【Laparoscopy in Hepatobiliary Surgery】Choledocholithiasis

With the increasingly wide application of minimally invasive surgery in abdominal surgery, the popularization of laparoscopic techniques, the increasing experience of general surgeons, and the continuous improvement of laparoscopic skills, laparoscopy combined with choledochoscopy cholecystectomy + choledochotomy for stone extraction (LC +LCBDE) has become an effective means for the treatment of choledocholithiasis.

Indications

1. Common bile duct stones: gallbladder stones complicated by common bile duct secondary stones (LC+LCBDE), or primary common bile duct stones; primary intrahepatic and extrahepatic bile duct stones, without bile duct strictures, stones can be removed through choledochoscopy without biliary or intestinal Drainage; or choledocholithiasis with obstructive jaundice or acute cholangitis.

2. Common bile duct diameter > 1.0 cm

3. Single or several stones in common bile duct

4. Common bile duct stones <1.5cm

Contraindications

1. For primary intrahepatic bile duct stones, it is difficult to remove all stones through choledochoscope or liver resection is required. 2. Stenosis at the lower end of the common bile duct requires cholangioenterostomy.

2. If the diameter of the common bile duct is less than 1.0 cm, laparoscopic choledochotomy may cause severe secondary injury and postoperative bile duct stricture.

3. The common bile duct stones are too large, and it is difficult to remove the stones with the stone mesh.

4. Severe adhesions in the abdominal cavity, especially in the hepatic hilum, the common bile duct could not be dissected and exposed.

5. Other contraindications to laparotomy (various conditions that cannot be treated by surgery, such as severe cardiopulmonary insufficiency, coagulation mechanism disorders, etc.).

Technical advantages

Laparoscopic combined with fibrous choledochoscopy transcystic duct stone extraction (LTCBDE), no need to dissect the common bile duct, no damage to the physiological structure of the common bile duct, less trauma, no need to place a T tube and suture the common bile duct, long-term T-tube indwelling It leads to electrolyte imbalance in patients, and the risk of accidental detachment is greatly increased, which brings inconvenience to patients' lives. The effect of T-tube-free surgery is significantly better than that of T-tube drainage, which significantly reduces the incidence of bile leakage, bile duct stricture and obstruction. It can effectively avoid the inconvenience caused by indwelling T tubes, shorten postoperative hospital stay, lower hospitalization fees, and greatly reduce the pain and economic pressure of patients.

1. The body wall neuromuscular is spared from cutting.

2. Fast recovery after minimal organ interference.

3. The puncture port is flexible and convenient for continuous treatment of multiple diseases.

4. The threat of infectious diseases is small, and the surgical personnel are safer.

Item preparation

1. Instruments: laparoscope, pneumoperitoneum, choledochoscope.

2. Instruments: laparoscopic kits, surgical laparoscopic instruments, debridement bowls, dry cylinders. 

3. Dressings and disposables: general surgical dressings, clothing bags, large hole sheet, 3-0 silk thread, 5ml syringe, gloves, aspirator connecting tube, beauty dressing, 4-0 absorbable thread, debridement trocar, 11 # Blades, electron microscope sets, various types of T tubes and drainage bags, latex tubes.

Body position: lying supine with head high and feet low, tilting 15º-30º to the left.

Anesthesia: general anesthesia.

Steps

1. Spread the drape for routine skin disinfection, and arrange the endoscopic instruments on the sterile instrument table in the order of use: pass toothed oval forceps and three pieces of iodophor gauze to disinfect the skin; routinely assist the doctor in laying sterile drapes. Disinfect the skin with an alcohol gauze. The hand-washing nurse handed the air tube, suction tube, cold light source line, monopolar line, and the lens of the electron microscope; the itinerant nurse connected the cold light source line, lens line, insufflator, TV system, monopolar line, suction tube, and put the Pedals are placed at the side of the surgeon's feet.

2. Establish pneumoperitoneum. Make a 10mm arc-shaped incision on the upper or lower edge of the umbilical cord, and puncture the abdominal wall with the Veress needle. After confirming that the Veress needle has entered the abdominal cavity, connect the CO2 insufflation machine, and start the operation after reaching the pneumoperitoneum pressure: pass the No. 11 blade on the umbilicus. Make a 10mm arc-shaped incision on the upper or lower edge, pass 2 towel forceps to lift the abdominal wall on both sides of the umbilical fossa, pass the Veress needle to the operator for puncture, and connect the Veress needle with a needle-free 5ml syringe filled with normal saline After confirming that the Veress needle has entered the abdominal cavity, connect the CO2 insufflation machine until the predetermined pneumoperitoneum pressure (1.73-2.00kpa) is reached, then take out the Veress needle.

3. Place the Trocar and observe the condition of the abdominal cavity, gallbladder and common bile duct: insert the 10mm Trocar through the incision, and insert the observation mirror into the cannula for observation. Place the Trocar 3 cm below the xiphoid process on the midline of the upper abdomen, 3 cm below the right costal margin on the right midline of the clavicle, and the right The corresponding Trocar is placed under the costal margin of the anterior axillary line, and the roving nurse can place the patient in a position with the head high and the soles of the feet, and tilt to the left by 30° for the operator to operate.

4. Dissect the gallbladder triangle, process the cystic duct and cystic artery, and fully expose the common bile duct: hand the toothed grasping forceps to clamp the bottom of the gallbladder, electrocoagulate the separation hook to free the cystic duct and cystic artery, and hand titanium clamps to the proximal end of the cystic duct respectively One titanium clip was applied at the distal end and two titanium clips at the proximal end of the cystic artery. Absorbable titanium clips or nylon clips are also available. Fully dissect the common bile duct.

5. Confirm and cut the common bile duct: puncture the bile with a 7-gauge needle, and after confirming that it is the common bile duct, place a piece of gauze at the omentum hole to prevent bile and stones from leaking into the lesser omentum sac, and cut the common bile duct longitudinally with scissors 8-10mm.

6. Exploring the common bile duct and removing stones: take out the stones with forceps or squeeze out the stones with forceps, and then under the supervision of the laparoscope, poke the hole from the 10mm Trocar under the xiphoid process and insert the choledochoscope for common bile duct exploration and stone removal with a basket, and remove the stones at any time Put it into the specimen bag to prevent the loss of stones, and flush the common bile duct after removing all the stones.

7. Place a T-tube for drainage: choose a suitable T-tube, trim it and poke a hole under the xiphoid process, place the two short arms into the common bile duct with a separating forceps, and hold the needle with 4-0 to absorb The common bile duct was sutured intermittently, and then the T-tube was taken out of the body through the 5mm Trocar poking hole on the midclavicular line below the right costal margin, and 50ml of normal saline was injected into the cavity to observe whether there was leakage around the suture of the common bile duct.

8. Resect the gallbladder and treat the wound of the liver bed: cut off the cystic duct and cystic artery with electric coagulation, and separate the gallbladder bed with forceps and electrocoagulation separation hook. , Pass the flushing suction device connected to warm saline flushing and check for active bleeding and bile leakage, and return the operating bed to the horizontal position.

9. Take out the gallbladder: Hand over the neck of the gallbladder with the grasping forceps, put it out at the umbilical incision or the subxiphoid incision together with the puncture cannula, and hand over the middle curved vascular forceps, suction head, and scissors for use.

10. After checking whether there is blood and fluid in the abdominal cavity, pull out the laparoscope, open the valve of the cannula to remove the CO2 gas in the abdominal cavity, and suture the wound: if abdominal drainage is needed, it is drawn from the 5mm Trocar poking hole in the anterior axillary line of the right costal margin. Each incision was sutured with a 10X28 angle needle 3-0 silk thread to cover the wound.

Postoperative Drainage Management

1. Management of abdominal drainage tube

Properly fix the drainage tube in vitro to avoid twisting or compression, keep the abdominal drainage tube unobstructed, and observe the drainage volume and properties. Generally, the abdominal drainage tube is removed 48-72 hours after the operation. If the drainage volume is large or bile fluid is drawn out, the time for removing the tube must be delayed.

2. T-tube management

(1) Properly fix the T-shaped tube in vitro to keep the drainage smooth. If the drainage of the T-shaped tube is not smooth, squeeze the T-shaped tube to let the rubber tube expand automatically, and the negative pressure will block the T-shaped tube stone residue, inflammatory secretions, etc. Aspirate, if necessary, gently flush the T-tube with 5-10ml of saline and withdraw the bile. the

(2) Observe the drainage volume every day. The amount of bile secretion is less due to the influence of anesthesia after the operation, and the bile can increase by 500-800ml after the diet is resumed. If more than 2000ml of thin bile is drawn out every day, it indicates that the liver function is poor, and it is necessary to protect the liver and pay attention to replenishing water and electrolytes.

(3) Elevate the T-shaped tube or intermittently clamp the T-shaped tube one week after the operation to allow bile to flow into the intestinal tract to avoid excessive loss of bile.

(4) T-tube angiography 10-12 days after operation, if there are no residual stones and the lower end of the common bile duct is unobstructed, the tube can be clamped and discharged the next day after the angiography, and the T-tube can be washed with 100-200ml of metronidazole solution every week after discharge 1- Twice, loosen the clamp for 2-3 hours a day, so that the bile can flush the T-shaped tube to prevent the growth of bacteria in the tube.

(5) People with jaundice

T-tube drainage is beneficial for jaundice to subside, and the clamping time is relatively delayed. Jaundice subsides slowly, excluding major biliary obstruction, capillary cholangitis and capillary cholangiohepatitis should be considered, liver protection, hormones and hyperbaric oxygen therapy can be taken.

(6) Dial the T-tube time

Laparoscopic surgery has less trauma, and it takes longer to form a solid sinus tract around the T-shaped tube than open surgery. Therefore, the time to remove the T-shaped tube should be 1-2 months after the operation. If postoperative biliary tract examination and stone removal are required, it should be performed after 2 months. Safer.

Complications and Treatment

Complications of LC surgery can also occur in patients with LCBDE surgery, which requires great attention. The following complications can also occur with LCBDE:

1. T-shaped tube comes out

The prolapse of the T-shaped tube is mostly due to accidental factors. It can also be caused by placing the T-shaped tube in the abdominal cavity too straight. Postoperative abdominal distension or coughing can cause the T-shaped tube to protrude out of the bile duct, causing bile leakage. The shorter the time from surgery, the greater the severity of T-tube prolapse. The sinus tract is not fully formed within 5-7 days. After the T-tube prolapses, bile leaks and accumulates in the subhepatic space or biliary peritonitis occurs. It is advisable to perform laparoscopic or open surgery as soon as possible to reset the T-tube and fully drain the abdominal cavity; 7-10 The sinus tract has been completely formed in Tianhou, and the T-shaped tube has protruded. As long as the sinus tract is not ruptured, the drainage of the fistula tract is maintained, and conservative treatment is performed under close observation, generally no serious consequences will occur. abdominal surgery.

2. Postextubation bile leak, biliary peritonitis

In clinical practice, no matter laparotomy or laparoscopic surgery, bile leakage and biliary peritonitis have been reported after T-tube removal within 1-2 months after surgery. There may be many factors:

① Patients with poor nutritional status, frail and emaciated, etc.

② There is a history of omentum resection, or the omentum has been adhered to other parts of the abdominal cavity

③ Improper postoperative extubation method, such as sinus tract rupture caused by violent force

The correct way to pull out the T tube:

① Open the T tube to drain bile for more than half an hour before extubation.

② Before extubation, instruct the patient to cough vigorously to discharge the bile in the biliary tract as much as possible to avoid biliary hypertension.

③ When pulling out the tube, press the abdominal wall of the T-shaped tube with one hand, and pull out the T-shaped tube slowly and forcefully, so as not to break or rupture the fibrous tissue sinus formed by the T-shaped tube in the abdominal cavity.

④ After extubation, rest on supine position for 1-2 hours.

Bile leakage caused by T-tube extraction can be cured conservatively without re-operation as long as the tube is re-inserted in time for smooth drainage and anti-infection treatment at the same time.

Complications and Prevention

Laparoscopic biliary exploration and cholecystectomy are also potentially dangerous. If not handled properly, it can cause a variety of serious complications, including:

1. Intraoperative and postoperative bleeding. The key to prevention and treatment is to strictly control the location of common bile duct incision and fine operation during the operation.

2. bile leak. The key to prevention and treatment: avoiding damage to the common bile duct and the fine technique of suturing the common bile duct.

3. Biliary stricture. The key to prevention and treatment: strictly control the indications, accurately suture the common bile duct, and prevent thermal injury of the bile duct.

4. Biliary residual stones. The key to prevention and treatment: remove all stones during the operation, angiography before pulling out the T-tube after operation, and use choledochoscope to remove stones through the common bile duct through the T-tube.

5. Abdominal infection. Key points for prevention and treatment: prevent bile from overflowing or leaking into the abdominal cavity, place abdominal drainage, and fight infection after surgery.

6. accidentally injuring other internal organs. Prevention and control points: careful operation.

7. Pneumoperitoneum-related complications. Preventive measures: Appropriate abdominal air pressure, exhaust the gas abdomen at the end of the operation.

As technical proficiency increases, the incidence of the above complications is significantly lower.

Any technique has its rationality and inherent limitations, and it must be selected and applied in light of the specific conditions of the patient in order to achieve the most ideal effect.