I. What are the gallbladder diseases? and symptoms?
Common gallbladder diseases include gallbladder stones, or combined acute and chronic cholecystitis, gallbladder polyps (cholesterol polyps, inflammatory polyps, adenomyosis), gallbladder cancer, etc. When, after eating excessive fatty food, one feels discomfort or stuffiness or pain in the upper abdomen, or paroxysmal colic in the right upper abdomen with or without radiating pain at the right scapula, which may be accompanied by nausea, vomiting, fever and other symptoms, one needs to be alert to the existence of gallbladder disease, which is often seen to be confused with stomach disease and delayed treatment. Long-term chronic cholecystitis can cause severe inflammation and adhesion to surrounding tissues, pus in the gallbladder, gallbladder perforation, and even the possibility of malignant transformation, as well as heart, lung or other tissue and organ complications.
Under what circumstances is it recommended to remove the gallbladder?
1, with typical clinical manifestations of gallbladder stone attack and auxiliary examination to determine gallbladder stones, such as multiple or filled type.
2, acute purulent, gangrenous, hemorrhagic and perforating cholecystitis.
3, recurrent episodes of chronic cholecystitis that have failed with conservative treatment.
4, solitary gallbladder polyp with diameter >1.0cm, large base, progressive growth, rich blood flow, thickened gallbladder wall at the attachment and adenomyosis of gallbladder.
Third, the indications and contraindications of laparoscopic cholecystectomy.
1. Indications.
(1) Symptomatic gallbladder diseases: gallbladder stones, gallbladder polyps, chronic cholecystitis, early acute cholecystitis, etc.
(2) Asymptomatic but comorbid gallbladder diseases: with diabetes mellitus, stable stage of cardiopulmonary dysfunction, etc.
(3) Gallbladder diseases that are likely to cause gallbladder cancer: gallbladder stones older than 60 years old, giant stones (diameter >2cm), gallbladder polyps with a single diameter >1cm, rapid growth and wide base, gallbladder neck polyps, etc.
2. Contraindications.
(1) With severe cardiopulmonary insufficiency and unable to tolerate anesthesia, pneumoperitoneum and surgery.
(2) With coagulation dysfunction.
(3) Acute cholecystitis with serious complications, such as gallbladder gangrene and perforation.
(4) Those with acute severe cholangitis or acute gallstone pancreatitis.
(5) Gallbladder cancer or gallbladder bulge-like lesions suspected to be gallbladder cancer.
(6) Chronic atrophic cholecystitis with gallbladder volume <4.5cm×1.5cm and wall thickness >0.5cm.
(7) Severe cirrhosis of the liver with portal hypertension.
(8) Those with middle or late pregnancy.
(9) Those with abdominal infection and peritonitis.
(10) Previous history of upper abdominal surgery and serious adhesions.
(4) The need for intermediate open surgery.
1, unclear anatomy of the gallbladder triangle: intraoperative finding of difficult to separate adhesions of the common bile duct, cystic duct and common hepatic duct at the gallbladder triangle and difficult to distinguish anatomical structures.
2, the opening of the cystic duct is too high and close to the hepatic portal, making it difficult to separate the cystic duct
3, the cystic duct is too short <3mm and too thick in diameter >5mm and cannot be clamped.
4, the cystic duct is parallel to the common hepatic duct or common bile duct
5, extrahepatic bile duct and gallbladder artery variation, making it difficult to identify the relationship between the cystic duct and common bile duct or easily causing fatal hemorrhage
6, intraoperative injury to the common bile duct: bile duct injury, electrical burns to the bile duct wall.
7, intraoperative discovery of active bleeding caused by already existing vascular injury.
8, adjacent organ injuries: stomach, duodenum, colon and other organ injuries.
V. Complications and treatment
1, common bile duct injury
The key to dissecting the gallbladder triangle is to clarify the connection between the gallbladder and the bile duct, to separate a clear surgical field between the bile duct and the gallbladder bed, to clarify the bile duct structure before using titanium clips, and to immediately turn to open surgery when dissection is difficult.
2.hepatic artery injury
Variants of the gallbladder vessels are common, as is the right hepatic artery. The gallbladder vessels should be separated all the way to the anterior wall of the gallbladder before using titanium clips. If the hepatic artery is injured, it must be transferred to open surgery immediately.
3. Puncture injury to internal organs
The first puncture to inflate the abdominal cavity is a blind puncture, and the procedure should be strictly followed. After the implantation of the laparoscope, the other puncture areas can be checked and other punctures can be done under direct vision to avoid injury.
4.Electrocautery of the organs
Electrocoagulation must be completed under direct vision to prevent electrical burns. Once the gastrointestinal wall is burned, it may cause postoperative gastrointestinal perforation, and if necessary, plasma muscle layer sutures should be performed at the burned area.
5. Gallbladder rupture and gallstone scattering
All stones must be found and removed together with the gallbladder in the extraction bag, and the epigastric cavity should be flushed and the abdominal drainage set if necessary.
6.Postoperative bile leak
ERCP can help to clarify the site of the injury, and T-tube drainage is feasible in the early stage, and stents can be placed under the endoscope in the later stage to reduce the resistance of the Oddi sphincter and establish a bypass to accelerate healing.
7.Postoperative obstructive jaundice
Mostly caused by the bile ducts by titanium clamps or caused by stenosis, early should release the stenosis and obstruction and T-tube drainage, later feasible biliary intestinal drainage.
8, adjacent organ injury
The gallbladder should be lifted up during intraoperative separation and electrocoagulated away from the stomach, duodenum, colon and other organs, which can generally avoid injury.
VI. Suggestions for postoperative diet
Early postoperative light diet, avoid fried food (French fries, etc.), sweet food (cake, chocolate, cream, etc.), high cholesterol food (eggs, liver and shrimp, etc.) for at least two weeks, after which the patient can gradually return to the previous diet, and it is recommended that the patient’s daily diet be based on soft foods, reduce the intake of calories and fine carbohydrates, and consume more dietary Fiber.
VII. Post-discharge recommendations.
Review 3 months after surgery. Pay attention to the following matters in life.
1. smoking, alcohol, coffee, strong tea, carbonated beverages, spicy and sour food and other stimulating foods should be abstained from.
2, should chew slowly, eat light, easily digestible food, avoid full, hard food.
3, fat intake should be limited, especially not too much animal fat at a time.
4, avoid eating too cold food, it is recommended to eat less and more meals, and not too much exercise after meals.
5, have a regular life, ensure sufficient rest and sleep, and exercise regularly.
Eight, the prevention of gallbladder disease
1, the most important point is to eat breakfast.
2, usually drink more water, eat less sweets, avoid gaining weight, overweight, obesity are related to the formation of gallstones.
3, a healthy and balanced diet, avoid eating a lot of fried food, avoid eating animal offal, egg yolk, fried and spicy stimulating food, etc.