At present, minimally invasive biliary surgery is becoming increasingly popular as awareness of gallbladder function increases. In order to carry out biliary surgery in a more standardized manner, guidelines for minimally invasive endoscopic biliary surgery have been developed.
Gallbladder Stones
Indications and contraindications for surgery
I. Indications
1. Diagnosis of gallbladder stones by ultrasound or other imaging examinations.
2. Normal gallbladder function confirmed by Te99 ECT or oral cholecystography.
3. The gallbladder is not visualized, but the stones can be removed intraoperatively and the gallbladder duct is confirmed to be patent.
Contraindications
1.Gallbladder atrophy and disappearance of gallbladder cavity.
2.Stones in the gallbladder duct cannot be detected intraoperatively by endoscopy and cannot be removed.
3.The gallbladder duct is confirmed to be obstructed by intraoperative imaging and cannot be released.
4.The presence of diffuse intermural stones in the gallbladder.
5.Gallbladder stones with cancer.
Surgical equipment and instruments
I. Conventional facilities
Cholangioscope, image display, image storage equipment, various lithotripsy baskets, high frequency generator, electrocoagulation guidewire, stone adsorber, etc.
II. Special equipment
Laparoscopic equipment, intraoperative B-ultrasound, C-arm X-ray machine, lithotripsy equipment, etc.
Surgical modalities and methods
I. Endoscopic minimally invasive biliary stone removal surgery
Endoscopic minimally invasive biliary lithotripsy includes: 1. Small incision minimally invasive biliary lithotripsy: it is the most basic procedure of minimally invasive biliary lithotripsy, which is suitable for gallbladder stones under various conditions, with clear vision and less side injuries. 2. Laparoscopic assisted biliary lithotripsy: it is suitable for gallbladder with large gallbladder, loose gallbladder wall, no obvious adhesions with omentum and good mobility. Its advantages are accurate incision positioning, small incision, simple operation, and timely transit LC, which is the most used surgical method at present.3. Minimally invasive biliary stone extraction under full laparoscopy: stone extraction and gallbladder suturing are done under laparoscopy, which has higher technical requirements and longer operation time, and is only suitable for patients with less gallbladder stones.
Endoscopic minimally invasive biliary stone extraction surgical methods
1.Small incision minimally invasive bile stone extraction.
1) Routine disinfection of the skin: 2) positioning by ultrasound, at the location of the projection of the body surface at the bottom of the gallbladder, incision of 3 to 100 px, layer by layer into the abdomen; 3) lifting the bottom of the gallbladder, and after confirmation by puncture, incision of the gallbladder at the bottom; 4) entering the choledochoscope, and removing all the stones in the gallbladder with the lithotripsy net; 5) carefully exploring the gallbladder duct, removing the stones in the duct, and observing the inflow of bile at the opening of the duct; 6) carefully inspecting (6) carefully examine the wall of gallbladder and remove the interstitial stones, if any; (7) close the gallbladder incision with absorbable sutures and embed the plasma muscle layer; (8) close the abdomen layer by layer and glue the skin with pulling adhesive strips.
2.Laparoscopic-assisted minimally invasive biliary lithotripsy.
1) routine disinfection of the skin and creation of pneumoperitoneum; 2) laparoscopic observation through peribulbar puncture channel; 3) trocar puncture on the abdominal wall nearest to the base of the gallbladder and lifting the base of the gallbladder to the abdominal wall with grasping forceps; 4) the rest of the operation is the same as small incision minimally invasive biliary stone extraction.
3.All laparoscopic minimally invasive cholecystectomy:
6) remove the trocar and suture the incision.
Basic principles of surgery
The basic principles of endoscopic minimally invasive cholecystectomy are: removal of stones, complete hemostasis, and effective management of gallbladder wall lesions.
Pre-surgery preparation
1.Blood, urine and stool routine, chest X-ray, electrocardiogram examination.
2, liver and kidney function tests, coagulation function tests, jaundice routine tests.
3.B ultrasound examination of liver, bile and pancreas.
4.ECT, OCG to evaluate gallbladder function.
5, CT, MRCP, ERCP examination if necessary.
6.Check whether there are stones in the bile duct before surgery, if there are stones in the bile duct, the stones in the bile duct should be treated first.
7.Fasten water for more than 6 hours before surgery.
Handling of special cases during surgery
The common cases in endoscopic minimally invasive biliary surgery are: stone impaction in the jugular abdomen of gallbladder, fine stones (less than 2mm) in the gallbladder, stones between the gallbladder walls, bleeding in the gallbladder wall, obstruction of the gallbladder duct, etc.
Treatment.
1.Stone impaction in the abdomen of the gallbladder: use lithotripsy equipment to break up the stones and remove them.
2, interstitial gallbladder stones: use choledochoscopic biopsy forceps to tear the mucosa on the surface of the stones. Then clamp out the stone or use suction device to remove it.
3.Small stones in the gallbladder: a special stone suction device can be used to remove the small stones.
4. Bleeding from the gallbladder wall: use coagulation electrode to stop bleeding under direct vision or rinse with norepinephrine saline. 5. Gallbladder duct obstruction: if no bile flow or poor flow is found in the gallbladder duct during surgery, perform intraoperative ultrasound examination and cholangiography if necessary to confirm that the gallbladder duct is clear and free of stones before suturing the gallbladder.
Post-operative observation and treatment
1. Closely observe the patient’s vital signs.
2.Give antibiotics to prevent infection.
3.Eat a light liquid diet on the second day after surgery, and gradually transition to a regular diet.
4.Two weeks after surgery, use tauro-ursodeoxycholic acid or ursodeoxycholic acid as appropriate to prevent recurrence.
5.After surgery, ultrasound should be repeated once a year to know if there is any stone recurrence.
Common complications of surgery
Minimally invasive biliary lithotripsy is safe, and few complications occur. The main complications are: 1. complications specific to laparoscopic surgery, such as vascular and organ damage complicated by puncture; 2. incisional infection; 3. acute cholecystitis; 4. biliary fistula; 5. stone residue.