Contraindications for elective laparoscopic cholecystectomy are. Indications and contraindications for laparoscopic cholecystectomy. Gallstone disease with "minor" symptoms
Inna Lavrenko
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The gallbladder, which forms the biliary system with the liver, is an important organ of our digestion. He is responsible for the accumulation of bile produced by the liver, bringing it to the desired concentration and supplying this hepatic secretion to the intestine when food enters it. Bile breaks down heavy fats, has an antibacterial effect and stimulates the secretion of the pancreas.
Stones in the gallbladder
Alas, like other internal organs, the gallbladder is subject to various diseases, some of which are treated only by surgery, which consists in removing the entire organ.
This operation is called a cholecystectomy. It is performed both in the traditional cavity method and with the help of laparoscopy (removal of the organ through small centimeter punctures in the abdominal wall).
The first technique is used in emergency cases and when laparoscopic intervention is contraindicated for any reason. Elective surgeries are usually performed by the laparoscopic method, since it is less traumatic and minimizes the risk postoperative complications, and the period of rehabilitation after such an operation is much shorter than after abdominal intervention. What are the indications for the removal of the gallbladder - the topic of our article.
Indications for cholecystectomy surgery:
- cholelithiasis (the presence of stones in the cavity of the bladder that cannot be removed naturally);
- choledocholithiasis (stones in the bile ducts);
- acute cholecystitis (inflammation of the walls of this organ);
- chronic calculous cholecystitis;
- pancreatitis (inflammation of the pancreas);
- other pathologies that are fraught with the occurrence of serious complications.
The most common reason for cholecystectomy is cholelithiasis. The essence of this pathology is the formation of stones (calculi) in the bladder cavity, the material for which is the so-called biliary sludge (a suspension consisting of precipitated crystals of cholesterol or bile pigment (bilirubin) with an admixture of calcium salts).
The main danger of the growth of such stones is that they are able to migrate into the bile ducts, blocking them. If the lumen of the duct is completely blocked, an immediate operation is necessary. If the stones are large or there are many, a planned cholecystectomy is also recommended, the purpose of which is to prevent possible serious complications.
Gallstone disease (GSD) - description and signs
At an early stage of stone formation, this pathology may not manifest itself for a long time and not bother the patient. This makes it difficult to diagnose and often stones in the bladder are found by chance, during an ultrasound of the abdominal cavity for completely different indications.
At a late stage of its development, cholelithiasis is manifested by pain in the right hypochondrium, heaviness in the abdomen, bitterness in the mouth, nausea, and stool disorders. The intensity of the pain syndrome can increase after eating fatty foods, with increased physical activity and as a result of stress.
As a rule, against the background of cholelithiasis occurs inflammatory process(cholecystitis), which adds to the already listed symptoms high temperature, chills and fever.
The most serious consequence of the development of cholelithiasis is the migration of the stone into the bile duct and its blockage. In this case, there is a strong sharp pain, the outflow of bile is disturbed, the pressure inside the bladder increases. A painful attack can last up to several hours and be accompanied by vomiting, in the masses of which bile is present.
No less dangerous complications of gallstone disease against the background of cholecystitis are abscesses, tissue necrosis and perforation (violation of the integrity of the organ membrane), which leads to biliary peritonitis. Accurate diagnosis of cholelithiasis is impossible without instrumental examinations, the most popular of which is ultrasound. This diagnostic technique allows not only to detect gallstones, but also to determine their size, number and location.
To clarify the diagnosis in complex cases, the following diagnostic methods are additionally used:
- x-ray;
- intravenous cholecystocholangiography;
- MRI (magnetic resonance imaging);
- CT (computed tomography).
As a rule, with the early diagnosis of this pathology, if the size and number of calculi do not cause serious concern, and the patient does not complain about any negative symptoms, doctors begin drug treatment and take a wait-and-see attitude, constantly monitoring the course of the pathology. A prerequisite for such conservative treatment is the observance of a diet called "Treatment Table No. 5".
If the stones are of a cholesterol nature, and their size is small, then drugs based on urso- or chenodeoxycholic acid (Ursofalk, Henofalk) and some traditional medicine are prescribed to help dissolve the stones and then remove them naturally. However, such therapy is applicable only to cholesterol calculi and takes a long time (sometimes several years). In addition, this treatment does not eliminate the cause of stone formation, and the risk of relapse is very high.
Single stones of small size are crushed using ultrasound. This technique is called shock wave lithotripsy. It only applies to small cholesterol gallstones.
A laser is used to crush bilirubin and mixed (calcified) stones, however, this method also has limitations in size and localization of gallstones. If no conservative measures lead to the desired result, a surgical operation is prescribed.
The main indications for cholecystectomy in gallstone disease are:
Surgery to remove the gallbladder
Contraindications for laparoscopic gallbladder removal
Despite the fact that most of these operations are performed using a minimally invasive laparoscopic technique, this intervention has a number of contraindications. For example, laparoscopy cannot be performed if the patient has previously undergone any surgical operation on the abdominal organs.
It is also contraindicated to carry out such an operation when:
- the presence of pathologies of cardio-vascular system;
- respiratory diseases;
- with obstructive jaundice;
- in late pregnancy;
- in the presence of diffuse peritonitis;
- in the presence of malignant processes.
It is also forbidden to carry out surgical intervention for violations of blood clotting, with an atypical location of the internal organs of the abdominal cavity and if the patient has a pacemaker. If laparoscopy is contraindicated for the patient, and the operation is still necessary, they resort to traditional abdominal cholecystectomy.
In the absence of this organ, the body needs time to adapt to the new conditions of existence. Since there is nowhere for bile to accumulate, it constantly flows through the bile ducts into the intestines, irritating its mucous membranes. In addition, not reaching the desired concentration, hepatic bile does its job of breaking down food much worse. In this regard, the body needs help in the normalization of bile flow and the process of digestion.
The main thing to remember is that after cholecystectomy, it is imperative to follow diet No. 5.
Its basic principle is fractional nutrition (frequent (five to six times a day) meals of small portions of food at regular intervals. Food should be warm, not hot and not cold. You can cook in three ways - steaming, boiling and baking. From the diet it is necessary to exclude fried, spicy and fatty foods, canned food, smoked meats, pickles, marinades, sauces (ketchups and mayonnaises), spices and spices.
Laparoscopic gallbladder removal
Alcohol, carbonated drinks, all types of mushrooms and legumes, sour fruits and berries, vegetables with a high content of essential oils (garlic, radish, spinach, sorrel, etc.), fast food, sweets, muffins and other products harmful to the gastrointestinal tract. It is recommended to eat dietary meats (veal, rabbit, chicken, turkey), low-fat fish, cereals (in the form of cereals and soups), vegetables, sweet fruits and berries, vegetable oil, dried fruits and other healthy foods. From the sweet you can honey, marshmallow and fruit marmalade.
It is also necessary to limit physical exercise and do physical therapy. The combination of all these requirements and constant medical supervision will help you return to a full life.
The surgical procedure to remove the gallbladder (GB) is called cholecystectomy. According to statistics, the removal of the gallbladder is one of the most common types of surgical intervention. However, it has a number of limitations, it is prescribed only if there are serious reasons.
Contraindications for removal of the gallbladder are:
- pancreatitis in the acute stage;
- malignant formations;
- the last stages of pregnancy;
- cirrhosis of the liver;
- inflammatory processes in the peritoneum;
- inflammation of the gallbladder;
- adhesive formations;
- heart diseases;
- vascular disease;
- kidney damage;
- respiratory diseases;
- hernia of the wall of the peritoneum;
- stone formation in the gallbladder in people over the age of seventy (in the absence of symptoms).
Everyone is worried about what the removal of the gallbladder is fraught with, whether the way of life will change, what is the duration of recovery. When prescribing this procedure, the doctor will inform you about what threatens the removal of the gallbladder.
Experts testify: it is in men after the removal of the gallbladder that negative consequences are often noted. The postoperative stage involves adherence to dietary nutrition and lifestyle adjustments.
Men are less disciplined, so they often violate the doctor's recommendations, which provokes deterioration.
Causes of gallstone disease
The gallbladder is a small organ shaped like a sac. Its main function is the production of bile (an aggressive fluid necessary for normal digestion). Stagnant phenomena lead to the fact that the individual components of bile precipitate, from which they later form stones. There are several reasons for this:
- Eating disorders. Abuse of foods high in cholesterol, fatty or salty foods, prolonged use of highly mineralized water leads to metabolic disorders and the formation of stones in the bile ducts.
- Taking certain types of drugs, especially hormonal contraceptives, increases the risk of developing calculous (inflammation of the bladder with stone formation) cholecystitis.
- Sedentary lifestyle, obesity, adherence to low-calorie diets for a long time lead to digestive disorders and congestion in the biliary tract.
- Anatomical features the structure of the gallbladder (the presence of bends or kinks) prevents the normal output of bile and can also provoke calculous cholecystitis.
Before prescribing the removal of the gallbladder, an examination is carried out. Only according to its results, the specialist determines whether a particular patient needs a gallbladder, and whether an operation is needed to remove it.
Cholecystectomy, despite its widespread use in surgical practice, is not considered an ordinary procedure. The operation can provoke serious complications, up to a fatal outcome. Decisions about when gallbladder removal is indicated are individual.
Common reasons for gallbladder removal include:
- malfunction of the ZHP;
- blockage of the bile ducts;
- development of calcification;
- cholesterosis;
- perforation;
- extensive foci of inflammation in the gallbladder.
If these symptoms are identified, the specialist compares the need for cholecystectomy with the likely complications. The development of colitis is not uncommon after removal of the gallbladder, as is reactive hepatitis, dysbacteriosis.
Types of surgery
Operations to remove the gallbladder with the least consequences are: classic - abdominal resection of the gallbladder and minimally invasive - laparoscopic cholecystectomy. The technique is determined by the doctor on the basis of well-being and the course of chronic diseases.
With good performance, it is better when the gallbladder is removed laparoscopically, since it has a number of advantages over resection of the gallbladder by the abdominal method. Indications for surgery to remove the gallbladder is mainly gallstone disease, which is the most common lesion of the gallbladder.
If a person has symptoms such as colic under the right rib, bloating, bitterness in the mouth, and some others, the doctor can diagnose cholelithiasis after diagnosis.
The gallbladder is one of those organs that is considered important for the smooth functioning of the body, but not essential. Without a gallbladder, a person can live a long and happy life.
Despite the fact that he is responsible for the collection and normal outflow of bile. Bile is a substance necessary for the digestion of fats.
In the absence of a place of its accumulation (gall bladder), it is excreted through the bile ducts. In this case, they take on an additional load.
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Symptoms
Often, patients are concerned about where the produced bile goes after the removal of the gallbladder. In a healthy body, bile from the liver, acquiring the desired concentration, enters the gallbladder, then into duodenum.
After excision of the gallbladder, the liver and duodenum participate in the process of bile excretion, where bile enters after removal of the gallbladder. The bile becomes less concentrated and only processes small amounts of incoming food. Therefore, when removing the gallbladder, you must adhere to the principles of fractional nutrition.
Many after cholecystectomy note increased gas formation, a feeling of fullness, bloating, loose stools. In addition to the pain associated with it, such symptoms cause suffering to a person. Therefore, everyone should know what to do if they constantly puff up and bouts of bloating occur after gallbladder surgery.
Specialists note cases when the removal of the gallbladder does not solve the problem with the outflow of bile, sometimes this procedure only worsens the situation. Removal of the gallbladder can provoke an exacerbation of chronic diseases.
Ways to treat gallstone disease
Antibiotics are indicated to prevent deterioration after removal of the gallbladder. When pain occurs, the doctor prescribes analgesics, then antispasmodic drugs. This therapy is carried out while the patient is in hospital.
After discharge, drugs with ursodeoxycholic acid are prescribed to prevent the appearance of stones. In some cases, taking such drugs lasts up to 2 years. After removal of the gallbladder, you should take medicines with bile and enzymes (Allohol, Cholenzim) and means to increase the production of your own enzymes (Ursosan, Ursofalk).
Treatment of gallstone disease can be carried out conservatively or radically. If the disease proceeds with little or no symptoms with a single attack of colic, then doctors usually use expectant tactics and observe the general condition of the patient for some time.
A special diet, medications and herbal medicine are prescribed. Dosed doses are also recommended. physical exercises and refusal bad habits.
Radical methods of treatment are used in cases where it is not possible to cure the patient by other methods. The most common and effective radical method of treatment is laparoscopic cholecystectomy.
In addition, there are some restrictions after gallbladder surgery, which we will discuss below.
After removal of the gallbladder, the need for pharmacological treatment is minimal. expressiveness pain in the postoperative area is insignificant, so painkillers are prescribed according to indications.
If the patient has a spasm of the muscular apparatus of the biliary tract or other digestive disorders caused by increased tone, then it is necessary to prescribe antispasmodics. Thanks to ursodeoxycholic acid preparations, it is possible to improve the rheological properties of bile and prevent the development of microcholelithiasis after removal of the gallbladder.
Operation progress
Before carrying out any type of cholecystectomy in the hospital, the patient is visited by a surgeon and an anesthesiologist. They tell how the procedure will go, about the anesthesia used, possible complications and obtain written consent for treatment.
It is advisable to start preparing for the procedure before hospitalization in the department of gastroenterology, after clarifying with the doctor recommendations on diet and lifestyle, to take tests. This will help make the procedure easier.
Preoperative
To be sure possible contraindications In order to achieve the best treatment results, it is important not only to properly prepare for the procedure, but also to undergo an examination. Preoperative diagnostics include:
- General, biochemical analysis blood and urine - surrender in 7-10 days.
- Clarifying analysis for blood type and Rh factor - 3-5 days before the procedure.
- Examination for syphilis, hepatitis C and B, HIV - 3 months before cholecystectomy.
- Coagulogram - tests for the study of the hemostasis system (blood clotting test). More often it is carried out in conjunction with general or biochemical analyzes.
- Ultrasound of the gallbladder, biliary tract, abdominal organs - 2 weeks before the procedure.
- Electrocardiography (ECG) - diagnostics of pathologies of the cardiovascular system. It is carried out a few days or a week before cholecystectomy.
- Fluorography or X-ray of the chest organs - helps to identify pathologies from the heart, lungs, diaphragm. It is given 3-5 days before cholecystectomy.
Only those people whose test results are within the normal range are allowed to undergo cholecystectomy. If a diagnostic tests revealed deviations, you must first undergo a course of treatment aimed at normalizing the condition.
Some patients, in addition to general tests, may need to consult narrow specialists (cardiologist, gastroenterologist, endocrinologist) and clarify the condition of the biliary tract using ultrasound or X-ray with contrast.
Since hospitalization
After hospitalization, all patients, with the exception of those who require emergency surgery, undergo preparatory procedures. The general steps include following the rules:
- The day before the cholecystectomy, the patient is prescribed a light meal. The last time you can eat no later than 19.00. On the day of the procedure, you should refuse any food and water.
- The night before, you need to take a shower, if necessary, shave off the hair from the abdomen, make a cleansing enema.
- The day before the procedure, the doctor may prescribe mild laxatives.
- If you are taking any medications, you should check with your doctor about the need to stop them.
anesthesia
For cholecystectomy, general (endotracheal) anesthesia is used. With local anesthesia, it is impossible to provide complete control over breathing, stop pain and tissue sensitivity, and relax muscles. Preparation for endotracheal anesthesia consists of several stages:
- Before surgery, the patient is given sedatives (tranquilizers or drugs with an anxiolytic effect). Thanks to the premedication stage, a person approaches the surgical intervention calmly, in a balanced state.
- Before cholecystectomy, an introductory administration of anesthesia is performed. For this, sedatives are injected intravenously to ensure falling asleep before the start of the main stage of the procedure.
- The third stage is to provide muscle relaxation. To do this, muscle relaxants are administered intravenously - drugs that tension and help to relax smooth muscles.
- At the final stage, an endotracheal tube is inserted through the larynx and its end is connected to the ventilator.
The main advantages of endotracheal anesthesia are maximum safety for the patient and control over the depth of drug-induced sleep. The possibility of waking up during surgery is reduced to zero, as well as the possibility of failures in the respiratory or cardiovascular system.
After recovery from anesthesia, confusion, mild dizziness, headache, and nausea may occur.
If a drain was installed during the operation, it is removed the day after the procedure. Before removing the stitches, the skin is dressed daily and the skin is treated with antiseptic solutions. The first few hours (from 4 to 6) after cholecystectomy, you need to refrain from eating, drinking, it is forbidden to get out of bed. After a day, small walks around the ward, food and water intake are allowed.
On the eighth or ninth day, if the operation was successful, the patient is discharged from the hospital. At this stage of rehabilitation, it is important to establish proper nutrition at home, according to the treatment table number 5.
You need to eat fractionally, giving preference to dietary products. All daily food should be divided into 6-7 servings.
Daily calorie content of dishes: 1600–2900 kcal. It is desirable to eat at one time so that bile is produced only during meals.
The last meal should be no later than two hours before bedtime.
- Laboratory studies of blood components.
- Magnetic resonance imaging. It is able to provide complete information about the nature and size of stones in the gallbladder, foci of inflammation, scars.
- Electrocardiogram.
- Examination of the state of blood vessels and organs respiratory system.
- CT scan. It is prescribed to detect adhesions and examine the tissues located around the gallbladder.
Analyzes of blood components will assess the condition of the internal organs of the patient and identify a failure in their work. Research includes:
- detailed and complex biochemical analysis;
- testing for HIV infection, the presence of hepatitis and syphilis;
- carrying out a hemostasiogram for blood clotting;
- determination of blood group and Rh factor.
When the preparatory stage is underway, the patient is prescribed which doctor to go to before the gallbladder removal procedure. Mandatory visits to the therapist and dentist.
This method is prescribed for inflammation of the gallbladder associated with peritonitis and diseases of the biliary tract. With this procedure, extensive injuries, scarring, and various complications are possible. The main advantage of abdominal excision of the gallbladder is free access to it.
Mostly the attending physician is asked: “How soon will I be discharged if my gallbladder was removed?”. The length of stay in the hospital depends on the presence of pain, the nature of complications, the speed of recovery. The patient's well-being after removal of the gallbladder is the main factor in the decision-making process to transfer him to outpatient treatment.
As a rule, the consequences of the abdominal method, which removed the gallbladder, are more difficult than the outcome of the minimally invasive method. Therefore, the length of stay in hospital depends on the type of excision of the gallbladder. After laparoscopic surgery to remove the gallbladder, recovery is faster.
In the postoperative period, the specialist may prescribe: special diet, medicinal preparations with a choleretic effect, medications.
During the first month after surgery, you need to eat often and in small portions. Daily water consumption is 1.5 liters. The intensity of physical activity should be kept to a minimum.
In many cases, gallstone disease is not treated. Just cut out the bubble, this ends the treatment. However, 40% of patients continue to experience difficulties for various reasons. For example, the high tone of the sphincter of Oddi, which does not release bile into the duodenum. Therefore, similar effects appear.
- Relapses (re-formation of stones) after cholecystectomy (removal of the gallbladder) and cholecystostomy (excision of the bottom of the gallbladder). Stones appear inside the liver, in the stump of the gallbladder, clog the ducts.
- Postoperative chronic (inflammatory) diseases in the stump of the gallbladder, ducts, diverticula, overgrowth of tracts with scars, the appearance of fistulas, proliferation of connective or cancerous tissue, biliary pancreatitis, cirrhosis.
- Inflammatory processes of the biliary tract and the space immediately adjacent to the operation site:
- Pancreatitis.
- Cholecystitis of the stump with complications (peritonitis, abscess).
- Liver or kidney failure.
- Sepsis.
- mechanical jaundice.
- Organ damage due to surgery, poor-quality sutures, ingestion foreign bodies, drainage prolapse, hernia and swelling.
- Damage to the portal vein and branches, hepatic artery, pancreas, duodenum.
- Simulation from the side nervous system, phantom pains, psychoses.
Often, postoperative symptoms are not related to the measures taken, they are caused by disorders of the musculoskeletal system (neuralgia, osteochondrosis).
Removal of the inflamed gallbladder can be performed in several ways: open, laparoscopic and endoscopic method.
Cholecystectomy by open method
Minimally invasive open cholecystectomy is performed under general anesthesia, the procedure lasts from 30 minutes to 1.5 hours. The surgeon makes a dissection of the abdominal wall on the right side under the costal arch, separates the gallbladder from fatty tissues, applies a ligature or clips the bile ducts that feed the artery and cuts off the gallbladder.
The bed is sutured or cauterized with a laser to stop bleeding. Stitches are placed on the surgical wound, which are removed after 6-8 days.
Before performing a cholecystectomy, a person must undergo a complete medical examination:
- esophagogastroduodenoscopy;
- Ultrasound of the abdominal cavity;
- cholecystography;
- blood chemistry;
- comprehensive examination of the heart and lungs;
- MRI, computed tomography;
- colonoscopy if indicated.
Diagnostic tests help to assess the size, structure of the bladder, the degree of filling, functionality, detect calculi, adhesions in the abdominal cavity.
Before surgery, the patient must prepare - for a week it is necessary to stop taking drugs that worsen blood clotting, non-steroidal anti-inflammatory drugs, vitamin E. You can not have dinner before the appointed procedure, the last meal should be no later than 19 hours.
During the first 4-6 hours after cholecystectomy, the patient is in the intensive care unit, he cannot get up, eat or drink. Then they are allowed to take a few sips of non-carbonated water and carefully rise under the supervision of medical personnel. The drainage tubes are removed on the second day and the wound openings are sealed.
The next day, the patient can eat liquid cereals, dairy products. In the future, compliance is required strict diet excluding fatty, fried, spicy foods, smoked meats, strong coffee, sweets, alcohol. At first, you need to eat oatmeal, baked apples, light soup, boiled dietary meat.
The duration of the rehabilitation period after laparoscopic cholecystectomy is 15-20 days, satisfactory health is noted already a week after discharge from the hospital. During the first month, patients are prohibited from performing intense physical activity, lifting a load of more than 2 kg. After band surgery, recovery can last up to 2-3 months.
Special drug treatment not required, non-steroidal anti-inflammatory drugs (Nurofen, Nise), antispasmodics (No-shpa) are prescribed to relieve pain. To improve the digestibility of food, the reception is shown digestive enzymes(Creon, Pancreatin).
2 days after the operation, it is allowed to take a shower, you can not rub the stitches with a washcloth, soap or other detergents. After hygiene procedures, the wounds are gently blotted with a towel and treated with antiseptics (iodine, brilliant green). The stitches are removed after 1 week, this procedure is absolutely painless.
A patient with a diagnosis of cholelithiasis should undergo a complete comprehensive examination, which will assess the general condition of the body and readiness for surgical intervention. To prepare for laparoscopy, you must undergo an examination by a therapist and pass the following tests:
- general blood test, for glucose;
- general urine analysis;
- coagulogram;
- blood chemistry;
- FG, ECG.
The surgeon who will perform the laparoscopic cholecystectomy must evaluate the results and risk to ensure that the consequences of gallbladder removal are minimal. The day before surgery, the patient is forbidden to take heavy food, and the last meal should be no later than 19:00.
In the evening, a cleansing enema is performed. The patient should not drink on the day of the operation.
If the tests show a deviation from the norm, the patient will have to undergo a course of treatment. And only after normalization general condition can go for surgery.
Despite the minimal risk and benefits of laparoscopy, not everyone can perform this procedure, as there are certain contraindications. So, you can not do laparoscopic cholecystectomy if the patient has already had some kind of surgical intervention in the abdomen.
In addition, contraindications for surgical treatment of the patient are:
- cardiovascular diseases;
- mechanical jaundice;
- pregnancy (late term);
- diffuse peritonitis;
- malignant processes.
It is forbidden to perform surgery if there is a disease in which blood clotting is disturbed, the location of organs in the abdomen is unknown, or a pacemaker is installed.
Gallstone disease appears as a result of the deposition of stones in the gallbladder itself and in its ducts. They are formed from cholesterol, bilirubin and calcium salts. GSD is widespread in older people. Concrements (stones) are different shapes and sizes: from 1 mm to 5 cm.
Gallstone disease has become today one of the most common phenomena among the pathologies of the abdominal cavity, and the operation to remove stones in the gallbladder is one of the methods of cardinal solution of the problem.
Gallstone disease - what is it?
This is a disease associated with the formation of stones (calculi) in the bile ducts and gallbladder. It develops for the following reasons:
- stagnation or changes in the composition of bile;
- inflammatory processes;
- violation of bile secretion (dyskinesia).
According to the composition, there are three types of stones. The most common (in 80-90% of cases) are cholesterol stones. Their formation contributes to the excess content of cholesterol in the composition of bile.
In this case, the formation of crystals occurs due to the precipitation of excess cholesterol in the sediment.
Irina 07.05. Gallbladder removal surgery
Dear readers, we continue the topic of the gallbladder. We talked about where the gallbladder is located, what are its functions, how to conduct an ultrasound of the gallbladder. Today we will talk about the operation to remove the gallbladder. It's called a cholecystectomy. Removal of the gallbladder may be necessary if stones form in it or in the bile duct leaving it.
Indications for an operation to remove the gallbladder are the following situations:
- the presence of stones in the gallbladder with signs of acute or chronic inflammation (acute calculous cholecystitis and chronic calculous cholecystitis);
- stones in the bile ducts (choledocholithiasis);
- gangrene of the gallbladder
If the patient was admitted to the hospital on an emergency basis, then all preoperative preparation takes place directly in the hospital, under the supervision of the attending physician - the surgeon.
Preparation for surgery to remove the gallbladder.
Faced with the prospect of an operation to remove the gallbladder, for sure everyone will want to know what methods of surgical intervention exist, how it goes and how long it takes, and also what is the preparation and rehabilitation period.
Methods of performing an operation to remove the gallbladder
Today in medicine there are two options for such an operation:
- laparoscopic - surgery is performed through small incisions in the abdominal wall using thin surgical instruments;
- traditional (cavitary or open) - removal is performed through a 15-cm incision from the right side.
Indications for removal of the gallbladder
The question of the limits of therapeutic treatment and indications for surgical intervention has been the subject of discussion for many years. Apparently, it is more correct to raise the question not of an obligatory early (during an attack of cholecystitis) operation, but of a timely operation at a time when there are still no complications from the liver, pancreas and other organs.
2) the presence of acute or chronic inflammatory enlargement of the gallbladder;
3) the presence of cholangitis, not amenable to treatment, especially with obstruction of the biliary tract;
4) the appearance of persistent jaundice;
5) secondary (early) changes in the liver with a violation of its main functions;
6) the presence of secondary pancreatitis.
Here are general indications to surgical treatment without taking into account a number of serious complications (perforation of the gallbladder, peritonitis, acute cholecystitis, etc.). An urgent operation is often necessary.
Medicine knows many diseases associated with this internal organ. For some pathologies, conservative methods of treatment are successfully used (drug therapy in combination with traditional medicine and a special diet), but there are also diseases that can be dealt with without surgical treatment is simply impossible.
For example, menstruation during gallbladder surgery is a contraindication, since during this period the level of hemoglobin in the blood of women increases, and blood clotting worsens. In addition, the risk of postoperative complications also increases. Also, contraindications to laparoscopy may be pathologies of the cardiovascular and respiratory systems.
Laparoscopy is the most optimal and least traumatic for the patient method of surgical intervention, since during such an operation the removal of the gallbladder is performed through a small (compared to abdominal intervention) incision.
The laparoscopic method of removing this organ during elective operations is currently given the greatest preference, since the complications of laparoscopy of this organ are minimal.
How is the gallbladder removed? Laparoscopic cholecystectomy is performed under general anesthesia. The duration of manipulation can be from 40 minutes to 3 hours, it all depends on individual characteristics and complexity of the case.
The first step is to introduce carbon dioxide into the abdominal cavity. This point is extremely important, because. otherwise, it will be difficult to perform manipulations on the organs.
For injection of gas, a special device called an insufflator is used. With its help, a constant supply of carbon dioxide is carried out, maintaining a stable gas pressure in the abdominal cavity.
Then, punctures are made in the abdominal wall for the introduction of trocars - devices that provide access for instruments to the abdominal cavity without loss of gas.
A puncture is also made near the navel, through which a laparoscope is inserted. This device is an optical tube through which the image is transmitted to the screen. At the same time, everyone present in the operating room can observe the progress of the operation. The laparoscope can give 40x magnification, which makes the visualization of organs even clearer.
It is also necessary to introduce an electric coagulator and clamps holding the gallbladder through the trocars. Using the electrical coagulation method, it is possible to separate the gallbladder from the liver and highlight important anatomical structures (arteries, ducts), which are subsequently clipped.
After the surgeon makes sure that the clips are securely applied, the clipped arteries and ducts are divided. To facilitate the removal of the gallbladder filled with stones, the stones are first crushed, so they are not always visible after cholecystectomy.
If the operation went without complications, then you can do without subsequent drainage of the abdominal cavity, but most surgeons prefer to play it safe. Drainage is represented by a rubber or silicone tube, which is removed through one of the postoperative holes.
Drainage is necessary to remove fluid that may accumulate in the operated area. Laparoscopic removal of the gallbladder is less traumatic and more comfortable for the patient, so rehabilitation after cholecystectomy takes much less time.
The patient's condition after cholecystectomy is characterized by the appearance of general weakness and slight disorientation. At the end of the operation, the patient is placed in the intensive care unit for a couple of hours.
This is done in order to carefully examine the patient and see how he comes out of anesthesia. If the patient has concomitant severe diseases or if the operation was complicated, then the length of stay in the intensive care unit increases.
After the doctor is convinced that the patient's life is not in danger, he is transferred to the surgical department for postoperative observation. After surgery, the patient is forbidden to eat and drink for 6 hours.
The patient is allowed to get out of bed after 5 hours. It is necessary to rise slowly and gradually.
Beforehand, it is better to sit for a while, make sure that there is no dizziness and sharp pain in the abdominal region. It is best to get out of bed in the presence of nurses.
Life without a gallbladder is almost no different from what it was before the operation. After removal of the gallbladder, patients are advised to follow a certain diet for some time, which will reduce the burden on the digestive organs and give the body time to adapt.
Within 2-4 months, stool disorders may occur. Six months after the operation, the bowel function returns to normal, and the patient begins to feel better.
It must be said that with a long course of cholecystitis, other organs (bile ducts, pancreas) can also be affected. In such situations, removal of the gallbladder will not eliminate all symptoms and additional treatment will be required to correct digestion.
The next day after the removal of the gallbladder, the patient is allowed to move freely around the department, eat liquid food and gradually return to their usual way of life. Within a week after laparoscopic intervention, any consumption of alcohol, coffee, chocolate, fried, fatty, smoked foods is completely prohibited.
If the operation went without complications, then the drain is usually removed the next day. The drainage removal procedure is painless and does not take much time.
Young patients are allowed to go home the next day after the operation, and it is advisable for the elderly to be observed in the hospital for at least 2 days. At discharge, the patient is given a sick leave certificate, if necessary, as well as a discharge sheet, which will indicate the diagnosis, recommendations for treatment and test results.
The disability certificate is issued no more than 3 days after discharge. If it needs to be extended, then it is best to contact the surgeon at the place of residence on this issue.
Removed the gallbladder - what medicines to take?
If the analysis shows the content in bile a large number components that provoke gallstone formation, then a course of special medications is required, which contain a lot of bile acids. These drugs include: Cholenzim, Lyobil, Allohol, Osalmid and Cyclovalon. Most of these drugs also have a good choleretic effect.
In addition to the medicines listed above, patients without a gallbladder are prescribed special medicines with a high content of ursodeoxycholic acid (for example, Ursosan, Enterosan, Hepatosan and Ursofalk).
This acid is absolutely safe for the body, but allows you to normalize the bile composition. Tablets after removal of the gallbladder must be drunk strictly according to the prescribed scheme.
For the first time after the operation, patients will have to drink antibiotics that disrupt the intestinal microflora. After that, it is necessary to drink the medicine to restore it. These drugs include: "Linex", "Bifidobacterin", "Bifidum" and so on.
A possible pain syndrome is well relieved by antispasmodic drugs, such as No-shpa, Buskopan, Duspatolin and others, which are available in the form of capsules and tablets.
Increased gas formation and belching are well eliminated by Meteospasmil, Espumizan, Sub-simplex, etc.
To stimulate the motility of the digestive tract, as a rule, Motilium, Cerucal and Debridat are prescribed.
In addition, the list of necessary drugs may include general strengthening and enzyme-containing drugs (for example, Creon, Essentiale Forte, Festal) and a multivitamin complex.
And remember: if the gallbladder is removed, only the attending physician decides which medications to take. Self-medication can cause serious harm to your health!
The use of fried, fatty and spicy, as well as acidic juices, carbonated drinks and alcohol is contraindicated. If such a diet is not followed, large gallstones may appear in the bile ducts, which can lead to blockage of the biliary tract, and this is very dangerous for the body.
Contraindications
Relative contraindications to the operation: previous surgical interventions in the abdomen, Mirizzi syndrome, jaundice, acute inflammation of the bile ducts, severe atrophy or sclerosis of the gallbladder. There are much fewer restrictions for open cholecystectomy, since the doctor has free access to the organ.
It is possible to carry out an operation with cholelithiasis only if there are certain indications for this. Indications for cholecystectomy:
- stones larger than 1 cm in diameter;
- there is a possibility of blockage of the bile duct;
- acute cholecystitis;
- polyps of the gallbladder;
- asymptomatic course of cholecystolithiasis.
Cholecystectomy is the removal of the gallbladder, indications for which are the presence of stones in it or acute cholecystitis. Also, the operation can be prescribed for chronic cholecystitis, in which the formation of stones is not observed.
If the patient experiences constant pain due to the fact that the stones prevent the outflow of bile, immediate removal of the gallbladder is necessary. In general, the operation does not reveal any difficulties in carrying out, and with a successful course of treatment, the patient can be discharged home after a couple of days.
There are a number of reasons why doctors prescribe a cholecystectomy:
- The presence of stones in the gallbladder (cholelithiasis).
- Formation of stones in the bile ducts (choledocholithiasis).
- Acute inflammatory processes in the gallbladder (cholecystitis).
- Perhaps the appointment of surgery for inflammation of the pancreas (pancreatitis).
The gallbladder affects the coordinated work of the human body only in the absence of pathological changes in it. Otherwise, the organ turns into a chronic reservoir of infection, pain syndrome appears, the function of the pancreas is disturbed, and unpleasant symptoms begin to disturb the patient.
Open cholecystectomy is performed in almost all patients for health reasons. Laparoscopy has absolute and relative contraindications. It is strictly forbidden to perform the operation if the patient has:
- inflammation of the abdominal cavity;
- compaction in the region of the neck of the gallbladder;
- obesity last stages;
- last trimester of pregnancy;
- myocardial infarction;
- oncology of the gallbladder.
Effects
The doctor informs the patient about all the complications that may be after the removal of the gallbladder. But they are quite difficult to predict, because they depend on different reasons.
Complications during surgical removal of the gallbladder can provoke:
- inflammation of the gallbladder chronic stage;
- age;
- excess weight;
- atypical structure of the gallbladder;
- foci of inflammation in the tissues of the operated area.
Complications after removal of the gallbladder are divided into:
- Early. Manifested in the form of re-bleeding, peritonitis, purulent inflammation under the diaphragm and liver.
- Late. This type of complication includes jaundice, the development of diseases unrecorded before the procedure for excision of the gallbladder.
- Operational - the consequences of unskilled actions of the surgeon.
In order to avoid complications after surgery to remove the gallbladder, it is necessary to undergo a comprehensive examination, trust an experienced qualified surgeon, and follow the postoperative recommendations of a specialist.
If the patient does not have a deterioration in the condition, it will take several months for him to fully recover after surgery to remove the gallbladder. However, whatever the consequences, if the gallbladder is removed, it is important to follow a number of rules. Restoration of digestion after removal of the gallbladder is recommended to start with a special diet.
In order to avoid undesirable consequences after removal of the gallbladder, complex treatment is recommended. Experts advise to include folk methods.
The consequences of the removal of the gallbladder in women often manifest themselves in the form of prolonged pain of an intense nature in the right hypochondrium.
The patient may experience bouts of nausea associated with severe painful attacks in the navel area. If at the same time he often vomits, shivering, the temperature rises, it is necessary to see a doctor. Such consequences of gallbladder surgery are extremely dangerous.
In 20–50%, postcholecystectomy syndrome develops, causing a deterioration in the general condition of the patient. Cause of pathology - undiagnosed diseases digestive system, mistake of the surgeon during the operation. To minimize the risk of complications, careful diagnosis is required in the preparatory period.
Prevention
It turns out that the causes of gallstone disease should be eliminated. Dealing with the consequences is too costly.
Primary prevention of diseases of the gallbladder, dangerous cholecystectomy: physical labor, maintaining an active motor regime, preventing psycho-emotional stress, eliminating infections, metabolic disorders.
Secondary prevention of recurrence of stones - enzyme therapy, psychological rehabilitation, spa treatment, timely diagnosis and treatment of complications.
How long do people live after gallbladder removal? Subject to the recommendations of doctors - the condition after cholecystectomy or laparoscopy does not affect life expectancy.
Diet
Adverse consequences after removal of the gallbladder can provoke foods included in the diet. It is important to follow a diet according to the doctor's recommendation.
The list of staples allowed after gallbladder removal includes:
- lean meats;
- light soups;
- oatmeal, buckwheat;
- low-fat dairy products.
Prohibited products include:
- fried, fatty foods;
- spicy, salty, pickled food;
- fish;
- sweet food;
- chocolate;
- strongly brewed tea, coffee;
- alcoholic drinks;
- sparkling water;
- bakery products from premium flour.
Along with this, it is highly desirable to give up smoking. In the postoperative period, it is necessary to monitor the regularity of the chair. In no case should constipation be allowed.
There are several options for such nutrition, which must be observed both in the process of preparing for surgery and throughout the entire rehabilitation period. It is optimal to follow such a diet throughout the life of the patient.
This principle involves eating food in small portions, but often (from five to seven times a day). This significantly reduces the load on the digestive system in the absence of a gallbladder.
Food is the main stimulant of bile formation, as a result of which it does not allow bile to stagnate and stimulates its removal through the bile ducts.
Some products have an enhanced choleretic effect. Such food products include: unrefined types of vegetable oils of the first extraction (especially linseed and olive), beets, carrots and some others.
You can learn more about the composition of various diet options No. 5 from your doctor or look on the Internet. We will only give a list of foods that patients after cholecystectomy surgery should exclude from their diet:
- fatty foods;
- fried foods;
- smoked meats;
- various pickles;
- canned vegetables and food;
- caviar;
- some types of nuts;
- all types of mushrooms;
- hot spices;
- garlic;
- spices;
- egg yolks;
- fatty meat, poultry and fish;
- broths based on these products;
- sweet pastries;
- fresh white bread (only in the form of crackers);
- various sweets (especially chocolate and ice cream);
- strong black tea;
- coffee (both ground and instant);
- any kind alcoholic beverages including beer;
- carbonated drinks;
- juices in packages.
Remember: removal of the gallbladder is not a sentence. The vast majority of patients after this kind of surgery return to a full life and feel great.
And if you have any questions - contact your doctor - and he will answer them in detail and competently. And yet, it is better to prevent the disease than to treat it for a long time.
Eat right, lead an active lifestyle - and many health problems can be avoided.
Diet is the basis for preventing complications after gallbladder removal. Within a month, it is advisable for the patient to stop drinking alcohol-containing drinks, simple carbohydrates and “heavy” foods.
During the 30 days of the postoperative period, it is best to give preference to fermented milk products (kefir, cottage cheese, fermented baked milk). Introduce foods into the diet should be gradual.
A month later, you need to consult with a gastroenterologist about expanding the diet.
To minimize possible postoperative consequences, certain restrictions are imposed on the patient's life at first. The first six months after cholecystectomy, you can not lift weights weighing more than 2 kg. Mandatory daily walking, light gymnastics, but you can not do exercises with the use of the press.
Mandatory nutrition correction, which implies:
- Plentiful drink.
- Exclusion of alcoholic beverages. Under a special ban beer, as it greatly complicates the work of the liver and pancreas.
- Fractional meals - 6 times a day.
- Exclusion of cholesterol-containing products for 1 month, then their content in the diet is allowed in a minimum amount.
Recovery after cholecystectomy requires minimal medical therapy. The operated patient may be prescribed analgesics and antispasmodics to relieve pain.
It is obligatory to take medications based on ursodeoxycholic acid, which prevent the possibility of developing microcholelithiasis and improve the lithogenicity of bile. The surgeon will tell you how to care for the wounds, since different methods of cholecystectomy imply different suture care.
Surgery to cut off the gallbladder is the most common. It is carried out in pathologies, when dieting and drugs no longer help. They operate by an open method, laparoscopically, minimally invasively.
The gallbladder stores bile, which is required to break down food into its constituents. Periodically, the organ becomes inflamed, causing discomfort, pain and pain. The patient experiences hellish torments and is ready to remove the pain in the hypochondrium by any means.
In addition to individual signs of disease (faculty classification of factors), disruption of the body provokes jaundice, peritonitis, biliary colic, cholangitis. Such complications lead to surgical intervention.
Indications for surgery
Abdominal operation
Open surgery involves penetration along the midline of the abdominal cavity. The doctor may make incisions under the ribs. This method allows the surgeon to examine the biliary system, additional dimensions, sounding. The course of the classical operation goes according to the scheme:
- The patient is placed on the table at an angle to the left side.
- Revision of affected areas at the site of excision of the abdomen.
- Stopping the outflow of bile by ligation of the ducts. Clipping of blood vessels.
- Removal of the gallbladder, antiseptic treatment of the site of the organ.
- Sewing up the incision after the doctor has placed the drain.
Laparoscopy
Cholecystectomy by this method is performed more often than others. The operation allows you to monitor the progress of manipulations. The abdominal organs are palpated instrumentally, which increases the level of safety. The patient's recovery is faster than after a classic removal. causes less pain during the adaptation period, and the patient is ready to resume his usual way of life three days after the operation.
Stages of laparoscopy:
- Four punctures are made:
- In the area just above or below the navel;
- 2-3 cm below the xiphoid process in the midline;
- 3-5 cm below the costal arch along the anterior line of the armpit;
- On the midclavicular line 2-3 cm below the ribs (right side).
- Ensuring visibility by injecting carbon dioxide.
- Compression and removal of the bile duct, cutting off the artery.
- After the removal of the gallbladder, medical instruments are removed.
- Suturing of surgical incisions.
The operation lasts from one to two hours, depending on the structural features of the body, the accessibility of the affected area. Stones before cutting off the body are crushed into small parts. In the hypochondrium after cholecystectomy, a drain is placed to drain the fluid.
Intervention with mini access
Laparoscopic surgery is not always indicated for patients. The minimally invasive method has become a salvation when it is impossible to use other methods. Mini-access is a cross between laparoscopic intervention and classical surgery. Endoscopic surgery includes the following steps:
- Puncture;
- Ligation of the duct with the artery;
- cutting off the gallbladder;
- Wound suturing.
The incision is from 3 to 7 cm under the costal arch on the right. Mini-access is indicated for patients with adhesions, tissue infiltration of the inflammatory course. Rehabilitation after the intervention is easier than in the case of open cholecystectomy.
Preoperative period - preparation
The patient undergoes examinations, according to the results of which the surgeon will assess the patient's condition and decide on the choice of operation. Appointed:
- Blood test (general and biochemical), blood for RW, hepatitis B and C;
- Analysis of urine;
- Ultrasound of the abdominal cavity;
- CT scan;
- Examination of pancreatic and liver enzymes;
- ECG, fluorography.
In a few days, drugs that affect blood clotting are canceled, laxatives are recommended for taking. Light dinner the day before and fasting 7 hours before surgery. Cleansing enema before cholecystectomy. Urgent intervention limits the time for the examination, two hours - the time for decision-making.
After operation
Hospital stay depends on the method of removal of the gallbladder. Stitches for open surgery are removed after 7 days. The patient is in the hospital for two weeks. He is allowed to get up and move around the surgery with caution 4 hours after passing anesthesia. The postoperative period after laparoscopy is about three days. The patient will start work in a month or two or three weeks, respectively.
To restore the body, a person is prescribed a therapeutic diet. Alcohol, fatty, fried, spicy foods are excluded. Eat little and often, do not get carried away with physical activity. Exercise therapy will help strengthen muscles (exercise "bike"). Preparations to maintain the functions of the gastrointestinal tract are selected individually. It takes a year for the body to adjust to life without a gallbladder.
The adaptation period is a complex process. The patient will be given a lecture on nutrition, lifestyle without a removed organ, and possible complications.
Cholecystectomy is the surgical removal of the gallbladder. The operation is performed with the formation of stones, acalculous, acute or chronic form of cholecystitis, dysfunction, atrophy of the organ. Resection is performed by an open or minimally invasive endoscopic method.
Bile is needed by the body to dissolve fats in the intestinal cavity, its reserves accumulate in the gallbladder and, after eating, are released into the duodenum, accelerating digestion, exerting a bactericidal effect. If stones are formed in the organ, a spasm of the sphincter of Oddi occurs, the outflow of bile acids becomes difficult, the walls of the bladder are stretched and injured, acute inflammation develops, as well as dyspeptic disorders. The patient complains of heaviness and cutting pains in the abdomen after eating, nausea, vomiting, flatulence, constipation or diarrhea, heartburn.
Indications for removal of the gallbladder:
- blockage of the bile ducts;
- calculi in the excretory tract;
- acute cholecystitis;
- cholelithiasis;
- calcification;
- organ dysfunction;
- rupture of the gallbladder;
- cholesterol polyps;
- cholesterosis is the deposition of lipoproteins on the walls of an organ.
Doctors have different opinions about whether or not to remove the bladder for gallstone disease without clinical symptoms. Most surgeons agree that surgery is necessary if the stones are larger than 2 cm in diameter, as there is a greater chance of blockage of the ducts. Elective surgery is recommended for people with diabetes.
Prolonged presence of stones in the gallbladder can lead to the formation of wall calcification, organ carcinoma, the risk of malignancy increases with age. Timely performed cholecystectomy excludes such a possibility, prevents the development of complications, which are often observed in acute inflammation.
Urgent indications for cholecystectomy are perforation of the gallbladder. This condition accompanies the following diseases:
- abdominal trauma;
- complication of chronic cholecystitis;
- malignant tumors;
- systemic lupus erythematosus.
Bile acids go beyond the body, contribute to the formation of an internal abscess, cholecysto-intestinal fistula.
Contraindications
Operations to remove the gallbladder by laparoscopy can not be performed in such cases:
Relative contraindications to the operation: previous surgical interventions in the abdomen, Mirizzi syndrome, jaundice, acute inflammation of the bile ducts, severe atrophy or sclerosis of the gallbladder. There are much fewer restrictions for open cholecystectomy, since the doctor has free access to the organ.
Operation techniques
Removal of the inflamed gallbladder can be performed in several ways: open, laparoscopic and endoscopic method.
Abdominal surgery is performed by dissection of the abdominal wall, it is prescribed for acute inflammation, high risk of infection, perforation of the walls, choledocholithiasis, with large stones that cannot be removed in another way.
Cholecystectomy by open method
Minimally invasive open cholecystectomy is performed under general anesthesia, the procedure lasts from 30 minutes to 1.5 hours. The surgeon makes a dissection of the abdominal wall on the right side under the costal arch, separates the gallbladder from fatty tissues, applies a ligature or clips the bile ducts that feed the artery and cuts off the gallbladder. The bed is sutured or cauterized with a laser to stop bleeding. Stitches are placed on the surgical wound, which are removed after 6-8 days.
With strip open cholecystectomy, a dissection is made along the white line of the abdomen, the incision should provide good access directly to the gallbladder, excretory ducts, liver, small intestine, pancreas. The indication for surgery is peritonitis, complex pathologies of the excretory ducts, bladder perforation, chronic, acute cholecystitis.
The disadvantages of open cholecystectomy include frequent postoperative complications:
- intestinal paresis;
- difficult and long recovery period;
- deterioration in respiratory function.
The open method of cholecystectomy can be performed for health reasons in a large number of patients, while removing the gallbladder by laparoscopy is possible only if there are no contraindications. In 1-5% of cases, it is impossible to cut the organ through a small hole. This is due to the peculiarities of the anatomical structure of the biliary system, inflammatory or adhesive process.
Features of laparoscopic cholecystectomy
The most sparing method of treatment is the operation to remove the gallbladder by laparoscopic method. The intervention is performed through small punctures in the peritoneum and navel, special instruments (laparoscope, trocars) are inserted into the holes, equipped with a video camera, clamps, a knife - with their help, clips are applied to the blood vessels and bile duct, a resection is made and the bladder is removed. For coagulation of the bed, a laser or ultrasound is used. The doctor monitors the progress of the operation on the monitor. After removing the trocars (5 and 10 mm), drainage is placed for a day, then it is removed and the wounds are sutured with absorbable material, sealed with a plaster.
Microlaparoscopic surgery is performed with instruments of smaller diameter, trocars are 2 mm in size and only one of them is 10 mm, through which the bladder is removed. After such a surgical intervention, a person recovers quickly, small scars remain on the skin.
This is a less dangerous method of treatment, its main advantage is the rapid recovery of the patient, minimal risk of infection. Rehabilitation takes up to 20 days, a person has practically no scars, no long-term hospitalization and removal of sutures is required, the patient is discharged from the hospital for 3-4 days.
In 10–20% of cases, a conversion is performed - a transition from laparoscopic surgery on the gallbladder to an open one. The indication is a rupture of the walls of the organ, prolapse of stones into the abdominal cavity, massive bleeding, features of the anatomical structure of the internal organs.
Removal using NOTES technology
This is an endoscopic surgical method that allows you to remove the gallbladder without external incisions through natural openings. The NOTES technique is performed by inserting a flexible endoscope through the mouth or vagina. The main advantage of the operation is the absence of scars on the abdominal wall. The innovative technique is not yet widely used, it is under development and clinical testing.
How the gallbladder will be removed is decided by the attending physician. The surgeon selects the necessary method of therapy, taking into account the form of pathology, the general condition of the patient, the presence of concomitant ailments.
Rules for preparing for surgery
Before performing a cholecystectomy, a person must undergo a complete medical examination:
- esophagogastroduodenoscopy;
- Ultrasound of the abdominal cavity;
- cholecystography;
- blood chemistry;
- comprehensive examination of the heart and lungs;
- MRI, computed tomography;
- colonoscopy if indicated.
Diagnostic tests help to assess the size, structure of the bladder, the degree of filling, functionality, detect calculi, adhesions in the abdominal cavity.
Before surgery, the patient must prepare - for a week it is necessary to stop taking drugs that worsen blood clotting, non-steroidal anti-inflammatory drugs, vitamin E. You can not have dinner before the appointed procedure, the last meal should be no later than 19 hours.
The patient is given an enema or is given laxatives to cleanse the intestines (Espumizan according to indications). On the day when the operation is to take place, it is forbidden to eat and drink any drinks. Before removing the gallbladder, the attack is stopped, the pain syndrome is relieved, and therapy for comorbidities may be required.
How is the postoperative period
During the first 4-6 hours after cholecystectomy, the patient is in the intensive care unit, he cannot get up, eat or drink. Then they are allowed to take a few sips of non-carbonated water and carefully rise under the supervision of medical personnel. The drainage tubes are removed on the second day and the wound openings are sealed.
The next day, the patient can eat liquid cereals, dairy products. In the future, a strict diet is required, excluding fatty, fried, spicy foods, smoked meats, strong coffee, sweets, and alcohol. At first, you need to eat baked apples, light soup, boiled dietary meat.
The duration of the rehabilitation period after laparoscopic cholecystectomy is 15-20 days, satisfactory health is noted already a week after discharge from the hospital. During the first month, patients are prohibited from performing intense physical activity, lifting a load of more than 2 kg. After band surgery, recovery can last up to 2-3 months.
Special drug treatment is not required, non-steroidal anti-inflammatory drugs (Nurofen, Nise), antispasmodics (No-shpa) are prescribed to relieve pain. To improve the digestibility of food, the intake of digestive enzymes (Creon, Pancreatin) is indicated.
2 days after the operation, it is allowed to take a shower, you can not rub the stitches with a washcloth, soap or other detergents. After hygiene procedures, the wounds are gently blotted with a towel and treated with antiseptics (iodine, brilliant green). The stitches are removed after 1 week, this procedure is absolutely painless.
What are the complications
After removal of the gallbladder, various complications can be observed:
- wound infection;
- intraperitoneal bleeding;
- choledocholithiasis -;
- vascular thromboembolism;
- exacerbation of chronic diseases of the gastrointestinal tract;
- damage to the biliary tract;
- internal abscesses;
- drug allergy.
In 20–50%, postcholecystectomy syndrome develops, causing a deterioration in the general condition of the patient. The cause of the pathology is undiagnosed diseases of the digestive system, the mistake of the surgeon during the operation. To minimize the risk of complications, careful diagnosis is required in the preparatory period.
In most cases, patients make a full recovery and return to normal life within 1-6 months. If complications arise in the postoperative period, there are concomitant ailments, longer treatment should be carried out, lead a healthy lifestyle, diet, and take medications.
You may also be interested
The operation to remove the gallbladder, or cholecystectomy, has been one of the most frequently performed abdominal surgeries for many decades. As a rule, they are forced to remove the gallbladder, which has gone far. Much less often, cholecystectomy is performed for diseases of a tumor nature, congenital anomalies of the biliary system, etc.
How to perform an operation to remove the gallbladder
In the operating room during laparoscopic surgery. The miniature camera of the laparoscope transmits a magnified image of the surgical field to an external monitor.
There are two methods of removing the gallbladder:
Ideally, these technologies should complement each other, not compete, but, unfortunately, this phenomenon does occur.
Laparoscopy of the gallbladder
Laparoscopic cholecystectomy involves surgical intervention through narrow channels in the abdominal wall (0.5-1 cm) using a telescopic device equipped with a video camera, light and other devices - a laparoscope, as well as a number of special tools.
Gone are the days when laparoscopic techniques had to prove their superiority over traditional open cholecystectomy. Laparoscopy has successfully won back its well-deserved place in abdominal surgery, the critical attitude towards it has remained the lot of inveterate retrogrades.
The advantages of laparoscopic gallbladder removal are obvious and undeniable:
- The most important advantage of the method, which is less emphasized, is the closed and apodactile method of operation, when contact with the operated tissues is carried out exclusively with the help of instruments, which significantly reduces the risk of infectious complications.
- Minor invasiveness of surgical intervention.
- Short-term hospitalization - 1-2 days, in some cases outpatient operations are also possible.
- Very small incisions (0.5-1 cm) guarantee an excellent cosmetic result.
- Rapid recovery of working capacity - within 20 days.
- One more thing should be noted positive quality methods - for patients with indications for surgery, it is easier to decide on laparoscopic intervention, which reduces the number of neglected cases.
Laparoscopic technology does not stand still. A technique for performing cholecystectomy through three channels has already been developed and is being successfully applied. And cosmetic micro-laparoscopy through ultra-thin channels with a diameter of only 2mm (only the main channel for the laparoscope is still 10mm) gives an ideal cosmetic result - traces of incisions can only be detected under a magnifying glass.
Disadvantages of laparoscopic cholecystectomy
The laparoscopic technique, along with indisputable advantages, also has specific disadvantages, which in some cases force it to be abandoned in favor of an open operation.
To ensure the working space and sufficient visibility during laparoscopy, it is inserted into the abdominal cavity under a certain pressure. carbon dioxide. Increased for this reason, the pressure in the venous system of the systemic circulation (the so-called central venous pressure), as well as pressure on the diaphragm, worsen the conditions for cardiac activity and respiration. This negative effect is significant only in the presence of serious problems with the cardiovascular and respiratory systems.
Laparoscopic technology significantly limits the possibilities of intraoperative (performed during the operation) diagnostics in comparison with open surgery, which provides the surgeon with the opportunity to "feel everything with his hands."
Laparoscopy is not applicable in unclear cases, when it may be necessary to change the operation plan in the course of its implementation, depending on the identified pathological changes.
The last two circumstances require the surgeon to have a different philosophy of preparation for the operation. The most thorough preoperative examination and the resolute rejection of the tactics of some old surgeons: "we cut it - we'll see" allow us to avoid embarrassment.
Contraindications for laparoscopy of the gallbladder
Contraindications to laparoscopic removal of the gallbladder are determined by the above features of laparoscopy:
- Severe general condition.
- Diseases that occur with severe heart and respiratory failure.
- Tumor nature of the disease.
- Obstructive jaundice (jaundice that has developed as a result of a mechanical obstruction to the outflow of bile in the extrahepatic ducts: stone, cicatricial narrowing, tumor, etc.).
- Increased bleeding.
- Pronounced adhesive process in the upper floor of the abdominal cavity.
- Calcification of the walls of the gallbladder, or the so-called. "porcelain" gallbladder. In this condition of the bladder, it can prematurely collapse in the abdominal cavity.
- Late pregnancy.
- Presence of acute pancreatitis.
- Peritonitis is a diffuse inflammation of the abdominal cavity.
It should be said that the development of laparoscopic techniques and the growing experience of surgeons are steadily narrowing the range of contraindications. So, until recently, acute cholecystitis and the presence of stones in the bile ducts were considered absolute contraindications to laparoscopic removal of the gallbladder. Now these contraindications have been successfully overcome.
Preoperative examination
Preoperative examination, in order to avoid unforeseen difficulties, often forcing to complete the started laparoscopy with an open operation through a large incision, should be thoughtful and comprehensive:
A high-quality and comprehensive examination preceding laparoscopy of the gallbladder makes it possible to foresee possible difficulties and make a decision in time about the method, volume, and, finally, the very expediency of surgical intervention.
Preparation for laparoscopy of the gallbladder
Like any abdominal surgery, laparoscopy of the gallbladder requires some preparation:
- a week before surgery, in agreement with the attending physician, it is necessary to stop drugs that reduce blood clotting (anticoagulants, non-steroidal anti-inflammatory drugs, vitamin E)
- on the day before surgery, eat only light meals
- after midnight before the operation, you can not eat or drink anything
- to cleanse the intestines the night before and in the morning, take special preparations as prescribed by the attending surgeon, or produce cleansing enemas
- take a shower in the morning before surgery, preferably with antibacterial soap
Open cholecystectomy
Open cholecystectomy, or removal of the gallbladder traditional way through a wide cut, should not be considered a relic of the past. Despite the expansion of the possibilities of laparoscopy of the gallbladder, open cholecystectomy remains relevant. It is indicated in the presence of specific to laparoscopy.
Open cholecystectomy has to complete 3-5% of laparoscopic operations when unforeseen difficulties appear.
A significant number of open cholecystectomies continue to be performed due to the lack of a real opportunity to perform laparoscopic removal of the gallbladder: the lack of the necessary equipment in a particular hospital, an experienced laparoscopist, etc.
And finally, the prejudice of some surgeons regarding laparoscopy also contributes.
So which is better: laparoscopy or open surgery?
laparoscopy of the gallbladder | open removal of the gallbladder | |
---|---|---|
testimony | ▪ cholelithiasis |
▪ acute and chronic cholecystitis ▪ cholelithiasis ▪ diseases of a tumor nature, etc. |
contraindications | It has | no contraindications for vital indications |
preparation for surgery | normal for abdominal operations | |
operation duration | 30-80 minutes | 30-80 minutes |
equipment requirements | Laparoscopic equipment required | conventional surgical instruments required |
requirements for the qualification of a surgeon | +++ | ++ |
anesthesia | anesthesia | anesthesia |
number and length of cuts | 3-4 cuts 0.5-1 cm long | one incision 15-20 cm long |
% complications | 1-5% | 1-5% |
pain after surgery | + | +++ |
seams | do not take off | removed for 6-7 days |
development of postoperative hernias | - | ++ |
cosmetic defect | - | ++ |
food after surgery | on the 1st day you can eat and drink | on the 1st day you can drink, from the 2nd day you can eat |
movement after surgery | on the 1st day you can sit up in bed, on the 2nd you can get up and walk | 3-4 days you can get up and walk |
length of hospital stay | 1-2 days | 10-14 days |
disability | up to 20 days | up to two months | after 5 weeks | after 2-2.5 months |
full recovery | 3-4 months | 3.5-4.5 months |
If a stone is in the common bile duct
It is not uncommon for gallstones to migrate from the gallbladder into the common bile duct. When a stone gets stuck in the common bile duct, a complete or partial violation of the outflow of bile from the liver to the intestine is possible, which is the cause of obstructive jaundice. There is also an asymptomatic stay of a stone in the duct.
Ideally, this should be known in advance. However, cases of undiagnosed stones in the duct were and are still taking place. Naturally, the operation does not bring the expected result, and only after additional examination the true cause of the failure is revealed. Such cases, of course, do not benefit the reputation of the surgeon, and therefore a good practice in gallbladder surgery is to check the patency of the common bile duct during cholecystectomy - intraoperative cholangiography. Such a check is performed by introducing a radiopaque substance into the bile ducts, followed by x-rays. Cholangiography is practiced both during open and laparoscopic cholecystectomy.
Until recently, a stone in the common bile duct, or even such a suspicion, was an absolute contraindication to laparoscopic removal of the gallbladder. Now, thanks to the improvement of laparoscopic techniques, surgeons are increasingly deciding to operate on such patients through a laparoscope.
Postcholecystectomy syndrome
Postcholecystectomy syndrome is a syndrome that develops after removal of the gallbladder. In medical science there is no single interpretation of this concept.
talking plain language, postcholecystectomy syndrome combines those cases when, after removal of the gallbladder, it did not get better, or it became even worse. According to various estimates, the incidence of postcholecystectomy syndrome reaches 20-50%. The reasons for such situations are varied:
- Undiagnosed diseases of the hepatopancreatic zone (chronic pancreatitis, cholangitis, stones and cicatricial narrowing of the common bile duct, tumors, etc.), peptic ulcer of the stomach and duodenum, reflux esophagitis, diaphragmatic hernia, the manifestations of which were mistaken for chronic cholecystitis.
- Errors in the operation, when too long a remnant of the cystic bile duct or even a part of the gallbladder is left, in which the inflammatory process finds shelter and even new stones form. There are also damage to the bile ducts, which leads to their cicatricial narrowing.
The best way to avoid the development of postcholecystectomy syndrome is the most thorough preoperative examination of not only the gallbladder, but also other abdominal organs, as well as full confidence in the advisability of cholecystectomy and in the ability of the surgeon to do it.
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