Since the first laparoscopic cholecystectomy (LC) was performed in Mouret, France, in 1987, LC surgery has become the preferred method and gold standard for the treatment of gallbladder stones as well as benign gallbladder disease. The authors performed 843 cases of LC surgery from March to August 2001, and the results are reported below, together with a review of the literature to discuss the anatomy of Calot’s triangle and the prevention and treatment of bile duct injury during LC surgery.
1. Clinical data
1.1 General data: Of the 843 cases, 398 were male and 445 were female, aged 17-81 years (mean 45.6 years). There were 645 cases of gallbladder stones, 198 cases of gallbladder polyps, 63 cases of acute cholecystitis, 38 cases of chronic atrophic cholecystitis, 5 cases of combined cirrhosis, 28 cases of combined hypertension, 36 cases of combined diabetes mellitus, 1 case of combined paraplegia, 12 cases of combined common bile duct stones (LC plus laparoscopic removal of common bile duct stones), 15 cases of history of upper abdominal surgery, and 33 cases of history of other parts of abdominal surgery. 33 cases.
1.2 Surgical methods: general anesthesia, conventional 3-hole method, dissection was performed by electrocoagulation hook, CO2 artificial pneumoperitoneum was established by Veress method, and abdominal pressure was set at 1.6-2.0 Kpa. irrigation was decided according to the cleanliness of the operative field, and abdominal drainage tubes were placed selectively.
1.3 Results: A total of 826 LC operations were completed in 843 cases, with a surgical success rate of 97.98%, an average operating time of 50 min (15-150 min), and an average postoperative hospital stay of 3 d (1-5 d). Two cases of postoperative complications occurred, and the complication rate was 0.24%. One case was a late fistula of the bile duct stump on the 9th postoperative day, which was cured by intraperitoneal flushing and drainage; one case was a subhepatic encapsulated fluid, which was cured by percutaneous puncture and drainage. No complications such as bile duct injury, postoperative intra-abdominal hemorrhage, intestinal perforation, enterocutaneous fistula and poke hole infection occurred. There were 17 cases that were referred to open surgery due to intraoperative gallbladder artery bleeding, severe intra-abdominal adhesions, and obvious inflammation in Calot’s triangle, with a 2.02% surgical turnaround rate.
2. Discussion
2.1 Anatomy of Calot’s triangle
2.1.1 Conventional anatomy method
The dissection of Calot’s triangle is a key step in cholecystectomy. The method adopted by the authors is: the operator pulls the gallbladder pot belly with the left hand, lifts the square lobe of the liver with the right hand electric hook, and swings the gallbladder up and down with the left hand to clearly reveal the anterior and posterior plasma membrane layers of Calot’s triangle and the cystic duct, keeping in mind the left margin of the gallbladder (pot belly), the course of the common bile duct (hepatic) and the position of the longitudinal groove between the left margin of the gallbladder (pot belly) and the common hepatic duct At this time, any ducts and even connective tissue filaments in the triangle of the gallbladder are clearly visible when they are free.
The ventral and dorsal plasma membrane of Calot’s triangle is cut along the left side of the longitudinal sulcus between the left edge of the gallbladder and the common hepatic duct, and the bed of the gallbladder can be reached, and the distance between the gallbladder and the common hepatic duct is enlarged after the ventral and dorsal plasma membranes are opened to achieve the requirement of “critical view of safety”. At this time, the gallbladder artery, the cystic duct, the common hepatic duct, the possible paracolic duct, and the branches of the cystic artery are clearly visible, so the common hepatic duct and the common bile duct will not be damaged by clamping the cystic duct and the cystic artery. When the cystic duct is short, the cystic artery can be dissected first under confirmed circumstances, which can reveal the gallbladder and common hepatic duct and their surrounding structures. The authors have encountered 2 cases where the paracolic duct converged into the junction of the cystic duct and the jugular of the gallbladder with a diameter of 1 mm. following this method together with patient and careful dissection, any anatomical variation can be consciously detected, thus avoiding accidental injury and postoperative bile leak and achieving timely and correct treatment.
2.1.2 Dissection in complex pathological conditions
Complex pathological conditions usually refer to acute or subacute gallbladder inflammation or stone impaction in the gallbladder neck, massive fat accumulation in Calot’s triangle, epigastric adhesions formed due to previous history of epigastric surgery, etc. In this case, it is crucial to search for and identify the common bile duct, cystic duct, and other related important structures, but the basic surgical idea remains the same.
In the case of an adherent gallbladder, the usual practice is to gradually separate the gallbladder along the base of the gallbladder toward the jugular, which in the authors’ opinion is not the best method, but a separation from the jugular to the base of the gallbladder would be more advantageous, facilitating structural identification and dissection, reducing false separations, and avoiding injury. The main reason for the increased difficulty of the gallbladder triangle containing a large amount of fat is the tendency of the adipose tissue to cover the structures in this area and to exude blood, which seriously affects the surgical operation. There is only one solution, which is the fine and appropriate electrocoagulation separation.
For the LC surgery in acute cholecystitis, the authors experienced that it can be performed within 96 h after the onset of the disease, which is consistent with the view of Kitano et al. However, in China, Ba Mingchen et al. believed that the operation should be performed within 48 h after the onset of the disease. In acute cholecystitis, the choice of anatomic site is sometimes easier, because there is often a more obvious division between the heavily inflamed gallbladder and the lightly inflamed bile ducts, and the first attack of acute cholecystitis is easier to separate, while the acute attack of chronic cholecystitis, especially those with thicker gallbladder walls, is very difficult to operate. The wall is left behind and the stump of the cystic duct is closed with microscopic sutures.
2.2 Prevention and detection of intraoperative bile duct injury
As an emerging technology, television laparoscopy has obvious advantages over open surgery in performing cholecystectomy, however, there are also shortcomings, such as the two-dimensional effect of television laparoscopy and the lack of tactile sensation, which form the basis for the occurrence of complications such as bile duct injury. Bile duct injury is a common and serious complication in LC, with an incidence of 0.65% ± 0.7% reported in foreign literature, significantly higher than the 0.2-0.22% in open cholecystectomy (OC). The rate of bile duct injury was 0.5% in 136,816 cases, and in some cases it was as high as 1.09% in the Mahatharadol checklist of 1522 LC procedures, of which there were 9 cases of bile duct injury, with an incidence of 0.59%. The prognosis of timely intraoperative detection and proper intraoperative management is mostly good, while postoperative detection and management is less effective and may even cause patient death. Therefore, timely intraoperative detection of bile duct injury is crucial. The authors experienced.
2.2.1 Good biliary surgical awareness is the basis for preventing bile duct injury Biliary surgical awareness is an all-round concept, which includes not only a rational grasp of basic theories such as biliary anatomy, but also a good perceptual understanding and further sublimation of biliary surgery. Adequate observation and understanding after entering the abdomen is very necessary and important [7], which is the first step to good LC surgery. Many surgeons are not really aware of this, and it happens that they are busy dissecting and freeing after entering the abdomen, and finally find out that the site is incorrect, and some even mistake the gallbladder pot belly for the common bile duct, making some low-level errors. The second step to a good LC is the selection of the starting anatomic site. A proper start will make the procedure look very nice and easy.
For patients without adhesions, the choice of the starting anatomic site is not difficult to grasp, but for patients with adhesions or even heavy adhesions or atypical anatomic structures, it is quite difficult, because too high a position (meaning close to the gallbladder) will increase the invalid work, and too low a position (meaning close to the bile duct) will not only increase the invalid work, but will probably damage the common bile duct. In either case, it will make the subsequent anatomical separation difficult, affect the identification of anatomical structures, increase the surgical trauma and surgical difficulty, and lay a hidden danger for the occurrence of bile duct injury and other complications.
In addition, in practice, bile duct injuries are mostly caused by misconceptions about the local structure of the gallbladder triangle, in addition to purely technical operational reasons. Therefore, in order to perform a good operation and avoid bile duct injury, it is necessary to work on the basic skills of biliary surgery and fully grasp the various anatomy of the gallbladder artery and bile duct and their variants.
2.2.2 Human factors are the primary cause of bile duct injury, and any thought of laparoscopic cholecystectomy is likely to cause bile duct injury. Guo Zhiming reported 13 cases of bile duct injury during simple cholecystectomy, among which 5 cases (38.5%) were caused by extrahepatic bile duct transection injury due to ideological disregard or overconfidence, Liu Xuedong reported 6 cases of bile duct injury, 2 of which were due to blind confidence and mistakenly ligated common bile duct, and Wang Hailong reported 6 cases of bile duct injury, 5 of which were done by senior doctors. Some physicians are not careful enough in surgical operation and are obsessed with the speed of surgery, while others blindly expand the surgical indications in order to pursue the success rate of LC, which leads to serious consequences.
Recently, Way further analyzed the root causes of bile duct injury complications in LC surgery by repeatedly viewing surgical videos and transcripts from an in-depth analysis of technical complications. The authors collected data on 252 consultation cases of bile duct injury from laparoscopic cholecystectomy, of which 77% were women and 23% were men, with a mean age of 46 years (19 to 86 years). The indications for surgery were chronic cholecystitis in 69%, acute cholecystitis in 29%, biliary pancreatitis in 2% and cholangitis in 0.4%. The reasons for operative errors were analyzed from the following aspects:
(1) perceptual information (visual and tactile); (2) knowledge and decision-making power; and (3) operation (skill and technical quality).
Judgment as a perceptual error is made in the following cases:
(1) The surgeon cuts one duct and believes it to be another duct at the time, e.g., cutting the common bile duct and believing it to be the cystic duct;
(2) The surgeon has damaged an unseen bile duct during the dissection and mistakenly believes that there is a safe distance from the bile duct.
Poor decision making or incorrect knowledge is determined in the following cases:
(1) The surgeon violated the traditional strategy of laparoscopic surgery;
(2) performing a procedure inappropriate for laparoscopic cholecystectomy. Of the 252 cases in the group, Stwart-Way classification type I (injury to the common bile duct) was 7%, type II (injury to the common hepatic duct) was 22%, type III (transection of the common bile duct) was 61%, and type IV (injury to the right hepatic duct) was 10%. The results of the analysis showed that 97% of the bile duct injuries were due to visual-perceptual illusions, and only 3% were due to technical errors, of which knowledge and judgment errors were not a major factor.
Twenty-three percent of injuries are detected intraoperatively, but only 6% are detected early enough to limit the damage. In type III injuries, the common bile duct is often mistaken for the cystic duct, and many of the object’s illusions stem from the specific uncommon contours of the structure; many surgical records assume that the operation was routine, but the video shows a strong convincing illusion. The above data strongly suggest that the main error leading to laparoscopic bile duct injury is never a technical problem, but due to illusion.
Therefore, we believe that the prevention of bile duct injury in LC is first of all to pay full attention from the ideological point of view, treating each operation as the first one, implementing the operation in strict accordance with scientific principles, and avoiding bile duct injury caused by carelessness, blind confidence and other human reasons.
2.2.3 Confirmation of the “three ducts” is the fundamental guarantee to eliminate bile duct injury This is crucial, and this principle must be adhered to at all times, and absolutely no empirical mistakes should be made. During the operation, we must be careful and patient, avoid “fighting in the blood”, and make sure to see clearly before doing anything, and the camera can be placed as close as possible to facilitate the identification of the structure. The triangle of the gallbladder is completely dissected, and finally only the cystic duct, cystic artery and bile duct are left, so that “conclusive identification” is achieved, and then the cystic duct and cystic artery can be dissected.
Using this method, the authors have found 2 cases of tiny confluent bile ducts to the cystic duct with a diameter of only about 1 mm, which, if treated as general adhesions, would have resulted in biliary fistulas after surgery. Some authors advocate routine intraoperative cholangiography in order to achieve confirmation of the three ducts. The authors believe that this is not necessary, and even if it is necessary, it should be performed selectively, and there is no need to routinely use it. Routinely performing cholangiography not only increases the operative time, but also increases the patient’s hospitalization costs.
2.2.4 The correct and reasonable use of bioclips and the judgment of their number help to detect intraoperative bile duct injury that has occurred. Most of the biliary arteries have only one, accounting for 89.9%, two for 7%, occasionally three for 3%, four for 0.1%, and the biliary arteries are small (<0.1 cm) or absent for 4.1%. Therefore, after laparoscopic surgery, there are usually only 2 biological clips left in the abdominal cavity, one for the bile duct and the other for the bile cyst artery, if there are more than 2 clips, the mind must be highly alert, at this time, the clips used must be fully confirmed, and the ducts that have been clamped must be well known, and if necessary, they can be If necessary, open it to confirm.
The authors’ clinical experience is that the number of biological clips is about 90% for 2, 5% for 3, and 5% for 1, and no 4 or 5 have been found.