Laparoscopic Cystectomy (LC)
Common bile duct exploration and removing the stone
Introduction
Common bile duct stones are divided into primary and secondary, with the former being the majority of stones originating from the gallbladder and the latter arising directly from the common bile duct. When the bile duct is not completely obstructed, the patient will suddenly develop a series of symptoms, including epigastric pain, chills, high fever, jaundice and, in severe cases, shock and impaired consciousness. This disease is more rapid than gallbladder stones, with severe symptoms and difficult to treat.
Laparoscopic cholecystectomy, known as minimally invasive surgery, is performed in vivo through a tiny incision in the abdominal wall using minimally invasive instruments, a laparoscope, intra-abdominal lighting and an electronic camera system.
Gallbladder morphology and function
The main function of the gallbladder is to store and concentrate the bile synthesized by the liver. When fasting, the bile enters the gallbladder and when eating, the gallbladder contracts and the bile enters the intestine through the cystic duct and common bile duct.
What are the common gallbladder diseases?
Common gallbladder diseases include: gallbladder stones and chronic cholecystitis, acute cholecystitis, gallbladder polyps and gallbladder adenomyosis.
Patients with gallbladder diseases should have a daily diet of light, easily digestible food, drink more water (1500-2000ml), eat easily digestible proteins, and should not overeat, avoid eating animal offal, egg yolk, fried food, spicy and stimulating food, etc.
When you feel discomfort or stuffy pain in the heart fossa after over-eating fatty food, or paroxysmal colic in the right upper abdomen with or without radiation from the right scapula, along with nausea, vomiting, fever and other symptoms, you need to be alert to the existence of gallbladder disease and not to confuse it with stomach disease and delay treatment.
Long-term chronic cholecystitis can lead to severe inflammation and adhesions, pus in the gallbladder, gallbladder perforation, and even malignant tumors of the gallbladder, as well as heart, lung, or other tissue and organ complications.
When is removal of the gallbladder recommended?
n Those with typical clinical manifestations of gallbladder stone attacks, those with adjunctive examinations confirming gallbladder stones, those with filled gallbladder stones or porcelain gallbladder, those with a high chance of malignant transformation.
n Acute purulent, gangrenous, hemorrhagic and perforated cholecystitis.
n recurrent episodes of chronic cholecystitis that have failed with conservative treatment.
n solitary gallbladder polyps, >1.0 cm in diameter, with a large base, progressive growth, abundant blood flow, thickened gallbladder wall at the attachment site, and attachment to the liver bed surface.
n magnetized gallbladder, adenomyosis of the gallbladder.
Pre-surgical preparation
l appropriate daily aerobic exercise, which is beneficial for postoperative recovery
l Strict smoking cessation.
l Blood tests, including routine blood, full biochemistry, electrolytes, coagulation, urine, stool, antibodies to hepatitis B, hepatitis C, HIV, syphilis, etc.
l Chest X-ray, electrocardiogram, abdominal ultrasound, abdominal CT, MRI.
l Relevant tests if other systemic diseases are present, such as heart and lung organs.
l an enema or oral laxative to cleanse the intestines the day before surgery
l A light diet the day before surgery and water abstinence from early morning on the day of surgery.
l appropriate fluids and intravenous antibiotics to prevent infection before surgery.
l placement of a gastric and urinary catheter on the morning of surgery.
If the inflammation is so severe that there are severe adhesions to the surrounding stomach, duodenum, large intestine or large omentum, it is possible to convert to conventional open cholecystectomy + common bile duct exploration.
Surgical approach
A 2-3 cm longitudinal incision is made in the anterior wall of the common bile duct, the common bile duct is explored, the stones are removed with a lithotripter, and intraoperative cholangioscopy or cholangiography is performed to confirm that there are no residual stones in the common bile duct, common hepatic duct and left and right hepatic ducts.
Traditional open cholecystectomy is traumatic, slow to heal, has a high rate of incision infection, and has a large, unsightly scar after healing, which can easily cause intestinal adhesions and is not conducive to postoperative recovery.
Compared with traditional open cholecystectomy, laparoscopic cholecystectomy has the advantages of less trauma, smaller incision, less wound pain, ability to eat and get out of bed on the first day after surgery, short postoperative medication time, short hospital stay, and significantly reduced incision infection and postoperative intestinal adhesions and other complications.
The 3-4 tiny incisions scattered in the abdomen are almost invisible after healing. At present, most (>95%) cholecystectomies can be completed laparoscopically, and laparoscopic exploration of the common bile duct is more difficult.
Postoperative
l After the operation, the patient may be observed in the surgical intensive care unit for one day before being transferred back to the general ward.
l Gastric tube is inserted into the stomach through the nostrils, and its main function is to drain the digestive juices in the stomach and prevent vomiting. If the daily drainage is not much after surgery, it can be removed after the intestinal function is restored (exhaustion).
l urinary catheters are placed in the bladder for drainage of urine and are usually removed on the second to third postoperative day.
l 1 or 2 abdominal drainage tubes are left in the abdomen to facilitate the flow of fluid from the abdominal cavity, please record the flow and color of the drainage daily, normal is a small amount of light red or light yellow fluid, we usually recommend removal after resumption of diet.
l Retained T-tubes are placed in the common bile duct, mainly for bile drainage, and are protected from dislodgement during activity.
l A deep venous puncture tube will be placed in the neck or upper extremities for postoperative infusion and administration of various medications, which can be removed when you resume eating.
l An elastic stocking to prevent thrombosis will be placed in the lower extremity and may be removed when you begin to move around.
l a pain pump will be connected through an intravenous or epidural catheter, allowing the patient to administer pain medication on their own. Appropriate use of pain medication will relieve pain during walking, coughing and deep breathing, and if pain is unbearable appropriate use of pain medication or seek medical help.
l You are advised to move to the floor early, generally recommended to start on the 2nd-3rd postoperative day, which can improve blood circulation, prevent thrombosis and promote recovery of gastrointestinal function.
l Patients will be asked to initiate coughing and deep breathing exercises, along with the use of a nebulized inhalation device, to prevent pulmonary atelectasis and lung infections.
l Wounds are usually changed on postoperative day 3, and health care providers are advised to inform them of any abnormal bleeding and oozing.
l The need for early postoperative treatment with intravenous fluid supplementation, parenteral nutrition solution, acid-suppressing drugs, antibiotics, etc.
l usually after removal of the gastric tube can begin to eat by mouth, initially starting with drinking water, then gradually changing to liquid, semi-liquid, until the ordinary diet.
l If there is no significant appetite at the beginning, enteral nutrition solution can be given under medical advice.
l If there is significant abdominal distension and nausea and vomiting then feeding needs to be postponed, a few patients may have significant gastrointestinal dysfunction and be unable to eat within a short period of time, and may even be reintroduced with a gastric tube
l A small number of patients have a mild fever (temperature between 37-38 degrees Celsius), which usually resolves within 3-5 days.
Special considerations: care of the T-tube
Patients should pay attention to the proper fixation of the T-tube, and should not pull or tug it (especially when sleeping), and pay attention to the cleanliness of the skin around the mouth of the tube. The consequences are serious and often require reoperation.
Pay attention to the amount and nature of the daily T-tube drainage fluid, which is usually 200-400mL per day, and the bile flow is clear and yellowish-brown.
Contact your doctor or nurse promptly if any of the following occur
l chills or a temperature above 38.5°C
l Redness or swelling of the incision or leakage of fluid.
l if there is a change in the color of the fluid in the drainage tube or a large increase in the amount of drainage.
l when there is an increase in abdominal pain or new symptoms of pain
l nausea, vomiting, diarrhea.
l persistent constipation for more than 2-3 days
l Other new or unexplained symptoms of discomfort.
Early diet after bile duct exploratory surgery
For at least 15 days after surgery, patients should avoid fried foods (French fries, fried meat, etc.), sweets (cake, chocolate, cream, etc.), and high-cholesterol foods (eggs, liver, and shrimp, etc.), after which they can gradually return to their previous diet, but it is recommended that the patient’s daily diet be based on soft foods, reducing the intake of calories and fine carbohydrates, and reducing fat and cholesterol intake along with more Dietary fiber should be consumed.
Post-discharge habits
After bile duct exploration, in addition to continuing medication and regular checkups as prescribed by the doctor, the following things need to be noted in life and diet
l Should abstain from smoking, alcohol, coffee, strong tea, carbonated beverages, spicy and sour foods and other stimulating foods.
l Chew slowly, eat light and easily digestible food, and avoid full and hard food.
l Limit fat intake, especially not too much animal fat at one time.
l avoid too cold food, it is recommended to eat less and more meals, and not to exercise excessively after meals.
l Have a regular life, ensure sufficient rest and sleep, and exercise regularly.
Dietary attention and contraindications
Food types
Allowed
Prohibited/reduced consumption
Staple food
Fine rice and noodles
Coarse grains, puffed and fried staple foods
Dairy products
Skim or low-fat milk or yogurt
Full-fat milk or chocolate milk
Eggs
Egg whites, up to 1 per day
Egg yolks, fried eggs
Beverages
Clear water, light tea
Alcoholic beverages, coffee, strong tea
Meat
Skinless poultry, fish and lean meat (pork, beef, sheep, etc., cut off fat)
Fatty meat, animal offal, fish roe, crab roe, shrimp head, bacon, salted meat, canned meat, etc.
Vegetables
Low-fiber vegetables, such as peeled winter squash, potatoes, eggplant, cucumbers, tomatoes, etc.
High-fiber vegetables, such as leeks, celery, beans, etc.
Fruits
Medium or low sugar fruits (such as watermelon, apple, kiwi, strawberry, etc.), purees and juices
Fruits with high sugar content (e.g. lychee, grapes, oranges, sugar cane, bananas, etc.)
Sweet food
Light honey water, lotus root powder
Excess cane sugar, sweets, chocolate
Edible oils
Peanut oil, olive oil, soybean oil, tea oil and other vegetable oils, total 10-15 g per day
Animal oils, margarine and various types of trans fatty acid foods
Others
Ketchup, garlic, vinegar, unbuttered popcorn
Fatty foods such as olives, peppers and cream (e.g. cakes)
Cooking methods
Steaming, stewing, etc.
Frying, deep-frying, etc.
Prevention of bile duct stones
l Healthy diet, balanced diet, avoid eating a lot of fried foods, animal foods containing high cholesterol, such as egg yolk, animal offal, stimulating foods, spicy foods, etc.
l Drink more water, eat less sweets, keep bowel movements smooth, change sedentary lifestyles, exercise regularly and lose weight at the right time.
l Overcome the bad habit of not having breakfast.
l pay attention to dietary hygiene and develop good hygienic habits (intestinal parasitic diseases and intestinal infections are the main causes of biliary stones in China).
l Regular physical examination, once the stones are found, they should be treated promptly.
Outpatient review
We recommend you to have your first follow-up examination 2 weeks to 1 month after discharge. During the outpatient consultation, your doctor will recommend blood tests, abdominal ultrasound, etc. according to your actual condition.