[Hepatobiliary Surgery Laparoscopy] Cholecystitis surgery

The question of whether laparoscopic or open surgery is better for acute cholecystitis has been debated for many years. In the 1990s, LC was still a relative contraindication for acute cholecystitis. Later, with the rapid development of surgical technology, surgical equipment, and optical equipment, the TG13 guideline considered abdominal surgery to be better than open surgery. Evidence-based medicine also believes that compared with laparotomy, laparoscopic surgery has the advantages of fewer complications, shorter hospitalization period (but there is no statistical difference), less incision pain, shorter hospitalization period, faster recovery time, and higher quality of life. This article focuses on surgical techniques and describes the key points of LC for acute cholecystitis.

The main causes of cholecystitis are

1. Biliary tract infection, and further development of biliary tract infection will cause gallbladder inflammation.

2. Intestinal parasitic diseases: For example, roundworms burrowing into the biliary tract can cause inflammation of the biliary tract.

3. Irregular meals, especially overeating, and excessive consumption of high-fat and cholesterol-rich foods can easily cause damage to the gallbladder and cause pathological changes.

4. In terms of mentality, long-term depression and poor mood can easily lead to obstruction of bile excretion. If things go on like this, you will also suffer from cholecystitis.

Indications for surgery

In principle, LC is indicated in cases of upper abdominal surgery without previous omentectomy, cases of acute cholecystitis in which Mirizzi syndrome has been ruled out, or stones at the confluence of the left and right hepatic ducts. Although the period of LC surgery for acute cholecystitis is still controversial, emergency and early cholecystectomy should be performed in cases of large stones embedded in the gallbladder neck for the first time. For cases of recurrent cholecystitis, cases with abnormal liver function, or cases with a long onset time, percutaneous hepatic gallbladder aspiration (PTGBA) or continuous drainage (PTGBD) can be performed first. After the inflammation subsides (about 1 week), cholangiography is performed to clarify the condition of the cystic duct and common bile duct before performing LC surgery.

Surgery field

Usually LC is performed under pneumoperitoneum. However, in acute cholecystitis, due to inflammation and edema, there may be more blood oozing when separating the hepatoduodenal ligament and gallbladder bed. In addition, the area holding the gallbladder is prone to perforation and bile leakage, requiring constant suction. At this time, if normal pneumoperitoneum is used, good vision cannot be guaranteed. Therefore, the subcutaneous puncture abdominal wall suspension method is often used in acute cholecystitis LC, so that irrigation and suction can be performed like laparotomy. Usually in acute cholecystitis, the preparation for LC is the same as that for laparotomy. The laparotomy bag and additional sterilized sling instruments are routinely prepared.

Separation and adhesion

In the initial onset of acute cholecystitis, inflammatory adhesions around the gallbladder such as the omentum can be bluntly separated in most cases. Bleeding or small bleeding points on the separation surface can be stopped naturally by flushing, or cauterized with an electric knife without excessive hemostatic operations. For cases with long onset time and severe adhesion, various hemostatic incision devices can be used to dissect along the gallbladder wall or retain a part of the gallbladder serosa to confirm that Rouviere's groove has been reached.

Intraoperative puncture and aspiration of gallbladder

The inflamed gallbladder with high tension and thick wall is difficult to control. You can first use a special puncture needle to puncture and aspirate the gallbladder through 5mm Trocar. When the wall is thick and hard, alligator-nose forceps with a large opening and strong holding power can be used to lift the gallbladder.

Operation of gallbladder duct confluence

Rouviere's groove is right at the transition point between the cystic duct and the gallbladder neck, and this is used as a target to determine the position of the cystic duct. When there is a stone incarceration in the neck of the gallbladder, Hartmann's capsule may be located at the right rear of the hepatoduodenum and cause adhesions. At this time, the neck of the gallbladder should be lifted to see the Rouviere groove clearly, and the adhesions should be separated from here.

The gallbladder wall is swollen and hypertrophic during acute cholecystitis. This can be used to peel off an onion (not the brown thin skin but the white thicker part) and keep the outer layer of the gallbladder wall on the gallbladder bed. This way, the cystic duct and cystic artery can be identified and treated safely. At this time, you cannot only use the electric knife to perform sharp dissection, but also use a suction device to properly perform blunt dissection while sucking out the oozing blood. The Hartmann's capsule is retracted to the lower right and the cystic artery is identified. Cutting off the cystic artery first facilitates transcystic duct cholangiography before cutting off the cystic duct. It can also reduce intraoperative bleeding and maintain a clear field of vision. Currently, in order to minimize the legacy of titanium clips in the body, absorbable sutures are used for intracorporeal or extracorporeal ligation of the cystic duct and cystic artery.

Intraoperative biliary tract angiography

For cases with large stones incarcerated in the neck of the gallbladder, if no abnormality in the common bile duct is found in preoperative imaging examinations, and clear bile flows out from the broken end of the common bile duct when the cystic duct is incised, cholangiography may not be performed at this time. When there is a small stone embedded in the cystic duct or purulent bile flows out from the broken end of the common bile duct, the cystic duct should be further carefully separated to the confluence of the three ducts, the cystic duct should be incised, the small stones or bile sludge in the cystic duct should be squeezed out, and a catheter should be inserted from this opening to perform cholangiography.

Isolation gallbladder bed

When separating the gallbladder bed in acute cholecystitis, the level of separation cannot be mistaken. Old surgical charts all record that before separating the gallbladder bed, normal saline or lidocaine should be injected into the gallbladder wall to form artificial edema to facilitate the separation of the gallbladder bed. In acute cholecystitis, the gallbladder wall happens to be edematous, and it is important to preserve part of the gallbladder wall on the liver side. It is not only necessary to separate from the portal side of the liver or the neck of the gallbladder,It is also necessary to perform appropriate separation from the bottom, left and right sides of the gallbladder. After finding the appropriate separation level, continue the separation at this level. When a suitable separation layer is not found, the separation should be carried out as close to the gallbladder as possible consciously, and the deep side of the liver should never be cut. The separate instruments are not just electric scalpels, but also electrified Maryland forceps, suction devices, ultrasonic scalpels and Ligasure.

Take out the specimen

Perforation and tearing of the gallbladder can occur due to manipulation and traction during puncture, suction or separation. In most cases, the excised gallbladder specimen has been destroyed. At this time, the gallbladder should be put into a specimen collector such as rubber gloves to protect the abdominal wall puncture wound and taken out of the body.

Rinse the wound and place a drainage tube

Usually, the patient's position is adjusted to a horizontal or slightly head-down position, and the wound is flushed with heparinized saline until the fluid in the abdominal cavity becomes clear. When there is purulent bile leakage or heavy bleeding, change the position and wash the lower abdomen. After flushing, confirm that there is no bleeding or bile leakage.

Then place a thin Penrose drainage tube at the Winslow orifice.

Clinical manifestations of cholecystitis

1. Abdominal pain: About 85% of patients with acute cholecystitis have right upper abdominal pain as the main symptom. The abdominal pain is mostly persistent, can worsen in paroxysms, and radiates to the right shoulder and back. The abdominal pain of chronic cholecystitis is often recurring, mostly dull and distending pain.

2. Fever: Fever in acute cholecystitis usually ranges from 38 to 39°C, usually without chills.

3. Nausea and vomiting are more common in acute cholecystitis.

4. Indigestion symptoms such as abdominal distension, belching, and aversion to greasy food can occur in both acute and chronic cholecystitis patients, but chronic cholecystitis is more common.

5. Jaundice: About 10% of patients with acute cholecystitis may develop mild jaundice, which may be caused by spasm of the lower common bile duct sphincter or the spread of infection to the biliary system.