RU2481793C2 - Method of performing laparoscopic cholecystectomy by drainage of cystic duct - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to surgery and can be used for performing laparoscopic cholecystectomy with drainage of cystic duct in patients with cholelithiasis. Inflation of nitrogen monoxide into abdominal cavity is performed with Veresh's needle 1 cm above umbilical ring. Laparoscopy is carried out and revision of abdominal cavity organs and exposure of cystic duct of artery and common bile duct are performed. If it is impossible to verify cystic duct and artery, as well as elements of hepato-duodenal ligament, within 1 hour, decision about starting laparotomy is made. If it is possible to differentiate cystic duct and artery, as well as elements of hepato-duodenal ligament, decision about continuation of laparoscopic interference is made, after which distal part of cystic duct is tied up with application of extracorporal method of knot formation. Intubation of cystic duct is carried out. Cystic duct drainage is fixed by means of extracorporal technique of knot tying. Intraoperative cholangiography is performed, the results of which are used to determine further volume of operation aid. If there are no concrements in common bile duct and evacuation of contrast in duodenum is good, operation is limited by cholecystectomy, if diagnosis of choledocolithiasis is confirmed and contrast evacuation is absent, choledocolithotomy is carried out.

EFFECT: method ensures reliable drainage fixation and its stable functioning in postoperative period.

1 ex

Description

The invention relates to medicine, in particular to surgery, and relates to a technique for performing laparoscopic cholecystectomy with drainage of the cystic duct in patients with cholelithiasis.

In a number of patients suffering from cholelithiasis, on the basis of complaints, anamnesis, objective examination data, laboratory and ultrasound data, it is not always possible to completely exclude the presence of extrahepatic bile duct pathology. Performing laparoscopic operations in these patients, the surgeon is faced with the need to install drainage of the cystic duct and perform intraoperative cholangiography in order to determine further treatment tactics.

However, the proposed techniques for intubation of the cystic duct and intraoperative cholangiography during laparoscopic cholecystectomy may be ineffective in 2% -5% of cases (Corbitt et al, 1991; Bagloo et al, 2010).

Currently, the installation of drainage of the cystic duct with laparoscopic cholecystectomy is possible using various techniques. Most often, intubation of the cystic duct is carried out using a special laparoscopic clamp to perform intraoperative cholangiography. This technique was described in 1992 (Flowers et al). Other authors perform a separate additional puncture of the anterior abdominal wall through which the drainage tube is inserted into the abdominal cavity and after cannulation of the cystic duct, the drainage is fixed in the lumen of the cystic duct using a clip (Hagan et al, 1992). In addition, it has been proposed to intubate the cystic duct with a catheter inserted through an additional laparoport (Norman et al, 1992). In this case, hermeticity is achieved by fixing the drainage in the duct with a metal clip. Robertson et al (1991) suggested using a special metal cannula for intubation of the cystic duct and cholangiography. However, discussions are still ongoing on methods for installing cystic duct drainage and intraoperative cholangiography for laparoscopic cholecystectomy. The variety of methods used and their inefficiency in a number of patients indicate that this problem has not yet been fully developed and further searches are needed for methods of installing cystic duct drainage and intraoperative cholangiography when performing laparoscopic cholecystectomy.

The closest analogue to the proposed method for performing laparoscopic cholecystectomy with installation of cystic duct drainage and performing intraoperative cholangiography is Norman et al (1992), in which a catheter is inserted into the abdominal cavity through a separate puncture of the anterior abdominal wall and fixed in the cystic duct using a metal clip. At the same time, the fixation by means of clipping with a metal clip is not always accompanied by reliable tightness, and with excessive force, the metal clip can survive the lumen of the drainage tube. Moreover, after performing intraoperative cholangiography, some patients need to leave the cystic duct drainage in order to correct the bile hypertension syndrome, and the metal clip cannot always ensure the case fixation of the drainage in the lumen of the cystic duct, it can be dislocated with the development of bile duct in the postoperative period.

The purpose of the invention is the development of a method for performing laparoscopic cholecystectomy with cystic duct drainage, which improves the reliability of the cystic duct drainage installation procedure and ensures, if necessary, the normal functioning of the cystic duct drainage in the postoperative period, thereby increasing the effectiveness of laparoscopic cholecystectomy.

This goal is achieved by the fact that according to the results of clinical, laboratory and instrumental examination, if the patient has a history of gallstone disease, pain attacks in combination with the effects of transient obstructive jaundice, with laboratory parameters: bilirubin level is more than 20.5 μmol / l and data of ultrasound examination: the presence of many bile stones with a diameter of less than 5 millimeters and a diameter of the common bile duct of more than 7 millimeters make a decision to perform surgery VA in the volume of laparoscopic cholecystectomy with intubation and drainage of the cystic duct by Holsted-Pikovsky drainage and intraoperative cholangiography: 1 cm above the umbilical ring with a Veress needle, nitrous oxide is insufflated into the abdominal cavity, laparoscopy is performed and the abdominal cavity is revised and revised of the common bile duct - if within 1 hour it is impossible to verify the cystic duct and artery, as well as elements of the hepatoduodenal ligament, then make a decision to switch to laparotomy, and if within 1 hour it is possible to differentiate the cystic duct and artery, as well as the elements of the hepatoduodenal ligament, then they decide to continue laparoscopic intervention, after which the distal part of the cystic duct is ligated using an extracorporeal knot formation technique, while the ends of the ligature, with which the cystic duct is ligated, is introduced into the abdominal cavity through a 10-mm trocar located in the epigastric region, the node is formed and they are loaded into the abdominal cavity through the right medial 5 mm trocar, and the ends of the thread are extracted through the right lateral trocar, with their help traction of the cystic duct and neck of the gallbladder is performed, after which the cystic duct is incised, a tube of drainage of the cystic duct with an inner diameter is inserted through the right lateral laparoport less than 2 millimeters, which is in the trocar along with the ligature, fixing the cervical-cystic transition, then, manipulating the clamps through the epigastric and right medial laparoports, The cystic duct is intubated, the cystic duct drainage is fixed using an extracorporeal knot tying technique, after which intraoperative cholangiography is performed, the results of which determine the further volume of the surgical aid, and in the absence of calculi in the common bile duct and good contrast evacuation in the duodenum, the cholecyst is limited. , and when confirming the diagnosis of choledocholithiasis and the absence of contrast evacuation, they decide to expand the volume operations before choledocholithotomy is performed, after which the cystic artery is clipped and the gall bladder is removed by electrocoagulation, which is removed through the umbilical laparoport, the subhepatic space is drained by trapping drainage with an internal diameter of at least 5 millimeters, the trapping drainage standing in the subhepatic space is removed: discharge on the 2nd day, with a discharge rate of serous discharge within 20-30 milliliters - on the 3rd day, in the presence of discharge of a discharge of more than 2 00 milliliters of bile solve the issue of performing relaparoscopy.

The proposed method of laparoscopic cholecystectomy with intraoperative cholangiography can be used in healthcare institutions involved in minimally invasive surgery of gallstone disease to increase the effectiveness of this surgical intervention in patients with suspected choledocholithiasis.

The method can be illustrated by one example of the operations performed.

Patient S., 34 years old, medical history No. 3015, was treated at the surgical department of the Municipal Clinical Hospital No. 4 of Volgograd from 03.15.2010 to 03.3.2010 with a diagnosis of Gallstone disease. Chronic calculous cholecystitis. Arterial hypertension (symptomatic). H is 0.

Upon receipt, she complained of periodic dull pain in the right hypochondrium that occurs after eating. From the anamnesis of the disease, it was revealed that suffers from cholelithiasis for several years. Notes the increase in pain attacks in recent months. In this case, the last few attacks were accompanied by phenomena of obstructive jaundice. Objectively: the general condition is closer to relatively satisfactory. Consciousness is clear. Skin and visible mucous membranes of normal color. In the lungs, vesicular breathing. Heart sounds are rhythmic. HELL - 130/80 mm Hg Pulse - 78 per minute. The abdomen is of the usual configuration, it participates in breathing, on palpation it is soft, slightly painful with deep palpation in the right hypochondrium. The gall bladder is not palpable. Symptoms of Ortner, Murphy are negative. The pulsation of the abdominal aorta is determined. There are no peritoneal phenomena.

Clinical and instrumental examination: a survey radiography of the chest organs - without focal and infiltrative changes. Ultrasound of the abdominal cavity noted that the gallbladder is 95 × 28 mm in size, many small stones are determined in its lumen, the diameter of the common bile duct is 7-8 mm, the pancreas is not changed, and no other pathology was detected. ECG - sinus rhythm of 75 per minute. An increase in the level of bilirubin to 27.8 μmol / L was noted in the laboratory. Other laboratory data are within normal limits.

Based on the medical history, laboratory and instrumental data, it was decided to perform laparoscopic cholecystectomy with intraoperative cholangiography.

03/16/2001 13.20-15.00 operation number 79 (3875). Under ETH above the navel, pneumoperitoneum is applied. At typical points introduced trocars. During the audit, the liver is fine-grained, the gall bladder is 9 × 4 × 3 cm, is shrouded in an omentum. The diameter of hepatocholedoch is 8 mm. The joints around the gallbladder are bluntly and sharply divided. A cervical-cystic junction was isolated; in the neck, the gallbladder was bandaged using an extracorporeal node. The ligature is removed through the right lateral laparoport. The cystic duct is incised. A DPP tube was inserted through the right lateral laparoport, by which the cystic duct was intubated. The DPP tube is reinforced with an extracorporeal suture. Intraoperative cholangiography. On the picture: hepatocholedoch diameter is 5 mm, evacuation to the duodenum is good, the lumen is uniform. There is no need to leave drainage of the cystic duct. Dpp removed. The cystic duct is cut off. His stump is clipped. The cystic artery was isolated, clipped, and resected. The gall bladder is removed subserously by an electrocoagulator. The control for hemo- and bile duct disease is dry. Trapping drainage into the subhepatic space. Layered stitches for wounds.

A drug. The gall bladder is 9 × 4 × 3 cm., In the cavity there are many stones 4-5 mm in diameter. Histological examination No. 3327-28 - acute calculous cholecystitis.

The postoperative period was uneventful. Conservative therapy was performed. Skin sutures were removed on the 6th day. Postoperative wounds are clean, healed by primary intention. By the time of discharge, the level of blood bilirubin was - 13.6 μmol / l, other laboratory data are also within normal limits. Was discharged on the 7th day with the recommendation of an outpatient treatment by a surgeon.

Summarizing the results obtained, it should be noted that the proposed method of laparoscopic cholecystectomy with intubation of the cystic duct and intraoperative cholangiography allows the installation of cystic duct drainage and intraoperative cholangiography to be performed without special technical difficulties and to ensure, if necessary, the normal functioning of the cystic duct drainage in the postoperative period.

Bibliography

1. Bagloo M.B. Single-access laparoscopic cholecystectomy with routine intraoperative cholangiogram. / Bagloo M.B., Dakin G.F // Surg Endosc - 2010 .-- 10 P.533-535.

2. Corbitt J.D. Laparoscopic cholecystectomy with operative cholangiogram. / Corbitt J D., Cantwell D V. // Surg Laparosc Endosc - 1991 .-- V.1, P.229-332.

3. Fligelstone L.J. Laparoscopic operative cholangiography: a simple, successful, cost-effective method. / Fligelstone L.J., Foster M.E., Hay D. // Annals of the Royal College of Surgeons of England. - 1992. - V.74, P.252-253.

4. Flowers J.L. Laparoscopic Cholangiography. / Flowers J.L., Zucker K.A., Scott M. et al // Ann. Surg. - 1992. - V.215, P.209-216.

5. Hagan K.D. A new technique of laparoscopic cholangiography. / Hagan, K D., Rosemurgy, A S. // J Laparoendosc Surg. - 1992. - V.2, P.127-130.

6. Norman J. An easy approach to laparoscopic cholangiography. / Norman J., Haney M. // J Laparoendosc Surg. - 1993. - V.3, P.67-71.

7. Robertson GSM. Use of a metal cannula for peroperative cholangiography. / Robertson GSM, Bullen BR, Gourevitch A. // Br J Surg. - 1991. - V.78, P.426.

Claims (1)

A method of performing laparoscopic cholecystectomy with drainage of the cystic duct in patients with cholelithiasis, including intubation of the cystic duct with Holsted-Pikovsky drainage, performing intraoperative cholangiography and removal of the gallbladder, characterized in that according to the results of clinical, laboratory and instrumental examination, if the patient has in the anamnesis of gallstone disease, pain attacks in combination with the phenomena of transient obstructive jaundice, with laboratory parameters: ur bilirubin reindeer more than 20.5 μmol / l and ultrasound data: the presence of many bile stones with a diameter of less than 5 mm and a diameter of the common bile duct of more than 7 mm decide to perform surgical intervention in the volume of laparoscopic cholecystectomy with intubation and drainage of the cystic duct by Holsted-Pikovsky drainage and performing intraoperative cholangiography: 1 cm above the umbilical ring with a Veress needle, nitrous oxide is insufflated in the abdominal cavity, laparoscopy is performed and revision of the abdominal organs and isolation of the cystic duct of the artery and common bile duct - if within 1 h it is not possible to verify the cystic duct and artery, as well as elements of the hepatoduodenal ligament, then a decision is made to switch to laparotomy, and if it is possible to differentiate within 1 h the cystic duct and artery, as well as elements of the hepato-duodenal ligament, then decide to continue laparoscopic intervention, after which the distal part of the cystic duct is ligated using extracorporeal using the technique of knot formation, while the ends of the ligature, with which the cystic duct is ligated, are introduced into the abdominal cavity through a 10 mm trocar located in the epigastric region, the knot is formed and immersed into the abdominal cavity through the right medial 5 mm trocar, and the ends of the thread removed through the right lateral trocar and with their help traction of the cystic duct and neck of the gallbladder is carried out, after which the cystic duct is incised, a tube of drainage of the cystic duct with an internal diameter is inserted through the right lateral laparoport a troma of at least 2 mm, which is located in the trocar together with a ligature that fixes the cervical-cystic transition, then manipulating the clamps through the epigastric and right medial laparoports, the cystic duct is intubated, the cystic duct is drained by the extracorporeal knotting technique, and then the intraoperative cholangiography is performed , the results of which determine the further volume of surgical benefits, while in the absence of calculi in the common bile duct and good contrast evacuation in the duodenum, the operation is limited to cholecystectomy, and when the diagnosis of choledocholithiasis is confirmed and the contrast is not evacuated, a decision is made to expand the scope of the operation until choledocholithotomy is performed, then the cystic artery is clipped and the gall bladder is removed by electrocoagulation, which is removed through the umbilical laparoportal drainage, drainage with an internal diameter of at least 5 mm, trapping drainage standing in the subhepatic space is removed: in the absence of a discharge separated on the 2nd day, with indicators of a serous discharge separated within 20-30 mm - on the 3rd day, in the presence of a discharge separated by a volume of more than 200 mm of bile, the question of relaparoscopy is solved.