antegrade cholecystectomy

Cholecystectomy is the most common procedure in biliary surgery. In most cases, the procedure is more standardized and the long-term effect after surgery is satisfactory. However, due to the characteristics of the local anatomical structure and the possibility of variability or complex lesions, the operation itself has certain risks. Every clinically, the serious consequences of the operation due to surgical errors can be ignored, so the details of all aspects of cholecystectomy should not be ignored. Curing disease: Indication An antegrade cholecystectomy is a cholecystectomy that begins with the cystic duct. Applicable to the gallbladder inflammation is not heavy, gallbladder neck and Calot triangle without obvious inflammation and edema, local anatomy clear. The advantage is that the gallbladder artery is treated first, and there is less bleeding during the separation and removal of the gallbladder. Contraindications 1, can not be treated with gallbladder lesions in the right upper abdomen chronic pain, B-ultrasound and gallbladder angiography found no gallbladder abnormalities. 2, the cause of obstructive jaundice should not be blindly removed before the gallbladder. 3, severe heart, liver, kidney, lung insufficiency or other serious medical diseases can not tolerate gallbladder resection. Preoperative preparation 1. Ask your medical history in detail. 2. A comprehensive system of physical examination. 3. Laboratory tests, in addition to routine items, should have serum bilirubin, alanine, aspartate aminotransferase (GPT, GOT), alkaline phosphatase, plasma protein, prothrombin time and activity before and after application of vitamin K11 , HBsAg, alpha-fetoprotein (AFP), serum potassium, sodium, chlorine, creatinine, urea nitrogen, blood glucose and other items. 4. Evaluation of important organ functions such as heart, lung, liver and kidney. 5. Re-examine all kinds of imaging diagnostic data to determine the location, nature and extent of the lesion, and provide a basis for the design of the surgical plan. 6. Application of prophylactic antibiotics. Under the following circumstances, antibiotics should be given before surgery; 1 emergency biliary surgery; 2 elderly patients; 3 severe obstructive jaundice; 4 intraoperative exploration of biliary tract; 5 biliary malignant tumors; 6 with other infectious diseases or diabetes . In his study, Kasholm confirmed that postoperative prophylactic antibiotics were 8.4% and 33%, respectively, after acute surgery for benign biliary tract disease, and prophylactic antibiotics in elective surgery cases. There was no significant difference in post-infection rate; however, he pointed out that with age, especially in those over 75 years old, the positive rate of bile bacterial culture was significantly increased. Therefore, in all emergency surgery, patients with acute cholecystitis, pancreatitis or history of jaundice and patients over the age of 75, prophylactic antibiotics should be given in both emergency and elective surgery. 7. Preoperative preparation for biliary surgery with concomitant disease (1) Biliary disease with liver dysfunction: The liver function of the patient should be analyzed and evaluated before operation. The reliable indicators for measuring liver damage are: plasma protein, serum aminotransferase, prothrombin time and activity, Serum bilirubin, with or without ascites. At present, the safest preoperative minimum indicators are: plasma albumin protein is not less than 35g / L (3.5g%), prothrombin activity is not less than 60%; serum bilirubin is 170mol / L (10mg%) Below; no ascites or only a small amount of ascites. The preoperative preparation points of this type of patients are: high protein and high carbohydrate diet; albumin or plasma in patients with hypoproteinemia; intravenous nutritional support for those who cannot eat for a long time; patients with ascites limit water and sodium intake, Intermittent administration of diuretics, abnormal blood coagulation function before the administration of vitamin K11, or intermittent input of fresh blood or multivalent coagulation factors; Huangqi special deep short-term PTCD or nasal bile duct drainage. (2) Preoperative preparation of biliary tract with cirrhosis: Cirrhosis increases the risk of biliary surgery. Special attention should be paid to the evaluation of liver reserve function and compensatory capacity before surgery, including the nutritional status of patients; liver function status (special Is the original time and activity of prothrombin); with or without esophageal varices, ascites, etc., clinical experience shows that the presence or absence of cirrhosis and severity, directly affect the effect of biliary surgery. Aranha noted that cholecystectomy with cirrhosis is 10 times more likely than cholecystectomy without cirrhosis. Glenn reported that the mortality rate of elective cholecystectomy was 0.3% to 1%, and the mortality rate of biliary tract surgery with cirrhosis was as high as 7% to 26%. Most of the causes of death are bleeding, liver failure, infection and multiple organ failure. Preoperative preparation work focuses on strict control of surgical indications, and should avoid acute biliary surgery as much as possible. For cases requiring emergency surgery, gallbladder incision or partial removal of the gallbladder may be used to preserve the posterior wall of the gallbladder or to perform gallbladder ostomy. These assumptions should be set before surgery to avoid excessive surgery during surgery. , bringing trouble after surgery. In patients with obvious cirrhosis or even portal hypertension who must do elective biliary surgery, a large amount of fresh blood should be given before surgery and vitamin K11 should be given in advance; patients with low plasma protein should be given albumin and fresh plasma; Patients should receive platelets. Of course, preventive antibiotics are indispensable. Preoperative preparations should be adequately prepared for the difficulties that may be encountered during surgery. Avoid extensive anatomy as much as possible to avoid damage to the varicose veins around the biliary tract. The puncture and incision of the bile duct should avoid the varicose veins. Before the bile duct is cut, hemostasis should be sutured on both sides of the incision. Some people advocate cirrhosis patients with severe portal hypertension and severe portal hypertension. If the biliary surgery is complicated, it should be staged surgery, that is, the first door shunt should be used to create conditions for future radical biliary surgery. However, patients with obstructive jaundice encountered in actual work are often not allowed to do the fenestration before the biliary drainage. For example, waiting for the biliary tract surgery after the shunt, not only the long treatment time but also the multiple liver function will be Seriously hit. Therefore, Schwartz pointed out that patients with good general condition, liver function, no gastrointestinal bleeding, no acute biliary tract infection and jaundice are not very serious, and advocate a first-stage operation. However, clinical experience shows that the mortality rate of patients with cirrhotic biliary tract surgery is significantly higher than that of patients without portal hypertension. The incidence of hemorrhage, blood transfusion and postoperative complications in patients with cirrhosis is closely related to the Child classification of liver function. It is generally considered that Child A, B grade patients with obvious symptoms can consider surgery; Indications for surgery, such patients should undergo strict and adequate preoperative preparation to change the C grade to A or B and consider elective surgery. In principle, surgical treatment is not recommended for asymptomatic gallstones. (3) biliary tract surgery with hypertension: Before the operation, the diastolic blood pressure should be controlled below 110mmHg and then elective surgery. In the past, it was advocated that patients with hypertension should stop taking antihypertensive drugs one week before surgery. However, because anesthesia after stopping the drug or easy to induce hypertensive crisis during surgery often makes the treatment more difficult, the current consensus is to continue to use the drug until the preoperative, if it has been taken together Diuretics should be discontinued before surgery, and low potassium caused by diuresis may cause severe arrhythmia and decreased myocardial contractility. If the blood pressure of emergency biliary tract surgery is too high, in addition to sedatives (diazepam, droperidol, etc.), nitroglycerin (oral or intravenous) should be given before anesthesia, sodium nitroprusside can be given to patients with difficult blood pressure control, but the process of use Blood pressure and pulse changes should be closely monitored to avoid accidents. (4) biliary tract surgery with diabetes: anesthesia, surgical trauma and infection, etc., postoperative diabetes can be aggravated, blood sugar must be controlled before surgery. Generally considered to be uncomplicated diabetes, blood sugar levels should be controlled at about 8.33mmol / L. If there is kidney damage or occlusive vascular disease at the same time, especially in the elderly, the chance of complications will increase. The blood sugar of these patients should not be too low, otherwise the glucose perfusion of the tissue will be reduced, which may cause damage to vital organs. Insulin should be used as appropriate according to fasting blood glucose, postprandial blood glucose and urine sugar before surgery. When the fasting blood glucose is below 6.66 mmol/L, 10% glucose should be instilled to prevent hypoglycemia. Insulin should be used for blood glucose of 8.33 to 13.88 mmol/L, and the ratio of sugar to insulin should be 8:1 or 6:1; blood glucose of more than 13.88 mmol/L can be administered at 4:1. The amount of insulin varies from person to person, and should be adjusted according to the initial dosage of urine sugar, so that the urine sugar can be maintained at (+). Patients with diabetes mellitus have reduced systemic and local resistance, have a higher chance of surgical infection, and routinely give preventive antibiotics before surgery. Surgical procedure 1, elective cholecystectomy, first comprehensive exploration of the various organs in the abdominal cavity. Before the cholecystectomy, the left hand indicates the extension into the Winslow hole behind the hepatoduodenal ligament, and the thumb is placed in front of the common bile duct for diagnosis. It is known whether there is thickening or not. There is no stone in the tube. If stones are found, the gallbladder should be explored first. The general manager took the stone and confirmed that the distal end had no obstruction and then the cholecystectomy. 2. The roll with the large gauze pad and the appropriate length of the incision is exposed, and the colon, stomach, omentum, duodenum and small intestine are pushed open and covered with a large yarn pad. The first assistant inserts the left hand into the wound. The palm is pulled down to help reveal the hilar area. At the same time, the bottom of the gallbladder or the Hartmann bag is pulled down with an oval or non-invasive forceps to clearly reveal the hepatoduodenal ligament and Winslow hole. 3. Cut the common hepatic duct and the common peritoneum of the common bile duct along the black dotted line in the right edge of the hepatoduodenal ligament. 4, blunt dissection, see the common bile duct and then find the cystic duct, blunt separation along the sides of the cystic duct. In this process it is possible to tear the gallbladder artery and have a large amount of bleeding. At this time, you should not blindly clamp the left hand thumb and index finger to oppress the hepatic artery, temporarily stop bleeding, absorb the blood, and treat it under direct vision. After the cystic duct was fully exposed, it was first ligated with a medium-sized silk thread at 0 and 5 cm from the common bile duct but not cut. The gallbladder artery is isolated above the cystic duct. There are many variations of the gallbladder artery. It may be single or double. It can be long or short. It can pass in front of or behind the left and right hepatic ducts, the common hepatic duct or the common bile duct. Sometimes it may be as thick as a fine right hepatic artery. . Normally divided into two or two before entering the gallbladder with their respective starting points. Due to these variations of the gallbladder artery or the ectopic initiation of the right hepatic artery, the Calot triangle is only in the gallbladder neck. The gallbladder artery is divided into the gallbladder. In order to prevent the right hepatic artery from being mistaken for the gallbladder artery, attention should be paid to distinguish The direction of the artery, after confirming its entry into the gallbladder wall, clamps the gallbladder artery close to the wall of the gallbladder and the proximal end of the gallbladder artery should be double-ligated or sutured. Since the gallbladder artery is shorter than the cystic duct, the gallbladder artery should be treated first to avoid tearing the artery when it is pulled after cutting the cystic duct. 5. Further free the cystic duct to make it visible at the junction of the common bile duct and the common hepatic duct. Two vascular clamps are placed at 0 and 5 cm from the common bile duct (ie, the original ligature). After the severing, the proximal cystic duct is double-ligated or perforated. tie. 6. Cut the gallbladder serosa along the sides of the gallbladder 1 cm from the liver bed. 7. Free gallbladder from the neck of the gallbladder to the bottom of the gallbladder. Electrocautery can also be used with scissors. In the free process, the veins and pipes from the gallbladder to the liver parenchyma should be cut and ligated. The gallbladder bed can be sutured intermittently with a thin thread, and it can be sutured without suturing. 8. Flush the surgical field, and dispose of the smoke in the Wen's hole. Suture the incisions in each layer of the abdominal wall. complication 1. Incision or subhepatic infection is often caused by poor drainage or intraoperative contamination. During the operation, the bile is aspirated as much as possible before the gallbladder is cut. After cutting, the surrounding tissue is contaminated as little as possible. 2, postoperative cholecystectomy syndrome occurs in patients with a long remaining cystic duct, especially when there are stones left in the stump of the cystic duct. 3. After partial resection of the gallbladder, intestinal obstruction may occur due to adhesion of the small intestine to the residual gallbladder wall. Its prevention method can cover the omentum on the residual gallbladder wall. 4, bile leakage due to gallbladder lower hepatic duct opening in the gallbladder posterior wall or cystic duct mouth closure is not strict, resulting in bile accumulation, a small amount can be drained, a large number of bile leakage can cause biliary peritonitis, surgical drainage.