The incidence of stone disease has been increasing in recent years, and biliary lithotripsy as a new treatment technology is recognized by many patients, so for the treatment of stone disease, what are the indications for biliary lithotripsy? Is it possible for all patients to undergo biliary surgery? In response to the confusion and consultation of many patients, the 2012 Technical Specification for Minimally Invasive Biliary Surgery to Remove Stones (Polyps) (Specification for Minimally Invasive Biliary Treatment of Gallbladder Stones) published by the Chinese Physicians Association Endoscopist Branch is forwarded for the reference of many patients.
Minimally invasive gallbladder stone treatment specifications
I. Indications for surgery
① Gallbladder stones diagnosed by ultrasound or other imaging examinations;
② The gallbladder is visualized by Te99ECT or oral cholecystography with good function;
③ Although Te99ECT or oral cholecystography does not reveal the gallbladder, but the stones can be removed intraoperatively to confirm the patency of the gallbladder duct.
Contraindications to surgery
①The gallbladder is atrophied and the cavity of the gallbladder has disappeared;
②Stones in the gallbladder duct cannot be removed, and it is expected that they will not be removed after surgery;
③The obstruction of the cystic duct is confirmed by intraoperative imaging;
④ intraoperative ultrasound or imaging of stones in the cystic duct that cannot be detected by intraoperative choledochoscopy;
(5) In case of combined common bile duct stones, the common bile duct stones should be treated first before biliary surgery.
Preoperative preparation
①Blood, urine, stool routine, chest X-ray, electrocardiogram examination;
②Liver function test, kidney function test, coagulation function test;
③Bilirubin test;
④Hepatobiliary and pancreatic ultrasound examination;
⑤ Oral cholecystography or Te99ECT gallbladder dynamic imaging;
(6) CT or MRCP, ERCP examination if necessary;
(⑦) Water abstinence for more than 6 hours before surgery.
Anesthesia
Continuous rigid anesthesia or intravenous compound general anesthesia.
V. Surgical steps.
1) Trans-laparoscopic minimally invasive bile stone extraction surgery
① Routinely disinfect the skin and create a pneumoperitoneum;
② Insert the tube sheath through the umbilical puncture to observe the laparoscope;
③ Place three to four sheaths in the middle of the epigastrium, right upper abdomen and right middle abdomen;
④The gallbladder is incised at the base of the gallbladder (the incision depends on the size of the stone);
⑤ After aspirating the bile, enter the choledochoscope and carefully observe the stone, and then use the stone retrieval net to remove the stone;
(6) For embedded stones, endoscopic lithotripsy should be used to remove the stones;
(7) Carefully explore the cystic duct and remove the stones from the duct;
⑧ Observe the flow of bile at the opening of the gallbladder;
If necessary, intraoperative cholangiography should be performed to confirm the patency of the cystic duct and the presence of stones;
If necessary, intraoperative ultrasound is performed to check whether the gallbladder stones are removed; the gallbladder incision is closed with absorbable sutures in a continuous layer and the pulpy muscle layer is buried in a layer; at the end of the operation, the abdominal wall wound is routinely treated.
2) Open minimally invasive cholecystolithotomy
①Routine disinfection of the skin;
②Locate by ultrasound, cut the skin 3-100px at the location of the projection of the gallbladder base, and then cut the subcutaneous tissue in order to bluntly separate the rectus abdominis muscle into the abdomen;
③Lift the gallbladder at the base of the gallbladder, and after confirmation of the gallbladder by puncture, incise the gallbladder at its base;
④Enter the choledochoscope (soft or hard) and remove all the stones from the gallbladder with the lithotripsy net;
⑤ For embedded stones, endoscopic lithotripsy should be used to remove the stones;
(6) Carefully explore the cystic duct and remove the stones from the duct;
⑦ Observe the flow of bile at the opening of the gallbladder;
(8) If necessary, intraoperative cholangiography should be performed to confirm that the cystic duct is free of stones and is patent;
(9) Intraoperative ultrasound examination is feasible if available to confirm that all stones are removed;
⑩The gallbladder incision was closed with absorbable sutures in successive golden layers and the plasma muscle layer was embedded. The abdomen is closed layer by layer, and the skin is glued with pulling adhesive strips.
VI. Postoperative treatment
①Water can be consumed 12 hours after surgery, and light liquid food can be consumed 24 hours after surgery;
②After 48 hours after surgery, you can eat light semi-liquid food;
③ Resume normal diet one week after surgery;
④Take ursodeoxycholic acid 300 mg/day for 6 months from 2 weeks after surgery;
⑤ Review ultrasound once a year after surgery.
Although there are many theoretical benefits of biliary lithotripsy surgery, such as maximum preservation of the anatomical structure and tissue function of human tissues and organs; however, just as a coin has positive and negative sides, everything has its two sides. This is also the source of many patients’ concerns.