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II. ДИАГНОСТИКА
COMPARATIVE EVALUATION OF DIFFERENT TYPES OF CHOLECYSTECTOMY
RaimzhanovaA.B. ABOUT ™E AUTHOR „ ,
Aygerim B. Raimzhanova - Master of Surgery, Department of Surgery, Semey
Semey State Medical University, Semey, Kazakhstan, Department of Surgery 'S^lMea^o.'^i.ru,
mob.+7-777-391-88-82.
Abstract K .
In this study, there are the advantages and disadvantages of various methods of cholycystectomy including postop- ,, . .
cholecystectomy,
erative complications, mortality, middle presents of patients in the hospital and rehabilitation terms. The indications and Mim-Assistant contraindications of traditional and minimally invasive surgery of cholelithiasis are analyzed. cholelithiasis. '
Холецистэктомияньщ эртурл1 эдютерш салыстырмалы багалау
Раимжанова А.Б. автортуралы
Раимжанова Айтерш Бауыржанк^1зы -СММУ магистранты,
Семей мемлекетткмедициналык,университе"п, Семей к,., Казахстан, Хирургия кафедрасы eT'mf7fff9i°88@2ait'ru,
Ацдатпа Туй!н свздер
Бул зерттеу, холецистэктомия v/pni эдютерш артык,шылык;гары мен кемшшнаерi операциядан кеишп холещстжтомт
аскынулар, ел1м-жтм, орташа аурухана болу жене оцалту кезец бер'шген. Дэстурл1 инвазивл хирургия жэне ет мини-ассистент, '
тас ауруы кезшде- yrniH керсетш1мдер мен кдрсы керсетш1мдер талдайды. ет тас ауры
Сравнительная оценка различных способов холецистэктомии
Раимжанова А.Б.
Семейский государственный медицинскийуниверситет, г. Семей, Казахстан, Кафедрахирургии
об авторе
Раимжанова Айгерим Бауыржанкызы - магистрант СГМУ, e-mait: aaaa9°. 1°@mait.ru, т. +7-777-391-88-82.
Аннотация
В представленной работе приведены преимущества и недостатки различных способов холецистэктомии с учетом послеоперационных осложнений, летальности, среднее пребывание больных в стационаре и сроков реабилитации. Анализируются показания и противопоказания к традиционной и миниинвазивной хирургии желчнокаменной болезни.
Ключевые слова
холецистэктомия, Мини-ассистент, желчнокаменная болезнь.
Surgical treatment of complicated gallstone disease remains an ongoing problem in hepatobiliary surgery despite the fact that a lot of research work and scientific articles have been published about this section of abdominal surgery. According to recent studies, about 10-15% of people in the world sufferfrom gall stones [1,2].
Currently, there are three main ways of doing cholecystectomy: Open, Laparoscopic and Endoscopic (Natural Orifice Transluminal Endoscopic Surgery) Open cholecystectomy (OC) can be divided into Traditional cholecystectomy (TC) and Mini cholecystectomy (MC) whereas Laparoscopic cholecystectomy (LC) can be divided into conventional Multiport Laparoscopic cholecystectomy (MPLC) and Single Incision Laparoscopic cholecystectomy (SILO).
OC as proposed by S. Langenbuch in 1882 remained an effective treatment for gallstones till the 80s. All surgical approaches in the TC provides a full audit of the liver, gallbladder, biliary tract, pancreas and duodenum, thus allowing the surgeon to perform an entire range of operations on the gall bladder and the hepatic ducts. In addition to the above, the advantage of performing TC when there is significant inflammation or scarring in the Calot's triangle, results in decrease incidence of iatrogenic injury to the biliary tree at the Porta Hepatis.
Disadvantages of the TC include:
1. Surgical trauma, which can result in the development of postoperative intestinal paresis (ileus), decrease in respiratory function and limited physical activity ofthe patient [2].
2. Interference in vascular perfusion and de-innervation of the anterior abdominal wall muscles results in an increase in early and late wound complications with resultant development of postoperative ventral hernias (6 to 18.1%) [2,3,4].
3. Mechanical trauma and drying of the peritoneum results in the development of aseptic inflammations, which subsequently leads to the development of adhesive disease [5].
4. Significant cosmetic defect [2,5,6].
5. An increase in hospital stay with consequent long period of rehabilitation [2,5].
Laparoscopic cholecystectomy (LC- MPLC) was first performed in Germany in 1985 by Erich Muche and in France in 1987 by P Mouret. It was a turning point and a major achievement in surgical hepatol-ogy towards the end of the twentieth century and has become the «gold standard» in the surgical
treatment of gallstone disease. It forced many in the surgical community to radically review their views and attitudes towards this new surgical technique.
The advantages of this (LC) method include: minimal surgical trauma, early mobilisation of patients with less pain, decreased incidence of postoperative ileus, decrease in average hospital stay, reduce morbidity, better aesthetics and consequently decreased hospital resource use.
Although widespread Laparoscopic cholecystectomy in clinical practice has not completely replaced the traditional cholecystectomy (TC), primarily because of certain specific contraindications. These are, severe concomitant cardiovascular and respiratory diseases, portal hypertension, morbid obesity, late pregnancy, upper abdominal adhesive disease, coagulopathy, suppurative and inflammatory changes in the anterior abdominal wall, large ventral hernia, Mirizzi's type 2-4,etc. In addition, it is also important to take into account the high cost of specialised equipment required in laparoscopy. [7,8,9,10,11].
According to several prominent authors, the rate of complication in Laparoscopic cholecystectomy is 3.6-13.3% with a mortality rate of 0.081.2% [12,13].
In addition, it has been shown that C02 insufflation used to create pneumoperitoneum can cause intra abdominal problems. The main causes that lead to these pathophysiological changes are an increase in intra abdominal pressure and C02 absorption. Also, in patients with underlying cardiovascular and respiratory compromise, the incidence of significant hypercapnia and acidemia cannot be corrected without interrupting C02 pneumoperitoneum which in turn can be an inconvenience for the operating surgeon (14,15) as the working space is limited due to low intra abdominal pressure (8 - 10 mm Hg). Also, an increase in intra abdominal pressure of over 14 mm Hg due to C02 pneumoperitoneum can lead to intra abdominal vein compression resulting in decrease in blood flow in the IVC, which in turn can cause haemodynamic instability. Laparoscopic cholecystectomy performed in patients with morbid obesity can sometimes lead to the development of fatal mesenteric thrombosis or mesenteric ischaemic as a result of mesenteric vascular compromise [16].
Numerous studies have shown that patients with underlying severe HTN, cardiac and respiratory insufficiency undergoing Laparoscopic cholecystectomy especially in Fowler's position significantly increasestheir anaesthetic risk [17,18,19,20].
These same researchers, if during laparoscopic cholecystectomy verification of tubular structures of the gates of the liver is not given possible, in this situation is recommended to go to a traditional cholecystectomy. This reduces the risk of damage to the bile duct and cystic artery bleeding.
In recent years, surgeons with limited laparoscopic expertise are widely advocating and performing Mini-Cholecystectomy in patients with complicated GS disease with the help of a special retractor called "Mini Assistant". This apparatus, the "Mini-Assistant" has greatly expanded the range of surgical procedures being performed on the gallbladder and adjacent structures, hence, improving the immediate and long term results of surgical treatment of patients with complicated GS disease.
The main advantage of Mini-Cholecystectomy is a combination of both the traditional and laparoscopic surgery with good traditional views and minimal surgical trauma and postoperative complications [24].
This method/approach has several advantages over existing traditional methods, important of which are good visual inspection and audit of hepatobiliary tree gallbladder and elements hepatoduodenal ligament, the operation not only from the neck, but also on the bottom as well as keeping volume and natural colors of fabrics. In addition, considerable importance is the preservation of tactile fingersurgeon [25,26].
Mini-Cholecystectomy does not always require general endotracheal anesthesia (GEA). This is especially important in elderly patients with concomitant co-morbidities in whom GEA and C02 pneumoperitoneum are undesirable. Thus, such pts can still have their required surgical intervention, i.e, Mini-Cholecystectomy using epidural anaesthesia.
Unfortunately, such patiens often tend to have complicated GS disease with the development of subhepatic collections, Cholangitis, Choledocholi-thiasis, etc.
The advantages of Mini-Cholecystectomy as compared to Lap Chole are:
1. No requirement for C02 pneumoperitoneum for performing cholecystectomy and hence no inadvertent intra abdominal changes.
2. The added advantage of direct vision and manual palpation of the gallbladder, bile ducts, liver, pancreas (HOP), duodenum and the stomach.
3. Minimal chance of inadvertent perforation of the gallbladder wall during retraction and dissection of the GB with consequent advantage of no spillage of intra luminal contents into the peritoneal cavity.
4. Advantage of performing classical operations on the CBD like choledochotomy with T-tube drainage and or bilioenteric anastomosis.
5. The advantage of performing additional surgical procedures if required like bilioenteric anastomosis, Roux-en-Y hepaticojejunostomy, etc.
6. Ease of conversion to Paramedian incision, if required [27,28,29].
With the help of «Mini-Assistant» retractor, surgeons at this institution have been able to conduct reconstructive operations on extrahepatic biliary strictures, e.g, Choledochojejunostomy, Roux -en-Y hepaticojejunostomy, etc and if required transhepatic drainage as per Prader-Smith [30 31].
The main contraindication for using the "MiniAssistant" retractor in performing cholecystectomy is the presence of biliary peritonitis, which in itself can bring a complication of Acute Gangrenous Cholecystitis.
The postoperative complications after Mini-Cholecystectomy is significantly lower at 1.9% -4.9% as compared to LC. The percentage of postoperative mortality is about the same and is in the range of 0.8-1.2% but it should be born in mind that Mini-Cholecystectomy is often performed on patients with complicated GS disease like Gangrenous Cholecystitis, Obstructive Jaundice and Cholangitis. The majority of these patients are also often elderly with significant co-morbidities [7].
In this study the effectiveness of using "Mini-Assistant" retractor was measured in terms of average duration of operation, the average postoperative hospital stay, the amount of analgesia (including narcotics) given to the patients in the postoperative period and the average cost of equipment required for performing cholecystectomy.
Since 2002 there has been extensive and widespread use of "Mini- Assistant" retractor in surgical practice especially interventions on GB and biliary tree including complicated forms. We believe its use is unduly restricted by many surgeons because of the lack of experience with "Mini-Assistant" retractor. Also, we have advocated its use in Mini-Cholecystectomy by surgeons who have extensive experience in GB and biliary tract surgery.
Given the above Mini-Cholecystectomy performed using the retractor «Mini-Assistant» has proved to have extensive clinical use in abdominal surgery and has improved the immediate and long term results of surgical treatment of complicated gallstone disease, hence reducing the overall morbidity and mortality rate.
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