Progress of the cholecystectomy operation. Laparoscopy of the gallbladder (removal of stones or the entire organ by laparoscopic surgery) - advantages, indications and contraindications, preparation and progress of the operation, recovery and diet

Content

The gallbladder is one of the main elements of the digestive and excretory systems. It is responsible for the accumulation, storage and release of bile, which the body needs to digest food. Dysfunction of the gallbladder leads to the development of many diseases. Drug treatment and diet in most cases help solve this problem. But in case of pathologies, the patient’s condition can be alleviated in only one way - cholecystectomy.

What is cholecystectomy

In medicine, the term implies a surgical procedure to remove the gallbladder. Literally translated from Latin it means “removal of the bile bladder.” The first such operation was performed by a German surgeon in 1882. At that time, many patients suffered from cholelithiasis. Much has changed since that moment - now such a procedure is considered no more difficult than removing the appendix. After the operation, the patient returns to his previous lifestyle, subject to certain rules.

The principles of biliary tract surgery, identified in the distant 19th century, are relevant to this day. These include:

• Removal of the gallbladder is mandatory. If this is not done, stones may form again, and then the procedure will have to be repeated.
• During surgery, it is necessary to examine the bile ducts for the presence of stones in them.
• The fewer attacks of cholecystitis there were before the intervention of surgeons, the greater the chances of quickly returning to normal life.
• The skill of the surgeon plays an important role in the results of the intervention.

Doctors do not immediately move on to radical measures to remove the gallbladder. First, medication and diet are prescribed, some turn to folk medicine. If all these procedures do not bring any effect, it is better to resort to the help of surgeons. Timely and high-quality surgery will relieve painful attacks and help restore the previous level of quality of life.

When is the gallbladder removed?

Availability in biliary inflammation, stones big size, is the main indication for organ removal. The stones can be different - from sand to a formation the size of a chicken egg. In this case, operations to remove the gallbladder are divided into planned, urgent and emergency. Planned ones are the most preferred. The following diseases are relative indicators for surgical intervention:

• chronic calculous cholecystitis;
• asymptomatic cholelithiasis.

There is a group of indicators in which removal of the gallbladder is necessary. Absolute indications include:

• biliary colic - pain due to impaired flow of bile, often occurs during pregnancy;
• malignant formations;
• bile duct obstruction – inflammation of the bladder due to infection;
• polyposis – growth of the epithelial layer of the bladder mucosa over 10 mm;
• Pancreatitis is a blockage of the duct connecting the duodenum to the pancreas.

Types of surgery

The operation of cholecystectomy of the gallbladder can be performed by four methods: abdominal laparotomy, laparoscopy, mini-laparotomy, transluminal surgery. The surgeon decides which type to choose based on the following indications:

• nature of the disease;
• patient status;
• the presence of complications from the gallbladder and other body systems.

Laparotomy refers to the traditional type of removal of the gall sac. Its main advantages include full access and overview of the organ being removed. Such intervention is indicated in the presence of peritonitis or a large lesion of the biliary tract. The disadvantages are postoperative complications, a large incision, and long rehabilitation of the patient.

Endoscopic cholecystectomy or laparoscopy is today the most common minimally invasive type of surgical intervention. The advantages of the method are:

• low rates of trauma, blood loss and the risk of bacterial infection;
• short term hospital stay – 2-3 days;
• fast recovery;
• minimal effect of anesthesia;
• small postoperative scars.

This method has its drawbacks. They are as follows:

• An increase in pressure in the venous system from gas introduced into the abdominal cavity. It can cause complications with breathing problems and cardiovascular problems.
• Limited visibility of the organ being removed.
• Unjustified risk in the absence of pathologies or the presence of contraindications.

IN modern medicine Transluminal gallbladder removal surgery is already in use. This method uses human natural orifices - oral cavity, vagina. Another popular method is cosmetic laparotomy. It involves removing the organ through the umbilical opening using microscopic incisions. After this operation, invisible stitches remain.

Preparation

If a planned operation is prescribed, you need to know some features. Preparation for cholecystectomy begins at home. The doctor prescribes a special diet and laxatives for 3-4 days. It is necessary to stop taking medications that affect blood clotting. The same applies to food additives and vitamins. The patient should think about a list of personal items that will be needed in the hospital.

To determine the patient's condition and approve the surgical technique, preliminary diagnostic studies are carried out. After hospitalization, the doctor may prescribe:

1. Ultrasound of the abdominal organs and gall bladder.
2. Computed tomography for an accurate examination of the organ being removed.
3. MRI for a complete study of pathologies.
4. Laboratory tests - blood and urine tests to establish quantitative indicators of the condition of the gall sac.
5. Comprehensive examination cardiopulmonary system.

Immediately before the operation itself, certain rules must be followed. These include:

• the day before the procedure, you are allowed to eat light, lean meals;
• Eating food and liquids 8 hours before removal of the bladder is strictly prohibited;
• a cleansing enema is required at night and in the morning on the day of surgery;
• Before the procedure, it is advisable to take a shower using antibacterial detergents.

Diet before surgery

Before surgery, the patient needs to reduce the load on the liver and digestive system. Therefore, 14 days before surgery, it is recommended to follow some nutritional rules. Food should be taken 5-6 times a day in fractional portions. Alcohol and coffee are completely excluded. Fried, fatty, salty, and spicy foods are prohibited for consumption.

Vegetable foods are allowed - liquid porridges, vegetable broths, herbal tea. Restrictions are tightened 3 days before the bubble is removed. Products that promote increased gas formation in the intestines are prohibited:

• black bread;
• carbonated drinks;
• legumes;
• foods high in fiber;
• kvass;
• fermented milk products.

How to remove the gallbladder

Surgeries to remove the gallbladder are performed only by qualified specialists. After all, the outcome of the procedure largely depends on the knowledge and skills of the surgeon. Deciding on the method of removing the bile bag rests almost entirely with the doctor. If possible, the patient's wishes are also taken into account. In this case, the psychological mood of the patient is very important.

Open cholecystectomy

The operation using the classical technique is performed under general anesthesia. Using local anesthesia is dangerous. At the beginning of the procedure, the surgeon makes a 20-30 cm incision in the abdomen along the midline from the navel to the sternum or under the costal arch on the right. There is extensive access to the organ being removed. Then it is separated from the fatty tissue and tied with surgical thread. At the same time, special clips are used to clamp the cystic arteries, bile ducts, and blood vessels.

Next, the bubble is excised. The nearby area is being surveyed for the presence of stones. A drainage tube is inserted into the common bile duct to drain fluid and ichor to avoid possible inflammation. Using a laser, liver bleeding is stopped. Using suture material, the surgical wound is closed. The entire procedure takes on average 1-2 hours.

Laparoscopic cholecystectomy

During laparoscopy, endotracheal (general) anesthesia is used. The patient is intubated and connected to a ventilator. This need is due to the fact that when general anesthesia All organs relax, including the diaphragm. The main instrument used is trocars - thin devices that move tissue apart. First, the surgeon uses trocars to make 4 punctures in abdominal wall– 2 x 5 cm, 2 x 10 cm. An endoscope, a miniature video camera, is inserted into one of the holes.

Next, the abdominal cavity is filled with gas - carbon dioxide. This action expands the surgeon's field of vision. Manipulators are inserted into the remaining punctures to clip the arteries and vessels of the bladder. Then the diseased organ is cut off and drainage is installed. The surgeon must perform a cholangiography - check the bile duct for any abnormalities. After this, the instruments are removed, large punctures are subject to suturing, small punctures are sealed with adhesive tape. The wound is treated with antiseptics.

Recovery after gallbladder removal

After operation open method, the patient is sent to the ward intensive care, and after waking up from anesthesia - to the general ward. After laparoscopy, there is no need for intensive care. The patient goes home the next day if there are no complications. For subsequent rehabilitation, it is important to follow all instructions prescribed by the attending physician. Recommendations include:

• diet;
• use of painkillers;
• care postoperative wound;
• compliance with the norm of physical activity.

Diet

An important component of the treatment and recovery period is diet. Main aspects of dietary nutrition:

1. The first 4-6 hours after removal - do not drink, only wet your lips.
2. After 5-6 hours, rinse your mouth with a small amount of water.
3. After 12 hours - water without gases in small sips at intervals of 20 minutes, volume - no more than 500 ml
4. On the second day - low-fat kefir, tea without sugar - half a glass every 3 hours, no more than 1.5 liters.
5. On days 3-4 – liquid mashed potatoes, grated soup, egg white omelette, steamed fish. Drink – sweet tea, pumpkin, apple juice.

Dietary nutrition should be followed for 6 months after removal of the gallbladder. Food should be taken at least 6 times a day, in portions of 150-200 g. This is due to the fact that in the absence of a reservoir, bile will be constantly released. To consume it, the process of digesting food is necessary. It is especially important to monitor the diet of overweight people suffering from constipation.

Treatment

After removal of the gallbladder, the patient is prescribed medical supplies. The patient may experience discomfort, decreased performance, and pain in the right hypochondrium. This is due to the fact that the regeneration process begins in the abdominal cavity, and additional stress is placed on the organs of the digestive system. Problems manifest themselves in the form of stool disorders and dyspeptic disorders. All complications that arise after surgery are called “postcholecystectomy syndrome.”

To relieve postoperative symptoms, medications are selected. They are divided into several groups:

• antispasmodics (Drotaverine, No-shpa);
• antibiotics (Ceftriaxone, Streptomycin);
• analgesics (bencyclane, hyoscine butyl bromide);
• enzymes (Creon, Mezim);
• hepatoprotectors (Phosphogliv, Hepatosan);
• choleretic (Allohol, Odeston).

Caring for a postoperative wound will prevent the possible consequences of its suppuration. It is necessary to wash it once a day with an antiseptic solution or soap and warm water, then bandage it with a clean bandage. After a week, you can take a shower, after covering the wound with a plastic bag. But you will have to give up baths, swimming pools, and saunas for at least 30 days.

Physical activity after surgery to remove the gallbladder should be present, but within the limits recommended by the doctor. Compliance with the instructions will not only preserve health, but also improve the patient’s quality of life. These tips include:

• lifting weights weighing no more than 3 kg;
• gymnastics to eliminate pain for 5-7 minutes without strain;
• daily walks 10-15 minutes.

Complications of cholecystectomy

After surgical intervention there is a risk of complications. According to statistics, they occur in 10% of postoperative patients. This is due to many factors - the qualifications of the surgeon, the presence of concomitant diseases, the age of the patient, and the individual characteristics of the body. Complications are divided into types:

• early
• late
• postoperative.

A possible consequence after open surgery is the formation of adhesions. This often occurs with cholangitis, acute cholecystitis. The main complications include:

• leakage of bile;
• infection postoperative suture;
• swelling of the wound;
• vascular thrombosis;
• allergic reactions;
• internal and secondary bleeding;
• exacerbation of pancreatitis;
• abscess;
• pneumonia;
• pleurisy.

Price

Urgent removal of the gallbladder is carried out free of charge, under a medical policy. Data on the cost of paid operations in the Moscow region are given in the table:

Name of the medical center	Type of surgery/Price, rubles
	open	laparoscopy	Minimally invasive
"On Clinic"
"Capital"
"Family"
"Best Clinic"
Scientific and Practical Center for Surgery
"European Medical Center"
Multidisciplinary medical center
Central Clinical Hospital No. 2 named after. ON THE. Semashko

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Attention! The information presented in the article is for informational purposes only. The materials in the article do not encourage self-treatment. Only a qualified doctor can make a diagnosis and give treatment recommendations based on the individual characteristics of a particular patient.

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Laparoscopic cholecystectomy: experience of 3165 operations
Yu.I. GALLINGER, V.I. KARPENKOVA
Russian Scientific Center for Surgery named after. B.V. Petrovsky RAMS, Moscow.

A detailed analysis of 3165 laparoscopic cholecystectomy (LCE) operations and their complications performed over 15 years was carried out.

It is concluded that during this period LCE has become the operation of choice for patients with benign diseases of the gallbladder, and the key to successful LCE is good technical equipment in the operating room, highly professional training of surgeons performing laparoscopic operations, thorough preoperative examination of patients, strict adherence to the rules for performing laparoscopic operations, as well as careful postoperative monitoring of patients.

Key words: laparoscopic cholecystectomy, intraoperative complications, postoperative complications.

Currently, laparoscopic cholecystectomy (LCE) is performed for most large multidisciplinary medical institutions became normal operation. However, the widespread introduction of this intervention in city and even district hospitals has led to a significant increase in the number severe complications(trauma of extrahepatic bile ducts, hollow organs and large vessels of the abdominal cavity) and transition to open surgery, often associated with complications.

In addition, in recent years there has been a significant expansion of indications for LCE. During the period of introduction of LCE into clinical practice, such concomitant diseases as heart defects with hemodynamic disturbances, chronic form coronary disease heart - coronary artery disease (angina pectoris of low exertion and rest), arterial hypertension (AH) II B, cardiac arrhythmias, hormone-dependent bronchial asthma(BA), high and extreme obesity, acute cholecystitis, choledocholithiasis and some others, as well as conditions after operations on the upper floor of the abdominal cavity were considered a contraindication to performing this operation.

Recently, publications about successfully performed operations for similar diseases and conditions have become increasingly common.

Materials and methods
From January 1991 to January 2006, 3165 LCEs were performed. 3069 (97%) operations were performed laparoscopically, 96 (3%) were completed laparotomy. In 2978 (94%) patients, the reason for the operation was chronic calculous cholecystitis (complicated in 11% of cases by empyema or hydrocele of the gallbladder), in 39 - acute calculous cholecystitis, in 128 - polyposis of the gallbladder, in 20 - chronic acalculous cholecystitis.

The patients were aged from 11 to 87 years, the majority were patients of the most working age - from 30 to 60 years, older patients age group(from 61 to 87 years) were 23.8%. At the time of surgery, 1/4 of the patients had severe concomitant pathology: 48 patients had a heart defect (5 had an atrial septal defect, 14 had combined and combined heart defects, 24 had mitral valve, 5 - aortic valve defects); Of these, 16 had previously undergone operations to correct defects, and 3 patients were operated on three times. About 500 patients at the time of the operation were under constant or periodic treatment for coronary artery disease, angina pectoris of moderate, low exertion and rest, hypertension stages 2 A and 2 B. 16 patients suffered myocardial infarction (MI) (three - twice).

Coronary artery bypass grafting (CABG) was performed in 8 patients. Severe heart rhythm disturbances were present in 12 patients (paroxysmal tachycardia in 7, atrial fibrillation in 3, Wolff-Parkinson-White syndrome in 2); cardiomyopathy - in 1 and myocardial dystrophy - in 1 patient. One patient underwent heart transplantation for dilated cardiomyopathy six months before LCE; another patient had a cardiac myxoma removed. At the time of surgery, one patient was diagnosed with an aneurysm of the abdominal aorta, and in 2 patients, an aneurysmal enlargement of the same section of the aorta. In 5 patients, blood changes were detected in the preoperative period: thrombocytopenia, von Willebrand disease, hypocoagulation syndrome, refractory anemia due to secondary myelodystrophic syndrome and anemia of unknown etiology. Hormone-dependent asthma was present in 20 patients, chronic pneumonia - in 2. Two patients had previously undergone surgery on the trachea (for tracheal stenosis after CABG) and larynx (for a laryngeal tumor). Three patients were on chronic dialysis for chronic renal failure. In addition, among the patients whom we operated on between 1991 and 2006, 305 (10%) were diagnosed with grade III-IV obesity: 291 - grade III, 14 - grade IV. For the majority of these patients, it was necessary to decide on the method of cholecystectomy and only after additional examinations (and in a number of patients - after drug therapy) it was decided to perform the operation laparoscopically.

Features of the implementation of individual stages of the intervention.
Anesthesia in most cases when performing LCE is intubation anesthesia with the use of muscle relaxants of moderate and short acting. In some cases, mask anesthesia was used with mandatory injection into the stomach nasogastric tube. To carry out the endoscopic operation, equipment from the companies “Karl Storz”, “Olympus”, instruments from the companies “Karl Storz”, “Olympus”, “Wing”, “Tet”, “Axioma”, “Medpharmservice” and some others were used. LCE in most cases was performed according to the standard technique, using 4 trocars (2 - 11- and 2 - 6-mm), in a position where the surgeon stands between the patient’s legs. Only in 7 patients of asthenic constitution, with a small volume of the abdominal cavity, without adhesions around the gallbladder, we found it possible to perform an operation of three punctures. In patients with an enlarged size of the left lobe of the liver, which covered the surgical area, as well as with a significant volume of the greater omentum, which “floated” onto the area of ​​the gallbladder neck and interfered with the operation, we had to introduce an additional 5th trocar. In most cases, these were patients with grade III-IV obesity.

As we gained experience, we changed the conditions for performing and some technical techniques for laparoscopic interventions on the gallbladder. Thus, for the last 5 years, when performing any laparoscopic interventions, we have been using large-format anterolateral 30-degree optics. This allowed us to operate on patients at an intra-abdominal pressure of 8-10 mm Hg, and, if necessary, to perform surgery at a pressure of 6-8 mm Hg, which significantly facilitates the course of the postoperative period and minimizes the risk associated with anesthesia, and thromboembolic complications in patients with concomitant cardiopulmonary pathology. In addition, the use of 30-degree optics simplifies the procedure for examining the pelvic organs and, most importantly, significantly facilitates the identification of elements of the gallbladder neck with pronounced scar-infiltrative changes in this area and in obese patients. In almost all operations, atraumatic clamps were used, which made it possible to avoid unnecessary trauma to organs and tissues and, as a consequence, hemorrhage and perforation.

With pronounced inflammatory phenomena in the area of ​​Calot's triangle, for better visualization of the elements of the gallbladder neck and the common bile duct (CBD), the technique of “drying” with a tupper began to be more often used. In the last 5 years, it has become more common to complete the operation by draining the suprahepatic and/or subhepatic space (in 35% of patients compared to 24-28% in the first 10 years). In addition, if in the first years graduates were placed in a paraumbilical wound extremely rarely, then recently (4 years) we use them in 45-50% of patients. These measures made it possible to minimize the percentage of purulent-inflammatory complications both in the abdominal cavity and in the area of ​​the paraumbilical wound.

Results and discussion
During laparoscopic intervention, 96 (3.4%) patients had to switch to surgery from the laparotomic approach. The reason for switching to laparotomy in 62 patients was a pronounced cicatricial adhesive process around the gallbladder or in the area of ​​its neck, in 15 patients there was a suspicion of bilio-biliary or biliodigestive fistulas, in 6 - choledocholithiasis, the assumption of which arose only during laparoscopic surgery. interventions. In 9 patients, the indications for laparotomy were a pronounced adhesive process in the abdominal cavity (in 5 patients), bile leakage from the bed (in 1), doubts when clipping elements of the neck of the gallbladder (in 1), mesenteric tumor (in 1), technical problems (in 1). In only 4 patients, the reason for changing the method of intervention was diagnosed intraoperative complications: in 2 cases - injury to the extrahepatic bile ducts, in 1 - bleeding from a large vessel of the liver in the area of ​​the gallbladder bed, in 1 - bleeding from the vessels of the round ligament.

We observed severe intraoperative complications (29) in 28 (0.88%) patients. Among them, the most severe category is 10 patients with injury to the extrahepatic bile ducts. Damage at the level of the common hepatic duct or CBD was noted in 8 (0.25%) patients. The main reasons for this complication were the surgeon’s insufficient identification of the intrahepatic part of the CBD (4 cases), persistent attempts to perform the operation laparoscopically in conditions of a pronounced adhesive process in the area of ​​the hepatoduodenal ligament (3 cases), an attempt to stop bleeding from the cystic artery through prolonged coagulation and clipping in conditions of poor visibility (1 case). Of the 8 cases, in 5 the injury was at the level of the common hepatic duct, in 3 - at the level of the CBD. By nature, these injuries were distributed as follows: complete intersection of the common duct - in 4 patients, partial intersection - in 2, complete closure of the CBD lumen with clips - in 1, combined injury (complete closure of the CBD lumen with clips and coagulation of the wall of the common hepatic duct) - in 1 Only in 2 cases a complication was noticed during laparoscopic intervention. In both cases, the operation was continued from the laparotomy approach. In 6 cases, the complication was diagnosed only a few days after the appearance of clinical signs of biliary peritonitis or obstructive jaundice. These patients underwent surgery via laparotomy within a period of 2 to 6 days, in two cases with preliminary relaparoscopy. In another 2 (0.07%) patients, when the cystic duct was isolated from dense adhesions, it was perforated below the level of the then applied clip. In one case, a defect in the wall of the cystic duct at the level of its entry into the intrahepatic part of the CBD was noticed during LCE and a decision was made to continue the operation by laparotomy, during which a separate suture was placed on the duct. In another case, undetected damage to the wall of the cystic duct below the clip in the postoperative period led to the development of peritonitis and a repeat operation by laparotomy. In our practice, there were 3 (0.1%) cases of bleeding from the cystic artery. Blood loss in all cases ranged from 200 to 400 ml. All of them were stopped by laparoscopic manipulations. In one case, the surgeon's desire to achieve hemostasis laparoscopically led to CBD injury.

We regarded bleeding from the liver tissue as a severe complication in only 2 (0.07%) patients. In one case, diffuse bleeding from the liver tissue in the area of ​​the gallbladder bed that could not be stopped for a long time by coagulation led to the formation of a subhepatic infiltrate in the postoperative period. In another case, we encountered massive (up to 400 ml) bleeding from an injured vessel in the upper third of the gallbladder bed, which could not be stopped by laparoscopic manipulations, which required emergency laparotomy. In another patient, during LCE, the capsule of a hemangioma adjacent to the gallbladder was accidentally perforated, which led to massive bleeding (blood loss of 350-400 ml), which was stopped by laparoscopic measures only after 30 minutes (total operation time 85 minutes). During LCE, one patient experienced quite intense bleeding from the round ligament of the liver, injured by the stylet of a 10-mm trocar. And, although hemostasis was achieved by laparoscopic manipulations, due to doubts about its reliability, it was decided to continue the operation from the laparotomic approach. In 9 (0.29%) patients, bleeding from wounds in the area of ​​the epigastric trocar was so intense that to stop it it was necessary to widen the skin incisions and suturing the bleeding vessels. In our entire practice, we encountered such a complication as pinpoint perforation in only 1 patient small intestine which arose during suturing of the aponeurosis in the area of ​​the paraumbilical wound, during the operation the suture was removed from the aponeurosis and the hole in the intestine was sutured with separate gray-serous and Z-shaped sutures. Among the most severe intraoperative therapeutic complications, in 2 (0.07%) cases we encountered a critical impairment of cardiac activity during LCE. In the first case, in a patient who had previously undergone a heart transplant, at the stage of applying pneumoperitoneum above 8 mm Hg. Asystole occurred twice, accompanied by a critical drop in blood pressure (BP). This was probably due to the reaction of the denervated heart to a decrease in blood flow through the inferior vena cava due to its compression when the level of pneumoperitoneum increased more than 8 mm Hg. and changing its position. After the elimination of pneumoperitoneum and the introduction of cardiotonics, cardiac activity was restored and the operation was performed laparoscopically at a pneumoperitoneum level of 6-7 mm Hg. In another case, despite therapy in the preoperative period, an elderly patient with hypertension and tachyform atrial fibrillation At the stage of gallbladder release, cardiac arrest occurred. Resuscitation measures were ineffective and the patient died. Severe postoperative complications (17) were noted in 16 (0.53%) patients: subhepatic abscesses - in 4, subhepatic infiltrate - in 6, limited peritonitis - in 2, bleeding from the liver tissue - in 2, parietal entrapment of the small intestine - in 1, myocardial infarction - in 2. Two patients were operated on on the 2nd and 3rd days after LCE due to an increasing clinical picture of peritonitis. In the first case, during LCE, the release of the gallbladder was complicated by a scarring process in the area of ​​its bed, accompanied by perforation of the bladder with leakage of bile, which necessitated washing of the subhepatic space. Appearance clinical picture peritonitis on the 3rd day, in our opinion, was due to the fact that during the operation the washing liquid with bile was not completely evacuated, and no drainage was left in the abdominal cavity. Subsequently, despite lavage of the abdominal cavity and its drainage, performed during relaparoscopy, and treatment with antibacterial drugs, the patient developed multiple liver abscesses, which necessitated long-term intensive care. In the second case, the development of the clinical picture of peritonitis on the 2nd day after LCE was associated with the opening of an old postoperative interintestinal abscess (the patient had previously undergone surgery on the lower floor of the abdominal cavity) during the application of pneumoperitoneum and the entry of purulent contents into the free abdominal cavity. The patient underwent drainage of the abscess and abdominal cavity from a laparotomy approach. In another 3 (0.1%) patients, in the period from 2 days to 2 months after LCE, liver abscesses were detected, which in 2 cases were drained by minilaparotomy, in 1 - under ultrasound control. The reason for them was early removal of drains and cessation of antibacterial therapy. Bleeding from the liver tissue occurred on the 1st day after surgery in 2 patients. In one case, there was mild bleeding from the liver tissue in the area of ​​the gallbladder bed, which was expressed only in the flow of a small amount (up to 30 ml per day) of hemorrhagic contents through the drainage. Hemostasis in this case was achieved by conservative measures. In the second patient, the bleeding from the liver wound was so active that it was accompanied not only by an intense flow of fresh blood through the drainage, but also sharp decline blood pressure, as well as a decrease in hemoglobin levels and the number of red blood cells in the peripheral blood. In this case, an emergency laparotomy was performed, during which a liver tissue injury was discovered in the area of ​​the epigastric trocar. The liver wound was sutured and the abdominal cavity was drained. One patient with grade III obesity developed a picture of intestinal paresis in the postoperative period, which was caused, as it turned out later, by strangulation of the small intestine in the sutures placed on the aponeurosis in the paraumbilical wound. On the 2nd day after LCE, she underwent relaparoscopy for diagnostic purposes, during which no reasons for paresis were identified, and on the 4th day, due to increasing intestinal obstruction, a laparotomy was performed, which made it possible to establish the diagnosis. In 2 (0.07%) patients, willful violation of bed rest on the 1st day (both repeatedly walked along the corridor and up the flights of stairs) after successfully performed LCE against the background of existing ischemic heart disease and hypertension led to the development of myocardial infarction with a favorable outcome after treatment. The duration of the operations ranged from 15 minutes to 190 minutes, while 15-minute operations were represented by interventions on the so-called blue bubbles, which were performed by experienced surgeons. Operations that last more than an hour, as a rule, are technically complex, often performed in patients with complex anatomy in the area of ​​the hepatoduodenal ligament, with symptoms of pronounced adhesions around the gallbladder or its acute inflammation, are accompanied by diffuse bleeding, perforation of the gallbladder with leakage of bile , loss of stones, etc. The postoperative period was successful in most patients. By the end of the 1st day, they were allowed to get up and walk around the ward, while being recommended to wear a postoperative bandage. On the 1st day they were allowed to drink small sips of still mineral water in limited quantities (250-300 ml), on the 2nd and 3rd days - up to 1.5 liters of liquid, a “second” broth, low-fat yoghurts, semi-liquid porridge or mashed potatoes and then a gradual expansion of the 5-5A diet with the recommendation of following it for 1.5-2 months. In the first years, we observed patients in the hospital after surgery for 6-8 days; in the last few years, patients have been discharged on the 3-5th day after surgery with the condition that if they have the slightest doubt about their well-being, they should call or come to the clinic. Since 1996, we have noted a steady trend towards a decrease in the number of patients hospitalized for laparoscopic operations at the Russian Scientific Center for Surgery of the Russian Academy of Medical Sciences from 333 (in 1991-1995. ) to 166 (in 1999-2005). In our opinion, this is due to the widespread use of the laparoscopic method in clinical regional surgery and the so-called free treatment, when there is an outflow of patients from large multidisciplinary medical institutions. This situation has both positive aspects (availability, “free”) and negative ones - just during these years, many publications appeared on severe intraoperative injuries (trauma of the extrahepatic bile ducts, bleeding from the cystic artery, trauma to large vessels and abdominal organs, etc.). ), and late postoperative (CB strictures, subhepatic abscesses, hernias and ligature fistulas in the area of ​​the paraumbilical wound, etc.) complications. The percentage of severe complications over the course of 15 years (from the moment the first operation was performed) at the Russian Scientific Center for Surgery of the Russian Academy of Medical Sciences fluctuates very slightly, but is steadily decreasing. Thus, in the period from 1991 to 1995, when 3 surgeons were actively operating, there were 59 (3.5%) conversions to laparotomy out of 1667 operations performed. In 15 patients, 16 (0.96%) severe intraoperative complications were observed, of which 5 (0.29%) were CBD injuries. Severe postoperative complications (10, or 0.6%) occurred in 9 patients. In the period from 1996 to 2005 inclusive, 1498 operations were performed (two surgeons operated), the transition to laparotomy was in 37 (2.47%) cases, severe intraoperative complications were observed in 13 (0.86%) patients, of which 3 (0.2%) - CBD injuries, 6 (0.4%) - severe postoperative complications. Thus, there was a decrease in the frequency of transitions to laparotomy by 1%, the frequency of intraoperative complications by 0.1%, postoperative complications- by 0.2%. Such an insignificant at first glance decrease in the main “negative” indicators of any operation, in our opinion, is due to the fact that initially these indicators are small, and behind every hundredth of a percent there is someone’s life.

conclusions
Over the past 15 years since the first operation was performed at the Russian Research Center for Surgery of the Russian Academy of Medical Sciences, LCE has become the operation of choice for patients with benign diseases of the gallbladder. Good technical equipment of the operating room, highly professional training of surgeons performing laparoscopic operations, thorough preoperative examination, strict adherence to the rules for performing laparoscopic operations, and mandatory postoperative observation of patients are the key to successful LCE.
LITERATURE
1. 50 lectures on surgery. Ed. V.S. Savelyeva. M 2004; 366-372.
2. Carroll B.J., Chandra M., Phillips E.H., Margulies D.R. Laparoscopic cholecystectomy in critically ill cardiac patients. Ann Surg 1993; 59: 12: 783-785.
3. Langrehr J.M., Schmidt S.C., Raakow R. et al. Bile duct injuries after laparoscopic and conventional cholecystectomy: operative repair and long-term outcome. Abstract book. 10 International Congress European Association for Endoscopic Surgery. Lisboa 2002; 155.
4. Amelina M.A. Laparoscopic cholecystectomy in patients with grade 3-4 obesity: Abstract of thesis. dis. ...cand. Med Sci 2005; 24.
5. Lutsevich O.E. Diagnostic and operative laparoscopy for diseases and injuries of the abdominal organs: Dis. ...Dr. med. Sciences 1993; 36.
6. Gallinger Yu.I., Timoshin A.D. Laparoscopic cholecystectomy. Practical guide. M 1992; 20-49.
ENDOSCOPIC SURGERY, 2, 2007 Media Sfera Publishing House

A large number of publications in periodicals and well-known authoritative monographs are devoted to traditional cholecystectomy and the results of its use. Therefore, let us only briefly recall the main provisions of the problem under consideration.

Indications: any form of cholelithiasis requiring surgical treatment.

Anesthesia: modern multicomponent endotracheal anesthesia.

Accesses: upper median laparotomy, oblique transverse and oblique subcostal incisions of Kocher, Fedorov, Biven-Herzen, etc. At the same time, wide access to the gallbladder, extra-biliary tract, liver, pancreas, and duodenum is provided. It is possible to examine and palpate almost all organs of the abdominal cavity and retroperitoneal space.

The entire program of intraoperative revision of the extrahepatic bile ducts is feasible:

• inspection and measurement of the outer diameter of the common hepatic duct and CBD;
• palpation of the supraduodenal and (after using the Kocher maneuver) retroduodenal and intrapancreatic sections of the CBD;
• transillumination of the supraduodenal CBD;
• IOCG;
• IOUS;
• choledochotomy with IOCG, study terminal department CBD with calibrated bougies, cholangiomanometry; Any options for completing choledochotomy are possible, depending on the specific clinical situation and the resulting indications;
• when using traditional access, it is possible to perform combined (simultaneous) surgical interventions;
• traditional cholecystectomy is the safest method of surgery in the presence of severe inflammatory or scar changes in the subhepatic region, in the area of ​​Calot's triangle and hepatoduodenal ligament.

Disadvantages of the method:

• moderate surgical trauma leading to the development of the catabolic phase of the postoperative period, intestinal paresis, and dysfunction external respiration, limitation physical activity sick;
• significant trauma to the structures of the anterior abdominal wall (with some access options, disruption of the blood supply and innervation of the muscles of the anterior abdominal wall), a significant number of early and late wound complications, in particular postoperative ventral hernias;
• significant cosmetic defect;
• long period of post-anesthesia and postoperative rehabilitation and disability.

Video laparoscopic cholecystectomy

Fundamentally, the indications for laparoscopic cholecystectomy should not differ from the indications for traditional cholecystectomy, because the task of these operations is the same; removal of the gallbladder. However, the use of laparoscopic cholecystectomy has a number of limitations.

Indications:

• chronic calculous cholecystitis;
• gallbladder cholesterosis, gallbladder polyposis;
• asymptomatic cholecystolithiasis;
• acute cholecystitis (up to 48 hours from the onset of the disease);
• chronic acalculous cholecystitis.

Contraindications:

• severe cardiopulmonary disorders;
• uncorrectable blood clotting disorders;
• diffuse peritonitis;
• inflammatory changes in the anterior abdominal wall;
• late stages of pregnancy (II-III trimester);
• obesity degree IV;
• acute cholecystitis after 48 hours from the onset of the disease;
• pronounced scar-inflammatory changes in the neck of the gallbladder and hepatoduodenal ligament;
• obstructive jaundice;
• acute pancreatitis;
• bilio-digestive and bilio-biliary fistulas;
• gallbladder cancer;
• previous operations on the upper floor of the abdominal cavity.

It should be said that the listed contraindications are quite relative: contraindications to the application of pneumoperitoneum are leveled by performing laparoscopic cholecystectomy with low intra-abdominal pressure or gas-free lifting technologies; improvement of operating techniques makes it possible to operate quite safely in cases of severe cicatricial and inflammatory changes, Mirizzi syndrome, and biliodigestive fistulas. More and more information is emerging about the possibilities of video laparoscopic surgeries on the CBD. Thus, the improvement of surgical techniques and the emergence of new technologies and instruments significantly reduce the list possible contraindications. The subjective factor is very important: the surgeon himself must make a decision, answering the question whether he is able and to what extent is it justified to use laparoscopic cholecystectomy in this particular clinical situation or are other surgical options safer?

During laparoscopic cholecystectomy, it may be necessary to switch to a traditional operation (conversion). Such operations are most often resorted to in case of detection of inflammatory infiltrate, dense adhesions, internal fistulas, unclear location of anatomical structures, impossibility of performing choledocholithotomy, intraoperative complications (damage to the vessels of the abdominal wall, bleeding from the cystic artery, perforation of a hollow organ, damage to the common hepatic duct and CBD, etc.), the elimination of which is not possible during laparoscopic surgery. There may also be technical malfunctions of the equipment that require a transition to traditional operation. The conversion rate ranges from 0.1 to 20% (planned surgery - up to 10%, emergency surgery - up to 20%).

Prognostic factors appear to be extremely useful in terms of the possible conversion of laparoscopic cholecystectomy to traditional cholecystectomy. It is believed that the most reliable risk factors are acute destructive cholecystitis, significant thickening of the walls of the gallbladder according to ultrasound, pronounced leukocytosis and increased levels of alkaline phosphatase. If the patient does not have any of the four listed risk criteria (factors), then the probability of a possible transition to traditional surgery is 1.5%, but it increases to 25% or more if all of the above prognostically unfavorable factors are present.

At the same time, a thorough preoperative examination, correct determination of indications for surgery, careful consideration of possible contraindications in each specific case, as well as high qualifications of surgeons performing laparoscopic interventions lead to a significant reduction in the proportion of inverted operations.

Pain relief is extremely important point during laparoscopic cholecystectomy. General anesthesia with tracheal intubation and the use of muscle relaxants is used. The anesthesiologist must understand that good muscle relaxation and the proper level of anesthesia. Decreased depth of neuromuscular block and level of anesthesia, appearance of independent movements of the diaphragm, restoration of peristalsis, etc. not only makes visual control in the operating area difficult, but can also cause severe damage to the abdominal organs. It is mandatory to insert a probe into the stomach after tracheal intubation.

Organization and technique of performing the main stages of laparoscopic cholecystectomy

The list of main devices used to perform laparoscopic cholecystectomy includes:

• monitor with color image;
• lighting source with automatic and manual adjustment of light intensity;
• automatic insufflator;
• electrosurgical unit;
• device for aspiration and injection of liquid.

The following tools are usually used to perform the operation:

• trocars (usually four);
• laparoscopic clamps (“soft”, “hard”);
• scissors;
• electrosurgical hook and spatula;
• applicator for applying clips.

The operating team consists of three surgeons (an operator and two assistants), an operating nurse. It is advisable to have an operating nurse present to control the light source, electrical unit, insufflator, and flushing system.

The main stages of the operation are performed with the head end of the table raised by 20-25° and tilted to the left by 15-20“. If the patient lies on his back with his legs brought together, the surgeon and the camera are to his left. If the patient lies on his back with his legs apart, the surgeon is located on the side of the perineum.

Most operators use four main points for inserting trocars into the abdominal cavity:

1. “umbilical” directly above or below the navel;
2. “epigastric” 2-3 cm below the xiphoid process in the midline;
3. along the anterior axillary line 3-5 cm below the costal arch;
4. along the midclavicular line 2-4 cm below the right costal arch.

Main stages of laparoscopic cholecystectomy:

• creation of pneumoperitoneum;
• introduction of the first and manipulation trocars;
• isolation of the cystic artery and cystic duct;
• clipping and intersection of the cystic duct and artery;
• separation of the gallbladder from the liver;
• removal of the gallbladder from the abdominal cavity;
• control of hemo- and bile stasis, drainage of the abdominal cavity.

Video laparoscopic surgery allows for inspection and instrumental palpation of the abdominal organs, and for performing cholecystectomy at a sufficient level of safety. In a highly qualified and well-equipped surgical hospital, if there are indications, it is possible to implement a program of intraoperative examination and sanitation in the non-hepatic biliary tract:

• carry out inspection and measurement of the outer diameter of the supraduodenal part of the CBD;
• perform IOCG;
• perform IOUS;
• carry out intraoperative inspection of the extrahepatic bile ducts and fibrocholedochoscopy through the cystic duct, removal of stones;
• perform choledochotomy, study of the CBD and hepatic ducts with special biliary balloon catheters and baskets, fibrocholedochoscopy, removal of stones;
• perform antegrade transductal sphincterotomy, ampullary balloon dilatation.

Videolaparoscopic techniques make it possible to complete choledochotomy with a primary duct suture, external drainage or choledochoduodenoanastomosis. It should be emphasized that laparoscopic surgeries on the CBD are feasible, but are far from easy to perform and cannot be regarded as generally available. They should only be performed in specialized departments.

Laparoscopic cholecystectomy has firmly gained a leading place in the surgery of the extrahepatic biliary tract, with the number of operations in some surgical teams exceeding several thousand. At the same time, it is very significant that at almost all recent international and Russian surgical forums one of the issues on the agenda was complications of laparoscopic cholecystectomy.

The main causes of complications of laparoscopic cholecystectomy

The body's response to tension pneumoperitoneum:

• thrombotic complications - phlebothrombosis in the lower extremities and pelvis with the risk of developing pulmonary embolism. Any surgical intervention leads to hypercoagulation, but with laparoscopic cholecystectomy, increased intra-abdominal pressure, the position of the patient with the head end raised, and in some cases the long duration of the operation have additional pathological significance;
• restriction of lung excursion with pneumoperitoneum;
• reflex inhibition of the motor function of the diaphragm in the postoperative period due to its overstretching;
• negative impact of absorbed carbon dioxide;
• decreased cardiac output due to decreased venous return to the heart due to blood deposition in the veins of the lower extremities and pelvis;
• disturbances of microcirculation of the abdominal organs due to compression during pneumoperitoneum;
• disturbances of portal blood flow.

The listed pathological reactions of the body to an increase in intra-abdominal pressure when carboxyperitoneum is applied with standard LCE within 60 minutes are minimally expressed or can be easily corrected by an anesthesiologist. However, their severity and danger increase significantly with prolonged surgery. Therefore, laparoscopic cholecystectomy lasting more than two hours should hardly be considered a minimally invasive procedure.

Complications caused by the need to apply pneumoperitoneum can be divided into two main groups:

• associated with extraperitoneal gas injection;
• associated with mechanical damage to various anatomical structures.

Insufflation of gas into the subcutaneous tissue, preperitoneal tissue, and into the tissue of the greater omentum does not pose a serious danger. If a vessel is accidentally punctured and gas enters the venous system, a massive gas embolism may follow.

Among mechanical damage, the most dangerous are damage to large vessels and hollow organs. Their frequency during laparoscopic cholecystectomy ranges from 0.14 to 2.0%. Trauma to the vessels of the anterior abdominal wall and the formation of a hematoma or intra-abdominal bleeding are diagnosed during laparoscopy and do not pose a threat to the patient’s life; trauma to the aorta, vena cava, and iliac vessels is much more dangerous, when delay in taking active action can lead to death.

Most often, such complications occur with the introduction of the first trocar, less often with a Veress needle. In our practice, damage to the aorta during the introduction of the first trocar occurred in a young patient, for whom a laparoscopic examination and possible surgery were performed for gynecological indications. Immediately after the introduction of the first trocar, massive bleeding was discovered in the abdominal cavity. cavity, and the anesthesiologist recorded a critical decrease in blood pressure. In a nearby operating room, one of the authors of these lines, together with another experienced surgeon, was preparing to perform another operation - this made it possible to perform a wide midline laparotomy almost without delay, detect a parietal aortic injury and suture it. The patient recovered.

Experts have developed a number of rules for applying pneumoperitoneum:

• the aortic palpation test allows you to determine the localization of the aorta and iliac arteries;
• horizontal position of the scalpel when making an incision in the abdominal wall above or below the navel;
• Veress needle spring test;
• vacuum test;
• aspiration test.

After insertion of the laparoscope, before the main stages of the operation begin, it is necessary to examine the abdominal cavity. Ultrasound mapping of the adhesive process in the area of ​​the anterior abdominal wall is of significant interest, especially when performing laparoscopic operations in previously operated patients. The most effective method prevention is the technique of “open” laparocentesis.

Laparoscopic cholecystectomy is the most common video-laparoscopic operation, accompanied, according to the literature, by average complications in the range of 1-5%, and so-called “major” complications in 0.7-2% of cases. In the works of some authors, the number of complications in the group of elderly people age reaches 23%. There are a number of classifications of complications of laparoscopic cholecystectomy, as well as the causes of their occurrence. From our point of view, most common cause development of complications is the surgeon’s overestimation of the capabilities of the method in its execution and the desire to certainly complete the operation laparoscopically. Bleeding during laparoscopic cholecystectomy occurs due to damage to the cystic artery or from the hepatic bed of the gallbladder. In addition to the threat of massive blood loss, bleeding from the cystic artery is dangerous due to additional injury to the bile ducts when trying to stop the bleeding in conditions of insufficient exposure and limited visibility. An experienced surgeon in most cases can cope with bleeding from the cystic artery without proceeding to laparotomy. Novice surgeons, as well as those with unsuccessful attempts at hemostasis, should be advised to perform a wide laparotomy without hesitation.

A possible cause of damage to hollow organs at the stage of cholecystectomy is most often a pronounced adhesive process and non-compliance with the rules of coagulation and visual control during the introduction of instruments into the operation area. The greatest danger is posed by the so-called “looked through” damage. If a wound to a hollow organ is detected in a timely manner, suturing the defect endoscopically does not cause much difficulty.

The most serious complication of laparoscopic cholecystectomy is injury to the extrahepatic bile ducts. The statement that with LCE the incidence of damage to the extrahepatic bile ducts is 3-10 times higher than with traditional surgery has, unfortunately, become generally accepted. True, some authors believe that the frequency of damage to the extrahepatic bile ducts during LCE and the traditional method of surgery is the same. Apparently, establishing the true state of affairs in this important issue is possible as a result of further prospective multicentric (interclinical) studies.

A fairly clear correlation has been established between the number of operations performed and the frequency of bile duct injuries. This fact indicates insufficient control over the preparation of surgeons for LCE and, unfortunately, the ineradicable practice of learning from their “own” mistakes in crossing a “foreign” bile duct.

The lack of possibility of manual revision of the identified structures, anatomical configuration options of the bile ducts and vessels, the desire for high-speed surgery, the intersection of tubular structures before their complete identification - these are far from full list causes of serious complications.

The reasons leading to the development of intraoperative complications can be divided into three groups.

1. “Dangerous anatomy” - a variety of anatomical variants of the structure of the extrahepatic bile ducts.
2. “Dangerous pathological changes” - acute cholecystitis, scleroatrophic gallbladder, Mirizzi syndrome, liver cirrhosis, inflammatory diseases of the hepatoduodenal ligament and duodenum
3. “Dangerous surgery” - incorrect traction leading to inadequate exposure, stopping bleeding “blindly”, etc.

Prevention of intraoperative injuries to the bile ducts is the most important task of laparoscopic surgery, which is due to the increasingly widespread use of laparoscopic cholecystectomy.

Open laparoscopic cholecystectomy

In 1901, the Russian gynecologist surgeon Dmitry Oskarovich Ott examined the abdominal organs through a small incision in the posterior vaginal vault using long hook-mirrors and a head reflector as a light source. By 1907, he had performed some operations on the pelvic organs with using the described method. It is this principle - a small incision in the abdominal wall and the creation of a much larger area in the abdominal cavity, accessible to adequate examination and manipulation - that forms the basis of the mini-laparotomy technique with “elements of “open” laparoscopy” according to M.I. Prudkov.

The basis of the developed set of “Mini-Assistant” instruments consists of a ring-shaped wound retractor, a set of replaceable hooks-mirrors, a lighting system and special surgical instruments. The design features of the instruments used (clamps, scissors, tweezers, dissectors, forks for tying ligatures deep in the wound, etc.) are designed taking into account the characteristics of the axis of the surgical action and have additional bends. A special channel is provided for displaying optical information on the monitor (open telelaparoscopy). By changing the angle of the mirror, fixed using a special mechanism, it is possible, with a 3-5 cm long incision in the abdominal wall, to obtain an area of ​​adequate examination and manipulation in the subhepatic space, sufficient to perform cholecystectomy and interventions on the ducts.

Long thoughts about the name of the operating technique according to M.I. Prudkova using the Mini-Assistant toolkit led to the development of the term MAC - cholecystectomy.

An incision in the anterior abdominal wall is made with an indentation of 2 transverse fingers to the right from the middle pinion, starting from the costal arch vertically downwards with a length of 3-5 cm. Very small incisions should be avoided, as this produces too much traction with the mirrors, which increases the number of wound complications in postoperative period. The skin, subcutaneous tissue, outer and inner walls of the rectus muscle vagina are dissected, and the muscle itself is stripped along the access axis to the same length. Careful hemostasis is important. The peritoneum is usually incised together with the posterior wall of the rectus sheath. It is important to enter the abdominal cavity to the right of the round ligament of the liver.

The main stage of the operation is the installation of a hook-mirror system and a lighting system (“open” laparoscopy). Most errors and unsatisfactory references about the method come from insufficient attention to this stage of the operation. If the mirrors are installed incorrectly, there is no complete fixation of the retractor, adequate visual control and illumination of the subhepatic space, manipulations are difficult and dangerous, the surgeon begins to use additional instruments not included in the kit, which often ends in a transition to traditional laparotomy at best.

First, two small hooks are installed in a direction perpendicular to the axis of the wound. Let's call them “right” and “left” in relation to the operator. The main task of these hooks is to stretch the wound in the transverse direction and fix the ring-shaped retractor. The angle of inclination of the right hook should be chosen in such a way as not to interfere with the subsequent removal of the gallbladder into the wound. The left hook is usually installed at an angle close to a straight line. A large napkin is inserted into the subhepatic space. A longer third hook is inserted into the lower corner of the wound in an unfixed state, and then, together with a napkin, is installed in the desired position and fixed. The movement of this hook resembles the function of the assistant's hand in a standard operation and opens the subhepatic space to the operator.

Surgical napkins with long “tails” of thick Mylar ligatures are installed between the hooks. The napkins are inserted completely into the abdominal cavity and placed between the mirrors as with TCE: to the left - under the left lobe of the liver, to the left and down - to retract the stomach and greater omentum, to the right and down - to fix the hepatic angle colon and loops of the small intestine. Most often, just three mirrors and napkins between them are enough to create an adequate surgical area, almost completely delimited from the rest of the abdominal cavity. A mirror with a light guide is installed in the upper corner of the wound; it simultaneously acts as a hepatic hook. In the case of a large “overhanging” right lobe of the liver, an additional mirror is required to retract it.

After correct installation of the system of hooks-mirrors, napkins and light guide, the operator clearly sees the lower surface of the right lobe of the liver, the gallbladder, when it is retracted behind Hartmann's pouch - the hepatoduodenal ligament and duodenum. The stage of open laparoscopy can be considered completed.

Isolation of the elements of Calot's triangle (cholecystectomy from the cervix) differs in technique from TCE only in the need for “remote” surgery and the inability to insert the hand into the abdominal cavity. A special feature of the instruments is the angular displacement of their working part relative to the handle so that the surgeon’s hand does not cover the surgical field.

These features of manipulation require some adaptation, but in general the surgical technique is much closer to conventional TCE than to LCE, which significantly facilitates the training process for surgeons.

Basic rules for performing open laparoscopic cholecystectomy:

• when identifying the elements of Calot's triangle, the wall of the common hepatic duct and CBD should be clearly visible;
• isolated tubular structures cannot be ligated or crossed until they are completely identified;
• if within 30 minutes from the beginning of the separation of the gallbladder from the inflammatory infiltrate or cicatricial adhesions, the anatomical relationships remain unclear, it is advisable to switch to traditional cholecystectomy.

The last rule, developed by the authors based on studying the causes of complications and conversion, is very important. In practice, especially during the daytime, it is advisable to invite an experienced surgeon for consultation and decide on the continuation of the operation or the need for conversion together.

After isolating the cystic duct, it is distally ligated, and at this point intraoperative cholangiography can be performed through the cystic duct, for which the kit includes a special cannula.

Next, the cystic duct is crossed, and its stump is tied with two ligatures. The knot is tied using a Vinogradov stick: the knot is formed outside the abdominal cavity and is lowered and tightened using a fork. The technique, as well as the instrument itself, are not new to an experienced surgeon, since they are used in traditional surgery in difficult situations.

The next step is to isolate, transect and ligate the cystic artery. To treat the stump of the cystic artery and cystic duct, clipping can be used.

The stage of separating the gallbladder from the bed should be performed as precisely as possible. As in classical surgery, the main condition is: “get into the layer” and, moving from the bottom or from the neck (after the cystic duct and artery are crossed, this is not important), gradually separate the gallbladder from the bed. As a rule, a dissector and scissors with thorough coagulation are used (the set contains a special electrocoagulator). The quality and safety of the stage largely depends on the characteristics of the electrical unit.

Removing a remote gallbladder during open laparoscopic cholecystectomy from a mini-access never poses any difficulties. The operation is completed by placing a silicone perforated drainage to the gallbladder bed through the counter-aperture. The abdominal wall wound is sutured tightly in layers.

Indications for open laparoscopic cholecystectomy:

• chronic calculous cholecystitis, asymptomatic cholecystolithiasis, polyposis, gallbladder cholesterosis;
• acute calculous cholecystitis;
• cholecystolithiasis, choledocholithiasis, unresolved endoscopically;
• technical difficulties with LCE.

Contraindications to open laparoscopic cholecystectomy:

• the need for revision of the abdominal organs;
• diffuse peritonitis;
• uncorrectable blood clotting disorders;
• cirrhosis of the liver;
• GB cancer. 

Anesthesia: multicomponent balanced anesthesia with the use of mechanical ventilation.

Advantages of open laparoscopic cholecystectomy from a mini-access:

• minimal trauma to the anterior abdominal wall;
• adequate access to the gallbladder, common hepatic duct and CBD;
• the possibility of performing the intervention in patients who have previously undergone abdominal surgery;
• the possibility of performing the operation in the second and third trimester of pregnancy;
• low invasiveness of the operation, absence of pneumoperitoneum;
• significant reduction in the number of early and late wound complications;
• absence of disturbances in the function of external respiration, intestinal paresis, reduced need for analgesics, early restoration of motor activity, rapid restoration of working capacity;
• short training period due to operating technology close to traditional;
• relatively low cost of equipment.

Mini-laparotomy with elements of “open” laparoscopy, performed using the “Mini-Assistant” set of instruments, allows, with a high degree of reliability and safety, to perform cholecystectomy in almost all clinical forms of calculous cholecystitis, and to carry out intraoperative revision of the extrahepatic bile ducts, including:

• inspection and measurement of the outer diameter of the CBD;
• transillumination of the supraduodenal CBD;
• IOCG through the cystic duct;
• IOUS;
• IOCG through the cystic duct.

If indicated, ingrooperative choledochotomy and stone removal are possible.

If necessary, it is possible to perform choledochoscopy, study the terminal part of the CBD with calibrated bougies, conduct an inspection of the ducts with a catheter with an inflatable cuff,

With a combination of choledocholithiasis and stricture of the terminal CBD or large duodenal papilla it is possible to perform fibroduodenoscopy during surgery and perform endoscopically controlled antegrade or retrograde papillosphincterotomy; it is technically possible to apply choledochoduodeno- and choledochoenteroanastomosis.

Choledocholithotomy can be completed with a primary duct suture, Kehr or Halstead drainage, etc. In other words, when performing OLCE from a mini-access, adequate restoration of bile outflow can be achieved in the vast majority of clinical situations.

The accumulation of experience in operating using the method described above allowed the authors to perform repeated and reconstructive operations on the bile ducts.

More than 60% of operations using the mini-laparotomy approach were performed for complicated forms of cholelithiasis - acute destructive obstructive cholecystitis, choledocholithiasis, obstructive jaundice, bilio-digestive and bilio-biliary fistulas.

Open laparoscopic cholecystectomy with choledocholithotomy and subsequent options for completing choledochotomy (from the primary CBD suture to the application of supraduodenal choledochoduodenoanastomosis) was performed in 17% of operated patients.

Repeated operations after previously undergone cholecystectomies (TCE or LCE), including excision of remnants of the gallbladder neck with stones, choledocholithotomy, choledochoduodenostomy, were performed in 74 patients. Reconstructive operations for cicatricial strictures of the hepaticocholedochus were performed in 20 patients.

A comparative assessment of the immediate and long-term results of LCE and OLCE from a mini-approach allows us to speak about the comparability of both surgical methods both in terms of the level of trauma and in the quality of life of operated patients in the long-term period. The methods are not only not competitive, but also largely complement each other: thus, LCE can be used when technical difficulties arise during LCE and allows the operation to be completed in a minimally invasive way.

Almost identical technical specifications operations that exclude palpation, the impossibility of examining the entire abdominal cavity during open laparoscopic cholecystectomy, similar indications and contraindications, allow us to recommend a general algorithm for the preoperative examination of patients with cholelithiasis for small access operations.

NOTES Natural Orifice Transluminal Endoscopic Surgery

This is a completely new direction of endoscopic surgery, when a flexible endoscope is inserted into the abdominal cavity to perform operations through natural openings, followed by viscerotomy. In experiments on animals, approaches through the stomach, rectum, posterior vaginal fornix and bladder were used. The complete absence or reduction in the number of punctures of the anterior abdominal wall ensures a reduction in the invasiveness of the operation and a high cosmetic effect. The idea of ​​using a flexible endoscope for intra-abdominal operations through natural orifices arose from the experience of Japanese surgeons who discovered the safety of perforation of the stomach wall during endoscopic removal tumors. This led to a new original concept of transgastric access to abdominal organs such as the liver, appendix, gallbladder, spleen, the fallopian tubes etc. without an incision on the anterior abdominal wall. In principle, access to the abdominal cavity can be achieved through natural openings - the mouth, vagina, anus or urethra. Recently, transgastric access by perforating the gastric wall with a knife-needle has been used for relatively simple endoscopic procedures, including drainage of pancreatic pseudocysts and abscesses. Complete removal of the necrotic spleen using transgastric endoscopic access was performed by Siffert in 2000. Kantsevoy et. al. 2006 reports that the first descriptions of surgical interventions through natural orifices occurred in 2000 during Digestive Deseases Week.

The use of flexible endoscopy to perform transluminal surgery through natural orifices has many names, such as “no-incision surgery,” but the generally accepted term is NOTES (Rattner and Kalloo 2006). The term refers to the insertion of a flexible endoscopic device through natural orifices followed by a viscerotomy to provide access to the abdominal cavity and perform surgery. The supposed advantages of using this operating technique are, first of all, the absence of any scars on the abdominal wall and a reduced need for postoperative pain relief. It is possible to use the technique in patients with morbid obesity and tumor obstruction, since they have difficult access through the abdominal wall and the risk of wound complications is very high. There are prospects for use in pediatric surgery, mainly related to the absence of damage to the abdominal wall.

On the other hand, NOTES carries the risk of many complications associated with the difficulties of inspection and manipulation during remote surgery, even more pronounced than with video laparoscopic techniques.

Analysis of the literature allows us to say that, despite quite a lot of experience in operations in the countries of South America, the techniques are in the development stage, and the comparative safety of the operation is still on the side of laparoscopic cholecystectomy.

Cholecystectomy is an operation to remove the gallbladder. The surgical technique began to be studied in the 19th century. During this time, surgical methods have improved significantly and do not pose any threat when performed.

Traditional type of cholecystectomy

Blue - laparoscopic procedure, red - standard method

The method is used for patients with any form of diseases of the gallbladder and its ducts. If there is a need for surgical intervention, the traditional method is used. Intervention is necessary if the patient has inflammatory processes or scarring on the liver tissue. The standard method has several disadvantages.

• Postoperative injuries may occur, which subsequently lead to disruption of normal bowel function, respiratory organs and to limit the patient's general physical activity.
• A ventral hernia may occur.
• Smaller imperfections include visual skin defects - scars.

Videolaparoscopic cholecystectomy

The purpose of videolaparoscopic cholecystectomy is similar to traditional one. Removing the gallbladder this way has some limitations. The method is prohibited for patients with diseases of the cardiovascular system and lungs, if normal blood clotting is impaired or if there is peritonitis. Also, such intervention is prohibited during pregnancy. Laparoscopic cholecystectomy is not used for cholecystitis.

Sometimes combined surgery is possible with a transition from one type to another. This process is called conversion and is usually explained by doctors discovering various pathologies in the patient in the form of adhesions, fistulas or incorrectly located anatomical structures, as well as heavy bleeding gastrointestinal organs.

If the normal functioning of the equipment performing video laparoscopic cholecystectomy is disrupted, a conversion process will also be performed.

Pain management is carried out by an anesthesiologist, taking into account the patient’s weight and his sensitivity to individual drugs. The doctor must provide long sleep and complete muscle relaxation during the operation.

Progress of the operation

Laparoscopic cholecystectomy, for its successful implementation, is performed under the guidance of three surgical specialists, one of whom carries out all the manipulations, the other two act as assistants. A nurse is present during the operation.

The table on which the patient is located is placed at an angle of 20-25 degrees and is well lit. During the operation, the patient can take two positions - lying on his back with his legs together and with his legs apart. In the first case, the doctor is on the left, as is the chamber for the operation. In the second case, the surgeon takes a position between the spread legs and continues the operation.

The instrument (trocar) can be inserted into the body in several ways:

• umbilical point - located above or below the navel;
• epigastric point - located at a distance of 2-3 cm under the urinary process;
• The point under the armpit is located at a distance of 3-5 cm under the costal arch;
• midclavicular point - at a distance of 2-3 cm under the costal arch.

This type of surgical intervention at the modern level of medicine provides safe treatment and quick recovery.

The technique is as follows. Laparoscopic cholecystectomy is performed by making 3-4 punctures in the abdomen, the size of which is 5-10 mm. Punctures are necessary to insert special tubes, through which carbon dioxide is then injected using a special pump. Gas injection is performed to provide the necessary space for doctors to work normally.

After introducing the gas, the incoming ducts and arteries are compressed using surgical instruments. After blocking all the incoming and outgoing pathways to the gallbladder, this organ is removed.

Postoperative period

After cholecystectomy, a rehabilitation course is completed. Moderate physical activity, adherence to a special diet and minimal treatment with medications are prescribed. During the 30-day period, diet and physical activity are necessary to adapt the body to changes in the functioning of the biliary system.

At first after removal of the gallbladder, changes in stool may occur - this is normal. Within six months, a person returns to a normal lifestyle, with the exception of some nuances - unhealthy foods (fatty, fried) and bad habits (alcohol) are prohibited.

After cholecystectomy, analgesics and antispasmodics may be prescribed if pain occurs in the surgical area. Postoperative sutures are removed a week after cholecystectomy; before this, dressings are performed and scars are covered with iodine solution.

Complications

If the patient had an advanced form of the disease and did not receive proper treatment for a long time, there may be the following complications– hemorrhages, infections and wound suppuration; in rare cases, hernias develop and in one case out of a thousand repeated intervention may be required.

If laparoscopic cholecystectomy is performed before complications occur, the person returns to a normal lifestyle within a month.

Surgery to remove the gallbladder, or cholecystectomy, has been one of the most commonly performed abdominal surgeries for many decades. As a rule, they are forced to remove the gallbladder, which is far advanced. Much less often, cholecystectomy is performed for diseases of a tumor nature, congenital anomalies of the biliary system, etc.

Methods of performing surgery to remove the gallbladder

In the operating room during laparoscopic surgery. The miniature television camera of the laparoscope transmits a greatly enlarged image of the surgical field to an external monitor.

There are two methods of gallbladder removal:

Ideally, these technologies should complement each other and not compete, but, unfortunately, this phenomenon occurs.

Laparoscopy of the gallbladder

Laparoscopic cholecystectomy involves surgical intervention through narrow channels in the abdominal wall (0.5-1 cm) using a telescopic device equipped with a video camera, a light and other devices - a laparoscope, as well as a number of special instruments.

The times when the laparoscopic technique had to prove its superiority over traditional open cholecystectomy are over. Laparoscopy has successfully won its well-deserved place in abdominal surgery; a critical attitude towards it remains the lot of inveterate retrogrades.

The advantages of laparoscopic removal of the gallbladder are obvious and undeniable:

• The most important advantage of the method, which is less focused on, is the closed and apodactylic surgical technique, when contact with the operated tissues is carried out exclusively with the help of instruments, significantly reducing the risk of infectious complications.
• Low invasiveness of surgical intervention.
• Short-term hospitalization is 1-2 days; in some cases, outpatient surgery is possible.
• Very small incisions (0.5-1 cm) guarantee excellent cosmetic results.
• Fast recovery ability to work - within 20 days.
• One more thing should be noted positive quality techniques - for patients who have indications for surgery, it is easier to decide on laparoscopic intervention, which reduces the number of advanced cases.

Laparoscopic technology does not stand still. A technique for performing cholecystectomy through three channels has already been developed and is being successfully used. And cosmetic micro-laparoscopy through ultra-thin channels with a diameter of only 2 mm (only the main channel for the laparoscope is still 10 mm) gives an ideal cosmetic result - traces of incisions can only be detected under a magnifying glass.

Disadvantages of laparoscopic cholecystectomy

The laparoscopic technique, along with undeniable advantages, also has specific disadvantages, which in some cases force it to be abandoned in favor of open surgery.

To provide a working space and sufficient visibility during laparoscopy, carbon dioxide is injected into the abdominal cavity under a certain pressure. The increased pressure for this reason in the venous system of the systemic circulation (the so-called central venous pressure), as well as pressure on the diaphragm, worsens the conditions for cardiac activity and breathing. This negative effect is significant only in the presence of serious problems with the cardiovascular and respiratory systems.

Laparoscopic technology significantly limits the possibilities of intraoperative (during the operation) diagnostics in comparison with open surgery, which gives the surgeon the opportunity to “feel everything with his hands.”

Laparoscopy is not applicable in unclear cases, when it may be necessary to change the plan of the operation during its implementation, depending on the identified pathological changes.

The last two circumstances require the surgeon to have a different philosophy of preparing for surgery. A thorough preoperative examination and a decisive rejection of the tactics of some old surgeons: “let’s cut and see” can help avoid embarrassment.

Contraindications to laparoscopy of the gallbladder

Contraindications to laparoscopic removal of the gallbladder are determined by the above-described features of laparoscopy:

• Severe general condition.
• Diseases occurring with severe cardiac and respiratory failure.
• Tumor nature of the disease.
• Obstructive jaundice (jaundice that developed as a result of a mechanical obstruction to the outflow of bile in the extrahepatic ducts: stone, cicatricial narrowing, tumor, etc.).
• Increased bleeding.
• Pronounced adhesions in the upper floor of the abdominal cavity.
• Calcification of the gallbladder walls, or so-called. "porcelain" gallbladder. With this condition of the bladder, it can collapse prematurely in the abdominal cavity.
• Late pregnancy.
• Presence of acute pancreatitis.
• Peritonitis is a diffuse inflammation of the abdominal cavity.

It should be said that the development of laparoscopic technology and the growing experience of surgeons are steadily narrowing the range of contraindications. Thus, until recently, acute cholecystitis and the presence of stones in the bile ducts were considered absolute contraindications to laparoscopic removal of the gallbladder. Now these contraindications have been successfully overcome.

Preoperative examination

Preoperative examination, in order to avoid unforeseen difficulties, which often force us to complete the begun laparoscopy with open surgery through a large incision, must be thoughtful and comprehensive:

A high-quality and comprehensive examination preceding laparoscopy of the gallbladder makes it possible to anticipate possible difficulties and make a timely decision on the method, volume and, finally, the feasibility of surgical intervention.

Preparation for laparoscopy of the gallbladder

Like any abdominal surgery, gallbladder laparoscopy requires certain preparation:

• one week before surgery, in consultation with the attending physician, medications that reduce blood clotting (anticoagulants, nonsteroidal anti-inflammatory drugs, vitamin E) should be discontinued.
• on the day before surgery, eat only light food
• You cannot eat or drink anything after midnight before surgery
• To cleanse the intestines the night before and in the morning, take special medications as prescribed by the attending surgeon, or perform cleansing enemas
• in the morning before surgery, take a shower, preferably with antibacterial soap

Open cholecystectomy

Open cholecystectomy, or removal of the gallbladder traditional way through a wide cut, should not be considered a relic of the past. Despite the expansion of the capabilities of gallbladder laparoscopy, open cholecystectomy remains relevant. It is indicated in the presence of specific conditions for laparoscopy.

Open cholecystectomy has to be completed in 3-5% of laparoscopic operations when unforeseen difficulties arise.

A significant number of open cholecystectomies continue to be performed due to lack of real possibility perform laparoscopic removal of the gallbladder: lack of necessary equipment, experienced laparoscopist, etc. in a particular hospital.

And finally, the prejudice of some surgeons regarding laparoscopy also contributes.

So, which is better: laparoscopy or open surgery?

	gallbladder laparoscopy	open gallbladder removal
readings	▪ cholelithiasis	▪ sharp and chronic cholecystitis ▪ cholelithiasis ▪ diseases of a tumor nature, etc.
contraindications	It has	at vital signs has no contraindications
preparation for surgery		usual for abdominal operations
duration of operation	30-80 minutes	30-80 minutes
equipment requirements	laparoscopic equipment required	conventional surgical instruments are required
surgeon qualification requirements	+++	++
anesthesia	anesthesia	anesthesia
number and length of cuts	3-4 cuts 0.5-1 cm long	one incision 15-20 cm long
% complications	1-5%	1-5%
pain after surgery	+	+++
seams	don't take off	removed on 6-7 days
development of postoperative hernias	-	++
cosmetic defect	-	++
nutrition after surgery	on day 1 you can eat and drink	on day 1 you can drink, from day 2 you can eat
motor mode after surgery	on the 1st day you can sit up in bed, on the 2nd you can get up and walk	on day 3-4 you can get up and walk
length of hospital stay	1-2 days	10-14 days
disability	up to 20 days	up to two months
in 5 weeks	in 2-2.5 months
full recovery	3-4 months	3.5-4.5 months

If the stone is in the common bile duct

It is quite common for stones to migrate from the gallbladder into the common bile duct. When a stone gets stuck in the common bile duct, there may be a complete or partial disruption of the outflow of bile from the liver to the intestine, which is the cause of obstructive jaundice. Asymptomatic presence of a stone in the duct also occurs.

Ideally, you should know about this in advance. However, there have been and still are cases of undiagnosed stones being left in the duct. Naturally, the operation does not bring the expected result, and only after additional examination is the true cause of the failure discovered. Such cases, of course, do not benefit the reputation of the surgeon, and therefore good practice in gallbladder surgery is to check the patency of the common bile duct during cholecystectomy - intraoperative cholangiography. This check is carried out by injecting a radiopaque substance into the bile ducts, followed by radiography. Cholangiography is practiced during both open and laparoscopic cholecystectomy.

Until recently, a stone in the common bile duct or even such a suspicion was an absolute contraindication to laparoscopic removal of the gallbladder. Now, thanks to the improvement of laparoscopic technology, surgeons are increasingly deciding to operate on such patients through a laparoscope.

Postcholecystectomy syndrome

Postcholecystectomy syndrome is a syndrome that develops after removal of the gallbladder. There is no single interpretation of this concept in medical science.

In simple terms, postcholecystectomy syndrome combines those cases when, after removal of the gallbladder, it did not get better, or it got even worse. According to various estimates, the incidence of postcholecystectomy syndrome reaches 20-50%. The reasons for such situations are very diverse:

• Undiagnosed diseases of the hepatopancreatic zone (chronic pancreatitis, cholangitis, stones and cicatricial narrowing of the common bile duct, tumors, etc.), peptic ulcer of the stomach and duodenum, reflux esophagitis, diaphragmatic hernia, the manifestations of which were mistakenly taken for chronic cholecystitis.
• Errors in the operation when a too long remnant of the cystic bile duct or even part of the gallbladder is left, in which it finds refuge inflammatory process and even new stones are formed. Damage also occurs bile ducts, which leads to their cicatricial narrowing.

The best way to avoid the development of postcholecystectomy syndrome is the most thorough preoperative examination of not only the gallbladder, but also other abdominal organs, as well as complete confidence in the advisability of cholecystectomy and in the surgeon’s ability to perform it.

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