The age structure of our population is undergoing significant changes, the proportion of elderly people in the population is increasing year by year, and more and more elderly patients with cholelithiasis are receiving LC treatment. Geriatric cholecystitis, gallbladder stones are often combined with coronary heart disease, hypertension, diabetes mellitus and respiratory diseases. Correct management of comorbidities and selection of appropriate timing of surgery are of great significance to the smooth performance of laparoscopic cholecystectomy and postoperative rehabilitation of patients.
I. Pay attention to case selection
All benign gallbladder disorders with indications for cholecystectomy are indications for LC, and LC should not be a contraindication for the elderly, but the impact of concomitant diseases on LC in the elderly should be paid attention to, and the indications and contraindications should be fully grasped.
1, onset time, the onset of acute cholecystitis does not exceed 72 hours, or the course of the disease, although more than 72 hours, but still within 1 week, and the acute phase of the disease has been controlled. In the early stage of inflammation, the edema of the gallbladder wall is lighter, and the triangular dissection of the gallbladder and separation of the gallbladder ducts are easier, which facilitates surgical operation. In acute cholecystitis, the duration of the disease is more than 1 week, and without any formal treatment, the edema of the gallbladder wall is obvious, and the triangular dissection of the gallbladder is unclear, so it is not easy to operate. It is recommended that LC should be performed 4-6 weeks after the inflammation has subsided. Early rather than late LC during acute attack is advisable, and the rate of timely LC within 3 days for those who are referred to open surgery is reduced by half compared with the latter in 3 days, and its complication and morbidity and mortality rate is lower than that of acute open surgery.
2, pay attention to the medical history, patients such as previous recurrent episodes, obvious symptoms, significant right upper abdominal peritoneal irritation signs, obvious enlargement of the gallbladder, surgery is difficult.
3. Preoperative ultrasound should be routinely performed to understand the thickness of the gallbladder wall, the number of stones, the presence of stone impaction, and to judge the difficulty of surgery before surgery.
4, emphasize the importance of preoperative MRCP, which can understand the direction of bile duct and pancreatic duct, whether there are anatomical variants, exclude the common bile duct occupying lesions, and facilitate the guidance of surgery.
5.If the elderly patient has dyspepsia, weakness, poor appetite, emaciation and anemia as the main symptoms, while the gallbladder stone symptoms are mild or absent, they should be alert to the combination of gastrointestinal tumor.
6, for patients with severe cardiopulmonary system or other diseases that are difficult to tolerate general anesthesia should be a contraindication to LC.
7. Combination of diffuse peritonitis, cholangitis, severe pancreatitis, advanced cirrhosis, portal hypertension and coagulation dysfunction, and high suspicion of gallbladder cancer should be a contraindication to LC.
II. Preoperative patient management
Patients with combined hypertension; monitor blood pressure every day after admission, and continue to take the previous medication for patients with blood pressure of 120-130/80-90 mmHg. For patients with blood pressure of 180/110 mmHg or more, ask the cardiology department to consult and adjust the medication so that the preoperative blood pressure can be stabilized at 150-160/90-100 mmHg before surgery. Add sedative drugs 2 to 3 days before surgery to ensure sleep.
Patients with combined coronary artery disease should stop using drugs that affect the coagulation mechanism, such as aspirin, 2 to 3 days before surgery; patients with a history of myocardial infarction should have echocardiography to understand the function of the heart, such as ejection fraction, movement of each ventricle and valve, etc. before surgery.
3, combined with respiratory diseases; preoperative pulmonary function tests must be performed; smokers should be prohibited from smoking before surgery, and deep breathing should be performed to enhance the ventilation function. For mild to moderate obstructive pulmonary dysfunction, preoperative anti-inflammatory, sputum, cough and bronchodilator treatment should be given to keep the airway open.
4. For those with combined diabetes mellitus, regular subcutaneous insulin should be injected before surgery to keep fasting blood sugar below 10 mmol/L and urine sugar (+), and LC should be performed when there is no ketoacidosis, and insulin and glucose-lowering drugs should be used after surgery according to the blood sugar and urine sugar.
Intraoperative treatment
1. The drug metabolism ability of the elderly is poor, so the anesthetic drugs should be reduced appropriately during LC surgery, and drugs that are harmful to liver and kidney function and have a greater impact on respiratory and circulatory functions should be avoided. Intraoperative cardiac and pulmonary function should be closely monitored to shorten the operation time as much as possible, and the operation should be completed by a skilled laparoscopic surgeon.
2, patients with pacemakers, intraoperative electrocoagulation, electric hook and other devices are prohibited, so as not to affect the function of the pacemaker, when needed, the ultrasonic knife to remove the gallbladder.
3, the elderly abdominal wall relaxation, pneumoperitoneum pressure should be controlled below 1.6kpa, the establishment of pneumoperitoneum should be slow, in order to reduce the impact of pneumoperitoneum on circulatory breathing.
4, for previous history of abdominal surgery, consider those with abdominal adhesions, can use small incisions on or under the umbilicus to open into the abdomen and establish a pneumoperitoneum.
5.If abnormal gallbladder triangle anatomy or difficult adhesion anatomy is found intraoperatively and gallbladder cancer is suspected, the patient should be promptly referred for open abdominal surgery to avoid medically induced bile duct injury.
IV. Postoperative treatment
After LC, the patient should be sent to ICU ward, and the tracheal intubation should be removed after the patient is awake, and the indicators such as blood pressure, pulse rate, respiration and oxygen saturation should be monitored continuously. Patients with combined coronary artery disease should receive continuous postoperative intravenous nitroglycerin to prevent angina pectoris, myocardial infarction and fatal arrhythmias. After the patient has eaten, then gradually transition to the patient’s preoperative oral medication for coronary artery disease. Those with combined respiratory disease are routinely treated with postoperative nebulized inhalation to dissolve sputum.
Due to the small trauma of LC, short operation time, light blow and disturbance to elderly patients, light postoperative pain, early recovery of gastrointestinal function, less rehydration, short hospital stay. light stress reaction caused by LC, compared with open surgery, LC recovery is fast, avoiding long-term bed rest, reducing the resulting heart, brain, lung, peripheral vascular and other complications. As long as the indications for surgery are strictly mastered, the perioperative management is strengthened, and the prevention of intraoperative and postoperative complications is enhanced, LC surgery for the elderly is safe and feasible.
In addition, when the inflammation of gallbladder is serious, the gallbladder triangle is “frozen” and it is difficult to dissect, so it is very easy to have uncontrollable bleeding, medical bile duct injury and cardiopulmonary complications, and once the complications occur in the elderly, the management will be quite difficult and the consequences are unimaginable. Therefore, we believe that elderly people with gallbladder stones, especially when combined with gallbladder polyps, should actively undergo LC as soon as possible even if they do not have symptoms of cholecystitis.