Cholecystectomy: types, technique and complications. Operations on the liver: surgical approaches, their advantages and disadvantages What are the complications after cholecystectomy?

Table of contents of the subject "Operations on the stomach. Operations on the liver.":

Oblique cut abdominal wall produced 2 cm below and parallel to the right costal arch (according to Riedel-Kokher or Fedorov).

Cholecystectomy from the neck, or retrograde cholecystectomy.

Liver lift up, duodenum is taken down, the gallbladder is freed from adhesions. In the hepato-duodenal ligament, the cystic, hepatic and common bile ducts are isolated. In Calo's triangle, the cystic artery is found and tied up.

Two ligatures are placed under the cystic duct and first they are tied up from the side gallbladder... If necessary, cholangiography is performed through the unbound part of the duct by introducing a catheter through the cystic duct into the common bile duct. After that, the terminal part of the cystic duct is ligated, retreating 0.5 cm from the place of its confluence into the common bile duct. The cystic duct is crossed between the ligatures. The gallbladder is isolated, incising the peritoneum along its lateral surfaces and separating it from the underlying tissues in a blunt and sharp way. The bubble is removed.

Produce peritonization of the bladder bed and hepato-duodenal ligament. It is important to cover the cystic duct stump with the peritoneum.

Cholecystectomy from the bottom, or antegrade cholecystectomy.

Cholecystectomy begins with the isolation of the gallbladder from its bed from the bottom. Then the cystic artery is ligated, the place where the cystic duct flows into the common bile duct is found, and the cystic duct is ligated with two ligatures - from the side of the bladder neck and 0.5 cm away from the place where the cystic duct flows into the common bile duct. The bladder is removed, its bed is peritonized.

Currently, in clinics that have video endoscopic equipment, almost all operations on the gallbladder are performed laparoscopically, starting most often from the neck. Only in rare cases of very complex topographic and anatomical variants of the course of the bile ducts or vessels in the hepatic-duodenal ligament, the operation is completed from the usual laparotomic access.

Anatomy video of laparoscopic cholecystectomy

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OPERATIONS ON PARENCHYMATIC ORGANS

Topographic anatomy spleen

The spleen is an unpaired lymphoid organ, in which the diaphragmatic and visceral surfaces, the anterior and posterior ends (poles), and the gate are distinguished.

Bundles:

gastro-splenic–From the greater curvature of the stomach to the hilum of the spleen (contains the left gastroepiploic vessels and short gastric arteries and veins);

splenic-renal–From the lumbar part of the diaphragm of the iliac kidney to the hilum of the spleen (contains the splenic vessels).

Holotopy:left hypochondrium.

Skeletotopy:between IX and XI ribs from paravertebral line to mid axillary line.

Attitude to the peritoneum:intraperitoneal organ. Blood supplyprovided by the splenic artery

from the celiac trunk. The splenic vein has a diameter 2 times larger than the artery, and is located below it.

Innervationcarry out celiac, left diaphragmatic, left adrenal nerve plexuses. Branches arising from these sources form a splenic plexus around the artery of the same name.

Lymphatic drainageoccurs in the regional lymph nodes of the first order, located at the gate of the spleen. Second-order nodes are celiac lymph nodes.

Along the edge of the costal arch:

l courvoisier-Kocher access -from the top of the xiphoid

th process two fingers below the costal arch and parallel to it (access to the gallbladder);

l fedorov's access -from the xiphoid process along the white line for 5 cm, turning into an oblique incision parallel to the right costal arch (access to the gallbladder and the visceral surface of the liver);

l access Rio Branco -consists of two parts: the vertical part is drawn along the white line, not reaching two transverse fingers to the navel, and the oblique is twisted at an angle and goes to the end of the X rib (wide access to the liver).

Longitudinal sections:

l upper midline laparotomy(access to the left lobep).

Combined incisions- opening of the pleural and abdominal cavities simultaneously:

l access Quino -an incision along the eighth intercostal space from the lower angle of the right scapula to the navel.

o Cross sections.

Methods for stopping bleeding from parenchymal organs are divided into the following groups:

mechanical (hemostatic sutures); physical (electrocoagulation, laser radiation);

chemical (Ca preparations, alpha-aminocaproic acid);

biological (blood products, hemostatic sponge, fibrin film, tamponade with an omentum).

In order to temporarily stop bleeding in case of liver damage, digital clamping of the hepato-duodenal ligament, together with the vessels in it, can be performed for 10-12 minutes.

For final stop bleeding in liver surgery, various methods of hemostatic suture have been proposed (MM Kuznetsov, Yu.S. Pensky, Giordano, Varlamov, etc.), the improvement of which is being carried out to this day. All methods are based on one principle: squeeze the edges of the bleeding wound and ligate large vessels. The imposition of a linear suture on a liver wound is possible only with small marginal lesions.

In order to avoid suture eruption, in some cases fascia plates, sickle ligament, synthetic tapes are used, which are applied along the perimeter of the wound, and then stitched together with the liver tissue. To seal the liver wounds, the omentum is sutured or the liver culture is covered with a sickle ligament flap (sometimes they achieve

sealing the seams of a linear wound of the liver with an additional layer of cyanoacrylate glue).

Liver resection:

1. Atypical resection - removal of a part of an organ within healthy tissues without taking into account internal structure.

Kinds:

wedge resection -is performed at the edge of the liver or on its diaphragmatic surface outside the projection site of the main vascular-secretory legs;

marginal resection -it is used for the marginal location of a pathological formation;

planar resection -it is used when the pathological formation is located on the diaphragmatic surface of the liver;

transverse resection -carry out in the lateral parts of the left half of the liver.

Atypical resections are economical, in terms of the amount of healthy tissue removed, are simple and quick to perform, but are accompanied by dangerous bleeding, possible necrosis due to vascular ligation and bile ductsremaining healthy segments, an opportunity air embolism through gaping stumps of transected hepatic veins.

In atypical resections, the main point is the suture of the liver, which is applied parallel to the incision of the liver, retreating 1 cm away from the part to be removed (with preliminary application of hemostatic sutures or after resection).

2. Anatomical (typical) resection -Produced by taking into account the internal structure of the organ along the lines of low-vascular spaces.

Kinds:

right-sided or left-sided hemihepatecto-

mia -resection of the right or left liver halves; lobectomy–Resection of the liver lobe; segmentectomy -resection of the liver segment.

Highlights of anatomical liver resection:

1) isolation and ligation of the elements of the glisson stem of the removed part of the liver;

2) ligation of the hepatic veins in the caval gate;

3) dissection of the liver along the interlobar gap;

4) covering the wound surface.

Over 30 surgical approaches have been proposed to expose the liver, gallbladder and bile ducts. These approaches can be divided into three groups: anterior, posterior, and superior.

The anterior approaches are the most numerous; they can be divided into oblique, vertical and angular

To oblique incisions of the anterior abdominal wall include the following: the Kocher, S.P. Fedorov, Pribram, Sprengel, and others sections. The Kocher and S.P. to the gallbladder, bile ducts and the lower surface of the liver.

Kocher cut start from the midline and carry out 3-4 cm below and parallel to the costal arch; its length is 15-20 cm.

Section according to S.P. Fedorov start from the xiphoid process and carry out first downward along the midline for 3-4 cm, and then parallel to the right costal arch; its length is 15-20 cm.

To vertical incisions of the anterior abdominal wall include: upper median, pararectal and transrectal.

Of this subgroup, the most commonly used is a midline incision made between the xiphoid process and the navel. If this access is insufficient, it can be widened by making an additional right transverse incision.

Lawson Tate's pararectal incisionand transrectal incision by O.E. Hagen-Thorn rarely used, although some clinics give them preference (V.A. Zhmur).

Corner and wavy cuts - Rio Branco, Cherni, VR Braitseva, Mayo-Robson, A. M. Kalinovskiy, etc. - give free access to the bile ducts and liver and are widely used.

Of this subgroup of cuts, rio Branco cut, which is carried out along the median line from the xiphoid process down and, not reaching two transverse fingers to the navel, turn right and up to the end of the X rib.

Wide exposure of the liver provides thoracoabdominal approaches F.G. Uglov, Kirchner, Brunschwig, Raiferscheid, etc.

Posterior (lumbar) approaches by A.T.Bogaevsky, N.P. Trinkler are used mainly for lesions, cysts or abscesses of the posterior surface of the liver.

Upper approaches: extrapleural A. V. Melnikov and transpleural Volkman-Israelused to expose the upper-posterior part of the diaphragmatic surface of the liver. These accesses are used for operations for abscesses, cysts and damaged liver.

Surgical access to the liver

1. Along the edge of the costal arch:

* Courvoisier-Kocher access - from the apex of the xiphoid process two fingers below the costal arch and parallel to it (access to the gallbladder);

* Fedorov's access - from the xiphoid process along the white line for 5 cm, turning into an oblique incision parallel to the right costal arch (access to the gallbladder and the visceral surface of the liver);

* Rio Branco access - consists of two parts: the vertical part is drawn along the white line, not reaching two transverse fingers to the navel, and the oblique is wrapped at an angle and goes to the end of the X rib (wide access to the liver).

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Operational accesses.For surgical interventions on the gallbladder and bile duct, longitudinal, oblique or combined incisions are used (Figure 6). Upper median lalarotomy is widely used. It creates sufficient access to the gallbladder and formations located in the thickness of the hepatoduodenal ligament. This incision is successfully used in any operation performed on the biliary system, in all patients with asthenic and normasthenic constitution.

Figure 6. Online accesses:
a - section along Brunschwig - Tom That Tungu; b - section along the Rio Branco; c - arcuate section; d - section along the joint venture. Fedorov; e - section along S.P. Fedorov, continued to the left; f - Longmeier-Prikel section, g - Sprengel section; h - section according to B.V. Petrovsky — E. A. Pochechuev

Starting from the costal arch, a right-sided 10-12 cm long pararectal incision also makes it possible to perform operations on the gallbladder and bile ducts, especially in obese men. The best access to the biliary tract and the ability to perform any surgical intervention give oblique incisions according to Kocher, De Ruben, Braitsev and a combined incision according to Fedorov. In addition to operations, they create an opportunity for drainage abdominal... It is considered appropriate to use these cuts when acute diseases biliary tract, especially in those cases when pronounced infiltrative inflammatory changes are expected, when the diagnosis is not clear, when the physique is hypersthenic, etc. When using an oblique incision, there is no need to cut the tissue near the costal arch, bleeding from the wound decreases, etc. The incision starts at the midline, then crosses the right rectus and external obliques. Used in some cases, small incisions, in which only part of the rectus muscle or do not cross it at all, cannot provide sufficient access to the biliary tract.

For repeated and reconstructive operations, the incision is usually made in the direction of the scar. There are exceptions and cases when an atypical incision was made during the primary operation or when in the area postoperative scar there is a purulent wound or fistula. After opening the abdominal cavity, further steps are aimed at creating access to the biliary tract, dissecting the adhesions that exist in the area of \u200b\u200bthe bottom of the gallbladder between the surrounding tissues and organs.

Before removal of the gallbladder, it is necessary to expose the anterior wall of the hepaticoholedochus by a cross-section of the peritoneum of this area. If it is necessary to perform manipulations on the bile ducts and OBD, it is necessary to mobilize the duodenum. Palpation of the bile ducts and revision with a probe are performed before using special research methods (cholangiomanometry, debitometry, cholangiography). If it is necessary to perform repeated and reconstructive operations to create access to the hepatoduodenal ligament, the upper surface of the liver is first isolated, separating the adhesions and adhesions between it and the diaphragm, and then the organs fused to its lower surface are separated.

Cholecystostomy. This operation, as a rule, is not particularly difficult. It is produced by laparotomic access. In order to avoid damage to the vessels of the GB bed, it is emptied by puncture. A small incision is made at the bottom of the gallbladder and a rubber catheter with lateral holes is inserted into the gallbladder lumen through it. The Petzer catheter is considered more convenient, which, after insertion into the gallbladder, is fixed with a catgut ligature. Around the catheter, two purse-string sutures are placed to fix the gallbladder to the parietal peritoneum. The cholecystostomy catheter is brought out with an additional incision in the abdominal wall (Figure 7). If it is impossible and difficult to hem the GB to the abdominal wall, cholecystostomy is applied “at a distance”. An incision in the wall of the gallbladder with two purse string sutures is fixed around the catheter. The latter is removed by a separate incision and fixed to the abdominal wall with several sutures.

Figure 7. Cholecystostomy technique:
a - puncture of the gallbladder; b, c - the imposition of a purse-string suture and the introduction of drainage; d - suturing the gallbladder to the parietal peritoneum and aponeurosis

IN last years began to perform laparoscopic cholecystostomy, which is performed under local anesthesia during laparoscopy. Using a puncture, the gallbladder is emptied and its bottom is removed through a small incision in the abdominal wall. The gallbladder is drained with a thin catheter and fixed to the skin with several sutures.

Cholecystectomy. The operation is usually performed after puncture and removal of its contents. This facilitates the differentiation and isolation of the anatomical elements of the gallbladder neck region. The adhesions between the gallbladder and adjacent organs, the peritoneum passing from the gallbladder to the hepatoduodenal ligament are dissected, and the RA and artery are isolated. They can be crossed only in conditions of good visibility of the gallbladder and the walls of the hepaticocholedochus. PA is ligated twice and crossed, leaving a stump no more than 3-4 mm long. If necessary, a canal or a plastic tube for cholangiography is inserted into the stump of the PN. The gallbladder is removed from the cervix. Bleeding from the bed is stopped by electrocoagulation of blood vessels, U-shaped interrupted sutures or a continuous suture. To avoid damage to the intrahepatic bile ducts, the liver tissue is not pierced deeply. After operating cholangiography, the cannula or tube is removed from the PN. The latter is tied up twice, one of the seams is stitched (Figure 8) [S.L. Kasumyan, OD. Barchuk, 1999].

Figure 8. Technique of cholecystectomy:
a, b, c - stages of bubble separation; d, e - removal of the gallbladder and ligation of the cystic duct; e - peritonization of the bladder bed

If it is technically difficult or impossible to remove the GB from the neck, it is removed from the bottom. For this purpose, novocaine is introduced subserously, after which the peritoneum is dissected over the gallbladder, at a distance of 1.5-2 cm from the liver. The gallbladder is separated from the liver, the bleeding vessels are ligated or electrocoagulated. Approaching the gallbladder area, it is necessary to differentiate the cystic, hepatic and common bile ducts. With difficult orientation in these and other anatomical structures, the gallbladder is removed after opening it in the bottom area, emptying from bile, pus, and removing stones. Subsequent separation of the gallbladder is performed over the finger inserted into its cavity. It is considered more expedient and safe to remove the gallbladder "from the bottom".

Cholecystodigestion anastomoses. They are applied in case of tumor and cicatricial obstruction of the terminal section of the CBD. The feasibility of applying a cholepistodigestive anastomosis is determined according to the data of an intraoperative study. It is technically easier to apply cholecystogastrostomy or cholecystoduodenostomy. From a functional point of view, cholecystojejunostomy is considered preferable. For the latter, take the initial section of the TC, at a distance of 50-60 cm from the Treitz ligament and separate it at some distance. An interintestinal anastomosis 4-5 cm wide is applied 20 cm further from the FOOD, side to side. To exclude digestobiliary reflux, it is considered advisable to make an anastomosis with a U-shaped bowel loop (according to Roux), the BDA diameter is 3-4 cm.It is formed with two-story sutures, the outer floor is nodular, the inner floor is a continuous suture, thin chrome kettut.

Suproduodenal choledochotomy. To perform this operation, the anterior and right-sided walls of the hepaticoholedochus are separated. The place of opening of its lumen is chosen (usually in the middle part). The incision is made in the longitudinal direction. Its length can vary from 0.5 to 3 cm. The incision is continued to the upper-horizontal part of the duodenum. The lumen of the duct is opened and stones existing in it are removed. After performing diagnostic and therapeutic manipulations, the OC is sutured with interrupted sutures, without involving CO in the sutures. With thin and delicate walls of the duct, it is sutured with a continuous suture. As a rule, a one-story suture with chrome-plated catgut or synthetic threads on an atraumatic needle is used. Drainage of the choledochotomy area is considered mandatory (Figure 9).

Figure 9. The GB is removed, the GB is opened. a stone is visible in it (according to Keru)

External drainage of the bile ducts. It is carried out through the holldochotomy wound, a separate opening of the hepaticocholedochus, the stump of the PP or through the liver parenchyma (transhepatic route). For this purpose, a T-shaped drainage tube is often used. The latter does not interfere with the outflow of bile in a natural way, does not deform the CBD and is easily removed. Around the drainage, the duct wall is carefully sutured with interrupted or continuous sutures. Usually catgut or lavsan threads are used. The tightness of the sutures and the position of the drain are monitored using cholangiography and a pressurized fluid injected into the drain.

Choledochoduodenoanastomosis (CDA). Anastomosis is applied with an atraumatic needle. CDA formation begins from the back wall. After suturing the back wall by imposing 3-4 sutures strictly sequentially and alternately, sutures are applied to the right and left semicircles of the future anastomosis, gradually moving from the bottom up. Sutures are applied through all layers of the intestine and duct, so that they are located on the duodenal wall from outside to inside, and on the wall of the CBD from the inside out. The peculiarity of suturing with this technique is that the sutures are not tied immediately, but are taken on the holders, so that they simultaneously tie the crossed vessels. Sipping these seams, a longitudinal incision 3 cm long is made between them in the common bile duct, not reaching the intestinal wall. This intervention is performed after mobilization of the duodenum according to Kocher, without separating the retroduodenal part of the common bile duct. The OCV intersects at its lowest point. Completing diagnostic and therapeutic manipulations (probing of the OBD, removal of stones), the duodenum lumen is opened in the transverse direction with a small incision. The direction of the latter is actually a continuation of the cut of the common bile duct.

Lateral suproduodenal lateolateral CDA is more commonly used. This method is technically available and more effective, it provides immediate and long-term stable results. Multiple methods (Finsterer, Jurash, Flerken, etc.) of HDA are proposed. The purpose of all these options is to ensure the reliability of the sutures of the anastomosis area, to improve functional results. surgical intervention, prevent digesto-biliary reflux and, if possible, reduce the inevitable formation of a "blind bag" on the switched off part of the common bile duct (Figure 10). It is very important to correctly match the edges of the anastomosis and to exclude its deformation and narrowing [V.V. Vinogradov, 1977]. To ensure tightness, the suture area is additionally covered with the peritoneum of the hepatoduodenal ligament. To prevent the development of insufficiency of anastomosis sutures, MK-2 glue is used. In all cases, an important condition is the imposition of an anastomosis with a width of at least 3-4 cm, since in the first months it narrows. In addition, a fairly wide anastomosis prevents stagnation of bile and the development of cholangitis [V.N. Vecherko, 1995; SL. Dadwani et al, 1999; Rathke, 1995].

Figure 10. Methods of choledochoduodenostomy:
a - Finsterer; b - Flerken; c - Yurasha

Transduodenal sphincteroplasty. The introduction of the method of endoscopic papillosphincterotomy has changed the tactics and technique of operations on the biliary tract and papilla of Vater. However, this valuable and attractive method is available only to a narrow circle of specialists, is technically difficult and is not devoid of the risk of developing severe complications. Because of this circumstance, endoscopic papillosphincterotomy cannot yet serve as an alternative traditional methods surgical treatment with choledocholithiasis and narrowing of the terminal section of the common bile duct.

Percutaneous-transhepatic drainage of the biliary tract. In recent years, the method of percutaneous-transhepatic drainage and decompression of the biliary tract has been used in clinical practice in breast cancer. If necessary, endoprosthetics of the biliary tract is also performed. These operations are used as a palliative. Transhepatic drainage consists of three sequential steps:
1) cholangioscopy;
2) cholangiography;
3) external, external-internal or internal drainage.

Papillosphincterotomy.It is performed with cicatricial-sclerotic narrowing of the OBD to restore the normal outflow of bile. After mobilization of the duodenum, its large papilla is found and dissected over the probe head on the anterior wall. The length of the incision is on average 15-20 mm (Figure 11).

Figure 11. Papillosphincterotomy and papillosphincteroplasty:
a - choledochotomy, insertion of the probe into the AZhL; c - the anterior wall of the duodenum is dissected, above the large papilla; c - dissection top wall duodenal papilla; d - stitching of the mucous membrane of the CBD and duodenum

Without violating the integrity of the opening of the main pancreatic duct, papillosphincteroplasty is performed, with a thin atraumatic needle the mucous membrane of the common bile duct and duodenum is sutured along the length of the incision. The duodenotomic wound is sutured with two-storied sutures, the common bile duct is drained. Check the integrity of the posterior wall of the duodenum and the retroduodenal part of the common bile duct. In recent years, endoscopic papillosphincterotomy has been used. Indications for it are choledocholithiasis, accompanied by jaundice, an extremely high risk of surgery, stones driven into the papilla of the Vater, benign stenosis and restenosis (after primary surgery) OBD, CP, caused by narrowing of the outlet of the pancreatic duct, residual stones, narrowing of the CDA [V.S. Savelyev et al., 1985; E.I. Halperin et al, 1988; AL. Shestakov et al, 1999; Ahaulli, 1981].

Circular suture of the common bile duct. It is applied in case of accidental damage to the duct or after excision of the scar-narrowed section. Anastomosis is applied U-shaped and continuous sutures, carefully matching the CO of the duct. To prevent the tension of the stitched ends, the Kocher duodenum is mobilized.

Through the opening of the duct, a T-shaped or one-lumen drainage is introduced into its lumen, which serves as a frame for the formation of the anastomotic area. In case of damage or cicatricial obstruction of the proximal hepatic duct, a restorative (reconstructive) operation is performed. Hepaticojejunoanastomosis is used more often, hepaticoduodenoanastomosis is relatively rare.

Operation completion methods. After the completion of the operation, the abdominal cavity is sutured tightly or drained. The first method is considered acceptable for cholecystectomy for XX, as well as when a fistula is imposed on a non-inflamed gallbladder. For suturing tightly, a necessary condition is the complete absence of bleeding and bile leakage into the abdominal cavity. In all other cases, it is shown to drain the abdominal cavity with a silicone tube 0.6-0.8 cm in diameter. The drainage tube is brought to the winding hole at a shallow depth. The outer end is brought out through an additional incision into the right hypochondrium.

The need for tamponing of the abdominal cavity occurs rarely: with non-stopping capillary bleeding from the bed of the gallbladder, the outflow of bile, and, finally, after opening the paravesical abscesses. The tampons are brought out through the lower corner of the surgical wound.

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Removal of the gallbladder is considered one of the most common operations. It shown at gallstone disease, acute and chronic cholecystitis, polyps and neoplasms. The operation is performed with open access, minimally invasive and laparoscopic.

The gallbladder is an important digestive organ that serves as a reservoir of bile for the digestion of food. However, it often creates significant problems. Presence of stones inflammatory process provoke pain, discomfort in the hypochondrium, dyspepsia. Often, the pain syndrome is so pronounced that patients are ready to get rid of the bladder once and for all, just not to experience more torment.

In addition to subjective symptoms, damage to this organ can cause serious complications, in particular, peritonitis, cholangitis, biliary colic, jaundice, and then there is no choice - the operation is vital.

Below we will try to figure out when it is necessary to remove the gallbladder, how to prepare for the operation, what types of intervention are possible and how you should change your life after treatment.

When is surgery needed?

Regardless of the type of intervention planned, be it laparoscopy or abdominal removal of the gallbladder, testimony for surgical treatment are:

• Cholelithiasis.
• Sharp and chronic inflammation bubble.
• Cholesterosis with impaired biliary function.
• Polyposis.
• Some functional disorders.

cholelithiasis

Cholelithiasis is usually the main cause of most cholecystectomies. This is due to the fact that the presence of stones in gallbladder often causes attacks of biliary colic, which recurs in more than 70% of patients. In addition, calculi contribute to the development of other dangerous complications (perforation, peritonitis).

In some cases, the disease proceeds without acute symptoms, but with heaviness in the hypochondrium, dyspeptic disorders. These patients also need surgery, which is performed routinely, and its main purpose is to prevent complications.

Gallstones can be found in the ducts (choledocholithiasis), which is dangerous due to possible obstructive jaundice, inflammation of the ducts, pancreatitis. The operation is always complemented by drainage of the ducts.

The asymptomatic course of gallstone disease does not exclude the possibility of surgery, which becomes necessary with the development hemolytic anemiawhen the size of the stones exceeds 2.5-3 cm due to the possibility of pressure ulcers, with a high risk of complications in young patients.

Cholecystitis

Cholecystitis - This is an inflammation of the wall of the gallbladder, acute or chronic, with relapses and improvements, replacing each other. Acute cholecystitis with stones is the reason for urgent surgery. The chronic course of the disease allows it to be carried out as planned, possibly laparoscopically.

Cholesterosis It is asymptomatic for a long time and can be detected by chance, and it becomes an indication for cholecystectomy when it causes symptoms of damage to the gallbladder and a violation of its function (pain, jaundice, dyspepsia). In the presence of stones, even asymptomatic cholesterosis is the reason for the removal of the organ. If calcification has occurred in the gallbladder, when calcium salts are deposited in the wall, then the operation is performed without fail.

The presence of polyps is fraught with malignancy, therefore, removal of the gallbladder with polyps is necessary if they exceed 10 mm, have a thin leg, and are combined with gallstone disease.

Functional disorders bile excretion is usually the reason for conservative treatment, but abroad, such patients are still operated on due to pain syndrome, a decrease in the release of bile into the intestines and dyspeptic disorders.

There are contraindications to the operation of cholecystectomy, which can be general and local. Of course, if necessary urgent surgical treatment due to the threat to the patient's life, some of them are considered relative, since the benefits of treatment are disproportionately higher than the possible risks.

TO general contraindications include terminal conditions, severe decompensated pathology internal organs, metabolic disorders that can complicate the operation, but the surgeon will "close his eyes" to them if the patient needs to save his life.

General contraindications for laparoscopy consider diseases of internal organs in the stage of decompensation, peritonitis, long-term pregnancy, pathology of hemostasis.

Local restrictions are relative, and the possibility of laparoscopic surgery is determined by the experience and qualifications of the doctor, the availability of appropriate equipment, the willingness of not only the surgeon, but also the patient to take a certain risk. These include adhesions, calcification of the gallbladder wall, acute cholecystitis, if more than three days have passed since the onset of the disease, pregnancy in the I and III trimester, large hernias. If it is impossible to continue the operation laparoscopically, the doctor will have to switch to abdominal intervention.

Types and features of operations to remove the gallbladder

Surgery to remove the gallbladder can be carried out both in a classical, open way, and with the involvement of minimally invasive techniques (laparoscopically, from a mini-access). The choice of method determines the patient's condition, the nature of the pathology, the doctor's discretion and equipment medical institution... All interventions require general anesthesia.

left: laparoscopic cholecystectomy, right: open surgery

Open operation

Abdominal removal of the gallbladder involves a midline laparotomy (access along the midline of the abdomen) or oblique incisions under the costal arch. At the same time, the surgeon has good access to the gallbladder and ducts, the ability to examine, measure, probe, and examine them using contrast agents.

Open surgery is indicated for acute inflammation with peritonitis, complex lesions of the biliary tract. Among the disadvantages of cholecystectomy by this method, one can indicate a large surgical trauma, poor cosmetic result, complications (disruption of the intestines and other internal organs).

Stroke open surgery includes:

1. Incision of the anterior abdominal wall, revision of the affected area;
2. Isolation and ligation (or clipping) of the cystic duct and the artery that supplies the gallbladder;
3. Separation and extraction of the bladder, treatment of the organ bed;
4. Imposition of drains (according to indications), suturing of an operating wound.

Laparoscopic cholecystectomy

Laparoscopic surgery is recognized as the "gold standard" of treatment for chronic cholecystitis and gallstone disease, and is the method of choice for acute inflammatory processes. The undoubted advantage of the method is considered a minor surgical trauma, a short recovery period, and a slight pain syndrome. Laparoscopy allows the patient to leave the hospital already 2-3 days after treatment and quickly return to their usual life.

The stages of laparoscopic surgery include:

• Punctures of the abdominal wall through which instruments are inserted (trocars, video camera, manipulators);
• Injection of carbon dioxide into the abdomen to provide visibility;
• Clipping and cutting off the cystic duct and artery;
• Removal of the gallbladder from the abdominal cavity, instruments and suturing of the holes.

The operation lasts no more than an hour, but it is possible even longer (up to 2 hours) with difficulties in accessing the affected area, anatomical features, etc. If there are stones in the gallbladder, then they are crushed into smaller fragments before the organ is removed. In some cases, upon completion of the operation, the surgeon installs a drainage into the subhepatic space to ensure the outflow of fluid that may form as a result of surgical trauma.

Video: laparoscopic cholecystectomy, the course of the operation

Mini-access cholecystectomy

It is clear that most patients would prefer laparoscopic surgery, but it may be contraindicated in a number of conditions. In such a situation, specialists resort to minimally invasive techniques. Mini-access cholecystectomy is a cross between abdominal surgery and laparoscopic.

The course of the intervention includes the same stages as for other types of cholecystectomy:formation of access, ligation and transection of the duct and artery, followed by removal of the bladder, and the difference is that for these manipulations, the doctor uses a small (3-7 cm) incision under the right costal arch.

stages of gallbladder removal

A minimal incision, on the one hand, is not accompanied by large trauma to the abdominal tissues, on the other hand, it provides a sufficient overview for the surgeon to assess the state of the organs. Such an operation is especially indicated for patients with a strong adhesive process, inflammatory tissue infiltration, when the introduction of carbon dioxide is difficult and, accordingly, laparoscopy is impossible.

After minimally invasive removal of the gallbladder, the patient spends 3-5 days in the hospital, that is, longer than after laparoscopy, but less than in the case of open surgery. The postoperative period is easier than after cavity cholecystectomy, and the patient returns home earlier to his usual business.

Each patient suffering from one or another disease of the gallbladder and ducts is most interested in how exactly the operation will be performed, wishing it to be the least traumatic. In this case, there can be no definite answer, because the choice depends on the nature of the disease and many other reasons. So, with peritonitis, acute inflammation and severe forms of pathology, the doctor will most likely have to go for the most traumatic open surgery. In the adhesive process, minimally invasive cholecystectomy is preferable, and if there are no contraindications to laparoscopy, laparoscopic technique, respectively.

Preoperative preparation

For best result treatment, it is important to conduct adequate preoperative preparation and examination of the patient.

For this purpose, carry out:

1. General and biochemical analyzes blood, urine, tests for syphilis, hepatitis B and C;
2. Coagulogram;
3. Clarification of blood group and Rh factor;
4. Ultrasound of the gallbladder, biliary tract, abdominal organs;
5. Radiography (fluorography) of the lungs;
6. According to indications - fibrogastroscopy, colonoscopy.

Some patients need consultation of narrow specialists (gastroenterologist, cardiologist, endocrinologist), all - a therapist. To clarify the state of the biliary tract, additional studies are carried out using ultrasound and radiopaque techniques. Severe pathology of internal organs should be maximally compensated, pressure should be brought back to normal, and blood sugar levels should be monitored in diabetics.

Preparation for surgery from the moment of hospitalization includes a light meal the day before, a complete refusal of food and water from 6-7 pm before the operation, and in the evening and in the morning before the intervention, the patient is given a cleansing enema. In the morning, take a shower and change into clean clothes.

If it is necessary to perform an urgent operation, the time for examinations and preparation is much less, therefore the doctor is forced to limit himself to general clinical examinations, ultrasound, allotting no more than two hours for all procedures.

After operation…

The time spent in the hospital depends on the type of surgery performed. With open cholecystectomy, the stitches are removed after about a week, and the hospital stay is about two weeks. In the case of laparoscopy, the patient is discharged after 2-4 days. The ability to work is restored in the first case within one to two months, in the second - up to 20 days after the operation. Sick leave issued for the entire period of hospitalization and three days after discharge, then - at the discretion of the doctor of the polyclinic.

The next day after the operation, the drainage is removed, if one was installed. This procedure is painless. Before removing the stitches, they are treated daily with antiseptic solutions.

The first 4-6 hours after removal of the bladder, you should refrain from eating and drinking, not getting out of bed. After this time, you can try to get up, but carefully, as dizziness and fainting are possible after anesthesia.

Pain after surgery can be experienced by almost every patient, but the intensity varies with different treatment approaches. Of course, one cannot expect painless healing of a large wound after open surgery, and pain in this situation is a natural component of the postoperative state. To eliminate it, analgesics are prescribed. After laparoscopic cholecystectomy, pain is less and quite tolerable, and most patients do not need pain relievers.

The day after the operation, it is allowed to get up, walk around the ward, take food and water.Of particular importance is the diet after removal of the gallbladder. In the first few days, you can eat porridge, light soups, dairy products, bananas, vegetable purees, lean boiled meat. Coffee, strong tea, alcohol, confectionery, fried and spicy foods are strictly prohibited.

Since after cholecystectomy, the patient loses important bodyaccumulating and releasing bile in a timely manner, he will have to adapt to the changed conditions of digestion. The diet after removal of the gallbladder corresponds to the table number 5 (liver). You can not eat fried and fatty foods, smoked meats and many spices that require increased secretion of digestive secretions, canned food, pickles, eggs, alcohol, coffee, sweets, fatty creams and butter are prohibited.

First month after surgery you need to adhere to 5-6 meals a day, taking food in small portions, you need to drink up to one and a half liters of water a day. It is allowed to eat white bread, boiled meat and fish, cereals, jelly, dairy products, stewed or steamed vegetables.

In general, life after removal of the gallbladder does not have significant restrictions; 2-3 weeks after treatment, you can return to your usual way of life and work. The diet is shown in the first month, then the diet is gradually expanded. In principle, it will be possible to eat everything, but you should not get carried away with foods that require increased bile secretion (fatty, fried foods).

In the first month after the operation, it will be necessary to somewhat limit physical activity, not to lift more than 2-3 kg and not perform exercises that require tension of the abdominal muscles. During this period, a scar is formed, with which the restrictions are associated.

Video: rehabilitation after cholecystectomy

Possible complications

Usually, cholecystectomy proceeds quite well, but some complications are still possible, especially in elderly patients, in the presence of severe concomitant pathology, with complex forms of biliary tract damage.

Among the consequences are:

• Suppuration of the postoperative suture;
• Bleeding and abscesses in the abdomen (very rare);
• Bile flow;
• Damage to the bile ducts during surgery;
• Allergic reactions;
• Thromboembolic complications;
• Exacerbation of other chronic pathology.

An adhesion process often becomes a possible consequence of open interventions, especially with common forms of inflammation, acute cholecystitis and cholangitis.