To explore the application of partial cis-combination method in laparoscopic cholecystectomy Methods The partial cis-combination method of LC was introduced. Among the 1750 cases of LC, 849 cases were resected by the partial cis-combination method, including 535 cases of chronic calculous cholecystitis, 166 cases of acute subacute calculous cholecystitis, 76 cases of chronic atrophic calculous cholecystitis, and 72 cases of gallbladder polyps. All patients were cured and no extrahepatic bile duct injury occurred. Conclusion This method absorbed the advantages of open cis-reverse combined cholecystectomy with less complications and bleeding, and also conformed to the characteristics of laparoscopic surgery.
In recent years, laparoscopic cholecystectomy (LC) has gradually become popular in China,1 and has been accepted as the “gold standard” for the surgical treatment of benign gallbladder diseases. the incidence of bile duct injury in LC is slightly higher than that in conventional surgery, which is about 0.5%. At present, the majority of LCs in China are performed by paracentral resection (first severing the cystic duct and then peeling the gallbladder from the neck to the base of the gallbladder), which is prone to extrahepatic bile duct injury due to misdiagnosis of the cystic duct. There are also a few LCs that use the retrograde resection method (i.e., first stripping the gallbladder from the gallbladder base toward the gallbladder neck and finally breaking the cystic duct), which is more difficult to operate laparoscopically due to the prolapsed liver lobe and free gallbladder affecting the operating space and more bleeding.
We have summarized some of the cis-reversal combination method LC which is in accordance with the characteristics of laparoscopic surgery, and we report as follows.
1. Information and methods
1. 1 General information
Among the 1750 cases of LC, 849 cases, 340 males and 509 females, aged 16-98 years, with an average age of 56 years, were treated by the partial cis-laparoscopic method. There were 535 cases of chronic calculous cholecystitis, 166 cases of acute subacute calculous cholecystitis, 76 cases of chronic atrophic calculous cholecystitis, and 72 cases of gallbladder polyps.
1. 2 Surgical methods and results
The position, anesthesia, CO2 pneumoperitoneum establishment and abdominal wall poking holes were performed with conventional LC, intravenous compound anesthesia, head high and foot low with 15 degrees left tilt, and “three-hole method”. After exploring the abdominal cavity, the hepatic hilum, hepatoduodenal ligament and gallbladder triangle were exposed, and the surgeon’s left hand held the gallbladder pot belly with gallbladder grasping forceps and pulled it to the upper right perpendicular to the direction of the bile duct, while the right hand used separating forceps with gauze strips to slightly push up the square lobe of the liver to reveal the hepatic hilum.
The left hand does the repeated “relaxation-distraction-relaxation-distraction of the gallbladder pot belly” movement, and the left hand is held at the “junction line” between the active plane and the fixed plane, that is, the Calo The right hand was switched to an electric hook and the plasma membrane was electrically incised to the body of the gallbladder neck, exceeding the right incision of the transverse hilar sulcus by about 1-2 cm, and then the gallbladder pot belly was pulled to the left side to reveal the posterior triangle of Calo t and the plasma membrane of the posterior triangle was electrically incised, the length of which was comparable to that of the anterior medial side. The plasma membrane and lax tissues behind the anterior Calo t triangle were separated from the body of the gallbladder neck at or above the right incision of the transverse hepatic hilar sulcus and met anteriorly and posteriorly, and then continued to dissect the gallbladder neck and cystic duct sharply and/or tonically by retrograde dissection downward. Each hook during sharp dissection must confirm that there are no significant ductal structures in the tissue on the hook arm.
The cystic duct can be separated with a separating forceps, or a separating forceps with gauze can be used to bluntly push away the loose tissue around the cystic duct, or the longitudinal axis of the electrocoagulation hook can be parallel to the longitudinal axis of the cystic duct, and the loose tissue next to the cystic duct can be pushed away while cutting with the back of the electrocoagulation hook, or the tip of the electrocoagulation hook can be lifted and cut through the loose tissue next to the cystic duct to completely reveal the cystic duct. When the confluence of the cystic duct and common bile duct is not clear, the cystic artery can be dissected, separated, clamped and cut, and then the Calo t triangle can be peeled off with gauze tonsure (as much as possible with gauze bluntly peeled off, which can prevent injury and also compress to stop bleeding and make the field of vision clearer), or pushed with the suction head while suctioning, and the loose fibrous tissue on the surface of the cystic duct can be cut off with the electric hook.
At this point, it can be seen that the gallbladder duct, gallbladder neck and part of the gallbladder body are completely suspended, and the right edge of the hepatoportal plate is completely empty, with no ductal structure entering the hepatoportal! At this point, the cystic duct was clamped and cut, and finally the gallbladder was stripped in a cascade. All 849 patients in this group were treated with partial cis-reverse combination method, and no bile duct injury occurred in any case. All of them were discharged from the hospital cured.
2. Discussion
2.1 The advantages and operability of partial cis-combination LC.
Open cis-retrogressive combined cholecystectomy has the advantages of less bleeding when stripping the gallbladder in the cis method and low incidence of bile duct injury when stripping the gallbladder in the retrogressive method, which is considered to be a more ideal surgical approach and widely used. This advantage has been fully absorbed by the inadvertent partial cis-retro approach. Due to the small operating space of LC, laparoscopy is not suitable for the universal use of retrograde dissection of the gallbladder.
In partial cis-retrogressive combination LC operation, the gallbladder base is attached to the liver bed, which gives a larger operating space than complete retrograde dissection of the gallbladder, and it is possible to “hollow out” the gallbladder triangle by careful dissection of the gallbladder triangle with the feature of local laparoscopic magnification, which makes laparoscopic partial cis-retrogressive combination cholecystectomy very operable. In our group of 849 patients with partial cis-combination LC, good results were achieved, which proved that this method is not only reasonable but also safe and feasible.
2.2 Precautions.
① Dissect the hepatobiliary triangle, always rely on the wall of the gallbladder along with the anatomical gap bluntly separated, mostly with yarn ball stoned separation or with electrocoagulation hook back “cold” push stripping. When using the electrocoagulation hook, be careful not to spark, and prohibit the hook tip from pointing in the direction of the common hepatic duct or common bile duct.
②In case of bleeding from the gallbladder artery, sedation should be used to keep the surgical field clear and do not use titanium clips or electrocoagulation blindly.
③Do not forcefully tear the tissue or grasp the common bile duct or common hepatic duct with excessive force, and do not forcibly dissect any duct system within the Calo t triangle. When the cystic duct is twisted and adherent and the Calot triangle is unclear, avoid forcibly separating the cystic duct with separating forceps to prevent extrahepatic bile duct lacerations.
④When disconnecting the cystic duct, first use scissors to test for other tissues below the cystic duct (to prevent accidental injury to the common hepatic duct), then use scissors to cut the leaves (avoid cutting with electrocoagulation), and cut the cystic artery must be close to the wall of the gallbladder.
⑤ When separating Calo t triangle, if the tissue is not very dense, try to use blunt dissection, including pushing with gauze, separating forceps to separate or tear off the loose tissue, or using the back of the electrocoagulation hook to bluntly push and peel, and observe whether there is a variant of the gallbladder artery and the gallbladder duct to prevent accidental injury.
When using the electrocoagulation hook, be sure to lift the tissue to be cut off and swing the electrocoagulation hook slightly in the longitudinal direction of the tissue, so that the back of the hook leaves the deep surface tissue and has a certain distance from the deep surface tissue, and then electrocoagulate and electrocut the tissue after confirming that there is no important structure in the raised tissue (pay attention to the power of electricity) or pull off the tissue after electrocoagulation with tension (the mastery of tension should be appropriate). When stepping on the electrocoagulation pedal, use the method of “dragonfly stepping”, stepping continuously for no more than 1 second each time, and do not continuously energize the tissue to avoid damage to adjacent tissues by the thermoelectric effect.
(7) Pay attention to the “junction line” between the triangular plane of Calo t and the plane of the hepatic portal, the upper part of the “junction line” is the safety zone, and the lower part of the “junction line” is the danger zone. In principle, anatomical operations should not be performed below the “junction line”.
⑧ Emphasize the dissection behind the gallbladder triangle. In practice, it is found that the lesions in front of the gallbladder triangle are usually heavy, while the lesions behind are relatively light, so dissection from behind the gallbladder triangle makes the operation easy and can reduce misinjury.