Compared with the traditional open cholecystectomy (OC), laparoscopic cholecystectomy (LC) has the advantages of simple operation, less trauma, shorter hospital stay, smaller scars and better patient compliance. In recent years, with the accumulation of experience, improvement of technology and upgrading of equipment, the safety of LC has been greatly improved, and the complication rate and morbidity and mortality rate of LC have been reduced to the level of OC; the indications for LC have been steadily expanded, and the traditional contraindications for LC, such as acute cholecystitis, atrophic cholecystitis, history of upper abdominal surgery and obesity, are being broken through one by one. In some specialized treatment centers, LC has become the standard procedure for the majority of cholecystectomies.
Due to the large number of layers in our medical system and the uneven level of development, LC is not yet commonly performed in a large number of county hospitals and even some prefectural and municipal hospitals in China. The main reason for this is the lack of systematic mastery of this technique by physicians and the lack of confidence of both doctors and patients in its safety, which makes it difficult to smoothly change from traditional open cholecystectomy to LC. Improving the standardization and safety of LC in primary care hospitals is undoubtedly an important prerequisite for the comprehensive promotion of LC in China. In this paper, we present a more systematic introduction of how to do LC from fourteen aspects at the technical level.
First, the grasp of indications and contraindications
The indications for LC mainly include symptomatic or asymptomatic gallbladder stones, non-stone dysfunctional cholecystitis, gallbladder augmentation-like lesions with a more obvious tendency to progress, gallbladder cancer suspects and gallbladder duct stones and stenosis. For beginners, the indications should be limited to non-obese patients with resting gallbladder stones, who have mild gallbladder inflammation, no obvious adhesions in the gallbladder triangle, easy separation and identification of structures during surgery, and high surgical safety. This is essential for beginners to gain experience and confidence.
The contraindication to the procedure is a relative concept. The contraindications should vary accordingly depending on the skill level and experience of the physician team. In the early stage of LC, acute cholecystitis, atrophic cholecystitis, obesity, advanced age, history of upper abdominal surgery, pregnancy, etc. should be listed as contraindications.
Pre-operative preparation
The main preparations include physician, patient psychology, anesthesia (described later), preoperative gastric and urinary catheters, etc. In terms of physicians, LC must be given high priority ideologically and the concept of LC as a minor surgery must be completely abandoned; a competent surgical team in terms of technology and experience must be organized according to the patient’s condition; psychological preparation is to educate the patient through necessary scientific knowledge to make him realize the necessity of LC and alleviate his concerns about diet after gallbladder removal. Preoperative antigastric tube can avoid intraoperative gastric and duodenal distention and help to visualize the hepatoportal region. However, gastric and duodenal distention can be effectively prevented if the stomach is continuously compressed during anesthetic denervation, so that the application of a gastric tube can be dispensed with, provided that the technical conditions are guaranteed. However, for beginners, routine application of a gastric tube for gastrointestinal decompression is recommended to facilitate the dissection and identification of the hepatoportal region. Under the premise of urination before anesthesia, the urinary catheter can usually be dispensed with, and its application is only considered when the operation takes longer.
III. Anesthesia preparation
The patient’s ability to tolerate the procedure is assessed from an anesthetic perspective. Tracheal intubation[u1] for general anesthesia should be chosen to ensure adequate abdominal muscle relaxation and to establish and maintain a stable pneumoperitoneum. Alternatively, a laryngeal mask or tracheal intubation may be chosen to control breathing, depending on the complexity of the condition and the prognosis for the duration of the procedure. Usually, LC can be accomplished by controlled breathing with a laryngeal mask.
IV. Establishment of pneumoperitoneum
The conventional method of establishing pneumoperitoneum is the closed method, in which a skin incision is made around the umbilicus, through which the abdominal cavity is punctured with a pneumoperitoneum needle, and whether the pneumoperitoneum needle penetrates into the abdominal cavity is determined by the water injection method or the air pressure level and gas flow. Obviously, this method is somewhat blind and risky, with the greatest risk being complications of intestinal perforation. The literature reports that the incidence of intestinal perforation complicating laparoscopic surgery is 0.22%, of which, 55.8% are small bowel perforations and 41.8% are caused by sheaths and pneumoperitoneum needles. Another literature review showed that in 696,502 laparoscopic procedures, bowel injury occurred in 28 patients during pneumoperitoneum establishment by pneumoperitoneum needle puncture, of which 17 were serious injuries, accounting for 0.0024% of the total number of procedures. It can be seen that although the incidence of intestinal perforation during the establishment of pneumoperitoneum by pneumoperitoneum needle is not high, it is difficult to obtain timely management because this type of intestinal perforation is not easily diagnosed intraoperatively and is prone to serious infectious complications such as abdominal infection and sepsis.
For those with a history of abdominal surgery, or those with abdominal adhesions, the closed method of establishing a pneumoperitoneum is more prone to complications such as intestinal perforation, and the open method of establishing a pneumoperitoneum is appropriate. The method is: a 15 mm skin incision around the umbilicus, a combination of electric knife incision and blunt separation, incision of the layers of the abdominal wall, opening the abdominal cavity and placing the sheath into the abdominal cavity. Obviously, the open approach has the advantages of being intuitive, less risky, and quicker to enter. However, it requires a longer skin incision and more surgical maneuvers to incise the abdominal wall layer by layer.
V. Establishment of abdominal wall access
Three or four abdominal wall accesses are usually required to complete LC, i.e., the three-hole or four-hole approach. In the three-hole approach, the abdominal wall accesses are located around the umbilicus, 10 mm below the glabella and 20 mm below the right midclavicular line rib margin, with sheaths of 10 mm, 10/5 mm and 10 mm, respectively. in the four-hole approach, a 5 mm sheath access is added to the three-hole approach at 20 mm below the right anterior axillary line rib margin, with the assistance of a second operator. When the three-port approach is used, the position of the subxiphoid access can be appropriately shifted upward so that the liver can be lifted using the bar of the right-hand detachment forceps, making the exposure of the gallbladder triangle easier. The difficulty of the procedure is significantly reduced because the four-port approach can assist in the exposure. The four-port approach should be used for beginners or when encountering complex situations.
In recent years, for aesthetic reasons, physicians are trying to perform LC with less access to the abdominal wall, and nowadays, single-port LC through the umbilicus has become a routine procedure for patients with scar-free abdominal wall needs. However, this type of procedure is significantly more difficult and risky than conventional LC and should be performed by experienced physicians.
VI Exploration of the abdominal cavity
After entering the abdominal cavity, limited exploration should be performed for conditions suggested by the preoperative examination. For example, in patients with viral hepatitis infection and cirrhosis, a biopsy should be taken?
First, the organs below the subumbilical incision should be explored for pneumoperitoneal needle puncture (the sheath at this port is also blinded)
VII. Revealing the gallbladder triangle
Revealing the gallbladder triangle is a key step in LC and is the basis for proper treatment of the cystic duct and gallbladder artery, and its technical points mainly include.
1. Separation of adhesions around the gallbladder
Blunt separation of possible adhesions between the gallbladder and the colon, duodenum and pylorus region. Try to avoid separation with electric hooks to avoid the formation of current-conducting injury to the above organs.
2.Reveal the bile duct boundary of the gallbladder triangle
The body of the gallbladder is lifted upward and separated along the lower edge of the gallbladder jugular and the cystic duct toward the common bile duct until it is close to the common bile duct and the location of the root of the cystic duct can be judged.
3.Reveal the border of common hepatic duct of gallbladder triangle
Grasp the confluence of the gallbladder potbelly and the cystic duct with grasping forceps and pull it downward, and the operator pushes the square lobe of the liver upward with the right curved forceps and peels off the plasma membrane along the front of the common bile duct toward the porta hepatis, so that the common hepatic duct can be revealed and the scope of the gallbladder triangle can be outlined to delineate the operating range for the next safe treatment of the cystic duct and cystic artery.
VIII. Treatment of the bile cyst duct
Proper handling of the bile cyst duct is a prerequisite for the prevention of bile duct collateral injury. Its technical points mainly include.
1.Separating the anterior peritoneum of the gallbladder triangle
2.Reveal the posterior peritoneum of the gallbladder triangle
The posterior peritoneum of the triangle of the gallbladder was revealed by grasping the confluence of the gallbladder jugular and the cystic duct with a grasping forceps and pulling it inward and upward, and then separating it from the middle of the common bile duct toward the lateral edge of the gallbladder bed with an electric hook.
3.Freeing the cystic duct
After separating the anterior and posterior peritoneum of the gallbladder triangle, it is easier to pass through the gallbladder triangle from anterior to posterior with curved forceps above the gallbladder duct, and the duct can be freed more adequately by gentle blunt separation.
4.Clamp closure and dissection of the cystic duct
Before dealing with the cystic duct, the anatomical relationship between the cystic duct, common hepatic duct and common bile duct should be confirmed as much as possible. Then, on the premise that the cystic duct has no traction tension and is perpendicular to the common bile duct, two titanium clamps or one absorbable clamp are applied at 0.5 cm from the confluence, and one titanium clamp is applied distally and then the cystic duct is disconnected. Note: Avoid excessive stretching of the cystic duct to avoid angulation of the common bile duct and the common hepatic duct, which may mistake part of the common bile duct as the cystic duct and ligate it together. Sometimes the cystic duct and common hepatic duct are long in parallel and the free part of the cystic duct is short, so there is some difficulty in the clamp closure.
IX. Treatment of the gallbladder artery
Since the location of the gallbladder artery is not fixed, more concealed, not intuitive, and the number may be 2 or more, improper treatment can be complicated by intraoperative or postoperative hemorrhage, its proper treatment is the most difficult and important step of LC, and beginners should pay attention to it when.
In the case of LC, it is not emphasized to isolate the cholecystic artery, and the gallbladder triangle can be treated by suture ligation if the tissue is thick and the adhesions are heavy. In the case of LC, since suture ligation is not used as a common tool, isolation of the cholecystic artery followed by proper clamping is necessary. In a small laparoscopic view, it is difficult to reveal large vessels such as the right hepatic artery emanating from the cholecystic artery, and it is even more difficult to identify the vessels of origin of the cholecystic artery. This requires the surgeon to be familiar with the variants of the gallbladder artery under laparoscopy to guide the identification of the gallbladder artery during LC.
The following principles should be followed in the management of the gallbladder artery.
1. When separating and freeing the gallbladder duct well, there is no rush to dissociate the duct. Pull the gallbladder jugular belly with appropriate tension outward and downward to fully expose the gallbladder triangle. Open the plasma membrane in front of the gallbladder triangle, observe and determine the position and direction of the gallbladder artery, dissociate the cystic duct, separate the gallbladder artery, and clamp the dissociation.
2.When separating the cystic duct, if the cystic artery is found to be parallel to the cystic duct or closely related, it can be clamped together with the cystic artery when dealing with the cystic duct.
3.When separating the connective tissue in the gallbladder triangle, especially when the gallbladder artery cannot be distinguished, the electric hook should be used to separate and disconnect the fine bundle and avoid disconnecting the thick bundle. The main point of disconnection is to hook up to the proximal side and disconnect.
4. When the gallbladder artery is not visible in the gallbladder triangle, it should not be rashly assumed that the gallbladder artery is absent. The residual edge of the gallbladder triangle and the bottom of the gallbladder should be carefully searched to see if there is any abnormal arterial pulsation.
5.When the gallbladder artery is not seen, or its treatment is inappropriate, a drainage tube should be placed at the postoperative Winslow’s hole to enable early diagnosis and treatment in case of postoperative abdominal bleeding.
When the gallbladder jugular and common hepatic duct are densely adherent and the gallbladder triangle is difficult to separate, it is not advisable to forcibly dissect the gallbladder triangle, and it is not advisable to forcibly search for the gallbladder artery. In this case, laparoscopic subtotal cholecystectomy (LSC) can avoid the separation of the gallbladder triangle to the greatest extent and is a safe choice.
X. Excision of the gallbladder
This procedure is safe and can be used as a “primer” for beginners. However, there are several requirements, including.
1, the left hand clamp to maintain good traction on the gallbladder in the appropriate direction to avoid twisting the gallbladder and failure to expose the gallbladder bed gap.
2, left-handed forceps to provide suitable tension for the gallbladder bed gap to facilitate separation between the lax tissues between the gallbladder and liver parenchyma to avoid splitting the gallbladder or entering the liver parenchyma at the level of separation, leading to liver bleeding and biliary fistula.
3. paying attention to the possible presence of paracolic ducts or vagal bile ducts, and clamp treatment if necessary.
4, if the inflammation of the gallbladder bed is heavy, or if the gallbladder bed is deep into the liver parenchyma and anatomical separation is more difficult, forced separation may easily cause liver hemorrhage, the LSC procedure that preserves part of the gallbladder bed can be chosen, and the residual part of the posterior wall of the gallbladder can be destroyed with electrocautery to destroy the mucosa
5, when the gallbladder bed is electrocoagulated to stop bleeding, the electric hook or electric shovel should be “as far as possible” from the gallbladder bed to avoid the formation of avulsion of the gallbladder tissue.
6, for deeper bleeding, compression is more effective to stop bleeding.
If bile overflow from the gallbladder bed and bile leakage from abnormal ducts are found, attention should be paid to the possibility of extrahepatic bile duct injury or ectopic confluence of extrahepatic bile ducts. small extrahepatic bile duct injuries that may have been missed.
Removal of the gallbladder
The neck of the gallbladder or the cystic duct is clamped and removed from the abdominal wall along with the sheath using gallbladder graspers introduced into the abdominal cavity through a 10 mm poke hole. If the stone is small and less, it can be easily removed; if the stone is larger or more, the bile in the gallbladder can be sucked out by suction first, and then the incision can be enlarged to remove the gallbladder. The gallbladder can also be removed after the large stones in the gallbladder have been crushed and removed with oval forceps. If the gallbladder is broken during surgery, or if the gallbladder is acutely inflamed and edematous or necrotic, the gallbladder should be removed after putting it into a specimen bag. If the stones spill into the abdominal cavity, the stones should be carefully removed and the abdominal cavity should be flushed.
After removing the gallbladder, a comprehensive observation of the gallbladder specimen should be carried out to find possible accidental gallbladder cancer.
XII. Placement of drainage tube
There are no principled guidelines for drain placement or not. If the inflammation is heavy, or if there are more traumatic bleeding points, or if the separation of the gallbladder triangle is uneasy, the placement of drains can be considered. However, studies have shown that routine postoperative placement of drains can increase the incidence of infection and prolong hospital stay, and their routine use is not advocated.
XIII. abdominal closure
The instruments are withdrawn under direct laparoscopic vision, the laparoscopic sheath is removed, and the abdominal cavity is evacuated of gas. Proper fascial sutures should be made for poke holes of 10 mm or larger, especially in the presence of high-risk factors such as elderly patients, high body mass index, and long operative time, to prevent sheath hernia from occurring. Skin closure with adhesive glue is desirable.
XIV. Postoperative management
In the absence of special circumstances, the postoperative recovery of LC is usually smooth. You can get out of bed 6 hours after surgery. A full liquid diet is available on the first postoperative day, and the transition to a normal diet is gradual according to the patient’s adaptation. Discharge from the hospital can be considered on the 2nd or 3rd postoperative day. The transition to a normal diet can be made gradually within 1 month after surgery.
If there are obvious signs and symptoms of peritonitis after surgery, bile duct injury and intestinal fistula should be considered as possibilities; if there are increased heart rate and decreased blood pressure, abdominal bleeding should be considered. For potentially serious complications, they should be actively diagnosed and properly treated.