retrograde 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. Treatment of diseases: acute cholecystitis Indication When there are: 1 acute cholecystitis due to high hyperemia and edema in the neck; 2 repeated acute exacerbation of chronic cholecystitis to form a dense fibrous adhesion; 3 atrophic cholecystitis makes the Calot triangle anatomical relationship unclear; 4 gallbladder neck has huge stones Incarceration makes the cystic duct obstruction, even if the stone is incarcerated between the gallbladder neck and the common bile duct, so that the disappearance of the cystic duct can not distinguish the exact relationship between the cystic duct and the common bile duct, it is difficult to perform the gallbladder artery and cystic duct according to the antegrade method. The treatment, from a safety point of view, to avoid accidental injury, can be retrograde cholecystectomy, that is, anatomy from the bottom of the gallbladder. Contraindications 1. Chronic pain in the right upper abdomen cannot be explained by gallbladder lesions. Gallbladder abnormalities were not found in B-ultrasound and gallbladder angiography. 2. The cause of obstructive jaundice should not be blindly removed before the gallbladder is clear. 3. Serious heart, liver, kidney, pulmonary 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. Hold the bottom of the gallbladder with a non-invasive forceps to pull and lift the bottom of the gallbladder. The gallbladder serosa is cut 1 cm from the liver. 2. Free gallbladder from the bottom of the gallbladder to the neck of the gallbladder. The loose tissue between the hepatic bed and the gallbladder can be cut with scissors or electrocautery. In case of larger blood vessels, the ligation should be clamped. 3. Before deciding to perform retrograde resection, if the gallbladder has adhesion to the surrounding tissue, all adhesions should be separated first. When the gallbladder tension is too high, the decompression should be performed first to facilitate the operation. When free to the neck of the gallbladder, gently pull down, look for the gallbladder artery above it, confirm that the artery is going to the gallbladder, close to the gallbladder wall and cut between the two vascular clamps. Sometimes due to adhesions or tissue congestion and edema, it is difficult to clearly show the gallbladder artery. The surgeon can use the left hand indicator to place behind the mesentery between the liver and the gallbladder neck. In front of it, use a hemostat to hold the left hand finger and pass it, close to the gallbladder wall. The mesangial tissue is clamped and cut, and the proximal tissue is double ligated or sewed. 4. After the gallbladder artery is ligated and cut, carefully dissected in the gap between the cystic duct and the right side of the common hepatic duct to expose the junction of the cystic duct and the common bile duct, clamp 0.5 cm from the common bile duct and cut the cystic duct. After the ends are ligated, they are sewn together. After the cholecystectomy, the residual hepatic serosa was sutured intermittently. The advantage of retrograde cholecystectomy is that it can reduce the iatrogenic bile duct injury in cases where the anatomical relationship of the gallbladder triangle is unclear due to inflammatory edema, and the operation should be gentle. Small stones with multiple gallbladder may cause small stones in the gallbladder to enter the common bile duct due to the squeeze in operation. Therefore, the common bile duct should be carefully examined after cholecystectomy. If there are stones in the common bile duct, the common bile duct should be explored. complication 1. Incision or subhepatic infection is often caused by poor drainage or intraoperative contamination. In the operation, the bile is aspirated as much as possible before the gallbladder is cut, and the surrounding tissue is contaminated as little as possible after the incision. 2. Post-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 is due to the gallbladder lower hepatic duct opening in the posterior wall of the gallbladder or the cystic duct mouth 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.