage device and subsequent sanitation of its cavity with the proposed solution in the early postoperative period.

All this will allow:

- to ensure decompression of the gallbladder in order to create functional rest in the early postoperative period;

- determine the functional state of the biliary tract sphincter apparatus (Lutkens, Mirizzy, Oddi-Westphal sphincters), carried out through cholecystostomy (the description of this study is presented in the form of a patent application);

- conduct, if available, biochemical, microbiological, microscopic studies of bile in the postoperative period;

- carry out sanitation of the gallbladder cavity, which helps to accelerate the healing of the postoperative wound of the gallbladder wall, more quickly restore its functions, eliminate risk factors for the development of cholecystolithiasis recurrence, since infection, inflammation, blood clots, fibrin filaments in the cavity and on the postoperative suture can be precipitation nuclei and facilitate the initiation of lithogenesis in the early and late postoperative periods.

According to this method, for the period from 2005 to 2007, 12 laparoscopic cholecystolithoextractions were performed. The age of patients ranged from 34 to 62 years. In any case, after operations there were no complications. The average hospital stay was 11.8 k / day. All patients after the operation underwent examination according to the developed plan: during the first year every 3 months, during the next year - once every 6 months, then once a year. Signs of a relapse of stone formation to date have not been identified.

Example

Patient D. was hospitalized at the RCCH on April 11, 2005. After an additional examination, she was diagnosed with cholelithiasis. Cholecystolithiasis. 04/12/2005, the patient underwent surgical treatment in the amount of laparoscopic cholecystolithoextraction with external drainage of the gallbladder according to the method described above. The early postoperative period was uneventful. Cholecystostomy functioned (up to 100 ml of bile). From April 14, 2005 to April 20, 2005, 3 times a day, sanitation of the gallbladder cavity was carried out. On April 20, 2005, the internal cholecystostomy was removed; on April 22, 2005, the external drainage (“watchman”) was removed. There is no bile leakage, the dressings are clean, dry. 04/23/2005, in satisfactory condition the patient was discharged. During the control examinations, the patient's condition is satisfactory, there are no complaints, the gallbladder is homogeneous, its function is preserved.

Claims (1)

A method for laparoscopic treatment of cholecystolithiasis, including dissection of the gallbladder wall, extraction of calculi, characterized in that a drainage is established in the cavity of the gallbladder through the dissected wall section after extraction of calculi and in the early postoperative period after the residual volume of bile is evacuated, the cavity is sanitized with a solution consisting of an antiseptic enzyme and anti-inflammatory drug in the ratio: furatsilin 0.02% 2 mg, chymotrypsin 0.2% 20 mg, hydrocortisone 0.5% 50 mg, the rest - yes up to 10 ml.

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