I. Indications and contraindications
(A) Indications
L. Symptomatic chronic stony cholecystitis.
2. Asymptomatic chronic cholecystitis with stones or thickened gallbladder wall with varying thickness.
3, asymptomatic gallbladder polyps >10mm.
4, symptomatic gallbladder polyps and other benign augmentation-like lesions.
5, atrophic cholecystitis.
6.Acute cholecystitis with attack time ≤72
7, Gallbladder perforation, requiring exploration.
(B) Potential contraindications.
1, Combined acute obstructive purulent cholangitis with unstable vital signs.
2, stony acute cholecystitis with severe intra-abdominal infection.
3, combined with acute necrotizing pancreatitis.
4.Mirrzzi syndrome type II.
5.Suspected gallbladder cancer.
6, combined with serious high-risk medical diseases.
7.With severe liver cirrhosis, portal hypertension.
8.With severe bleeding disorders.
9.Gallbladder stone surgery during pregnancy may cause miscarriage, preterm delivery, etc.
10.Contraindication to anesthesia.
Second, laparoscopic cholecystectomy perioperative preparation.
Preoperative preparation for laparoscopic cholecystectomy includes the following aspects.
1, comprehensive and meticulous history taking to understand the patient’s general condition, especially the potential risk factors affecting surgery should be paid more attention to.
(1) Heart, lung, liver and kidney function.
2) Any history of jaundice.
3) Any recent history of pancreatitis attack.
4) History of recent lithotripsy treatment.
5）History of hematologic diseases.
6) History of infectious diseases.
7) History of previous abdominal surgery.
8）History of metallic foreign body implantation in the body.
9) History of long-term anticoagulant drugs, such as aspirin.
10）History of other related diseases.
2.Pre-operative routine laboratory tests, such as three major routine, liver and kidney function, coagulation function determination, etc.
3, Preoperative routine chest X-ray and electrocardiogram.
4.Imaging examinations.
1） B ultrasound.
2） CT of liver, biliary and pancreatic (if necessary).
3） ERCP (if necessary).
4） MRCP (if necessary).
5. For patients over 70 years of age, or patients with cardiopulmonary diseases, preoperative cardiopulmonary function tests are recommended. 6. All physiological indicators should be within the normal range as far as possible.
In conclusion, comprehensive medical history collection and perfect preoperative examination will provide sufficient basis for correct preoperative diagnosis, surgical difficulty assessment, intraoperative treatment and postoperative therapy, and help improve LC safety.
7.Preoperative talk.
8.Complex LC surgery time is long, a catheter should be placed.
9. Pre-operative symptomatic treatment.
The qualification requirements of the surgeon.
(1) obtain the “Physician’s Certificate” and “Physician’s Certificate of Practice”; (2) have the professional and technical position of general surgeon or above, with more than 5 years of biliary surgery experience, and can independently complete a variety of routine biliary surgery (3) in the provincial health department recognized by the tertiary hospital laparoscopic (biliary surgery) treatment-related professional not less than 6 months of systematic training and (4) within six months after completing training in laparoscopic (biliary surgery) treatment-related specialties in a tertiary hospital, continue to complete at least the same number of cases as required during training as an operator under the guidance of a superior physician in a medical institution qualified to carry out laparoscopic (biliary surgery) treatment; (5) recommended by two physicians who are qualified in laparoscopic biliary surgery treatment technology and have the professional qualifications of associate chief physician (5) recommended by two physicians who are qualified in laparoscopic biliary surgery and have the professional qualifications of associate chief physician or above; (6) physicians who have received laparoscopic (biliary surgery) treatment system training for three months or more outside of China, with a certificate issued by the training institution, and after relevant examinations and assessments, can engage in laparoscopic (biliary surgery) treatment.
Fourth, the basic laparoscopic surgical instruments required
Essential laparoscopic instruments: 10mm puncture trocar, 5mm puncture trocar, 5mm converter, 5mm scissors, 5-10mm laparoscopic separating forceps, 5-10mm grasping forceps, 5-10mm titanium clamping forceps, suction rinser, specimen bag, etc.
V. Basic operations of laparoscopic cholecystectomy
(A) Anesthesia and position.
General anesthesia, tracheal intubation.
Position: supine position/truncated position head high foot low right tilt.
(B) Surgical steps.
l.Disinfection and towel laying
2.Establishment of CO2 pneumoperitoneum
3.Trocar puncture
(1) Point A puncture point (11 mm).
This puncture point is a blind puncture point with an incision at the umbilical rim or within the umbilical foramen.
(2) Point B puncture (Ф5.5-llmm): the main operating hole for the operator. Generally, 3-4 cm below the raphe on the right side of the lower midline of the abdomen 2 cm as the puncture point, the best puncture point should be through this trocar into the instrument can reach the triangular plane of the gallbladder vertically or nearly vertically at the lower edge of the liver.
(3) C-point puncture (Ф5.5mm): the operator’s left hand assists in operating the hole. Generally 2-3 cm below the rib in the right midclavicular line, special cases should be adjusted according to the position of the gallbladder.
(4) D-point puncture (Ф5.5mm): assistant operation hole. If the operator uses the three-hole method LC, this hole does not need to be punctured. It is usually placed 2-3cm below the moving rib in the right anterior axillary line.
4, pulling the gallbladder assistant clamps the bottom of the gallbladder to the right outer upper pulling the operator’s left hand to assist the clamp, pulling the gallbladder pot belly to the right lower pulling requirements: the gallbladder tip and the main axis of the common bile duct vertical, fully expand the triangular plane of the gallbladder, can not be pulled excessively so that the common bile duct into the angle to avoid extrahepatic bile duct injury.
5.Dissection of the gallbladder triangle is the key link in LC surgery.
Exposure, confirmation of common bile duct, common hepatic duct and cystic duct relationship, separation, titanium clamping/ligation of cystic duct: cystic duct stump <5mm, separation, titanium clamping/ligation of cystic artery: It is safest to separate the cystic artery carefully near the cervical lymph node of gallbladder to avoid damage to the variant right hepatic artery and variant bile duct.
In the case of gallbladder duct stone impaction, the gallbladder is enlarged and under high tension, a small hole can be cut at the bottom of the gallbladder to aspirate part of the bile for decompression to facilitate surgical operation.
In the case of acute talk, chronic intussusception of gallbladder stones, chronic atrophic cholecystitis or Mirrzzi syndrome type I, it is often more difficult to dissect the gallbladder triangle directly first.
6, stripping the gallbladder bed from the liver O.5cm incision of the gallbladder plasma membrane layer in accordance with the principle of “shallow to deep, avoid digging holes” heavy inflammation of the gallbladder, the gallbladder bed structure level is unclear, it is appropriate to close to the wall of the gallbladder electrocoagulation stripping, rather than break the gallbladder than injury to the liver, if necessary, the gallbladder bed residual part of the gallbladder tissue and then electrocautery treatment of the gallbladder mucosa.
The three-hole method LC, the lack of assistant assistance, the most important need to solve the problem of revealing and cutting plane tension, in the limited space, the use of “one tool for two uses” that is to reveal itself and independent operation, the use of natural counterforce to create cutting surface tension and facilitate the operation.
When separating the gallbladder, it is inevitable to accidentally break the gallbladder to make the bile or stones spill out, so titanium clamps can be used to close the broken mouth.
7, remove the gallbladder umbilicus or subxiphoid poke hole is to remove the outlet of gallbladder and stones.
If it is difficult to pull out, cut the gallbladder under gauze isolation to release the bile, and then remove the stone and gallbladder by chewing the large stone.
8, abdominal irrigation, abdominal drainage in the gallbladder parting broken or heavy inflammation of the gallbladder triangle, fully aspirate the leaking fluid, saline repeatedly rinse until the rinse fluid is clear.
Serious contamination of the operative field or suspected blood leakage from the gallbladder bed, biliary fistula, fluid accumulation, drainage tubes should be placed in the subhepatic space.
9, lift the pneumoperitoneum to fully examine the abdominal cavity for active bleeding, bile leak and pay injury. Withdraw each instrument and trocar one by one under direct vision, and finally withdraw the laparoscope and its trocar.
10, perforation hole treatment contamination heavy LC, “pipe” effect is difficult to avoid perforation hole contamination, take the gallbladder accidental rupture of the gallbladder or specimen bag rupture, contamination of the perforation hole, treatment: contaminated specimens into the specimen bag can prevent perforation hole infection perforation hole sterilization suture peritoneum without suture subcutaneous placement of drainage strips to prevent fat liquefaction and incision infection.
VI. Postoperative observation and treatment
1.Go back to the ward after complete awakening from anesthesia
2.Observation of vital signs
3, drainage tube management in general, the postoperative drainage flow does not exceed 50ml, light red; drainage of fresh blood, we should be highly alert to traumatic oozing, small vessel bleeding or gallbladder artery titanium clip slippage, more than 300ml/h, it is appropriate to re-operate to stop bleeding; drainage tube drainage of bile should be considered bile leak or duodenal leak. Except for vagal bile duct leakage and bile cystic duct stump leakage which can disappear on their own after smooth drainage, the remaining causes usually require immediate surgical treatment.
4, abdominal condition observation For non-placement of abdominal drainage tube LC, it is especially important.
The presence of bile leak, bleeding and gastrointestinal injury will generally result in peritonitis within 24 h. A few patients with bile leak do not show signs of peritonitis due to the application of antibacterial drugs, but only show abdominal distension and gastrointestinal function does not recover for several days, which is very likely to delay diagnosis and treatment. Timely diagnostic laparotomy and bile extraction is the most direct and reliable basis for the diagnosis of bile leak.
5. The presence or absence of jaundice within a week or several weeks of deep yellow urine and yellow sclera of the skin should be highly suspected of extrahepatic bile duct injury and the possibility of bile duct residual stone, and it is necessary to make ultrasound, CT, ERCP or MRCP examination for early diagnosis and early treatment.
6, gastrointestinal function recovery and dietary requirements are mostly recovered within 4-12h after surgery, and semi-liquid food can be entered on the first day after surgery.
7, CO2 pneumoperitoneum adverse reactions to observe the patient’s slow breathing, PCO2 elevation, etc., should be considered hypercapnia may shoulder pain, vomiting is mostly due to residual CO2 stimulation phrenic nerve, symptomatic treatment, generally 24-48h can disappear on its own.
8. Encourage the patient to be semi-recumbent and get out of bed early
VII. Complications of laparoscopic cholecystectomy and prevention
(a) Residual stones in the common bile duct LC is a more common complication and often occurs as follows.
(i) Incomplete history taking ignoring the past history of jaundice or cholestatic pancreatic pulsitis of biliary origin or recent history of stone removal.
(ii) Inaccurate ultrasound examination.
③ Intraoperative handling is rough or the procedure is inappropriate and the stone is squeezed into the common bile duct.
If suspicious signs of common bile duct stones are found preoperatively, CT, MRCF, or ERCPE or intraoperative imaging should be performed preoperatively to clarify the diagnosis, and those who are clearly diagnosed with common bile duct stones should undergo laparoscopic transcystic duct extraction or common bile duct excisional lithotomy or EST.
(ii) Biliary tract injury Biliary tract injury is one of the most common complications of LC, and the consequences are often catastrophic. Types of biliary tract injury, there are transection, laceration, penetration, clamp closure and electrothermal conduction burns and other types.
1, the common causes of occurrence are as follows.
① rough operation, separating the forceps to split or tear the bile duct.
② Separation of the gallbladder triangle, electric hook accidental injury or heat conduction injury to the bile duct.
③The bile duct is short and thick, or if the thinner common bile duct is mistakenly cut off as the bile duct.
④accidental injury not identified during bile duct variant surgery, mainly due to the abnormal relationship between the cystic duct and bile duct, hepatic duct and the injury caused by the presence of variant bile duct.
⑤ Excessive stretching of the gallbladder neck causes the bile duct to be partially clamped at an angle.
⑥The gallbladder is stripped too deeply, injuring the right anterior hepatic lobe bile duct and vagal bile duct.
(7) Blind operation, such as blind clamping to stop bleeding when bleeding, and underestimation of bile duct displacement and deformation caused by heavy adhesions.
2, prevention and control measures.
① Strictly according to the principle of gallbladder triangle anatomy, “three ducts and a pot belly” anatomical structure is identified correctly before dealing with the bile duct.
②Do not meet the “three ducts and a pot belly” anatomical relationship is particularly important to prevent injury to the variant bile duct.
③Gentle movements, avoid large pieces of separation.
④Caution when using electrocutting and electrocoagulation close to the bile duct, and be careful of “hooked back” electrical conduction damage to the bile duct when triangular electrocoagulation and electrocutting of the gallbladder.
⑤ Properly handle the artery and branches of the gallbladder to avoid bleeding; in case of bleeding, do not rush to stop the bleeding and damage the bile ducts; if there is difficulty in stopping the bleeding under laparoscopy, promptly transfer to open abdomen to stop the bleeding.
(6) In acute inflammation, gallbladder decompression can improve the exposure of gallbladder triangle and facilitate dissection.
(7) Avoid excessive stretching of the gallbladder so that the cystic duct, common bile duct becomes a straight line.
⑧ For those with parallel-type cystic duct converging into the common bile duct, avoid electrical separation, and push and grasp blunt separation and sharp separation as finely as possible ⑨ Those who encounter serious adhesions and unclear structure of the gallbladder triangle with little surgical experience should promptly ask an experienced person on the table, which may avoid biliary tract injury and unnecessary intermediate opening. Those who do not have the condition should be opened in time.
Careful examination of the gallbladder triangle and gallbladder bed should be an essential step routinely after ⑩LC. Timely intraoperative detection and treatment of biliary tract injury is the best chance for a good prognosis.
If bile duct injury is found, the best treatment should be chosen according to the injury site, type and degree to minimize the damage to the patient as much as possible.
(C) postoperative bile leak refers to the phenomenon of postoperative bile leak caused by improper treatment of the stump of the bile cystic duct, failure to clamp the vagus bile duct, failure to detect bile duct injury during surgery, or improper treatment after detection during surgery. In general, a small number of patients with bile leak can be cured spontaneously only by smooth drainage, while some patients need nasobiliary duct or biliary stent drainage, and many patients need to be treated by surgery again.
1, bile leak common causes ① untimely detection of bile duct injury.
② Intraoperative discovery of bile duct injury but improper treatment.
③ Separation of adhesions mistakenly treating tiny bile ducts as fibrous adhesions or cut by vascular electrocoagulation.
(iv) Incomplete, incomplete or slipped bile duct clamping.
(5) The vagus bile duct is not clamped.
(6) Bile duct residual stone, LC postoperative biliary ascariasis, and bile duct stenosis at the lower end of the common bile duct induce bile leakage due to increased biliary pressure.
2, bile leak prevention and control measures ①Before the bile duct is cut, the bile duct must be confirmed to be free of errors.
②The stump of the cystic duct should preferably be on double titanium clamps or double ligation.
③The thick gallbladder duct should be silk ligated and then clamped or double ligated, and if necessary, sutured closed.
④The ductal structures into the gallbladder should all be clamped.
⑤The triangular dissection of the gallbladder, encountering the tubular structure between the common bile duct and the gallbladder, should not be cut off easily, and it is better to go on titanium clips.
(6) Avoid bile duct injury.
⑦ Intraoperative timely detection of bile duct injury and timely and correct treatment.
⑧Check carefully after surgery, and put drainage if in doubt.
For bile duct stump leakage and vagal bile duct leakage, most of them can be cured conservatively by unobstructed drainage, but if larger bile duct injury causes bile leakage, all of them need to be treated by surgery again.
(D) Vascular injury Vascular injury is a common complication of LC surgery, and its incidence lacks comprehensive and accurate statistics both at home and abroad. The main reason is that most of the vascular injury after intraoperative timely treatment did not occur serious consequences, not objectively reported, but in clinical practice, each surgeon should be objective and correct understanding, vascular injury is not uncommon in the clinic, the consequences are sometimes very serious, such as puncture injury abdominal aorta, vena cava, rough operation damage portal vein, etc., if it is too late to stop bleeding, blood transfusion can cause patient death.
1, common causes of vascular injury ① improper choice of puncture location ② improper operation ③ unclear anatomical structure relationship ④ improper vascular treatment vascular injury sites in laparoscopic cholecystectomy are mostly in the gallbladder artery, right hepatic artery, portal vein and retroperitoneal vessels, other vessels such as mesenteric vessels and omental vessels.
2, vascular injury prevention ① laparoscopic physicians should be strictly trained before “induction”.
②Strengthen the preoperative evaluation of the indications and difficulty of LC.
③Fully understand the performance of surgical instruments and master the correct use method.
④Pay attention to the application of anatomy of the gallbladder triangle under laparoscopy and fully understand the possible variation of anatomical structures.
⑤ Pay attention to the careful inspection of the surgical trauma before the end of LC.
3. Treatment of vascular injury ①Once large vessel injury occurs, it will lead to hemorrhage and rapid hemorrhagic shock endangering the patient’s life, which must be treated with emergency dissection to stop bleeding and active shock.
② gallbladder artery injury, first with gauze or gallbladder compression to stop bleeding, quickly find the bleeding on the titanium clip to stop bleeding, if the vascular retraction of the common hepatic duct, common bile duct posterior laparoscopic processing difficulties, should be immediately dissected to stop bleeding.
③ For omental and mesenteric vascular injury, choose electrocoagulation, ligation or suture according to the specific situation.
④For bleeding from the superior abdominal wall artery with deep location and poor exposure, ligature or suture should be clamped under direct vision with extended incision if necessary.
(⑤ postoperative bleeding a small amount of bleeding, mostly traumatic bleeding, by hemostasis, drainage can generally be self-stopping, if the amount of bleeding, more than 300ml / h, should be timely re-operation to stop bleeding.
(E) Endoluminal injury in laparoscopic cholecystectomy is second only to bile duct injury and vascular injury at the liver. Timely detection and timely treatment generally do not produce serious consequences, many cases due to intraoperative failure to detect, postoperative peritonitis and not properly recognized, often delayed diagnosis and treatment, resulting in serious consequences, endoluminal injury is mostly cavity organ damage, a few for the substantive organ damage, such as liver, spleen. Once the visceral injury is found, it should be dealt with in a timely manner, and if there are difficulties in lumpectomy, it should be immediately transferred to open treatment.
Injuries to the empty cavity organs are more common in the stomach and small intestine, followed by the colon, and occur due to.
① Blind puncture or violent puncture.
(2) Excessive force or improper method of operation by the operator or assistant, poking the stomach and intestine.
③ Electrical conduction injury.
Duodenal injury is a serious cavity organ injury, intraoperative timely detection of timely open treatment, the prognosis is generally better. If postoperative celiac disease is only discovered, the success rate of cesarean surgery repair is much lower than LC intraoperative timely detection and timely treatment, once the duodenum re-leak, handling is extremely difficult, and to pay an expensive economic price, or even life.
The healing of jejunal, ileal, and colonic injuries is better than duodenal injuries, and timely detection and repair generally does not produce intestinal leakage; if postoperative peritonitis is detected and treated only after dissection, the chance of intestinal leakage increases.
Liver injury mainly occurs in the case of puncture poke, instrument poke and separation of the gallbladder bed, the level is too deep and so on. When discovered, prompt electrocoagulation to stop bleeding, spraying trauma sealant or bioprotein gel if necessary, rarely requires open surgery.
Splenic injuries are rare, mainly occurring after accidental overexertion of instruments or peri-splenic adhesions to the pneumoperitoneum causing increased abdominal pressure and splenic laceration, which can be easily overlooked during surgery and only discovered after surgery due to bleeding dissection.
(F) Other complications such as abdominal infection, incisional infection, incisional hernia, stump gallbladder and transmission of certain infectious diseases in LC. They are also seen in clinical practice and should also be given high priority. Early prevention, early detection and early treatment in strict accordance with the principles of surgical treatment and infectious disease control are powerful measures to prevent and treat LC complications.