【Laparoscopy in Hepatobiliary Surgery】Cholelithiasis surgery

With the improvement of living standards, the adjustment of dietary structure, and the gradual popularization of physical examinations, the prevalence of gallbladder stones in my country is gradually increasing, and the prevalence rate is more than 10%. It has become a common and frequently-occurring disease in my country. Since gallbladder stones can cause gastrointestinal symptoms such as abdominal distension and indigestion, and severe cases can induce biliary colic, complicated by bile duct infection, obstructive jaundice, pancreatitis, etc., and are closely related to bile duct tumors, sufficient attention should be paid to its treatment. Achieve early detection and early treatment.

In recent years, with the continuous development of modern technology and the advancement of endoscopic technology, people have once again focused on gallbladder stone removal surgery. Gallbladder-preserving stone removal is to remove stones under direct vision, which can ensure that all stones are removed and avoid recurrence caused by residual stones. Therefore, gallbladder-preserving stone removal can not only avoid the complications caused by cholecystectomy, but also meet the patients' requirements for gallbladder preservation, and no serious complications and deaths have been seen. Therefore, we believe that for some patients with good gallbladder function and strong willingness to preserve gallbladder, gallbladder stone removal can be regarded as a humanized treatment.

The application prospect of gallstone-preserving surgery depends on the research progress on the causes of gallstones. At the same time, the problems found during gallstone-preserving treatment will also provide valuable information feedback for the research on the causes of gallstones. In the minimally invasive era, the research on the treatment of gallbladder preservation and stone removal is in its infancy, and it is worthy of in-depth exploration and research.

Meaning

Remove stones, reduce or avoid complications, and preserve gallbladder function.

Methodological debate

The surgical treatment of gallbladder stones has been dominated by cholecystectomy for more than 100 years. Its pioneer is Professor Langenbuch, a German doctor. very necessary". Under the guidance of this concept, most surgeons think that the gallbladder is a dispensable organ, so they ignore everything about the gallbladder with stones. More than a hundred years ago when science and technology were underdeveloped, it is understandable that the understanding of gallbladder stones remained at the level of cholecystectomy. Cholecystectomy is also an effective method for the treatment of certain gallbladder diseases; but with the rapid development of science and technology, human organs The understanding of function is constantly improving, and the research on gallbladder disease is changing with each passing day. It seems to be backward to still follow the concept of more than one hundred years ago.

The gallbladder is an important organ of the human body. It should not be removed at will, and the function of the organ should be protected to the greatest extent. This is the real concept of minimally invasive treatment. Pay attention to the function of the gallbladder, play the role of the gallbladder, and protect the existence of the gallbladder. Clinical research in recent decades has shown that after cholecystectomy, patients often have a certain degree of impact:

1. In terms of digestive function, the gallbladder has an important regulatory function. Cholecystectomy patients often experience symptoms such as indigestion and steatorrhea after eating a high-fat diet due to the lack of assistance of concentrated bile. In addition, after cholecystectomy, bile continues to flow into the duodenum, increasing the chance of reflux into the stomach, which can easily cause alkaline reflux gastritis and esophagitis.

2. The gallbladder also has the function of regulating the pressure balance in the bile duct. After cholecystectomy, the compensatory dilation of the bile duct makes the opening of the bile duct relatively narrow, and the bile here forms a vortex, which is also one of the theories of gallstone formation. Clinical practice has also proved that the incidence of choledocholithiasis after cholecystectomy increases.

3. For a functional gallbladder, the impact on enterohepatic circulation and lipid metabolism after resection cannot be fully compensated. Moreover, primary bile acids continuously enter the gut and come into contact with bacteria to form large quantities of secondary bile acids. Secondary bile acids can stimulate the mitosis of the colonic mucosa, which may increase the risk of colon cancer.

4. Post-cholecystectomy syndrome is often related to increased bile duct pressure and immune dysfunction after cholecystectomy, causing inflammation and dysfunction of the sphincter of Oddi. In addition, the iatrogenic injury caused by cholecystectomy has not been completely avoided. Therefore, the gallbladder is not an optional organ.

It is precisely based on the in-depth understanding of gallbladder function that people are constantly challenging the treatment method of cholecystectomy. Various methods are used to remove stones while trying to preserve gallbladder function, including oral drug stone dissolution, traditional Chinese medicine stone removal, and extracorporeal shock wave lithotripsy. etc., but most methods fail due to the high recurrence rate of stones, which also provides evidence for the prevalence of cholecystectomy. It is against this background that gallstone-preserving surgery has gradually developed.

Development path

1. The forced "gallstone removal" technique

Long before Professor Langenbuch performed the first cholecystectomy, there were reports of gallbladder stone removal. In 1867, Professor Bobb performed gallbladder stone removal for a patient with gallbladder stones and acute cholecystitis. This was because limited by the medical conditions and technical level at that time, only stone removal was performed for patients who could not remove the gallbladder to ensure the patient’s life safety.

2. The old-fashioned "gallstone preservation" technique

In traditional laparotomy, the gallbladder is cut open to remove the stones and then the gallbladder is sutured. Therefore, the surgical method removes stones under the naked eye, leaving a "blind area", and the tiny stones cannot be found, which increases the residual rate of stones in the gallbladder, which is called "blind" stone removal. This surgical method has large trauma and slow recovery, and has long been eliminated.

3. Percutaneous cholecystoscopy "gallstone removal"

Under the guidance of ultrasound, percutaneous gallbladder puncture is performed first, and then the puncture needle is expanded and a cholecystoscope is inserted into the gallbladder. Under direct vision of the cholecystoscope, the stones are crushed with ultrasound and the crushed stones are sucked out. Due to the extremely high rate of residual stones in this gallstone-preserving method, it has been eliminated.

4. Extracorporeal (shock wave) shock wave lithotripsy

In the case of proper use, extracorporeal shock wave lithotripsy generally does not cause great pain or serious complications. After treatment, there may be transient hematuria and subcutaneous congestion spots, and generally it will not cause obvious damage to the lungs, liver, and gastrointestinal tract. . Biliary colic, jaundice, and cholangitis may occur during the excretion of fragmented stones. A very small number of patients may be complicated with acute pancreatitis or incarcerated fragments of stones may require surgical treatment. But the most critical problem is the recurrence of gallbladder stones. After stopping the stone-dissolving treatment, the final recurrence rate can reach 50% or higher. Due to the high cost of treatment, long course of treatment, and high recurrence rate of gallstones, it is rare in clinical practice. application.

5. Minimally invasive fiberoptic choledochoscopy gallbladder stone removal

This is a relatively advanced "gallstone preservation" surgery that has emerged with the rapid development of endoscopy. The gallstones in the gallbladder are removed under direct vision of the fiberoptic choledochoscope. While preserving the gallbladder, the stone removal rate is high, the trauma is small, and the recovery is fast, effectively reducing the recurrence rate of gallstones.

6. Laparoscopic combined with choledochoscopy minimally invasive gallbladder-preserving stone removal

This gallstone-preserving method combines the advantages of laparoscopy and choledochoscopy. At the same time, it avoids small incisions, achieves minimal invasiveness as much as possible, and uses choledochoscope to ensure the removal of stones. However, due to the need for choledochoscopy and laparoscopic suturing and ligation during the operation, the operation is relatively difficult and the entry threshold is high.

Indications Contraindications

There is no universally recognized uniform standard for the indications and contraindications of gallbladder stone removal. We believe that the indications for gallstone-preserving stone removal should be strictly formulated, and the best indications for gallstone-preserving stone removal should be actively explored in clinical practice, so that the operation can benefit as many patients with gallstone disease as possible. "People" vary, because "guts" vary.

Indications

1. The shape and function of the gallbladder are normal. B-ultrasound examination shows that the outline of the gallbladder is clear, the position and size are normal, the wall thickness of the gallbladder is <4mm, and the contraction function of the gallbladder is good.

2. Simple gallbladder stones, small in number, moderate in size, not combined with choledocholithiasis, and no recent acute attack of cholecystitis.

3. No history of upper abdominal surgery, liver cirrhosis and other medical history.

4. Have a clear willingness to insure gallstones, and fully understand the possibility of stone recurrence.

Contraindications

1. Patients with acute inflammation of gallbladder stones, nonfunctional gallbladder, occlusion of cystic duct, and atrophy of gallbladder are not suitable for gallbladder preservation surgery.

2. The operation should not be performed for gallbladder stones that are too large or full of stones, or gallbladder sediment-like stones.

3. For elderly patients with cardiopulmonary insufficiency, try not to perform this operation.

4. The possibility of malignant gallbladder disease cannot be ruled out.

Surgical methods

Gallstone-preserving surgery mainly includes small-incision gallstone-preserving surgery, laparoscopy-assisted small-incision gallstone-preserving stone removal, and total laparoscopic gallstone-preserving stone removal.

Some patients undergoing gallbladder-preserving stone removal through small incisions are difficult to operate because of their obesity and high gallbladder position. At the same time, it is impossible to observe the whole picture of the gallbladder during the small incision gallbladder-preserving stone removal operation, and it is difficult to evaluate whether there is adhesion around the gallbladder and the severity of the adhesion. For other organs in the abdominal cavity, accurately locate the gallbladder fundus to guide the selection of the incision. At the same time, the condition of the gallbladder can be observed during the operation. If it is not suitable for gallbladder-preserving treatment, laparoscopic cholecystectomy can be transferred. In addition, the gallbladder incision is sutured under direct vision for gallbladder stone removal through small incision, which is accurate, reliable and safe. After the gallbladder is reset, the gallbladder can be repeatedly squeezed under the microscope to confirm that there is no leakage, and the overflowing fluid can be washed away.

Completely laparoscopic gallbladder-preserving stone removal, also known as laparoscopy combined with choledochoscopy, has the advantages of laparoscopic-assisted small incision gallstone-preserving stone removal, while avoiding small incisions and achieving as minimally invasive as possible. Choledochoscopic exploration and laparoscopic suturing and ligation are required in China, so the operation is relatively difficult and the entry threshold is high. It is only carried out in hospitals with relatively mature laparoscopic technology.

Postoperative prophylaxis

Long-term clinical experience has proved that if gallstones are removed and the gallbladder is preserved, gallstones may form again within a few months. The famous German doctor Langenbuch proposed in 1882 that "cholecystectomy is not because the gallbladder contains stones, but because the gallbladder can grow stones." The success of the surgical method does not mean the success of the therapeutic purpose. Since the gallbladder-preserving stone removal has not undergone large-scale long-term follow-up and repeated verification, it is difficult to evaluate the mid-term and long-term curative effects. Hospitals with insufficient conditions or patients with insufficient preparation still use abdominal surgery. Endoscopic cholecystectomy is safe and reliable.

The new gallbladder-preserving stone removal technique has a high stone removal rate, and postoperative oral administration of ursodeoxycholic acid to increase the concentration of bile acid has a certain effect on reducing cholesterol stones. Instruct patients to maintain good living habits, adjust diet, maintain and promote the recovery of gallbladder function in order to avoid recurrence of gallstones. Long-term follow-up is still required after surgery, and how to reduce the recurrence rate is a topic worthy of further study in the future.

Main condition

In recent years, the incidence of gallstones has been increasing. According to statistics, the incidence of gallstones in my country is as high as 10%. The main function of the gallbladder is to store bile and is an indispensable organ in the body. For patients with gallstones, whether to "preserve gallbladder" or "cut gallbladder" has always been controversial in the medical community.

In this regard, Professor Hu Hai, Chief Physician of the Department of Cholelithiasis at Dongfang Hospital Affiliated to Tongji University, believes that gallstone preservation is the direction of medical development, and patients who are suitable for gallbladder preservation should be selected to preserve gallbladder. For patients with a high probability of gallstone recurrence and no cause of stone formation can be found, or patients with other diseases, such as diabetes and coronary heart disease, the risk of surgery is increased, it is still recommended to have the gallbladder removed.

Gallbladder Conditions Required

(1) The gallbladder has a reserved value, and the gallbladder has a good contraction function and a high-efficiency bile reserve function (it can concentrate bile 10 times).

(2) Stones are not easy to recur. Generally, single or multiple stones of similar size are not easy to recur; multiple small stones are easy to recur.

Required patient condition

(1) No serious cardiovascular complications.

(2) Mental health, fully aware of the consequences of gallbladder protection.

(3) No symptoms of chronic cholecystitis.

Minimally invasive advantage

1. Safe and painless

Because minimally invasive gallbladder stone surgery has less trauma, patients will not feel severe pain during the treatment process, which is relatively safe.

2. Remove stones

The application of laparoscopy in minimally invasive gallbladder stone surgery enables the operation to have a larger field of view than traditional open surgery, and it is more convenient for doctors to suck bile and pus, and then remove the stones.

3. Less visceral damage

In minimally invasive gallbladder stone surgery, a certain amount of carbon dioxide will be injected into the abdominal cavity to expand the abdomen evenly to form a pneumoperitoneum, which helps the doctor to clearly see the internal organs of the patient on the display screen, and even small blood vessels can be clearly displayed come out. This is not only conducive to the doctor's operation, but also can avoid unnecessary damage to internal organs and blood vessels.

4. Good effect and fast recovery

Generally, you can get out of bed six to eight hours after minimally invasive gallbladder surgery. Under normal circumstances, you can take in liquid food one day after the operation.

Usually, after traditional laparotomy, centipede-like incision scars are often left on the abdominal skin, which is beautifully damaged and may have adverse effects on the life and work of patients in the future. In minimally invasive gallbladder stone surgery, because the opening is very small, it usually heals without sutures, and the prognosis is good.

Postoperative precautions

Patients with gallstones should absolutely fast on the first day after surgery. They can drink a small amount of thin rice soup, eat some digestible soft food on the second day, and then adopt a gradual diet; Take a deep breath and turn over on the bed every hour, which is good for the expansion of the lungs and the wound heals faster; take a bath one week after the medicine line is removed; gradually return to normal diet and work in one month after the operation. Within one month, pay attention to prevent excessive abdominal pressure and try to avoid lifting heavy objects.