Endoscopic cholecystectomy operation progress. Cholecystectomy - what is it?

For citation: Gallinger Yu.I. Laparoscopic cholecystectomy // Breast cancer. 1996. No. 3. P. 8

After reading the lecture you will know:

After the lecture You will know:

• advantages laparoscopiccholecystectomy (LC) bycompared to otherstreatment methodscholelithiasis- medicinal and ultrasonic lithotripsy, laparotomy and abdominal cholecystectomy;
• selection principlespatients for HL. Absolute and relative contraindications tocarrying out the operation.
• Algorithm preoperativeexamination of patients, peculiarities preoperative preparation and anesthesia;
• stages of LC implementation. Possible intra- andpostoperativecomplications, tacticspostoperativepatient management, criteria ability to workpatients who underwent HL.

X Surgical operation still remains the main method of treating patients with calculous cholecystitis, the number of which is increasing. With a long history, serious complications develop, while urgent operations, often performed in the absence of proper equipment and the surgeon’s experience, often give an unfavorable result, so all over the world they are striving to carry out interventions in a planned manner in the early stages of the occurrence of pathological changes in the gallbladder.
Abdominal surgery is always associated with a certain risk of complications both during the intervention itself and in the postoperative period. Cholecystectomy is accompanied by significant trauma to the soft tissues of the anterior abdominal wall, which often leads to purulent complications from the wound in the early postoperative period and a hernia of the anterior abdominal wall in the future. In addition, even with an uncomplicated postoperative period, the period of restoration of working capacity is very long. Therefore, the search for other, non-operative treatment methods is undoubtedly justified. cholelithiasis.
The search for methods of chemical dissolution of gallstones has been going on for a long time. However, the currently available drugs are not universal; their litholytic effect is limited, as a rule, to cholesterol stones; when taken orally, a long course of treatment is required, which is poorly tolerated by a number of patients due to toxic side effects. The direct effect of litholytic drugs on stones in the gallbladder requires a preliminary cholecystostomy, an intervention that carries the risk of complications.
Great hopes were placed on extracorporeal ultrasound destruction of stones in the gall bladder. Numerous clinical observations have shown that using a directed ultrasonic wave, it is possible to destroy gallstones into small fragments that can be removed through the cystic duct into the hepaticocholedochus, and then from there into the duodenum. When using improved lithotripters, the procedure is fairly painless, and with single stones in the gall bladder, therapeutic success is achieved within several sessions. The method of extracorporeal lithotripsy, despite the high cost of the equipment, began to be used quite widely in developed countries, however, further clinical observations also revealed a number of negative consequences of this method: sufficiently large fragments, migrating from the bladder, can cause the occurrence of obstructive cholecystitis, obstructive jaundice or pancreatitis, requiring urgent abdominal or endoscopic surgery.
Litholytic therapy and extracorporeal lithotripsy have another significant drawback - even complete elimination of gallstones does not mean curing the patient from cholelithiasis, since pathological changes in the gall bladder persist along with those factors that previously led to the formation of gallstones.
Abdominal surgery has made a significant step forward in recent years thanks to the development and introduction into clinical practice of a number of laparoscopic operations (appendectomy, vagotomy, hernia repair, colon resection, etc.), among which cholecystectomy occupies a leading place.
For the first time, laparoscopic cholecystectomy in humans was performed by Ph. Mouret (Lyon, France) in 1987 and then gained rapid distribution and recognition in developed countries of the world. Laparoscopic cholecystectomy combines radicality (the pathologically altered gallbladder with stones is removed) with low trauma (the integrity of the soft tissues of the abdominal wall, primarily the aponeurosis and muscles, is almost completely preserved), due to which the recovery time for patients is significantly reduced. Considering that cholelithiasis is more often observed in women, often under the age of 30 - 40 years, the cosmetic effect of the intervention is also important - small skin incisions (5-10 mm) heal with the formation of barely noticeable scars.
Laparoscopic cholecystectomy also has advantages over cholecystectomy from a small (5-6 cm long) laparotomy incision, used by some domestic and foreign surgeons. A small incision in the anterior abdominal wall limits inspection and manipulation deep into the wound, especially when isolating elements of the gallbladder neck. With cholecystectomy under laparoscopic control, the visibility of the intervention area is usually better even compared to surgery from a large laparotomy incision, especially in relation to the cystic duct and the cystic duct and the artery of the same name. In addition, during laparoscopic surgery, a non-traumatic examination is possible, and, if necessary, instrumental revision of all organs abdominal cavity and small pelvis. If concomitant diseases are detected (chronic appendicitis, small ovarian cysts, etc.), after completion of the main intervention, a second operation can be performed. The advantages of laparoscopic cholecystectomy have made it now the main method of treating calculous cholecystitis in many countries of the world, including in our country.
Indications for cholecystectomy using laparoscopic techniques:

• chronic calculous cholecystitis;
• polyps and cholesterosis of the gallbladder;
• acute cholecystitis (in the first 2-3 days from the onset of the disease);
• chronic acalculous cholecystitis;
• asymptomatic cholecystolithiasis (large and small stones).

Among these indications, the main one is chronic calculous cholecystitis. It should be emphasized that neither the size of the stones, nor their number, nor the duration of the disease should significantly influence the decision on the choice of surgical intervention.
Gallbladder polyposis is currently being diagnosed more and more often thanks to the widespread introduction of ultrasound examination into clinical practice. Surgical intervention in this category of patients should be considered mandatory due to the possibility of degeneration of polyps, the subsequent formation of stones in them, as well as the development of complications when papillomatous growths detach and obstruct the cystic duct or distal section common bile duct. The advantages of laparoscopic surgery in patients with polyps and cholesterosis of the gallbladder are beyond doubt, since in this case the peri-process is absent or weakly expressed, and removal of the gallbladder from the abdominal cavity through a small puncture is not associated with technical difficulties.
Acute cholecystitis was initially considered by surgeons as a contraindication to cholecystectomy using the laparoscopic technique. However, subsequently, as clinical experience accumulated, it became obvious that for a qualified specialist in the field of laparoscopic surgery, performing laparoscopic cholecystectomy for acute cholecystitis is technically quite possible, especially in the early stages of the onset of the disease, before pronounced infiltrative changes in the area of ​​the gallbladder and hepatoduodenal ligament.
The presence of stones in the gall bladder, even in the absence of clinical manifestations (so-called stone carriers), should still be considered an indication for surgical treatment, since there is no guarantee that acute cholecystitis or other complications will not arise in the future. The question of surgical treatment in this category of patients should be especially urgent if there are small and large stones in the gallbladder due to the danger of their migration into the cystic and common bile ducts and the likelihood of a pressure sore of the gallbladder wall. Cholecystectomy using laparoscopic technique in these cases should certainly be preferred.
Contraindications. The main contraindications to laparoscopic cholecystectomy should be considered:

• severe pulmonary-cardiac disorders;
• disorders of the blood coagulation system;
• late stages of pregnancy;
• malignant lesion of the gallbladder;
• previous operations on the upper floor of the abdominal cavity.

Laparoscopic cholecystectomy is performed in conditions of a fairly tense pneumoperitoneum (12-14 mm Hg), which elevates the diaphragm and impairs its mobility, which, in turn, cannot but have a negative effect on cardiac and respiratory functions, despite artificial ventilation. . Therefore, in patients with severe pulmonary-cardiac disorders, surgery through laparotomy, i.e., without pneumoperitoneum, may be preferable to laparoscopic intervention.
Disturbances in the blood coagulation system that are not corrected by therapeutic measures, accompanied by increased tissue bleeding, will create great difficulties at all stages of laparoscopic intervention, which are much easier and more reliable to overcome during surgery by laparotomy.
Late pregnancy should be considered a contraindication to laparoscopic surgery for two main reasons.
Firstly, an enlarged uterus will significantly complicate the application of pneumoperitoneum and the introduction of trocars, and intestinal loops pressed against the liver will limit access to the gallbladder. Secondly, a sufficiently long and intense pneumoperitoneum will certainly have a negative effect on the condition of the uterus and fetus.
Gallbladder cancer is a relative contraindication to laparoscopic cholecystectomy, since it is technically quite difficult to completely remove the lymph nodes in the area of ​​the hepatic hilum and retroperitoneal space. In this regard, if there is a reasoned suspicion of the presence of a malignant lesion of the gallbladder based on clinical symptoms, ultrasound data and preoperative cholangiography, intervention by laparotomy should be preferred.
Previous operations on the organs of the upper abdominal cavity (stomach, pancreas, liver, transverse colon, etc.) are contraindications for laparoscopic cholecystectomy, since this sharply increases the risk of damage to the abdominal organs when introducing trocars and reduces the likelihood of access to gallbladder and hepatoduodenal ligament due to organs soldered to the anterior abdominal wall and adhesions in the subhepatic space. An exception may be limited operations on the left half of the upper floor of the abdominal cavity (gastrostomy, splenectomy), in which the adhesive process in the epigastrium is most often insignificant, and in the right hypochondrium is usually absent. Previous operations on the lower abdominal cavity and pelvic organs, as a rule, are not a contraindication to laparoscopic cholecystectomy.
Preoperative examination. Before laparoscopic surgery, patients should undergo a comprehensive clinical examination. During laparoscopic surgery, there is no possibility of manual inspection of the abdominal and pelvic organs, and the load on the respiratory and cardiovascular systems is high.
These factors should be taken into account during the preoperative evaluation of patients planned for laparoscopic cholecystectomy.
In this category of patients, it is currently mandatory to conduct an ultrasound examination aimed at identifying changes as completely as possible not only in the liver, bile ducts and pancreas, but also in the kidneys, bladder, uterus and appendages. This is due to the need to resolve the issue of simultaneous intervention for concomitant diseases and knowledge of the possibility of their manifestation in the postoperative period. According to indications, cholecystocholangiography and endoscopic retrograde pancreaticocholangiography are performed.
It should be emphasized that a thorough preoperative examination not only facilitates the choice of method and extent of intervention, but also reduces the need for intraoperative cholangiography, which lengthens the total time of laparoscopic intervention.
Anesthesia. Cholecystectomy using laparoscopic techniques should be performed under general anesthesia with tracheal intubation and the use of muscle relaxants. After tracheal intubation, it is necessary to insert a tube into the stomach to empty it of air and liquid and leave it there throughout the intervention.
Technique of laparoscopic cholecystectomy. Laparoscopic cholecystectomy, like other similar operations (appendectomy, vagotomy, hernia repair, etc.), is performed by a team of surgeons, and all intra-abdominal manipulations are carried out using a color image on a monitor transmitted from the laparoscope using a small video camera. It should be noted that the quality of the television image (sharpness and clarity of the picture, color shades, image stability) is important when performing laparoscopic operations.
During laparoscopic cholecystectomy, four small incisions are made in the skin of the anterior abdominal wall for trocars, through which the laparoscope and other necessary instruments are inserted.
First, an incision is made above or below the navel, a needle is inserted through it to apply pneumoperitoneum, and then a trocar for the laparoscope is inserted.
During a general laparoscopic examination of the abdominal and pelvic organs, attention is paid to the condition of the liver, spleen, stomach, omentum, loops of the small and large intestines, uterus and appendages. In patients who have previously undergone abdominal operations, it is necessary to carefully examine the adhesions between the parietal peritoneum of the anterior abdominal wall and the underlying organs and, in the presence of single cords, decide on their intersection to prevent possible intestinal obstruction in the postoperative period. In addition, a detailed examination of the greater omentum should be carried out - whether carbon dioxide has entered it and whether the vessels are damaged during puncture of the abdominal cavity with a needle or during the insertion of a trocar. With the operating table in a horizontal position, the gallbladder is usually poorly accessible for inspection, since it is covered with an omentum or loops intestines. Therefore, after completing the general examination, even before the introduction of three instrumental trocars, the position of the operating table is changed, raising the head end by 20 - 25° and tilting the table to the left. In this position, the intestinal loops and the greater omentum move slightly downward, and the stomach moves to the left, and the gallbladder, if it is not fused with the surrounding organs, becomes more accessible to inspection.
If at the stage of a general examination of the abdominal organs no contraindications to laparoscopic cholecystectomy were identified, three more trocars for instruments are inserted into the abdominal cavity.
If upon examination it is discovered that the gallbladder is overly tense (edema or chronic empyema of the bladder) and its wall is difficult to grasp with a clamp, then its contents are first partially evacuated. To do this, the gallbladder in the fundus is punctured with a needle, and the contents are aspirated with a syringe or using suction.
There are several main stages of laparoscopic cholecystectomy:: 1) isolation of the gallbladder from adhesions with surrounding organs; 2) isolation, clipping and intersection of the cystic duct and the artery of the same name; 3) separation of the gallbladder from the liver; 4) removal of the gallbladder from the abdominal cavity. Each of these stages of laparoscopic intervention can be quite complex, which depends on the severity of pathological changes in the gallbladder and its surrounding organs.
Often there are adhesions between the gallbladder and its surrounding organs. Most often, strands of the omentum are soldered to the gallbladder, less often - the stomach, duodenum and colon.
To isolate the gallbladder, it is grabbed with a clamp in the bottom area and lifted upward along with the liver. Then, if the adhesions between the bladder and the omentum are “tender” enough, the strands of the omentum are mechanically removed from the gallbladder using a “soft” clamp. For denser adhesions, scissors or an electrosurgical hook can be used to separate them. When performing these manipulations, it is important that mechanical or high-frequency intersection of adhesions is carried out directly at the very wall of the gallbladder. As the adhesions separate, the gallbladder and the liver are increasingly “thrown back” under the diaphragm until they reach the area of ​​the bladder neck.
Manipulations in this area should be carried out most carefully.
After isolating the gallbladder from adhesions with surrounding organs, a “hard” clamp is applied to the area of ​​Hartmann’s pouch, with which the neck of the bladder is pulled up and to the right, after which the area of ​​the cystic duct and cystic artery becomes accessible to observation and manipulation.
In biliary surgery, knowledge of the normal anatomy of the junction of the cystic duct and hepaticocholedochus, as well as possible abnormal variants, is of great importance. To isolate the cystic duct and the cystic artery, the peritoneum in the area of ​​the gallbladder neck is first dissected, which can be done using scissors or an electrosurgical hook. The sequence of isolation of the cystic duct and the artery of the same name can be different, this largely depends on their relative position and the severity of fatty tissue in Calot’s triangle. In the vast majority of cases, the cystic artery is located behind the duct and therefore its isolation in the first place is justified only in patients in whom the fat layer of this zone is not expressed.
After dissection of the peritoneum in the cervical area, the cystic duct is exposed using a preparation tip, a dissector and an electrosurgical hook. If there is a loose connective tissue layer around the cystic duct, then it is moved downwards with a tupper, towards the hepaticocholedochus. Dense cords and small vessels in this area are captured and crossed with an electric hook. To perform subsequent manipulations on the cystic duct (applying clips and crossing), it is advisable to release it for 1 - 1.5 cm. Clips are applied to the isolated cystic duct using an applicator and then it is crossed. The mucous membrane of the cystic duct stump can be additionally coagulated using an electrosurgical hook by briefly turning on a high-frequency current. When the cystic duct is isolated, the cystic duct artery may be damaged, the diameter of which is significantly smaller than the diameter of the cystic artery, and therefore the bleeding from it is less intense.
Most often, it is more convenient to isolate the cystic artery, especially in patients with pronounced fatty tissue in the area of ​​the hepatoduodenal ligament, after crossing the cystic duct. It is advisable to isolate the cystic artery using an electrosurgical hook and a dissector. A dissector is used to bypass the cystic artery, isolating it for 1 cm, and apply clips.
Crossing the artery between applied clips can be done with scissors or an electrosurgical hook if there is sufficient space between the clips. It is quite acceptable to clip only the proximal part of the artery, and burn out its distal part or its branches close to the wall of the bladder using an electrosurgical hook.
The need for intraoperative cholangiography when performing laparoscopic cholecystectomy occurs less frequently if a full preoperative examination of the biliary tract has been performed. The main indication for performing cholangiography is the difficulty in identifying the topographic-anatomical relationships of the cystic duct and hepaticocholedochus.
The technical details of isolating the gallbladder from the liver bed to a certain extent depend on the characteristics of the anatomical relationships between these two organs.
Gallbladder located in a depression on the lower surface of the liver called the gallbladder bed. The depth of the bubble in the liver is quite variable. Rarely is it located deep in the parenchyma, so that only 1/2 or 1/3 of its lower semicircle is visible on the surface; most often it lies shallow, and in some cases even has the semblance of a mesentery. Between the wall of the gallbladder and the liver tissue there is a layer of loose connective tissue, which, however, in a number of cases can become denser and thinner as a result of inflammatory processes. In the connective tissue layer of the gallbladder bed and in the peritoneum, passing from the surface of the liver to the side walls of the gallbladder; there are many arterial and venous vessels, from which quite significant bleeding is possible if the dissection or blunt dissection is performed without prior coagulation.
The gallbladder can be separated from the liver by peeling it off with a small gauze pad or spatula; capturing and pinching connective tissue strands containing vessels with an electrosurgical hook; dissecting the boundary zone between the bladder and the liver with a spatula-type instrument using a high-frequency current. In the process of separation of the bladder from the liver, its neck and body are gradually more and more thrown up so that the transition zone between the back wall of the bladder and the liver bed is always available for visual observation.
When the gallbladder is isolated from the liver tissue, despite the use of electrocoagulation, bleeding of varying intensity from the bed area may occur, which is usually stopped by additional coagulation.
Removal of the gallbladder from the abdominal cavity can be carried out through umbilical or epigastric trocars. The umbilical incision for performing this manipulation has certain advantages. In the epigastric region, the thickness of the abdominal wall is usually greater than in the umbilical zone; the epigastric trocar is inserted in an oblique direction through the rectus abdominis muscle, due to which the wound channel is even longer; if it is necessary to expand the wound in the epigastrium, it is necessary to dissect both the anterior and posterior layers of the sheath of the rectus abdominis muscle, which, in turn, requires a significant enlargement of the skin incision; in the epigastric zone it is technically more difficult to perform layer-by-layer suturing of the wound of the anterior abdominal wall; in addition, infection of not only the preperitoneal and subcutaneous tissue, but also muscle tissue is possible. The umbilical trocar is usually carried directly above the navel through the midline, the rectus abdominis muscles are not damaged, the wound canal is straight and short, which makes subsequent suturing easier. In addition, if it is necessary to enlarge the skin incision (usually it borders the navel from above), it is less noticeable, since it is usually retracted into the umbilical recess.
When pulling out the gallbladder, care should be taken, since with excessive force, leakage of bile residues into the abdominal cavity may occur through micro-holes in its bottom, arising from a previously applied clamp. Moreover, a rupture of the bladder wall may occur with the loss of stones into the abdominal cavity, the search and extraction of which are technically quite difficult. To prevent such complications, as well as to remove a gallbladder with an existing wall defect that arose when it was isolated from adhesions or from the liver bed, the gallbladder can first be placed in a sufficiently dense plastic bag.
It should be noted that removing the gallbladder from the abdominal cavity is much easier if there is good medicated muscle relaxation, as well as when most of the insufflated carbon dioxide is removed from the abdominal cavity.
Since when removing the gallbladder, infection of the wound canal of the abdominal wall can occur, it is better to rinse the latter with an antiseptic solution. The defect in the aponeurosis is sutured with 1-3 sutures. Then pneumoperitoneum is created again and a repeated control examination of the abdominal cavity is carried out, and, if necessary, it is washed and thoroughly dried.
Laparoscopic cholecystectomy, like any surgical and endoscopic operation, can be accompanied by various complications, including very serious ones, requiring immediate laparotomy. The frequency of these complications, their timely diagnosis and elimination largely depend on the experience of the surgeon.
Most errors and complications arise during laparoscopic surgery, a smaller part of them - in the postoperative period, however, they are often associated with technical errors and mistakes made during the intervention.
Intersupersistent complications can occur at all stages of laparoscopic intervention; The main complications are as follows:

• damage to the vessels of the abdominal wall;
• perforation of the stomach, duodenum and colon;
• damage to the hepaticocholedochus;
• bleeding from the cystic artery and its branches;
• bleeding from the liver bed.

The likelihood of damage to the abdominal organs during the introduction of trocars is very insignificant if it is carried out with a sufficiently tense pneumoperitoneum, especially since three out of four trocars are already carried out under visual control through a laparoscope.
A slight leak of blood from the puncture site of the abdominal wall is not so rare, but more often than not it stops quickly. If the bleeding does not stop, then hemostasis can be achieved by injecting a solution of novocaine with adrenaline around the trocar or coagulation along the wound channel with an electrosurgical instrument passed through the trocar, gradually removing it outward.
If sufficiently large arterial vessels are damaged, such measures may be ineffective, and then more radical methods should be used. Bleeding can be stopped by suturing the entire thickness of the anterior abdominal wall above and below the trocar and tightening the ligature on a gauze swab.
When the gallbladder is released from the adhesive process, damage to a hollow organ can occur: the stomach, duodenum, small and large intestines. Perforation of the stomach is less likely, since its wall is quite thick.
Perforation of the gallbladder at one stage or another of laparoscopic cholecystectomy occurs quite often. It most often occurs when the gallbladder is separated from the liver, when there are scar changes in the connective tissue layer between these two organs. The resulting defects, as a rule, are small in size (2-3 mm), rarely larger, through which small stones can fall out of the gallbladder. However, in both cases, the resulting perforation of the bladder wall usually does not have a significant impact on the subsequent course of the intervention and the course of the postoperative period.
Damage to the hepaticocholedochus is one of the most serious complications of laparoscopic cholecystectomy. The risk of this complication when using a laparoscopic intervention technique is even slightly higher compared to traditional surgery, since there is no possibility of manual revision and transition, if necessary, to isolating the gallbladder “from the bottom.” The likelihood of hepaticocholedochus injury certainly increases in anatomically complex situations, with scar-infiltrative processes in the area of ​​the gallbladder neck, cystic and common bile ducts, especially if they disrupt the usual topographic-anatomical relationships of organs. Unfortunately, incision or even complete intersection of the extrahepatic bile ducts can also occur in fairly simple cases: with a short cystic duct, when the narrow common bile duct is easily pulled up by traction by the neck of the bladder and can be mistaken for the cystic duct, especially when its diameter does not exceed 4 - 6 mm.
In case of gross damage to the hepaticocholedochus, it is necessary to perform a laparotomy and correct the resulting complication. If the extrahepatic bile duct is slightly incised, it can be sutured using laparoscopic technology, completing the operation with external drainage of the hepaticocholedochus through the stump of the cystic duct.
A serious complication of laparoscopic cholecystectomy is bleeding from the cystic artery, especially if it is completely crossed or torn off near the hepatic artery. The best option in this case, apparently, would be immediate laparotomy. More often, however, bleeding can be observed from the branches of the cystic artery or its trunk, but near the wall of the gallbladder. In this case, it is quite possible to stop the bleeding by grasping the vessel with a clamp, and then apply a clip or coagulate.
Separation of the gallbladder from the liver, despite the use of electrosurgical instruments, is often accompanied by slight bleeding from various parts of the bed, especially when the gallbladder is deep, but they are easily stopped by additional coagulation. In case of more intense bleeding, to achieve hemostasis, it is better to grasp the bleeding vessel with a clamp and then carry out coagulation.
Many intraoperative complications are quite easy to prevent or eliminate without switching to laparotomy, and they do not have any noticeable impact on the course of the postoperative period.
Complications after laparoscopic cholecystectomy are quite rare. A serious complication of laparoscopic intervention is bile leakage into the abdominal cavity. It can arise from the stump of the cystic duct (poor clipping or ligation of the duct), from the liver bed, and from damaged hepaticocholedochus. If drainage is left in the subhepatic space and in the absence of signs of peritonitis, expectant management is justified.
If there is a suspicion of damage to the extrahepatic bile ducts, then before deciding on laparotomy, it is advisable to perform endoscopic retrograde cholangiography, which can, according to indications (insufficiency of the cystic duct stump, limited injury of the hepaticocholedochus) be completed with nasobiliary drainage through the major duodenal papilla. If there are clinical signs of peritonitis, laparotomy is indicated for the purpose of thorough inspection and sanitation of the abdominal cavity, as well as eliminating the cause of biliary peritonitis.
When the gallbladder is removed through it, the paraumbilical wound is injured to a much greater extent than others. Therefore, the occurrence of infiltration of the anterior abdominal wall in this area is quite understandable. To reduce the likelihood of infiltration formation, it is necessary to ensure that no accumulation of blood or wound exudate is observed in the subcutaneous tissue in the first days.
Postoperative management. We only stop at general principles management of patients after laparoscopic cholecystectomy. The peculiarities of the operation itself, certain postoperative complications, the age of the patient and concomitant diseases force one to make certain, sometimes very significant, adjustments and carry out targeted therapy.
Due to the insignificance of the injury inflicted on the anterior abdominal wall, postoperative period in patients after laparoscopic cholecystectomy it is easier than after a similar surgical operation through a wide laparotomy approach. Already on the first day after the intervention, patients are moderately bothered by abdominal pain, which makes it possible to reduce the dosage of narcotic analgesics or even abandon their use.
In patients with acute cholecystitis, especially if during the operation purulent contents from the gallbladder entered the abdominal cavity, antibiotic therapy for 4-5 days is justified. In patients whose cholecystectomy was completed by drainage of the supra- and subhepatic space, up to 100-150 ml of bloody fluid is usually released during the first 2 hours after the operation (despite careful aspiration, it is not possible to completely remove all fluid from the abdominal cavity during laparoscopic intervention ). In the normal course of the postoperative period, when there are completely no signs of intra-abdominal bleeding or bile leakage, it is advisable to remove the thin drainage tube by the end of the 1st day, since, having fulfilled its function, it can only further contribute to infection of the abdominal cavity and limit the patient’s mobility.
Within a few hours after the operation, the patient can be allowed to turn on his side and sit down, and by the end of the 1st day he can stand up and move independently. The next day after laparoscopic cholecystectomy, despite the general good health, the patient should limit himself only to fluid intake; by the end of 2 days, table 5A can be prescribed if there are no signs of impaired motor-evacuation function gastrointestinal tract. Eating too early, in our opinion, is not justified, since it can provoke or increase the severity of postoperative complications that are still occurring latently.
It should be noted that many patients in the first days after laparoscopic cholecystectomy are bothered by pain in the supraclavicular region, which most often occurs on the right side, but in some patients on both sides. They often cause patients more trouble than pain from wounds of the anterior abdominal wall. These pains go away on their own within 3 to 4 days, without requiring any drug therapy. We believe that such pain is caused by sufficiently long intraoperative stretching and irritation of the diaphragm by carbon dioxide introduced into the abdominal cavity to create pneumoperitoneum (phrenicus symptom).
The general condition of patients after laparoscopic surgery in most cases, in principle, allows them to be discharged from the hospital on the 2nd day, which is what is done in many foreign medical institutions. Such an early discharge, if we take into account not only the financial side of the issue, in our opinion, is hardly justified. Postoperative complications may arise or appear only on the 3rd–4th day (acute pancreatitis, subhepatic or paraumbilical infiltrates, etc.), and then there is a danger that the patient will not receive a timely medical examination and, therefore, appropriate treatment will not be prescribed. We believe that during the normal course of the postoperative period, patients should not, as a rule, be discharged earlier than on the 3rd day; discharge on the 4-5th day after surgery is optimal, if the patient does not live too far from the hospital.
When deciding on the timing of resumption of work in patients after laparoscopic cholecystectomy, it is certainly necessary to take into account age and concomitant diseases. Since the trauma inflicted on the muscular aponeurotic layers of the anterior abdominal wall is usually minor, in the case of an uncomplicated postoperative period, activities not related to physical activity can be started 10-14 days after the intervention.
It is advisable to delay physical work for up to 4-5 weeks, depending on the size of the aponeurosis incision in the paraumbilical zone, which was required to remove the gallbladder from the abdominal cavity. In general, the period of disability of patients after laparoscopic cholecystectomy can be 2-3 times shorter compared to those after conventional surgery.
Laparoscopic cholecystectomy should become the leading treatment method for patients with chronic calculous cholecystitis.
The experience of domestic surgeons confirms the data of foreign authors that laparoscopic cholecystectomy has a number of advantages over a similar operation through laparotomy, mainly due to less trauma to the anterior abdominal wall.
It is necessary, however, to emphasize that laparoscopic cholecystectomy is a rather complex “jewelry” operation that requires excellent knowledge of the topographic-anatomical features of this zone and the skills of performing instrumental manipulations using a television image. There is no doubt that you can begin to independently perform this operation only after completing a special training course, not only by the surgeon-operator, but also by an assistant working with the laparoscope. The success of the intervention largely depends on the coordination of the actions of the operating team. In addition, the first independent operations, as in conventional surgery, should be carried out with the assistance of a surgeon who already has extensive experience in performing such interventions.
We are now at the origins of a new promising direction of low-traumatic surgery, which, undoubtedly, will expand the arsenal of its operations every year. Its fate depends on the validity of their clinical application - with our work we can facilitate or, conversely, complicate its development.

A) Indications for cholecystectomy:
- Planned: symptomatic cholelithiasis.
- Alternative operations: laparoscopic surgery.

b) Preoperative preparation:
- Preoperative studies: ultrasonography, gastroscopy, possible intravenous cholangiography, X-ray contrast examination of the stomach (exclusion of ulcers and hiatal hernia).
- Patient preparation: nasogastric tube for acute cholecystitis or choledocholithiasis, perioperative antibiotic therapy for cholecystitis, choledocholithiasis, and in patients over 70 years of age.

V) Specific risks, informed consent of the patient:
- Bile leakage, biliary fistula (0.5% of cases)
- Peritonitis (0.1% of cases)
- Missed stone (1% of cases)
- Damage to the bile duct (0.3% of cases)
- Damage to the duodenum or colon (0.1% of cases)
- Damage to blood vessels (portal vein, hepatic artery; 0.1% of cases)
- Abscess (0.2% of cases)

G) Anesthesia. General anesthesia(intubation).

d) Patient position. Lying on your back (a radiolucent table may be required).

e) Access for cholecystectomy. Right subcostal incision, right upper transverse incision.

Educational video of the anatomy of the gallbladder, bile ducts and Calot's triangle

and) Stages of cholecystectomy:
- Skin incision
- Dissection of Calot's triangle
- Exposure of the cystic duct
- Crossing of the cystic duct
- Transection of the cystic artery
- Retrograde gallbladder dissection
- Hemostasis of the gallbladder bed
- Drainage of the gallbladder bed
- Antegrade (“from the bottom”) dissection of the gallbladder

h) Anatomical features, serious risks, operational techniques:
- The course of the bile duct is very variable.
- Warning: Do not confuse the common or right hepatic duct with the cystic duct, or the right hepatic artery with the cystic artery.
- Small bile ducts can flow directly into the gallbladder and must be ligated and sutured.

And) Measures for specific complications:
- Postoperative bile leakage through drainage: usually due to a small accessory bile duct in the gallbladder bed. Leave the drain and maintain watchful waiting; Nasobiliary bile duct drainage or endoscopic placement of a temporary stent may be required.
- In unclear postoperative situations, perform ERCP.

To) Postoperative care after cholecystectomy:
- Medical care: remove nasogastric tube after 1 day, remove drainage after 2-3 days.
- Re-feeding: oral fluids from day 1, then rapidly increasing diet.
- Activation: immediately.
- Physiotherapy: breathing exercises.
- Period of incapacity for work: 1 week.

l) Operative technique of cholecystectomy.

1. Skin incision. Today, open cholecystectomy is an exception. However, certain circumstances still require routine open cholecystectomy (approximately 10% of cases) even in the era of laparoscopy. A transverse incision in the right hypochondrium has proven itself best. The traditional approach is the right subcostal incision, but this gives a less favorable cosmetic result.

2. Dissection of Calot's triangle. After opening the abdominal cavity and inserting two liver retractors, dissection begins under the gallbladder in Calot's triangle. The common bile duct and cystic duct are secreted towards the gallbladder. To do this, the overlying peritoneum is incised, allowing these structures to be clearly seen.

3. Exposure of the cystic duct. After dissection of the peritoneum, it is recommended to grasp the gallbladder with tupfer forceps and take it ventrally. This helps to stretch the cystic duct. Small accompanying veins (often flowing into the cystic duct) are crossed between the ligatures. The cystic duct is only accurately identified when the common hepatic duct is clearly visible above its confluence with the cystic duct.

Identification is based on identifying differences in duct diameters, following the common hepatic duct in a cranial direction, and clearly visualizing the junction with the cystic duct. Only after this can an Overholt clamp be passed through the cystic duct.

4. Crossing the cystic duct. Once the cystic duct has been positively identified, it should be divided close to the common bile duct between the Overholt forceps. The distal part is ligated with stitching; the proximal part can simply be ligated. If the anatomical situation is unclear, or if there is evidence of a stone in general bile duct, then before crossing the cystic duct, cholangiography is performed to radiographically see the common bile duct all the way to the duodenum.

Cholangiography is performed in all cases where intraoperative findings are uncertain or choledocholithiasis is suspected.

5. Transection of the cystic artery. The cystic artery usually lies in a cephalic direction from the cystic duct, although there are significant deviations, especially associated with the course of the right hepatic artery and its atypical origin from the common hepatic artery. It is important to identify the branch that goes to the gallbladder and ligate it as close as possible to it.

The ligation is performed between Overholt clamps; on the proximal side, the vessel is ligated with suturing.

6. Retrograde gallbladder dissection. After crossing the cystic duct and cystic artery, the next step is retrograde separation of the gallbladder from its bed in the liver, which is performed by gently pulling the bladder neck in a cranial direction. The fibrous connections to the liver are divided with scissors, and hemostasis is performed by diathermy. Separation of the gallbladder from the bed can lead to significant bleeding, especially with severe inflammatory changes, which will require additional measures for reliable hemostasis in the liver parenchyma (sutures, coagulation, etc.).

7. Hemostasis of the gallbladder bed. Separation of the gallbladder from its bed is carried out gradually with scissors and diathermy. In order to achieve reliable hemostasis of the bed, it is necessary to spend time. This is not always possible in the presence of severe inflammatory changes, and the surgeon may resort to local pressure and the application of hemostatic materials (sutures, tamponade with gauze pads, etc.).

8. Drainage of the gallbladder bed. After achieving hemostasis and re-examination of the cystic duct and cystic artery stumps, drainage of the subhepatic space can be resorted to in cases where this seems necessary. An ideal cholecystectomy should be performed without drainage. Drains are indicated only in complicated cases.

9. Antegrade (“from the bottom”) gallbladder dissection. In cases of dense fibrous adhesions in the region of Calot's triangle, a better understanding of the anatomy can be obtained by performing an antegrade dissection of the gallbladder (i.e., finding the cystic duct and cystic artery antegrade). To do this, the gallbladder is gradually separated from the bed in the liver, starting from the bottom, in the ventral direction, until the triangle of Kahlo is completely exposed. Here, it is important to accurately identify the hepatic duct and right hepatic artery in order to avoid damage to these structures during the exposure and separation of the gallbladder.

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

Conducted detailed analysis 3165 laparoscopic cholecystectomy (LCE) operations and their complications performed over 15 years.

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) has become a common operation for most large multidisciplinary medical institutions. However, the widespread introduction of this intervention on the basis of city and even district hospitals has led to a significant increase in the number of severe complications (trauma of the extrahepatic bile ducts, hollow organs and large vessels of the abdominal cavity) and transitions to open surgery, often associated with complications.

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

Recently, there are more and more publications about successfully performed operations for similar diseases and conditions.

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

The patients were aged from 11 to 87 years, the majority were patients of the most productive ages - from 30 to 60 years, patients of the older age group (from 61 to 87 years) accounted for 23.8%. At the time of surgery, 1/4 of the patients had severe concomitant pathology: 48 patients had heart disease (5 had an atrial septal defect, 14 had concomitant and combined heart defects, 24 had mitral valve defects, 5 had defects aortic valve); 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 at the time of LCE. 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 most of these patients, it was necessary to resolve the issue of 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 by laparoscopic method.

Features of the implementation of individual stages of the intervention.
Anesthesia in most cases when performing LCE is intubation anesthesia with the use of medium- and short-acting muscle relaxants. In some cases, mask anesthesia was used with the obligatory insertion of a nasogastric tube into the stomach. 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 onset clinical signs biliary peritonitis or obstructive jaundice. These patients underwent surgery via laparotomy within 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 disturbance 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 fall blood pressure(HELL). 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 efforts 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 the lavage of the abdominal cavity and its drainage performed during relaparoscopy, and the treatment antibacterial drugs, the patient developed multiple liver abscesses, necessitating 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 was early removal drainage and cessation 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, bleeding from a liver wound was so active that it was accompanied not only by an intense flow of fresh blood through the drainage, but also by a sharp decrease in blood pressure, as well as a decrease in the level of hemoglobin 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 postoperative bandage. On the 1st day they were allowed to drink in small sips mineral water without gas in a limited amount (250-300 ml), on the 2nd and 3rd days - intake of liquid up to 1.5 liters, a “second” broth, low-fat yoghurts, semi-liquid porridge or mashed potatoes and then a gradual expansion of the diet 5- 5A with a recommendation to comply with 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 sides(availability, “free”), and negative - just during these years, many publications appeared about severe intraoperative (trauma of the extrahepatic bile ducts, bleeding from the cystic artery, injury to large vessels and abdominal organs, etc.) and late postoperative (CBD 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%, and 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 the 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

There are similarities and differences in the conduct of operations, as well as in recovery after them.

Why is cholecystectomy performed - is it necessary to have surgery, and why?

Like all organs, the gallbladder performs a special function in the human body, intended specifically for it. In a healthy state, it takes an important part in the digestive process. When food moves through the digestive tract and enters the duodenum, the gallbladder contracts. The bile it produces enters the intestines in an amount of about 50 ml and helps normal digestion of food.

If there are pathological changes, it begins to bring problems to the human body instead of benefit!

A diseased gallbladder causes:

• frequent, sometimes constant pain;
• disorder of all biliary functions of the body; negatively affects the normal functioning of the pancreas;
• creates a chronic reservoir of infection in the internal organs.

In this case, to cure the body of the resulting pathology, surgical intervention becomes vital!

Statistics show that out of one hundred percent of patients who underwent such an operation, in almost 95 percent of patients all painful symptoms disappeared after removal of the gallbladder.

Since Langenbuch performed the first gallbladderectomy in 1882, it has consistently been the most important method of curing people from diseases of this organ.

Here are some figures and facts indicating the constant growth of this disease in the world:

• in the countries of the European continent, about 12 percent of people have cholelithiasis;
• in Asian countries this percentage is four;
• in the United States, 20 million Americans suffer from gallstones;
• American surgeons perform gallbladder removal on more than 600 thousand patients every year.

Absolute and relative indications: when is surgery necessary?

As for any surgical intervention, there are both absolute and relative indications for surgery to remove the gallbladder.

• acute cholecystitis due to cholelithiasis;
• chronic cholecystitis that cannot be treated conservatively and its exacerbation;
• non-functioning gallbladder;
• symptomatic or asymptomatic gallstone disease, that is, the presence of stones in the bile ducts;
• development of gangrene of the gallbladder;
• intestinal obstruction caused by the presence of gallstones.

A relative indication for removal of the gallbladder is an established diagnosis of chronic calculous cholecystitis, if its symptoms are caused by stone formation in the gallbladder.

It is important to exclude diseases accompanied by similar symptoms!

Such diseases include:

• chronic pancreatitis;
• irritable bowel syndrome;
• peptic ulcer of the stomach and duodenum;
• urinary tract disease.

The types of operations performed for this pathology are:

Progress of open cholecystectomy surgery

Open surgery is performed under general anesthesia. It is applicable to most patients suffering from cholelithiasis. Performed according to vital indications.

The progress of the operation can be described as follows:

1. During the operation, the surgeon makes a 15 to 30 centimeter incision along the midline of the abdomen from the navel to the sternum or under the right costal arch.
2. Thanks to this, the gallbladder becomes available. The doctor separates it from adipose tissue and adhesions, bandages it with a surgical thread.
3. At the same time, the bile ducts and blood vessels approaching it are clamped with metal clips.
4. The gallbladder is separated from the liver by the surgeon and removed from the patient's body.
5. Bleeding from the liver is stopped using catgut, laser, and ultrasound.
6. The surgical wound is sutured with suture material.

All stages of the operation to remove the gallbladder last from half an hour to one and a half hours.

After the operation, you must strictly follow all medical recommendations!

This will help prevent possible complications:

• bleeding from a trocar wound;
• outflow of blood from the clipped cystic artery;
• opened blood flow from the liver bed;
• damage to the common bile duct;
• intersection or damage to the hepatic artery;
• leakage of bile from the liver bed;
• bile leakage from the bile ducts.

Advantages of laparoscopic cholecystectomy – video, surgical technique, possible complications

For surgery with a laparoscopic approach, the following indications are needed:

• acute cholecystitis;
• gallbladder polyposis;
• chronic calculous cholecystitis;
• gallbladder cholesterosis.

Laparoscopy is fundamentally different from open surgery in that no abdominal tissue incision is made. It is performed only under general anesthesia.

The step-by-step technique of laparoscopic surgery in this case is as follows:

1. In the navel area and above it, 3 or 4 punctures of different sizes are made. Two of them have a diameter of 10 mm, two are very small, with a diameter of 5 mm. Punctures are made using trocars.
2. Through one trocar tube, a video camera connected to a laparoscope is placed into the peritoneal cavity. This allows you to monitor the progress of the operation on the monitor screen.
3. Through the remaining trocars, the surgeon inserts scissors, clamps, and a tool for applying clips.
4. Clamps in the form of titanium clips are applied to the vessels and bile duct connected to the bladder.
5. The gallbladder is disconnected from the liver and removed from the abdominal cavity through one of the trocars. If the diameter of the bubble is greater than the diameter of the trocar tube, stones are first removed from it. The bladder, which has decreased in volume, is removed from the patient’s body.
6. Bleeding from the liver is prevented using ultrasound, laser or coagulation.
7. The surgeon sutures large, 10 mm, trocar wounds with dissolving threads. Such seams do not require further processing.
8. Small, 5 mm, trocar holes are sealed with adhesive tape.

When laparoscopy is performed, the progress of the operation is monitored by doctors on the monitor screen. A video is also shot, which you can always watch later if necessary. For clarity, a photo of the operation with the most important moments is also taken.

In five percent of cases, endoscopic surgery for this pathology is impossible to perform.

• with an abnormal structure of the biliary tract;
• in acute inflammatory process;
• in the presence of adhesions.

Laparoscopy has a number of advantages:

• postoperative pain is extremely rare, more often there is none at all;
• There are practically no postoperative scars;
• the operation is little traumatic for the patient;
• significantly lower risk of infectious complications;
• the patient has very little blood loss during the operation than during open surgery;
• short period of a person's stay in the hospital.

Recovery Features

The patient needs time to recover after surgery. Rehabilitation after open surgery lasts longer than during laparoscopic surgery surgical intervention.

After traditional surgery, the sutures are removed on the sixth or eighth day. The operated patient is discharged from the hospital, depending on his condition, after ten days or two weeks. In this case, general working capacity is restored for quite a long time - from one to two months.

After laparoscopic surgery, there is usually no need to remove sutures. The patient is discharged from the hospital on the second or fourth day. Normal working life is restored after two or three weeks.

After surgery you must:

• adhere to the diet recommended by doctors;
• maintain a general regime that is comfortable for the body;
• conduct massage courses;
• use safe choleretic agents.

If there is no gallbladder in the body, it is necessary to remove bile from the body regularly, four or five times a day! This process is associated with eating. Therefore, you need to eat no less than five times a day.

Then the human body will quickly adapt to the new condition, and the person operated on will be able to live the normal life of a healthy person.

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Operation cholecystectomy: complications, pain and patient’s condition after removal of the gallbladder

In case of inflammation of the gallbladder, an operation is performed - laparoscopic cholecystectomy. This type of surgery is performed to remove a pear-shaped organ called the gallbladder.

Its volume is no more than 80 ml and its main function is to ensure normal digestion. It acts as a reservoir that stores bile. The more actively a person eats, the more the liver works, taking on most of the enzymes. Initial signs of the disease may not appear at all.

What is cholecystectomy?

Diseases of the gastrointestinal tract can be caused either by a lack of the required amount of bile or by its excess. All this negatively affects the pancreas. Endoscopic cholecystectomy is performed if:

and implies the need for surgical intervention.

During the operation the following is used:

Before the operation, the doctor performs a mandatory CT and ultrasound, which will provide all the necessary data that the surgeon will need to perform the operation. Cholangiography may also be prescribed. Such studies are carried out in several stages, and the surgical intervention itself must be performed exclusively by a highly qualified surgeon and gastroenterologist, who independently determine the necessary classification of the disease.

For any form of cholelithiasis, a traditional cholecystectomy is prescribed. Endotracheal anesthesia is used as an anesthetic. During the operation, it becomes possible to examine the retroperitoneal space and the organs of this cavity. Simultaneous surgical interventions are also possible if additional ones were discovered:

For the patient, this is the safest method of solving the problem.

The main disadvantages of cholecystectomy

• long-term disability due to postoperative rehabilitation, during which any stress is prohibited;
• a scar will remain, regardless of the suture technique used;
• trauma to the anterior abdominal wall, which can lead to a number of complications and the formation of a hernia;
• During the operation, a moderate injury is caused, which can lead to limitation of physical activity, impaired respiratory function and intestinal paresis.

During video laparoscopic cholecystectomy, only the gallbladder is removed. Initial pain, tests and other indicators should not differ from those for which a traditional cholecystectomy is prescribed.

Contraindications for surgery

1. Previous operations in the same part of the abdominal cavity.
2. Jaundice.
3. Problems with the heart or lungs.
4. Pancreatitis.
5. Obesity of the last degree.
6. Impaired blood clotting.
7. Peritonitis.
8. Last stages of pregnancy.
9. Fever for five days.
10. Subcostal heart pain.

But all these indications are more than relative. The emergence of new surgical techniques and the latest medical equipment will help reduce the risk to a minimum, thereby reducing the above list to a minimum. The subjective factor will always play a fundamental role, since much still depends solely on the opinion and experience of the surgeon himself.

Indications, causes and symptoms for cholecystectomy

If the future patient has symptoms such as:

The doctor can diagnose gallstone disease. You should not self-medicate, since there are still a number of diseases that require prompt surgical intervention. Most doctors recommend removing even asymptomatic stones, as they can lead to serious consequences. Some complications may occur without clinical manifestations, for example:

Reasons for performing laparoscopic cholecystectomy:

1. Presence of acute cholecystitis. After the operation are observed clinical manifestations bile leakage after LCE, discharge of which can occur externally, through a drained opening.
2. Choledocholithiasis. It is worth considering that drains are left for a very long time.
3. Asymptomatic course of gallstone diseases.
4. When the bile ducts are blocked.
5. The presence of acute inflammation.
6. The presence of a number of symptoms of cholelithiasis.
7. With perforation of the gallbladder.
8. The presence of polyps in the gallbladder.
9. Cholesterosis.
10. Calcinosis.

The gallbladder affects the functioning of the entire body, and in the event of an infection, it turns into a reservoir for its storage and further spread. If the functions of the gallbladder and pancreas are impaired, the patient begins to worry characteristic symptoms and pain.

Cholecystectomy: preparation, operation progress

When first appears pain, you must act very quickly. To carry out the most complete diagnosis and determine the method of operation, the patient is prescribed a planned comprehensive diagnosis. Such preparation is carried out in order to avoid possible complications in the postoperative period.

Preparation for laparoscopic cholecystectomy

For this purpose the following is carried out:

• respiratory and of cardio-vascular system(Dopplerography, ECG, X-ray of the lungs);
• CT scan;
• examination of the pancreas and liver;
• tomography and intraoperative MRI;
• Ultrasound of the liver, pancreas and gall bladder.

Preoperative diagnosis

Such preoperative diagnostics will make it possible to find out general state the body and its individual organs. After receiving the necessary information, you will need to comply with the following requirements:

• preoperative procedures regarding personal hygiene are carried out exclusively with the help of antibacterial gel or soap;
• on the eve of the operation, the intestines are cleansed with the help of auxiliary medicines or enemas in case of constipation, and to avoid diarrhea;
• stop drinking water 12 hours before surgery;
• stop taking it 48 hours before cholecystectomy medicines and various food additives which may affect blood clotting.

Progress of the operation

• During the operation, an incision is made in the abdominal cavity.
• The gallbladder is displaced and then moved away from the liver using special forceps.
• If stones are found at its bottom, the bottom opens and bile is aspirated.
• Large stones, like smaller ones, are crushed in different ways.
• After desufflation is performed, the trocars are removed.
• The incision is closed with one stitch.

Condition after cholecystectomy: pain, nutrition, complications

After abdominal surgery, for a speedy recovery, it is necessary to follow a number of measures. For 54 days, doctors oblige patients to:

• take daily walks, at least half an hour a day;
• reduce the volume of liquid consumed to one and a half liters per day;
• eat exclusively dietary products which are steamed;
• reduction physical activity, including lifting containers whose weight exceeds four kilograms.

Treatment after cholecystectomy of the gallbladder

Treatment after cholecystectomy of the gallbladder should be carried out comprehensively and under the supervision of the attending physician. Laparoscopy, or rather its postoperative period, is many times easier than after laparotomy. The almost complete absence of pain allows you to minimize the use of analgesics.

The patient can move independently a few hours after the operation, and after four days, he can be safely discharged. Depending on daily stress, recovery may take from 2 to 6 weeks. The condition and recovery after cholecystectomy ICD-10 will not allow you to start working as soon as possible.

How is the gallbladder removed?

• maintaining an active and healthy lifestyle;
• completely eliminating all bad habits, including alcohol;
• You should regularly undergo tests to determine the level of bilirubin formation.

Possible complications

Like any other operation, cholecystectomy can cause a number of complications. Postcholecystectomy syndrome may be accompanied by:

• motor impairment;
• motor function of the duodenum.

Timely diagnosis and frequency of such cases largely depends on the surgeon.

Additional possible complications:

1. Bleeding of organs and ducts located nearby the gallbladder.
2. Damage to the hepaticocholedochus.
3. Perforation of the intestines and stomach.
4. Damage to the vessels located in the abdominal cavity, which have to be re-sutured.

You should not try to save on your own health by choosing a surgeon based on the cost of his services. Most of the negative consequences occur due to the fault of doctors who made mistakes during the operation.

Diet for cholecystectomy: menu, what you can and cannot eat after surgery

Any operation harms our body, regardless of its level of complexity. At first, the stitches may hurt. To begin with, we advise:

• limit possible physical activity as much as possible;
• switch to proper, more balanced nutrition;
• the first few hours after surgery, it is prohibited to take liquids or any food;
• You can sit down only after 12 hours;
• For the first 6 hours, it is recommended to only lubricate your lips with an ice cube or moistened cotton wool;
• after a day, you can drink no more than a liter of water per day;
• it is necessary to start moving, while having constant safety net;
• on the third day you can start drinking kefir or herbal compote without sugar;
• a single volume of liquid consumed should not exceed 100 ml, but the total volume can be increased to one and a half liters;
• more nutritious foods (mashed potatoes, jellies and fresh juices) can be consumed only on the fifth day after surgery;
• the first meal of solid food occurs only on the sixth day, in the form of crackers or stale bread;
• after a week, you can include in your diet dietary dishes that are steamed, but only in a pureed state;
• on the tenth day it is allowed to eat not pureed food, but exclusively dietary food;
• At first, a person may experience diarrhea due to the forced refusal of heavy and rough foods.

General conclusions

One of the standard types of operations is single-port laparoscopic cholecystectomy. It is prescribed for the treatment of diseases such as:

• cholecystitis,
• choledocholithiasis, which may also be present.

Any surgeon can perform this operation due to the fact that laparoscopy is now taught to all surgeons, and not just those who have chosen this specialty, as was the case before.

An important aspect that will lead to a minimum number of postoperative complications is the experience of the surgeon himself. The use of new technologies has made it possible to carry out similar operations of any level of complexity, which is an undeniable advantage for any patient, including international ones.

The cost of a cholecystectomy operation is about $445, taking into account the rehabilitation period, which can last as long as the sutures fuse (poor clotting). To see a doctor, you only need a desire, but you shouldn’t look for a reason.

Laparoscopic cholecystectomy

Technique for performing laparoscopic cholecystectomy.

• All cases of acute and chronic cholecystitis (calculous and acalculous), stone carriers.
• Gallbladder polyposis
• Gallbladder cholesterosis

Position of the patient and the operating team

Currently, there are two main positions for the patient (and, accordingly,) surgeons - the American one (the patient is in a supine position, with his legs together) and the European one, in which the patient’s legs are spread apart.

We usually use the “American” position of the patient on the operating table, since this position allows us to perform gall bladder surgery in all cases. Only if we assume a simultaneous operation, we use the “European” position of the patient, in which the operator stands between the patient’s legs. In some cases, it is convenient to be located between the assistant’s legs (especially when working together - a surgeon and one assistant), with the surgeon located to the left of the patient.

After applying pneumoperitoneum through a Verisch needle (usually up to 10 mm Hg), a 10 mm trocar is installed in the paraumbilical area and a laparoscope is inserted. After revision of the abdominal cavity, additional trocars are installed. A second 10 mm trocar is inserted into the epigastrium, and it should be installed so as to enter the abdominal cavity to the right of the round ligament, but as close to it as possible. The next trocar, 5 mm, is installed below the costal arch along the midclavicular line, and the 4th along the anterior axillary line 4-5 cm below the costal arch.

The first trocar is installed in a certain place, then the location of the rest may have some variations. The trocar in the epigastrium should be positioned so as to be to the right of the round ligament, but at the same time as close to it as possible. The trocar should enter the abdominal cavity above the edge of the liver and in an upward and lateral direction (relative to the patient). The third trocar should enter the abdominal cavity below the edge of the liver and go towards the neck of the gallbladder.

The main danger when installing trocars, especially the first one, is the early penetration of the abdominal organs and retroperitoneal space. To avoid this, it is necessary to insert the trocar only after pneumoperitoneum has been established. It is advisable to use a trocar with protection. Even when using a trocar without protection, when inserting it, it is necessary to insert it slowly, clearly controlling the passage of the layers of the abdominal wall and not applying too much force.

The next problem that you may encounter at this stage is bleeding from the abdominal wall. As a rule, it is not intense, but the constant leakage of blood drop by drop makes it difficult to work. Therefore, prior to manipulation, bleeding must be stopped. The most convenient way to do this is to use an Endo-close (AUTO SUTURE) type needle or a so-called furrier’s needle. The needle is inserted parallel to the trocar and the abdominal wall is sutured through all layers.

The operating table is moved to the Fowler position (raised head end) and tilted to the left by 15 - 20 degrees. From 4 trocars, the instrument grasps the bottom of the gallbladder and takes it as far upward as possible to the diaphragm. With a pronounced adhesive process, this is not always possible; then the liver is lifted with an instrument and the adhesions are separated. To do this, a soft clamp is inserted from the third trocar, which grasps the omentum soldered to the bladder, and a working instrument is inserted from the epigastric trocar. The adhesions are separated either with scissors or with a hook electrode. “Loose” adhesions are separated in a blunt way - with a dissector, scissors or a tupfer. When separating dense adhesions, it is necessary to carry out all manipulations as close to the bladder as possible, using minimal coagulation. After isolating the bottom of the gallbladder, it is grabbed with a clamp that was used to lift the liver and taken upward to the diaphragm. If the gallbladder is tense and is not captured by the instrument, then puncture is performed. The needle is inserted through the 3rd trocar, the bladder is punctured. After the bile is evacuated, the needle is removed and the bladder is grabbed at the puncture site. After that, the entire bladder is gradually isolated up to the neck.

The main problems at this stage are bleeding and damage. internal organs. To prevent this, it is necessary to carry out all manipulations almost along the wall of the bladder. If, despite this, the omental vessel is damaged, it can be coagulated. To do this, it is captured by a dissector and coagulated. It is necessary to caution against coagulation “blindly”, as this can cause more serious complications. The bleeding site is washed and dried with an aquapurator, and only under visual control is captured with a dissector.

Damage to internal organs occurs when working in conditions of poor visibility and when using coagulation. If there is an adhesive process with the intestine or stomach, it is necessary to separate them either bluntly or without using coagulation with cuticles.

After separating the adhesions, an instrument inserted through 3 trocars grasps Hartmann's pouch and retracts it laterally, opening Calot's triangle. A hook-shaped electrode is inserted through the epigastric trocar to mobilize the neck of the gallbladder. It is safest to use a 3mm tool. First, the peritoneum is dissected in the neck area along both the anterior and posterior surfaces of the bladder. After this, the adipose tissue is separated step by step, using the cutting mode. Minor bleeding in this area can be controlled with coagulation. Isolation of the cystic artery and duct is carried out to the point of their connection with the gallbladder. In this case, it is necessary to clearly ensure that these structures go to the bubble. The artery and duct are clipped separately, placing 2 clips on the proximal segment and one on the distal segment. The artery and duct are crossed with scissors between the clips. Clipping and crossing begin with the artery, since if the cystic duct is crossed, the artery can easily be torn. When crossing structures, coagulation is not used, since the clips heat up and this can cause necrosis of the wall of the duct or artery with the development of corresponding complications.

Further isolation of the gallbladder from the bed is carried out using a hook-shaped electrode subserosally. In this case, bleeding usually does not occur. Bleeding is possible if the discharge occurs through the liver tissue, or if there is an atypical location of a large vessel. Having almost completely isolated the gallbladder from the bed, it is necessary to leave a “bridge” of the peritoneum, the bladder is tilted upward and the bed is examined. If necessary, we coagulate bleeding areas. For coagulation, an electrode in the form of a spatula or ball is used. For diffuse bleeding from the gallbladder bed, argon-enhanced coagulation is of great help.

After this, the bed and subhepatic space are washed and thoroughly dried (in case of “dry” discharge of the bladder, we do not wash). The bridge connecting the gallbladder to the liver is crossed and the bladder is placed in the subphrenic space.

Removal of the bladder from the abdominal cavity is usually performed through an umbilical wound. To do this, the laparoscope is moved into the epigastric trocar, and under its control, a “rigid” clamp is inserted through the umbilical trocar. The gallbladder is grabbed by the neck (preferably by the cystic duct with a clip) and brought to the trocar and, if possible, drawn into it. Together with the trocar, the bladder (or part of it) is brought to the abdominal wall. The bubble is captured by Mikulich's forceps, and if it is large it is emptied. After this, the wound is expanded if necessary and the bladder is removed from the abdominal cavity.

After removing the bladder, the umbilical wound is sutured. In this case, it is necessary to suture the aponeurosis.

After suturing the wound, pneumoperitoneum is applied again, the subhepatic space and the gall bladder bed are examined. For convenience, the liver is elevated with an instrument inserted through the fourth trocar. If necessary, the bed is additionally coagulated. The third and fourth trocars are removed under visual control. After removal of the pneumoperitoneum, the epigastric trocar is removed along with the laparoscope, and all layers of the abdominal wall are examined to monitor hemostasis. The wounds are sutured.

Operation laparoscopic cholecystectomy

The patient can be positioned on the operating table in two different ways, depending on what surgical approach the surgeon uses. Conventionally, these two variants of technology are called "French" and "American".

In the first option (“French” technique) of surgical access, the patient is placed on a table with his legs apart, the surgeon is between the patient’s legs. The assistants are located to the right and left of the patient, and the operating nurse is located at the patient’s left leg.

When using the “American” technique, the patient lies on the table without spreading his legs; the surgeon is located to the left of the patient, the assistant is on the right; the assistant is on the camera at the patient’s left leg, the operating nurse is at the right.

The differences between these two techniques also concern the points of insertion of trocars and fixation of the gallbladder. It is believed that these differences are unimportant and are a matter of personal habit of the surgeon. At the same time, when using the “American” method, which uses cephalic traction of the bottom of the gallbladder using a clamp, a much better exposure of the subhepatic space is created. Therefore, we will describe this option in the future.

Placement of equipment and instruments during laparoscopic cholecystectomy.

Traditionally, articles and manuals do not pay attention to this issue. special attention, although it is of practical importance. Thus, the irrational location of the rack with equipment and monitors can lead to the fact that during the operation of laparoscopic cholecystectomy the monitor screen is covered with foreign objects or the anesthesiologist's head, and then the surgeon and assistants take a forced tense position and quickly get tired; irrational placement of cables and tubes on the patient can lead to the fact that at the end of the operation they get tangled into a knot. Of course, it is difficult to give unambiguous recommendations for all cases, and probably each surgeon in the course of practice must develop for himself the most satisfying options. Most often, confusion of communications occurs if they are fixed to the surgical linen at one point. Therefore, we divide them into two bundles: (1) gas supply hose + electrocautery cable and (2) irrigation/suction hoses + camera cable + light guide. The end of the electrocoagulation cable is passed into the ring of the clip, which fixes the surgical linen to the arc. To the left of the patient, a wide pocket is formed from the surgical linen using pins from the arch to the patient’s left leg. The presence of such a pocket prevents these items from accidentally falling down outside the sterile area and, therefore, breaking asepsis. The arc along which the camera cable and light guide are located must be free so that by the end of the operation, when removing the bladder through the paraumbilical puncture, the telescope can be easily moved to the subxiphoidal port.

Technique of laparoscopic cholecystectomy.

The operation of laparoscopic cholecystectomy begins with the application of pneumoperitoneum using a Veress needle. Most often, a Veress needle is inserted through a paraumbilical approach. Technically, performing a cosmetic paraumbical incision is made easier if you initially make a small puncture of the skin (3-4 mm) along the line of the intended cosmetic incision, apply pneumoperitoneum, and then make the incision. The length of the paraumbilical incision is initially at least 2 cm and can be widened if necessary. The pneumoperitoneum is maintained at 12 mm Hg. Art., gas supply speed 1-6 l/min. After making a skin incision, a 10 mm trocar is inserted into the abdominal cavity through it, and a gas supply hose is connected to its nozzle.

An optical tube is inserted into the abdominal cavity through the trocar and a general examination of the entire abdominal cavity is performed. At the same time, attention is paid to the presence of fluid in the abdominal cavity, the condition of the liver, stomach, omentum, and intestinal loops. This moment of the operation is very important, since if you immediately concentrate on the right hypochondrium, you may not notice, for example, blood at the site of injury to the greater omentum directly below the navel or ongoing bleeding from the point of insertion of the first trocar, or miss metastases in the left lobe of the liver if the oncological process is not suspected before surgery, or pathology of the female genitalia (cysts, oncological processes). If the surgeon identifies such changes, this may change the entire further plan of action, may force one to refuse to perform cholecystectomy, or may prompt the surgeon to introduce trocars in other places than the standard.

If nothing unexpected was detected in the abdominal cavity, then the following trocars are introduced. The current standard is to insert a total of four trocars: two 10 mm trocars and two 5 mm trocars. All trocars, with the exception of the first, are inserted under mandatory visual control: in this case, the sharp end of the trocar should always be in the center of the field of view. A subxiphoidal trocar is inserted at the border of the upper and middle third of the distance between the xiphoid process and the navel to the right of the midline, one of the 5 mm trocars is inserted along the midclavicular line 2-3 cm below the costal arch, and the second 5 mm trocar is inserted along the anterior axillary line at the level of the navel . The subxiphoidal trocar is inserted in an oblique direction (approximately 45°) so that its end enters the abdominal cavity to the right of the falciform ligament of the liver; if it ends up to the left of the ligament, this may complicate further manipulations. One 5 mm trocar (along the midclavicular line) is inserted perpendicular to the abdominal wall. The other (along the anterior axillary line) is inserted in an oblique direction, orienting its end to the bottom of the gallbladder; this arrangement of the puncture channel is optimal, since the work of the instrument inserted through this trocar proceeds for the most part along this axis, with tears in the peritoneum, especially noticeable towards the end of the operation, will be minimal, and in addition, if it is necessary to introduce drainage through this port, it will be directed clearly to the bed of the gallbladder.

Through the lateral 5 mm trocar, the assistant introduces a grabber, which captures the bottom of the gallbladder. In this case, you should use a clamp with a lock, since holding the bottom of the bubble with a clamp without a lock is very tiring for the assistant. Before fixing the bottom of the bladder, the surgeon can help by lifting the edge of the liver or grabbing the bladder. In cases where it is not possible to capture the wall of the bubble into a fold due to its pronounced tension due to the liquid, the bubble should be punctured.

Then the assistant moves the bottom of the bubble upward, i.e. creates the so-called cephalic traction. In this case, adhesions, if any, are clearly visible. Delicate and transparent adhesions can be easily cut with an electric hook. This manipulation is made easier if the adhesion is pulled away from the bladder with a soft clamp inserted through the free port. In cases where the adhesive process is pronounced, the adhesions are dense and opaque, this work should be done very slowly, carefully and gradually, since cases of damage to the colon, which was involved in the adhesive process in the area of ​​the bottom and body of the bladder, have been described, and many cases of damage are known duodenum when separating adhesions in the area of ​​Hartmann's pouch. In addition, in such cases, electrocoagulation should be used with extreme caution, since damage to these organs can be in the nature of thermal burns and necrosis.

During the dissection of a large number of adhesions during laparoscopic cholecystectomy, a significant amount of blood and clots can accumulate in the subhepatic space, which significantly reduce the quality of visualization and the level of illumination (since blood absorbs light). To prevent clot formation and improve visibility, it is advisable to periodically rinse this area with liquid with the addition of heparin (5 thousand units of heparin per 1 liter of liquid). The addition of heparin relieves clot formation in the free abdominal cavity, so the spilled blood can be freely aspirated. Studies have shown that the addition of heparin has no effect on overall blood clotting.

After releasing the gallbladder from the adhesive process, it is fixed with a clamp and behind the area of ​​Hartmann's pouch. In this case, attention should be paid to creating the correct exposure: the bottom of the bladder continues to be retracted in the cephalic direction, and the Hartmann's pouch is retracted laterally and away from the liver. It is a mistake if the assistant presses the Hartmann's pouch to the liver - this not only complicates the preparation, but is also simply dangerous, since it does not make it possible to well verify the anatomy of this zone.

Dissection of tissue in this area can be carried out either using an electric hook or using scissors with electrocoagulation. This is a matter of the surgeon’s individual habit, although the hook still has some advantages: for example, it can capture a smaller portion of tissue, and in addition, the dissected tissue can be raised, i.e. dissection becomes much more delicate. Initially, the peritoneum around the neck of the bladder should be incised, the incision should be made on both the right and left sides of the bladder, and it should be in the shape of a parabola, with the branches directed upward. Using an electric hook, you can make a notch in the peritoneum in the upper left part of the parabola, and then, gradually lifting the peritoneum and cutting it, move further. At the same time, the assistant gradually turns the Hartmann pocket in the direction opposite to the direction of the cut, and thereby improves the exposure.

Then they begin to highlight the anatomical elements in the area of ​​the Calot triangle. This preparation can again be carried out using an electric hook, and you can also combine crochet work with a dissector. Gradually capturing and crossing small bundles of connective tissue (the criterion for intersection may be the thinness and transparency of the dissected elements). These connective tissue elements are dissected on both sides of the cervix; the assistant rotates the Hartmann's pouch to do this. Tubular structures are gradually revealed: the cystic duct and artery. Most often, the cystic duct lies closer to the free edge of the “mesentery” of the bladder, and the artery is further away, but this is not always the case. An artery marker can be lymph node, which is located here, and which, against the background of chronic inflammation, is often hyperplastic. After identifying these tubular structures, an attempt should be made to see the confluence of the cystic duct and hepaticocholedochus. In the literature, there are conflicting opinions about the need to clearly see the junction of the cystic duct with the hepaticocholedochus: for example, some authors consider it necessary to always do this, others do not consider it mandatory. Probably, if there is no doubt about the anatomical situation and subject to a number of rules, the desire to dissect this area at all costs is unjustified and may increase the likelihood of injury to important anatomical structures.

The next stage of the laparoscopic cholecystectomy operation is the intersection of the cystic artery. It should be noted that the cystic artery is divided before the cystic duct. Two clips are placed on the trunk of the artery as close to the wall of the bladder as possible on each side of the intended intersection line, after which it is crossed with scissors. Some authors recommend crossing the artery after electrocoagulation, considering this technique more reliable than clipping alone; in any case, if the surgeon applies a clip to the coagulated trunk of the artery before crossing it, this probably will not harm.

Video: Laparoscopic cholecystectomy in vivo

Crossing the artery while preserving the cystic duct makes it possible to fulfill one of the main conditions for safe dissection: to create a “window” between the neck of the bladder, the cystic duct, the liver and the hepatoduodenal ligament. If such a window is created, then this largely guarantees the surgeon against damage to the common bile duct. If it is not intended to perform intraoperative cholangiography or choledochoscopy through the cystic duct, then it is clipped twice on each side of the intersection line and crossed with scissors. Crossing the cystic duct using electric current is unacceptable: the electric current can flow through the metal clips as if through a conductor, this will lead to thermal necrosis of the wall of the cystic duct around the clips. It is advisable that a section of the cystic duct of about 0.5 cm remains above the clips, this will reduce the likelihood of the clips moving in the postoperative period.

In some cases, laparoscopic cholecystectomy requires intraoperative cholangiography.

Based on extensive experience in laparoscopic operations and analysis of a large number of complications in the world literature, a number of rules have been developed that can be considered as the “gold standard” in the technique of safely performing laparoscopic cholecystectomy, and compliance with which should reduce the risk of complications to a minimum:

• Perform maximum cephalic traction on the bottom of the gallbladder.
• Using a clamp placed at the junction of the bladder funnel into its duct, the Hartmann pouch should be shifted laterally and moved away from the liver.
• Dissection should begin high at the bladder neck and continue medially and laterally near the wall of the organ.
• Once the anatomical structures have been clearly identified, the artery should be divided first.
• After dissecting the tissue in the Calot triangle, the neck of the gallbladder must be freed, the junction of the wall of the bladder body with its bed on the liver must be clearly defined to create a “window”, and only then the cystic duct must be crossed.
• When applying clips, you need to clearly see the location of their distal ends.
• In unclear cases, perform intraoperative cholangiography.

After crossing the cystic duct, the neck of the bladder becomes much more mobile. The next task is to separate the bubble body from its bed. The key point In performing this stage, the peritoneum is dissected on the sides of the bladder body. This dissection should be made at a distance of about 0.5 cm from the liver tissue. To facilitate such a dissection, techniques are used that are known in the world literature as “right turn” and “left turn”. When performing a “right turn,” the neck of the bubble is retracted to the right, while the bottom, on the contrary, moves to the left. In this case, the transitional fold of the peritoneum on the medial side of the gallbladder is exposed. The peritoneum along the fold is dissected with a hook or with scissors for about 2 cm, then a left turn is made, in which the neck of the bladder is retracted to the left and the bottom to the right. The left turn exposes the lateral transitional fold, which is also dissected for about 2 cm. After this, the neck is retracted upward and the connective tissue elements in the bed area are crossed. Then again repeat the right and left turns and separation from the bed. These techniques are repeated until the gallbladder is connected to the bed only in the fundus. It is important that the surgeon immediately stops bleeding from the bed that occurs, without leaving it “for later,” since the bed may subsequently “fold” and the source of bleeding may be in a hard-to-reach place.

Once the bladder is only fundally connected to the bed, the dissection procedure is stopped and the surgeon performs a final inspection of the bladder bed and the condition of the cystic duct stump and artery for bleeding, bile flow, or clip displacement. To do this, the subhepatic space and the bladder bed are thoroughly washed with a liquid with the addition of heparin, followed by aspiration of the liquid. The sufficiency of washing is determined by the degree of transparency of the liquid in the subhepatic space - the liquid should be as transparent as possible. It is almost always required to stop capillary bleeding from the bed area. It is convenient to do this using a flushing spoon-shaped electrode - a jet of liquid supplied through the channel with a syringe allows you to accurately see the localization of the source, which facilitates its targeted coagulation.

After the bleeding has completely stopped, the bottom of the bladder is separated from the bed. To facilitate this stage, a special technique is used, when the traction of the bottom of the bladder changes from the cephalic direction to the caudal one. Traction of the bladder neck is performed in the same direction. In this case, the peritoneum connecting the bottom of the bladder with the liver, and the connective tissue elements of the bed, become clearly visible, stretched, and they can be easily crossed with a power tool. After separation of the bubble, it is advisable to rinse the subhepatic space again.

The next stage of the laparoscopic cholecystectomy operation is the removal of the gallbladder from the abdominal cavity. From a cosmetic point of view, the most reasonable is the removal of the bladder through the paraumbilical port; in the presence of technical difficulties, this access easily expands around the navel to a length of 3-4 cm, without compromising cosmetics. Technically, in typical cases, this is done as follows: the camera is moved to the subxiphoidal port, and a clamp is inserted through the paraumbilical port, which has teeth on the working surfaces. The bladder is grabbed with a clamp by the area of ​​the neck and cystic duct, and this section of the bladder is removed out together with the trocar. The assistant immediately fixes the neck of the bladder with a clamp, already extracorporeally. If the bladder contains a little bile and the stones occupy a small volume, then it is possible to remove the bladder out through moderate traction by the neck, without expanding access. In most cases, to extract the bladder, it is necessary to expand the paraumbilical access. This can be done in two ways.

In one method, before removing the trocar, a special retractor is inserted along it, like a guide. This instrument passes through the entire thickness of the abdominal wall, and then, when the expander handles are compressed, it stretches the wound channel, and after that it is easier to remove the bubble. In some cases, when the gallbladder has a thick wall or contains stones big size, such divulsion of the wound channel may not be sufficient to extract the organ. In this case, you can proceed as follows: if such a situation is anticipated in advance, the skin incision is cosmetically expanded around the navel, the upper edge of the skin incision together with the subcutaneous tissue is pulled in the cephalic direction so that the aponeurosis along the white line becomes visible, the trocar is pressed from the inside to the anterior abdominal wall, and on the trocar the aponeurosis is dissected upward by 2-3 cm with a scalpel. After this, two atraumatic hooks, for example Farabeuf hooks, are inserted into the abdominal cavity, the wound canal is stretched and the bladder is removed using traction movements.

In cases where the bladder has destruction of the wall, and in cases where during the operation there was a violation of the integrity of the wall of the organ, especially containing a large number of small stones, then in order to avoid infection of the wound channel or squeezing stones into the abdominal cavity through a wall defect, which is almost inevitable If the traction is quite strong, we consider it rational to remove the bubble in the container. The container can be either special or adapted. A suitable container can be a sterilized 6 x 10 cm plastic bag from a blood transfusion system or a surgical glove (sterilized without talc). A special container is most convenient: it is inserted into the abdominal cavity through a 10 mm trocar using a special rod, and then it opens like a net on a flexible circular metal ring. The bladder is placed in a container, which is then tightly closed with traction using a special thread, and after the canal is expanded, it is removed from the abdominal cavity. When using an adapted container, difficulties may arise already when inserting it into the abdominal cavity.

The most convenient laparoscopic cholecystectomy operation in this case may be the following technique: a container (plastic or glove) is rolled up into a tube as tightly as possible and grabbed with an endoscopic clamp from the end where the container opens. The subxiphoid trocar is then removed and the container is passed directly through the wound channel using a clamp. Attempts to pass a folded, adapted container through a trocar are in most cases very labor-intensive and unproductive. After inserting the container, the trocar is put back in place. After this, as a rule, there are no gas leaks from the abdominal cavity through this wound channel. Using clamps, the container unfolds and opens, and is installed so that its bottom is directed towards the diaphragm. This makes it much easier to insert the gallbladder into it. The following technique greatly facilitates the immersion of the bladder into the container: the wide open hole of the container is placed as flat as possible on the organs, and the gallbladder is placed with a clamp in the area of ​​the center of the hole. Then the container is lifted with clamps by its opposite edges and shaken so that the bubble moves to the bottom of the container. This technique is much more effective than trying to pass the bubble into a container held suspended. Afterwards, the container with the bladder is removed through the paraumbilical access after its expansion. Removing a bubble in a container also has certain features. So, after removing the edges of the container outward, its edges are stretched by hand so that the organ becomes visible deep in the wound. After this, the bubble itself is removed with a clamp, and not the wall of the container, since if you simply pull on the container, its wall can easily rupture and the contents of the bubble, or it itself will slip into the abdominal cavity.

After removing the bladder during laparoscopic cholecystectomy, the paraumbilical access is sutured. Some authors talk about the possibility of not suturing the wound canal if its diameter is 1 cm or less. However, at the paraumbilical point through which the bladder is removed, such a condition is observed extremely rarely, and in the vast majority of cases sutures have to be placed on the aponeurosis. Often the surgeon is in a difficult position: the desire to achieve maximum cosmetic efficiency by making a minimal skin incision conflicts with the technical difficulties of suturing the aponeurosis deep in the narrow wound channel. Suturing can be done in two ways. One of them is “traditional”, in which the surgeon uses a needle holder and a small needle with high curvature, while manipulation can be facilitated by grasping the edges of the aponeurosis incision with clamps. As a rule, a total of 2-3 interrupted sutures are required.

The second method of suturing the wound canal during laparoscopic cholecystectomy is the use of long needles with a handle and an “eye” for thread at the working end. The use of this method is complicated by the fact that the tightness of the abdominal cavity is lost after the bladder is removed, and to carry out visual control it is necessary to lift the anterior abdominal wall with hooks. The use of a conical obturator, which has side holes for a straight needle, greatly facilitates suturing a narrow wound. For visual control, it is optimal to use an angled optical tube passed through a subxiphoid puncture. After completion of suturing of the paraumbical access, an endoscopic examination of this area is performed for possible blood leakage, which may require additional sutures.

Video: Laparoscopic cholecystectomy in Israel – Ichilov Hospital

After restoring the tightness of the abdominal cavity during laparoscopic cholecystectomy, a second examination is performed, the lavage fluid is aspirated as much as possible and, if necessary, drainage is installed in the subhepatic space. The issue of drainage of the abdominal cavity after laparoscopic cholecystectomy is still under study. More and more authors are inclined to believe that after a smoothly performed operation, routine drainage of the abdominal cavity is not required. Drainage is installed only according to indications (doubts about the stability of hemostasis, acute cholecystitis, a “dirty” operation). A thin drainage is carried out through one of the lateral 5 mm trocars, its end is grabbed with a clamp passed through another 5 mm trocar, and installed in the subhepatic space. Many surgeons believe that it is more convenient to place drainage while the bladder is not yet completely separated from the liver. After this, the gas from the abdominal cavity begins to be slowly released, and as the anterior abdominal wall descends, the drainage is slightly tightened, making sure that it does not bend in the abdominal cavity.

Removal of trocars from the abdominal cavity during laparoscopic cholecystectomy is performed under visual control. In this case, some kind of power instrument, for example a spoon-shaped electrode or clamp, is inserted into the abdominal cavity, and the trocar is removed using the instrument. This is necessary so that in the presence of blood leakage through the puncture, it would be possible to perform electrocoagulation of the wound channel when removing the power tool. Endoscopic control is also performed when the subxiphoidal trocar is removed: when the optical tube is slowly removed, the wound channel is well visualized in layers.

The skin is sutured in the usual way for a surgeon. The stitches can be replaced with metal staples.

The gallbladder in its normal state is necessary as part of the digestion process. When food enters the body, bile is released from the bladder to help digest food. If the functioning of the gallbladder is impaired, the organ becomes a source of additional diseases, worsening the patient's condition. The protocol used by Japanese doctors includes intensive drug treatment, however, it is often ineffective. In this case, surgical intervention is indicated.

Cholecystectomy is the surgical removal of the gallbladder. The operation relieves symptoms caused by the pathological condition. Cholecystectomy is most effective in the early stages of the disease. In general, the procedure does not affect digestion. The body will need to get used to the changes in the process; after the operation, you will need to follow a diet for several months. After the recovery period, the patient becomes symptom-free.

The main indication for cholecystectomy is complications associated with the presence of stones in the gall bladder. The doctor may prescribe removal for other reasons:

• complications in forms of cholelithiasis: cholelithiasis, choledocholithiasis;
• presence of symptoms of cholelithiasis: attacks of pain, bitter taste;
• acute chronic stone or acalculous cholecystitis;
• destruction of red blood cells;
• presence of large stones;
• cholesterosis;
• presence of polyps;
• dysfunction of the gallbladder.

The decision to perform the procedure is made by the entire operating team. Frequent contraindications:

• impaired blood clotting;
• dying of the body;
• disruption of the functioning of organs necessary for life;
• narrowing of the common hepatic duct;
• previous abdominal surgery;
• infections;
• pregnancy.

Cholecystectomy is performed under anesthesia; make sure there is no drug intolerance and tell your doctor about possible allergic reactions.

Types of cholecystectomy

The operation can be general, minimally invasive or laparoscopic.

Laparoscopic cholecystectomy

Laparoscopic cholecystectomy - removal of the bladder through a puncture in the abdominal wall. First, the doctor inserts tubes into 4 punctures one centimeter in diameter, and carbon dioxide, a video camera and instruments for performing the operation are supplied through the devices. The artery and duct of the gallbladder are clamped with staples. Then the bubble is cut off and taken out through the puncture. The laparoscopic method hardly injures the abdominal wall; after the operation, the patient recovers quickly and feels almost no pain. Although the procedure is gentle, it is not always possible to perform it. When there is an abnormality in the structure of the bile ducts, severe inflammation, the presence of adhesions, and complications arise during surgery, the doctor may switch to open surgery.

Minimally invasive cholecystectomy

Minimally invasive open cholecystectomy is designed to minimize damage to the abdominal wall in an operation without video equipment. To do this, an incision approximately 5 cm long is made on the right side under the ribs (laparotomy), through which the gallbladder is removed. The operation is recommended when filling the peritoneum with gas is impossible. Recovery after minimally invasive cholecystectomy requires more time; the patient remains in the hospital for up to five days.

Traditional cholecystectomy

With the traditional open form, incisions are made to allow other organs to be examined digestive system. The course of the operation allows you to remove the gallbladder and carefully examine the bile ducts. The traditional technique is indicated for acute cholecystitis with extensive inflammation of the peritoneum or for serious conditions of the biliary tract. The procedure seriously injures the anterior abdominal wall and is often accompanied by complications. There remains the possibility of postoperative hernia, paralytic intestinal obstruction, breathing and physical impairment. Recovery from anesthesia and rehabilitation take a long time. During this time, the patient's ability to work is limited.

All types have a similar principle, the difference is access. The type of cholecystectomy suitable for a particular case is determined by the doctor, having previously studied the patient’s condition, criteria for the course of the disease, and concomitant diseases. Usually, laparoscopic cholecystectomy is resorted to in the presence of polyps and the diagnosis of chronic cholecystitis. At acute forms diseases of the gallbladder are carried out with a minimally invasive procedure, with severe inflammation of the peritoneum - open.

Preparation for the procedure

To have a complete picture of the state of the body, a number of examinations are performed before surgery:

• General inspection.
• Clinical and biochemical research blood.
• Glucose level analysis.
• General urine analysis.
• Test for syphilis and hepatitis.
• Study of blood clotting, group, Rh factor.
• Ultrasound of the liver, biliary tract, pancreas.
• Fluorography.
• Endoscopy of the esophagus, stomach, duodenum.
• Colonoscopy.

If necessary, a scheduled consultation of highly specialized doctors, a study of the biliary tract is carried out.

Preparation for cholecystectomy involves cleansing the body. The day before surgery, it is recommended to avoid heavy foods. The doctor prescribes enemas or laxatives. Sometimes it is necessary to undergo a course of treatment before surgery. Cholecystectomy is performed on an empty stomach, and drinking is also prohibited. You should take a shower in the morning.

Process description

Cholecystectomy is performed under general anesthesia, which means that the patient does not feel anything. The duration depends on the complexity, on average the procedure lasts 40 minutes.

The first stage in laparoscopic surgery is the imposition of carboxyperitoneum through a special needle. Carbon dioxide raises the abdominal wall, making room for instrumental intervention. The pressure is controlled by the device. The doctor makes punctures with the help of tubes, ports are placed and instruments are inserted. To control the process, endoscopic equipment is used - a laparoscope with a video camera. An enlarged image appears on the monitor.

Electrocoagulation helps to identify the bladder itself, its artery and duct, and clearly distinguish between them. After this, the artery and duct are clipped. Unlike suturing performed during open surgery, the use of titanium clips is considered safe and without concern. The gallbladder is cut off and taken out through an incision one to three centimeters long. After surgery, there is still a possibility of fluid accumulation inside the abdomen. To avoid such consequences, a tube is left in the patient's body.

Recovery in a hospital setting

Recovery period at home

The first week they follow a diet consisting of easy-to-digest foods: low-fat boiled meat, yogurt, cereals, mashed potatoes, hateful soups. It is prohibited to eat sweets, fatty foods, fried foods, drink coffee, and alcohol. You should return to your normal diet in stages. For a complete recovery, it is important to follow the doctor’s recommendations regarding exercise, nutrition, and medication use. Within a month, the body restores its functioning.

Even if the patient’s health after the operation does not cause concern, it is recommended to avoid prolonged activities for a week. For a month, it is forbidden to lift objects that weigh more than 4 kg, or strain the abdominal muscles so that the injured abdominal wall heals. Usually the healing process is painless; if necessary, a pain reliever is prescribed.

You should pay attention to the care of puncture sites, which are sutured and sealed with a special film. Take a shower two days after surgery, limiting mechanical impact on the wounds. After a shower, it is recommended to smear the seams with iodine solution. It is possible to take a bath or swim while the stitches are removed. Scars and wounds in the abdominal cavity after an endoscopic procedure are minimal, and the risk of complications is reduced.

Complications

Like any operation, cholecystectomy has the potential for complications. Bruising should not be a cause for concern, but redness and hardness near the stitches may be signs of infection. Before the wounds begin to fester, consult a doctor. If bile leaks through a drainage tube, your hospital stay may be longer. The process does not require intervention if it is not caused by damage to the ducts. If the ducts are still damaged, repeat surgery will be required. An exacerbation of gastrointestinal diseases is possible. Very rarely, bleeding and purulent processes occur in the abdominal cavity, requiring surgery.

If there are undetected stones in the patient's bile duct, they may cause obstructive jaundice after surgery. Indications for endoscopic sphincterotomy are determined.