Introduction
Choledochal calculi are divided into primary and secondary, with the former being the majority of stones originating from the gallbladder and the latter being produced directly in the common bile duct. When the bile duct is not completely blocked, the patient will suddenly develop a series of symptoms, including epigastric pain, chills, high fever, jaundice and, in severe cases, shock and impaired consciousness. This disease is more rapid than gallbladder stones, with severe symptoms and difficult to treat.
Laparoscopic cholecystectomy, known as minimally invasive surgery, is performed in vivo through a tiny incision in the abdominal wall using minimally invasive instruments, a laparoscope, intra-abdominal lighting and an electronic camera system.
Gallbladder morphology and function
The main function of the gallbladder is to store and concentrate the bile synthesized by the liver. Bile enters the gallbladder during fasting, and when the gallbladder contracts during feeding, the bile enters the intestine through the cystic duct and common bile duct.
What are the common gallbladder diseases?
Common gallbladder diseases include: gallbladder stones and chronic cholecystitis, acute cholecystitis, gallbladder polyps and adenomyosis, etc.
Patients with gallbladder diseases should have a daily diet should be based on light, easy-to-digest food, drink more water (1500-2000ml), eat easy-to-digest protein, should not overeat, avoid eating animal offal, egg yolk, fried food, spicy and stimulating food, etc.
When you feel discomfort or stuffy pain in the heart fossa after over-eating fatty food, or paroxysmal colic in the right upper abdomen with or without radiation from the right scapula, along with nausea, vomiting, fever and other symptoms, you need to be alert to the existence of gallbladder disease and not to confuse it with stomach disease and delay treatment.
Long-term chronic cholecystitis can cause severe inflammation and adhesions, pus in the gallbladder, gallbladder perforation, and even malignant tumors of the gallbladder, as well as heart, lung, or other tissue and organ complications.
When it is recommended to remove the gallbladder
Those with typical clinical manifestations of gallbladder stone attacks, those with auxiliary examinations that identify gallbladder stones, those with filled gallbladder stones or porcelain gallbladder, those with a high chance of malignant transformation
Acute purulent, gangrenous, hemorrhagic and perforated cholecystitis.
recurrent episodes of chronic cholecystitis that have failed with conservative treatment.
solitary gallbladder polyps, >1.0 cm in diameter, with a large base, progressive growth, abundant blood flow, thickening of the gallbladder wall at the attachment site and attachment to the liver bed surface.
Magnetized gallbladder, adenomyosis of the gallbladder.
Pre-surgical preparation
Appropriate daily aerobic exercise, which is beneficial for postoperative recovery.
Strict cessation of smoking.
Blood tests, including routine blood, full biochemistry, electrolytes, coagulation, urine, stool, antibodies to hepatitis B, C, HIV, syphilis, etc.
Chest X-ray, electrocardiogram, abdominal ultrasound, abdominal CT, MRI.
Relevant examinations if other systemic diseases are present, such as heart and lung organs.
An enema or oral laxative to cleanse the intestines the day before surgery.
A light diet the day before surgery and water abstinence from early morning on the day of surgery.
appropriate fluids and intravenous administration of antibiotics to prevent infection prior to surgery
placement of a gastric and urinary catheter on the morning of surgery.
If severe adhesions to the surrounding stomach, duodenum, large intestine or large omentum are present due to excessive inflammation there is a possibility of intermediate conversion to conventional open cholecystectomy + common bile duct exploration.
Surgical approach
A 2-3 cm longitudinal incision is made in the anterior wall of the common bile duct, the common bile duct is explored, the stones are removed with a lithotripter, and intraoperative cholangioscopy or cholangiography is performed to confirm that there are no residual stones in the common bile duct, common hepatic duct and left and right hepatic ducts.
Traditional open cholecystectomy is traumatic, slow to heal, has a high rate of incision infection, and has a large, unsightly scar after healing, which can easily cause intestinal adhesions and is not conducive to postoperative recovery.
Compared with traditional open cholecystectomy, laparoscopic cholecystectomy has the advantages of less trauma, smaller incision, less wound pain, ability to eat and get out of bed on the first day after surgery, short postoperative medication time, short hospital stay, and significantly reduced incision infection and postoperative intestinal adhesions and other complications.
The 3-4 tiny incisions scattered in the abdomen are almost invisible after healing. At present, most (>95%) cholecystectomies can be completed laparoscopically, and laparoscopic exploration of the common bile duct is more difficult.
Postoperative
(a) After the operation, the patient may be observed in the surgical intensive care unit for one day before being transferred back to the general ward.
a gastric tube is inserted into the stomach through the nostrils, the main function of which is to drain the digestive juices in the stomach and prevent vomiting. If there is not much drainage per day after surgery, it can be removed when the intestinal function is restored (exhaustion)
a urinary catheter is placed in the bladder for drainage of urine and is usually removed on the second to third postoperative day
1-2 abdominal drainage tubes will be left in the abdomen to facilitate the flow of fluid from the abdominal cavity, please record the flow and color of the drainage daily, normal is a small amount of light red or light yellow fluid, we usually recommend removal after resumption of diet
retained T-tube is placed in the common bile duct and is mainly used for bile drainage, take care to protect it from dislodging during the activity.
a deep venous puncture tube will be placed in the neck or upper extremity for postoperative infusion and administration of various medications, which can be removed when you resume eating
an elastic stocking to prevent thrombosis will be placed in the lower extremity and may be removed when you begin to move around.
a pain pump will be connected via an intravenous or epidural catheter, allowing the patient to administer their own pain medication, which can be used appropriately to relieve pain during walking, coughing and deep breathing, or to seek medical help if the pain becomes unbearable
you will be advised to move off the floor early, generally recommended that this can be started on the second to third postoperative day, which will improve blood circulation, prevent thrombosis and promote recovery of gastrointestinal function
patients will be asked to initiate coughing and deep breathing exercises, along with the use of a nebulized inhalation device, to prevent pulmonary atelectasis and lung infections
Wounds are usually changed on postoperative day 3, and health care providers are advised to be informed of any abnormal bleeding and oozing.
the need for early postoperative treatment with intravenous fluid supplementation, parenteral nutrition fluids, acid-suppressing drugs, and antibiotics
(b) Usually, transoral feeding can be started after removal of the gastric tube, initially starting with water and then gradually changing to a liquid, semi-liquid diet until a regular diet.
If there is no significant appetite at first, enteral nutrition solution may be administered under medical advice
delayed feeding if there is significant abdominal distention and nausea and vomiting, and a small number of patients may develop significant gastrointestinal dysfunction and be unable to eat in a short period of time, and may even be reintroduced to a gastric tube
A small number of patients have a mild fever (temperature between 37-38 degrees C) that usually resolves within 3-5 days.
Special considerations: care of the T-tube
Patients should pay attention to the proper fixation of the T-tube, and should not pull or tug it (especially when sleeping), and pay attention to keep the skin around the mouth of the tube clean. The consequences are serious and often require reoperation.
Pay attention to the amount and nature of the daily T-tube drainage fluid, which is usually 200-400mL per day, and the bile flow is clear and yellowish-brown.
Contact your doctor or nurse promptly if any of the following occur
Chills or a temperature above 38.5°C
Redness or swelling of the incision or leakage of fluid.
A change in color of fluid from the drainage tube or a large increase in drainage volume
increased abdominal pain or new symptoms of pain.
Nausea, vomiting, diarrhea.
Persistent constipation for more than 2-3 days.
Other new or unexplained symptoms of discomfort.
Early diet after bile duct exploratory surgery
For at least 15 days after surgery, patients should avoid fried foods (French fries, fried meat, etc.), sweets (cakes, chocolate, cream, etc.), and high-cholesterol foods (eggs, liver, and shrimp, etc.), after which they can gradually return to their previous diet, but it is recommended that the patient’s daily diet be based on soft foods, reducing the intake of calories and fine carbohydrates, and reducing fat and cholesterol intake along with more Dietary fiber should be consumed.
Post-discharge habits
After bile duct exploration, in addition to continuing medication and regular checkups as prescribed by the doctor, the following things need to be observed in life and diet
Should abstain from smoking, alcohol, coffee, strong tea, carbonated beverages, spicy and sour foods and other irritants
Chew slowly, eat light and easily digestible food, and avoid full and hard food.
Limit fat intake, especially not too much animal fat at one time.
avoiding excessively cold food, suggesting smaller and more frequent meals, and not exercising excessively after meals
Have a regular life, ensure sufficient rest and sleep, and exercise regularly.