How Is Laparoscopic Cholecystectomy

Laparoscopic cholecystectomy has become a mature surgical technique, which is accepted by the majority of patients with the characteristics of less trauma, less pain and rapid recovery.

(1) Indications

① Symptomatic gallstones.

② Symptomatic chronic cholecystitis.

③ Gallstone with diameter > 3cm.

④ Filled gallstones.

⑤ Symptomatic and surgically indicated protuberant lesions of the gallbladder.

⑥ The symptoms of acute cholecystitis were relieved after treatment, and there were surgical indications.

⑦ It is estimated that the patient is well tolerated.

(2) Relative contraindications

① Acute attack of calculous cholecystitis.

② Chronic atrophic calculous cholecystitis.

③ Secondary choledocholithiasis.

④ History of upper abdominal surgery.

⑤ Fat body.

⑥ External abdominal hernia.

(3) Absolute contraindication

① Acute cholecystitis with serious complications, such as gallbladder empyema, gangrene, perforation, etc.

② Gallstone acute pancreatitis.

③ With acute cholangitis.

④ Primary common bile duct stones and intrahepatic bile duct stones.

⑤ Obstructive jaundice.

⑥ Gallbladder cancer.

⑦ Protuberant lesions of the gallbladder are suspected to be cancerous.

⑧ Cirrhosis and portal hypertension.

⑨ Middle and late pregnancy.

⑩ Abdominal infection, peritonitis.

Chronic atrophic cholecystitis, gallbladder less than 4.5cm × 1.5cm, wall thickness > 0.5cm (ultrasonic measurement).

Accompanied by hemorrhagic diseases and coagulation dysfunction.

Those with incomplete function of important organs, difficult to tolerate operation and anesthesia, and those with cardiac pacemaker (electrocoagulation and electrocautery are prohibited).

The general condition is poor, it is not suitable for operation or the patient is old, there is no strong indication of cholecystectomy, diaphragmatic hernia.

The scope of indications for laparoscopic surgery is expanding with the development of technology. Some diseases that were originally contraindications to surgery have also been tried to be completed by laparoscopy. If the secondary choledocholithiasis has been partially solved by laparoscopic surgery. After obtaining the necessary experience, more diseases can be treated by laparoscopic surgery.

(4) Surgical procedure

① Create pneumoperitoneum. Make an arc incision along the lower edge of the umbilical fossa, about 10mm long. If the lower abdomen has been operated on, cut the skin on the upper edge of the umbilical fossa to avoid the original surgical scar.

The operator and the first assistant each hold cloth towel pliers to lift the abdominal wall from both sides of the umbilical fossa. The operator held the pneumoperitoneum needle (Veress needle) with the thumb and index finger of his right hand, exerted force on his wrist, and stabbed into the abdominal cavity vertically or slightly obliquely into the pelvic cavity.

In the process of puncture, when the needle breaks through the fascia and peritoneum, there is a sense of breakthrough twice; Judge whether the needle tip has entered the abdominal cavity. A syringe with normal saline can be connected. When the needle tip is in the abdominal cavity, it shows negative pressure. Connect the pneumoperitoneum machine. If the inflation pressure does not exceed 1.73kpa, it indicates that the pneumoperitoneum needle is in the abdominal cavity. Do not inflate too fast at the beginning. Use low flow inflation, 1 ~ 2L per minute.

At the same time, observe the intraperitoneal pressure on the pneumoperitoneum machine. The pressure during inflation should not exceed 1.73kpa. If it is too high, it indicates that the position of the pneumoperitoneum needle is incorrect, the anesthesia is too shallow and the muscle is not loose enough. Appropriate adjustment should be made. When the abdomen begins to bulge and the liver dullness boundary disappears, it can be changed to high flow automatic inflation until the predetermined value (1.73 ~ 2.00kpa) is reached. At this time, the inflation is 3 ~ 4L, the patient's abdomen is completely bulged, and the operation can be started.

Lift the abdominal wall with towel pliers at the umbilical pneumoperitoneum needle and puncture with 10mm trocar. The first puncture has a certain "blindness", which is a more dangerous step in laparoscopy. Be extra careful. Rotate the trocar slowly and enter the needle evenly. When entering the abdominal cavity, there is a feeling that the resistance disappears suddenly. Open the closed air valve and gas escapes. This is the success of puncture. Connect the pneumoperitoneum machine to maintain constant pressure in the abdominal cavity. Then put the laparoscope in and puncture at each point under the monitoring of the laparoscope.

Generally, puncture 2cm below the xiphoid process and put 10mm casing for discharge hook, clamp applicator and other instruments; Puncture 2cm below the costal edge of the right middle clavicular line or 2cm below the outer edge of rectus abdominis and the costal edge of the axillary front with 5mm trocar respectively to put in the irrigator and gallbladder fixed grasping forceps. At this time, artificial pneumoperitoneum and preparations have been completed.

Due to the manufacture of pneumoperitoneum and the first trocar puncture, the large blood vessels and intestines in the abdominal cavity can be accidentally injured, and it is not easy to find during the operation. Recently, many people have made a small opening in the umbilicus to find the peritoneum and directly put the trocar into the abdominal cavity for inflation. After the successful manufacture of pneumoperitoneum, the operation was started.

② Dissect the Calot triangle. Grasp the neck of gallbladder or Hartmann's bursa with grasping forceps and traction to the upper right. It is best to draw the cystic duct perpendicular to the common bile duct in order to clearly distinguish the two, but pay attention not to draw the common bile duct into an angle. The serous membrane on the cystic duct was cut with an electrocoagulation hook, the cystic duct and cystic artery were passively separated, and the common bile duct and common hepatic duct were distinguished. Since it is close to the common bile duct, electrocoagulation should be used as little as possible to avoid accidental injury to the common bile duct. Use the electrocoagulation hook to separate the cystic duct upstream and downstream, and see the relationship between the cystic duct and the common bile duct. Place the titanium clip as close to the gallbladder neck as possible. There should be sufficient distance between the two titanium clips. The titanium clip should be at least 0.5cm away from the common bile duct. Cut between the two titanium clips with scissors, and do not use electric cutting or electrocoagulation to prevent damage to the common bile duct due to heat conduction. Then find the cystic artery behind it and cut it with titanium clip. After cutting off the gallbladder artery, do not pull hard to avoid breaking the gallbladder artery, and pay attention to the posterior branch of the gallbladder. Carefully peel off the gallbladder, electrocoagulation or hemostasis with titanium clip.

③ Cholecystectomy. Clamp the gallbladder neck and pull it upward, carefully peel it off along the gallbladder wall, and the assistant should assist in pulling to make the gallbladder and liver bed have a certain tension. Completely peel off the gallbladder and place it on the upper right side of the liver. The liver bed was hemostatic by electrocoagulation, carefully rinsed with normal saline, and checked for bleeding and bile leakage (a piece of gauze was disposed at the hepatic hilum, and checked for bile staining after removal). After absorbing all the water in the abdominal cavity, transfer the laparoscope to the lower sleeve of the xiphoid process and give way to the umbilical incision, so that the gallbladder containing stones greater than 1cm can be taken out from the umbilical incision with loose structure and easy expansion. If the stones are small, they can also be taken out from the puncture hole under the xiphoid process.

④ Remove the gallbladder. Put the toothed claw forceps into the abdominal cavity from the cannula at the umbilicus, grasp the residual end of the cystic duct under monitoring, slowly drag the gallbladder into the cannula sheath and pull it out together with the cannula sheath. When grasping the gallbladder, pay attention to placing the gallbladder on the liver to avoid accidental injury to the intestinal canal by sharp forceps. If the stone is large or the tension of the gallbladder is high, do not pull it out with force to avoid rupture of the gallbladder and leakage of stones and bile into the abdominal cavity. At this time, the incision can be enlarged with vascular forceps and taken out, or the incision can be expanded to 2.0cm with an expander. If the stone is too large, the incision can be extended. If bile leaks into the abdominal cavity, wet gauze shall be used to enter from the umbilical incision to suck up the bile.

If the stone is too large to be removed from the incision, you can also open the gallbladder first, suck up the bile in the gallbladder with an aspirator, and take it out one by one after crushing the stone with forceps. If a stone is found to fall into the abdominal cavity, take it out. After checking that there is no blood and liquid in the abdominal cavity, pull out the laparoscope, open the valve of the cannula to discharge the carbon dioxide gas in the abdominal cavity, and then pull out the cannula. The incision with 10mm cannula is sutured with thin thread as fascia layer for 1 ~ 2 stitches, and each incision is closed with sterile adhesive film.

(5) Major complications

① Bile duct injury. Bile duct injury is one of the most common and serious complications of laparoscopic cholecystectomy.

The incidence of bile duct injury and bile leakage is about 10%. It should be paid enough attention. It is mainly due to the unclear anatomy of Calot triangle, especially the lack of vigilance against the common variation of common bile duct or cystic duct. When separating the cystic duct, the bile duct was inadvertently thermally damaged, there was no bile leakage during the operation, and the necrosis and falling off of the tissue in the thermally damaged area after the operation could also cause bile leakage. In addition, there are often large vagal bile ducts in the gallbladder bed. Intraoperative electrocoagulation can not completely coagulate, and bile leakage can also be formed. The main manifestations of bile duct injury are severe upper abdominal pain, high fever and jaundice. Patients with typical manifestations are usually treated in time after operation; However, a few patients only showed abdominal distension, lack of appetite, low fever and progressive exacerbation. Such patients should be closely observed. It was reported that intraabdominal bile accumulation was found a few months after operation. To judge whether there is bile leakage mainly depends on ultrasound or CT, and then confirmed by fine needle puncture under the guidance of ultrasound or CT or radionuclide hepatocholangiography.

② Vascular injury. One is massive hemorrhage caused by needle tip injury to abdominal aorta, iliac artery or mesenteric vessels during pneumoperitoneum and trocar placement. There are many reports of death caused by trocar puncture. Therefore, after successful pneumoperitoneum, laparoscopy should peep the whole abdomen once to prevent missing vascular injury.

The other is the unclear anatomy of the hepatic portal or the wrong clamping of the right hepatic artery or proper hepatic artery due to gallbladder artery bleeding. There are also reports of portal vein injury during anatomy. There have been reports of right hepatic necrosis caused by wrong clamping of hepatic artery.

③ Intestinal injury. Intestinal injuries are mostly accidental injuries caused by electrocoagulation, mainly because the electrocoagulation hook is not placed in the TV monitoring picture and is not found. Abdominal pain, abdominal distention and fever occur after operation, resulting in serious peritonitis, and its mortality is high.

④ Postoperative intraperitoneal hemorrhage. Postoperative intraperitoneal hemorrhage is also one of the serious complications of laparoscopic surgery. The injured parts are mainly the blood vessels near the gallbladder, such as hepatic artery, portal vein and abdominal aorta or vena cava during periumbilical puncture. The manifestations were hemorrhagic shock, abdominal bulge and peripheral circulatory failure. Open surgery should be performed immediately to stop bleeding.

⑤ Subcutaneous emphysema. The causes of subcutaneous emphysema are as follows: first, when making pneumoperitoneum, the pneumoperitoneum needle did not penetrate the abdominal wall, and high-pressure carbon dioxide entered the subcutaneous; Second, due to the small skin incision, the trocar is embedded very tightly, and the puncture hole of the peritoneum is relatively loose. During the operation, carbon dioxide gas leaks into the lower skin layer of the abdominal wall. Postoperative examination can find abdominal subcutaneous twisting pronunciation, generally without special treatment.

⑥ Others. Such as incisional hernia, incisional infection and abdominal abscess.