The gallbladder is usually removed when stones form in the cavity of the bladder itself or in the bile ducts. If the presence of stones is not accompanied by any painful symptoms, the doctor may postpone removal, but this is not a cancellation of the operation, but rather a delay - the prolonged presence of stones can lead to perforation of the bladder, the occurrence of a malignant tumor, and the development of an acute inflammatory process.

Acute cholecystitis (inflammation of the gallbladder) is an absolute indication for surgery, as is chronic cholecystitis, which is often recurrent and difficult to respond to drug therapy.

Also, the need for removal arises in the event of obstruction of the bile ducts, dysfunction of the liver or pancreas caused by gallbladder disease, or the development of a malignant or benign tumor.

Is it possible to avoid surgery?

It is impossible to get rid of stones using tablets or herbal decoctions. Sometimes patients believe that by following a strict diet and taking their usual medications, they can avoid surgery or at least postpone it indefinitely. This often ends badly - with advanced cholelithiasis or chronic inflammation, there is a high risk of perforation of the bladder walls, peritonitis, and gangrene of the bladder.

The longer surgery is delayed, the higher the risk of developing liver and gallbladder dysfunction. Over time, the chances of full recovery after surgery decrease.

Fear of cholecystectomy is often caused by misconceptions about this operation, possible complications and lifestyle features after the bladder. Currently, removal is increasingly performed by laparoscopy - this is a low-traumatic method in which surgical manipulations in the abdominal cavity are performed through one or several small punctures.

Laparoscopic operations have a shorter recovery period and are less likely to cause complications. It is also important that puncture marks are less noticeable than the long postoperative scar remaining after open cholecystectomy. However, with advanced disease, laparoscopy may be impossible; traditional open surgery is necessary.

Full recovery after cholecystectomy is possible provided that all doctor’s recommendations are followed. The body's compensatory capabilities are not limitless - if you delay the operation for a long time, returning to your normal lifestyle after it will be much more difficult.

Cholecystectomy Contraindicated in critically ill patients who cannot tolerate general anesthesia, or in cardiac patients who cannot tolerate pneumoperitoneum. Patients with serious liver disease or blood clotting disorders should not undergo laparoscopic surgery. Careful selection is required for patients who have previously undergone operations on the abdominal organs (interventions on the pancreas, liver or gastroduodenal zone). Patients with common bile duct stones that cannot be removed preoperatively should undergo open surgery. Patients with severe thickening or hardening of the gallbladder wall should also undergo open surgery.

Patients with biliobiliary or biliointestinal fistulas, acute gangrenous or perforated cholecystitis, porcelain cholecystitis, and patients with an artificial pacemaker should not undergo laparoscopic cholecystectomy. At the dawn of the use of laparoscopic cholecystectomy, acute cholecystitis was a contraindication for this operation due to the high operational risk. Currently, experienced surgeons operate on 80% of such patients laparoscopically. Despite this, it is necessary to warn the patient that in case of acute cholepistitis, it is often necessary to switch from laparoscopic to open surgery.
In general, it has been noted that the more experienced the surgeon, the less contraindications.

Visit the section.

Preparation for laparoscopy.

For laparoscopic, as for open surgery, if such a need arises later, the patient is placed in a supine position. The surgical site is prepared as usual; The navel is especially carefully treated and disinfected to prevent omphalitis. The surgeon is located to the left of the patient, the second assistant supporting the laparoscope is to the left of the surgeon. The first assistant, operating room nurse and instrument table are located to the right of the patient. The television screen, video recorder, camera control system, light source and electronic carbon dioxide monitoring system are located to the right of the patient's head. The surgeon and the second assistant will face the image on the monitor.

The first assistant will be able to view the television image on another monitor located to the left, at the head end of the operating table.

In France, as well as in some European and Latin American countries, the patient's lower limbs are separated, and the surgeon stands between them. This is the so-called “French position”.

To perform laparoscopy pneumoperitoneum is required. To establish pneumoperitoneum, carbon dioxide is insufflated. since it: (a) is harmless;, (b) dissolves in the blood; (c) diffuses easily; (d) not explosive; (e) does not irritate the peritoneum; (g) cheap. Monitoring the concentration of carbon dioxide during surgery is mandatory.

Usually for overlay pneumoperitoneum use a Veress needle. There are two types of Veress needles: a metal needle for reusable use and a disposable one. The latter is used more often, has an outer diameter of 2 mm and a length of 70 to 120 mm, an obturator with a blunt end and a safety latch. The blunt end of the obturator is designed to cover the bevel of the needle while it is passed through the peritoneum. This provides protection to the internal abdominal organs and blood vessels. Some surgeons prefer to create pneumoperitoneum using the so-called “open” method using a Hasson trocar.

Carbon dioxide insufflation through the Veress needle may cause hypercapnia and acidosis. Therefore, throughout the entire operation, it is important to carry out constant strict monitoring of the activity of the cardiovascular and respiratory systems. If cardiovascular or respiratory problems occur, carbon dioxide must be removed. The Veress needle must be inserted very carefully to avoid damaging the abdominal organs or blood vessels.

To insert the Veress needle and passing a trocar with a diameter of 10-11 mm in the fold of skin directly above the navel, an incision 10 mm long is made. Then, using a blunt method, using a finger or a gauze pad, the subcutaneous tissue is separated to the fascia. Some surgeons make an incision in the crease below the belly button, while others make an incision through the belly button. The patient is in the Trendelenburg position, with an inclination of 15-20. Backhaus clamps are placed on both sides of the navel, grasping the skin, subcutaneous layer and anterior layer of the rectus sheath. The clamps are pulled upward to pull the anterior abdominal wall away from the abdominal organs, which reduces the possibility of injury to internal organs when inserting the Veress needle. When performing this technique, it is important to grasp the anterior layer of the rectus abdominis sheath along with the skin and subcutaneous tissue. After performing this maneuver, a Veress needle is inserted through the incision in the umbilical fold.

Experienced surgeons neglect the Trendelenburg position and do not direct the needle towards the pelvis. At the moment of perforation of the peritoneum with a Veress needle, the click of the needle protective mechanism is clearly audible.

Before carbon dioxide insufflation it is necessary to make sure that the end of the needle is freely located in the abdominal cavity. In order to confirm this, 5 ml of an isotonic solution is injected through a needle into the abdominal cavity. This solution should pass easily into the abdominal cavity and cannot be aspirated back through the same needle. Aspiration through the needle should not produce gas bubbles, indicating perforation of the hollow organ. You can finally verify the correct position of the end of the needle as follows: a drop of isotonic solution placed on the upper end of the needle quickly passes into the abdominal cavity after lifting the anterior abdominal wall using Backhaus clamps.

After making sure With the tip of the Veress needle in the abdominal cavity, begin the administration of carbon dioxide, using at first a slow flow of gas and observing the disappearance of hepatic dullness by percussion. Insufflation is gradually increased until the abdominal pressure reaches 14 mmHg. Art., which usually requires 3-5 liters of carbon dioxide. At this time, the insufflator should indicate low intra-abdominal pressure, allowing gas to flow freely. The hazard alarm should not go off. The patient must be provided with good relaxation.

Laparoscopy of the gallbladder is an endoscopic operation that is performed through small incisions 1-1.5 cm long. Depending on the goals, laparoscopy can be diagnostic (to examine the organ and identify pathology) or therapeutic (most often cholecystectomy is performed - removal of the gallbladder). Sometimes the operation is initially performed for diagnosis, but during the operation the surgeon decides to remove the gallbladder, and diagnostic laparoscopy becomes therapeutic.

Some facts about gallbladder laparoscopy:

• cholecystectomy, removal of the gallbladder, is one of the most common laparoscopic operations;
• the first removal of the gallbladder by laparoscopic method was performed in 1987 in France by the surgeon Dubois (operation through an incision has existed for more than 100 years);
• with the advent of laparoscopy of the gallbladder, surgeons began to increasingly avoid open operations: in modern clinics, in 90% of cases, cholecystectomy is performed laparoscopically;
• but at first the method was perceived skeptically by many doctors - only later was its effectiveness and safety proven.

Today, laparoscopy of the gallbladder has become the “gold standard” in the treatment of gallstone disease. Patients always had a hard time with open operations, and complications often occurred after them. But as long as the gallbladder remained in place, the disease was not cured - the stones formed again. Laparoscopy helped solve this problem.

Features of the anatomy of the gallbladder

The gallbladder is a hollow organ that resembles a sac. It is located under the liver.

Parts of the gallbladder:

• Bottom- a wide end that protrudes slightly from under the lower edge of the liver.
• Body- the main part of the gallbladder.
• Neck- the narrow end of the organ, opposite the bottom.
• Gallbladder duct– continuation of the neck, 3.5 cm long.

The gallbladder duct then connects with the hepatic duct, and together they form the common bile duct, the common bile duct. It is 7 cm long and drains into the duodenum. At the confluence there is a muscle sphincter, which regulates the flow of bile into the intestine.

The upper part of the gallbladder is adjacent to the liver, and its lower part is covered by the peritoneum, a thin film of connective tissue. The middle layer of the organ wall consists of muscles, thanks to which the gallbladder is able to contract and push out bile.

The inside of the gallbladder wall is lined with a mucous membrane, which contains many glands that secrete mucus.

The bottom of the gallbladder is adjacent from the inside to the anterior wall of the abdomen.

The main function of the gallbladder is that it stores bile, which is produced in the liver, and then, as needed, releases it into the duodenum. Typically, the emptying of the gallbladder occurs as a reflex when food enters the stomach.

The gallbladder is not a vital organ. A person can easily do without it. But the quality of life decreases, and certain restrictions are imposed on the diet.

Bile ducts And pancreatic duct in different people they can have different lengths, connect to each other and flow into the duodenum in different ways. Sometimes, in addition to the main duct, additional ones branch off from the body of the gallbladder. The doctor has to take these features into account during laparoscopy.

Options for connecting the bile ducts.

The blood supply to the gallbladder comes from the cystic artery, which arises from the artery that supplies the liver.

What are the advantages of laparoscopy of the gallbladder over incision surgery?

Advantages	Laparoscopy of the gallbladder	Operation through an incision
Less traumatic intervention	4 punctures of 1 cm each.	The incision is 20 cm long.
Lower blood loss	During laparoscopy of the gallbladder, the patient loses on average 30-40 ml of blood.	Blood loss is significantly greater.
Shorter rehabilitation times	The patient is discharged from the hospital after 1-3 days.	The patient is discharged from the hospital after 1-2 weeks
Faster recovery	Performance is fully restored within a week.	Recovery takes 3-6 weeks.
Less pain after surgery.	As a rule, ordinary painkillers are sufficient to relieve pain.	Sometimes the pain is so severe that the patient has to be prescribed narcotics.
Lower incidence of postoperative complications.	Adhesions and hernias form much less frequently after laparoscopy.

What is a laparoscope? How is gallbladder laparoscopy performed?

Endoscopic equipment used by the surgeon during laparoscopy of the gallbladder:

How do you prepare for laparoscopy of the gallbladder?

Tests that may be prescribed by your doctor before laparoscopy:

• Complete blood count and general urine test - 7-10 days before surgery.
• Biochemical blood test - 7-10 days before surgery.
• Determination of blood group and Rh factor.
• Blood test for RW (for syphilis) - 3 months before surgery.
• Rapid blood test for hepatitis B, C.
• Blood test for HIV.

Liver and gallbladder studies may also be ordered before surgery.:

Preparation for laparoscopy of the gallbladder

Before surgery is performed in a hospital, a surgeon and an anesthesiologist approach the patient. They talk about the upcoming operation and anesthesia, provide information about possible consequences and complications, and answer the patient’s questions. At the end, they ask you to confirm your consent to the operation and anesthesia in writing.

It is advisable that the patient begins to prepare for laparoscopy in advance, before hospitalization. The doctor gives recommendations on diet and exercise. This will help make the surgery easier.

Before laparoscopy, chronic diseases need to be treated.

Preparation in hospital:

• On the eve of the operation, the patient is prescribed a light meal. Her last appointment is at 7:00 p.m. - after that you can’t eat.
• On the day of surgery, you are prohibited from eating and drinking in the morning.
• The night before and in the morning before laparoscopy, a cleansing enema is given. The day before the intervention, the doctor may prescribe a laxative.
• In the evening or morning you need to take a shower and shave the hair from your stomach.
• If you take medications, you need to ask your doctor if you can take them on the day of laparoscopy.
• The night before and shortly before the operation, the patient is given special sedatives.
• Before going to the operating room, you need to take off your glasses, contact lenses, and jewelry.

Anesthesia for laparoscopy of the gallbladder

During laparoscopy of the gallbladder, general endotracheal anesthesia is used. First, the anesthesiologist puts the patient to sleep using mask anesthesia or intravenous injection. When consciousness turns off, the doctor inserts a special tube into the trachea and pumps gas for anesthesia through it - this way you can better control your breathing.

How is the operation performed?

The patient is placed on the operating table on his back. Possible provisions:

Each doctor chooses a method that is more convenient from his point of view.

During laparoscopic operations on the gallbladder on the abdomen, 4 punctures are usually made strictly in the established sequence:

• First– just below the navel (sometimes a little higher). A laparoscope is inserted through it, and the abdominal cavity is filled with carbon dioxide using an insufflator. All other punctures are done under the control of a video camera - this helps not to damage the internal organs.
• Second- in the middle just below the sternum.
• Third– 4-5 cm below the costal arch on the right on a vertical line mentally drawn through the middle of the collarbone.
• Fourth– at the level of the navel, on a vertical line mentally drawn through the anterior edge of the armpit.

Sometimes, if the liver is enlarged, a fifth hole has to be made. Today, cosmetic operations on the gallbladder have been developed, which are performed through three punctures.

First, the surgeon always examines the gallbladder and liver and determines the existing pathological changes. If a diagnostic laparoscopy was initially planned, then it may end there or, if necessary, go into a therapeutic one.

If the operation cannot be performed laparoscopically, the surgeon makes an incision.

After laparoscopy of the gallbladder is completed, sutures are placed at the puncture sites (usually one suture for each puncture). Subsequently, barely noticeable scars remain in these places.

Indications for diagnostic laparoscopy of the gallbladder

• Suspicion of a malignant tumor of the liver or gallbladder when it cannot be detected using other diagnostic methods.
• Determining the stage of a malignant tumor, its germination into neighboring organs.
• Liver disease that cannot be accurately diagnosed without laparoscopy.
• Accumulation of fluid in the abdomen, the causes of which cannot be determined.

Laparoscopic gallbladder surgery

Currently, the following types of surgical interventions are performed for diseases of the gallbladder:

• severe swelling of the gallbladder and surrounding tissues, which does not allow laparoscopic surgery to be performed safely;
• a large number of adhesions;
• suspicion of a malignant tumor of the gallbladder or bile ducts;
• fistula between the gallbladder and intestines;
• destruction of the gallbladder wall as a result of the inflammatory process, an abscess in the gallbladder area;
• vascular damage and bleeding;
• damage to the bile ducts;
• damage to internal organs.

How is the postoperative period going?

• On the day of surgery, the patient is usually allowed to stand up, walk and eat liquid food.
• The next day you can eat normal food.
• Approximately 90% of patients can be discharged within 24 hours after surgery.
• Within a week, performance is restored.
• Small bandages or special stickers are applied to postoperative wounds. The stitches are removed on the 7th day.
• After surgery, you may experience pain for some time. To relieve them, regular painkillers are used.

What complications are possible after laparoscopic gallbladder surgery?

Complications are possible with any operation, and laparoscopy of the gallbladder is no exception. Compared to open surgery through an incision, interventions using endoscopy have a very low risk of complications - only 0.5%, that is, in 5 out of 1000 operated on.

Main complications of gallbladder laparoscopy:

• Bleeding due to vascular damage. Bleeding at the site of trocar insertion can most often be stopped with sutures. Bleeding from the liver can be stopped by electrocoagulation. If a large vessel is damaged, the surgeon is forced to make an incision and continue the operation openly.
• Damage to the bile ducts. This also often requires a transition to open surgery. If bile remains in the abdominal cavity, this will lead to the development of inflammation. Moreover, after laparotomy, the patient experiences severe pain under the right rib and body temperature rises.
• Suppuration at the surgical site. Occurs rarely. It is easy to deal with due to the small size of the punctures. The doctor prescribes antibiotics. If an abscess forms under the skin, it is opened.
• Damage to internal organs. Most often, liver damage occurs during gallbladder laparoscopy. Slow bleeding occurs - it can be easily stopped using an electrocoagulator.
• Damage to the intestine during puncture of the abdominal wall with a trocar. In most cases, an incision must then be made and the damaged intestine sutured.
• Subcutaneous emphysema- accumulation of gas under the skin. This occurs if the trocar did not enter the abdominal cavity, but under the skin, and the doctor began to supply air with an insufflator. Most often, this complication occurs in people who are overweight. A swelling forms at the puncture site. This is not dangerous - the gas usually resolves on its own. Sometimes it has to be removed with a needle.
• Spread of tumor throughout the abdominal cavity. If the patient has a malignant tumor of the liver or gallbladder, then during laparoscopy tumor cells may spread throughout the abdominal cavity. The patient experiences symptoms that resemble inflammation. And only later, during the examination, metastases are detected.

Inna Lavrenko

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The gallbladder, which forms the biliary system with the liver, is an important organ of our digestion. It is responsible for accumulating bile produced by the liver, bringing it to the required concentration and supplying this liver secretion to the intestines when food enters there. Bile breaks down heavy fats, has an antibacterial effect and stimulates pancreatic secretion.

Gallstones

Alas, like other internal organs, the gallbladder is susceptible to various diseases, some of which can only be treated with surgery, which involves removing the entire organ.

This operation is called cholecystectomy. It is performed both in the traditional abdominal method and using laparoscopy (removal of the organ through small centimeter punctures in the wall of the abdominal cavity).

The first technique is used in emergency cases and when laparoscopic intervention is contraindicated for some reason. Planned operations are usually performed laparoscopically, since it is less traumatic and minimizes the risk of postoperative complications, and the rehabilitation period after such an operation is much shorter than after abdominal surgery. What are the indications for removing the gallbladder? This is the topic of our article.

Indications for cholecystectomy surgery:

• cholelithiasis (the presence of stones in the bladder cavity 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 serious complications.

The most common reason for cholecystectomy is cholelithiasis. The essence of this pathology is the formation of stones (calculi) in the cavity of the bladder, 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, clogging them. If the lumen of the duct is completely blocked, immediate surgery is necessary. If the stones are large or there are many of them, a planned cholecystectomy is also recommended, the purpose of which is to prevent possible serious complications.

Gallstone disease (GSD) - description and signs

At the early stage of stone formation, this pathology may not manifest itself for a long time and not bother the patient. This complicates its diagnosis and often stones in the bladder are discovered 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 may increase after eating fatty foods, with increased physical activity and as a result of stress.

As a rule, against the background of cholelithiasis, an inflammatory process (cholecystitis) occurs, which adds high temperature, chills and fever to the already listed symptoms.

The most serious consequence of the development of cholelithiasis is the migration of stones into the bile duct and its blockage. In this case, severe sharp pain occurs, the outflow of bile is disrupted, and the pressure inside the bladder increases. A painful attack can last up to several hours and be accompanied by vomiting, the masses of which contain bile.

No less dangerous complications of cholelithiasis due to cholecystitis are abscesses, tissue necrosis and perforation (violation of the integrity of the organ membrane), which leads to bile 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 difficult cases, the following diagnostic methods are additionally used:

• X-ray;
• intravenous cholecystocholangiography;
• MRI (magnetic resonance imaging);
• CT (computed tomography).

As a rule, with early diagnosis of this pathology, if the size and number of stones do not cause serious concern, and the patient does not complain of any negative symptoms, doctors begin drug treatment and take a wait-and-see approach, constantly monitoring the course of the pathology. A prerequisite for such conservative treatment is adherence to 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 stones 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 small stones 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 the size and location of gallstones. If no conservative measures lead to the desired result, surgery is prescribed.

The main indications for cholecystectomy for cholelithiasis are:

Surgery to remove the gallbladder

Contraindications to laparoscopic surgery to remove the gallbladder

Despite the fact that most of these operations are performed using minimally invasive laparoscopic techniques, this intervention also has a number of contraindications. For example, laparoscopy cannot be performed if the patient has previously undergone any surgical operation on the abdominal organs.

This operation is also contraindicated if:

• the presence of pathologies of the cardiovascular system;
• respiratory diseases;
• with obstructive jaundice;
• in late pregnancy;
• in the presence of diffuse peritonitis;
• in the presence of malignant processes.

It is also prohibited to perform surgical intervention in case of blood clotting disorders, in case of atypical location of the internal organs of the abdominal cavity and in the presence of a pacemaker in the patient. If laparoscopy is contraindicated for the patient, but surgery is still necessary, they resort to traditional abdominal cholecystectomy.

In the absence of this organ, the body needs time to adapt to new living conditions. Since bile has nowhere to accumulate, it constantly flows through the bile ducts into the intestines, irritating its mucous membranes. In addition, not reaching the required concentration, liver bile does its job of breaking down food much worse. In this regard, the body needs help in normalizing bile flow and the digestion process.

The main thing to remember is that after cholecystectomy it is imperative to follow diet No. 5.

Its main principle is fractional nutrition (frequent (five to six times a day) small portions of food at equal intervals. Food should be warm, not hot or cold. You can cook it 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 mayonnaise), herbs and spices.

Laparoscopic method of gallbladder removal

Also prohibited are alcohol, carbonated drinks, all types of mushrooms and legumes, sour fruits and berries, vegetables with a high content of essential oils (garlic, radishes, spinach, sorrel, etc.), fast food, sweets, baked goods and other products harmful to the gastrointestinal tract. It is recommended to consume dietary types of meat (veal, rabbit, chicken, turkey), low-fat fish, cereals (in the form of porridges and soups), vegetables, sweet fruits and berries, vegetable oil, dried fruits and other healthy foods. For sweets, you can have honey, marshmallows and fruit marmalade.

It is also necessary to limit physical activity and engage in physical therapy. The combination of all of the above requirements and constant medical supervision will help you return to a full life.

Introduction

Gallbladder removal is the most commonly performed surgery. Today, gallbladder removal is performed laparoscopically. The medical name for this operation is laparoscopic cholecystectomy.

Absolute indications for cholecystectomy

· acute cholecystitis;

· chronic cholecystitis with a usual history (recurrent biliary colic) and non-functioning gallbladder (according to ultrasound or cholecystography);

common bile duct stones:

· in persons under 70 years of age - ERCP; sphincterotomy; according to indications - cholecystectomy;

· in persons over 70 years of age and in the presence of a high surgical risk, endoscopic sphincterotomy gives less mortality, but the risk of relapse of choledocholithiasis remains;

· gangrene of the gallbladder - urgent cholecystostomy (safer than cholecystectomy), cholecystectomy is possible in the future, but often you can limit yourself to spontaneous closure of the wound;

· intestinal obstruction caused by a gallstone - surgery to eliminate intestinal obstruction followed by cholecystectomy.

Relative indications for surgery

chronic calculous cholecystitis, if the symptomatic manifestations of the disease are associated with the presence of stones in the gall bladder. In this case, it is necessary to exclude gastric and duodenal ulcers, irritable bowel syndrome, chronic pancreatitis, and urinary tract diseases, which may have symptoms simulating chronic cholecystitis.

Contraindications. The main contraindications to laparoscopic cholecystectomy should be considered:

· severe pulmonary-cardiac disorders;

· disorders of the blood coagulation system;

· late stages of pregnancy;

· malignant lesion of the gallbladder;

· previous operations on the upper floor of the abdominal cavity.

Position of the patient and the operating team

Currently, there are two main positions for the patient (and, accordingly,) surgeons - the American one (the patient is in a supine position, with his legs together) and the European one, in which the patient’s legs are spread apart. We usually use the “American” position of the patient on the operating table, since this position allows us to perform gall bladder surgery in all cases. Only if we assume a simultaneous operation, we use the “European” position of the patient, in which the operator stands between the patient’s legs. In some cases, it is convenient to be located between the assistant’s legs (especially when working together - a surgeon and one assistant), with the surgeon located to the left of the patient.

Main stages of the operation

1.Installation of trocars

After applying pneumoperitoneum through a Verisch needle (usually up to 10 mm Hg), a 10 mm trocar is installed in the paraumbilical area and a laparoscope is inserted. After revision of the abdominal cavity, additional trocars are installed. A second 10 mm trocar is inserted into the epigastrium, and it should be installed so as to enter the abdominal cavity to the right of the round ligament, but as close to it as possible. The next trocar, 5 mm, is installed below the costal arch along the midclavicular line, and the 4th along the anterior axillary line 4-5 cm below the costal arch.

The first trocar is installed in a certain place, then the location of the rest may have some variations. The trocar in the epigastrium should be positioned so as to be to the right of the round ligament, but at the same time as close to it as possible. The trocar should enter the abdominal cavity above the edge of the liver and in an upward and lateral direction (relative to the patient). The third trocar should enter the abdominal cavity below the edge of the liver and go towards the neck of the gallbladder.

The main danger when installing trocars, especially the first one, is the early penetration of the abdominal organs and retroperitoneal space. To avoid this, it is necessary to insert the trocar only after pneumoperitoneum has been established. It is advisable to use a trocar with protection. Even when using a trocar without protection, when inserting it, it is necessary to insert it slowly, clearly controlling the passage of the layers of the abdominal wall and not applying too much force.

The next problem that you may encounter at this stage is bleeding from the abdominal wall. As a rule, it is not intense, but the constant leakage of blood drop by drop makes it difficult to work. Therefore, before starting manipulations, bleeding must be stopped. The most convenient way to do this is to use an Endo-close (AUTO SUTURE) type needle or a so-called furrier’s needle. The needle is inserted parallel to the trocar and the abdominal wall is sutured through all layers.

2. Separation of adhesions

The operating table is moved to the Fowler position (raised head end) and tilted to the left by 15 - 20 degrees. From 4 trocars, the instrument grasps the bottom of the gallbladder and takes it as far upward as possible to the diaphragm. With a pronounced adhesive process, this is not always possible; then the liver is lifted with an instrument and the adhesions are separated. To do this, a soft clamp is inserted from the third trocar, which grasps the omentum soldered to the bladder, and a working instrument is inserted from the epigastric trocar. The adhesions are separated either with scissors or a hook-shaped electrode. “Loose” adhesions are separated bluntly - with a dissector, scissors or a tupper. When separating dense adhesions, it is necessary to carry out all manipulations as close to the bladder as possible, using minimal coagulation. After isolating the bottom of the gallbladder, it is grabbed with a clamp that was used to lift the liver and taken upward to the diaphragm. If the gallbladder is tense and is not captured by the instrument, then puncture is performed. The needle is inserted through trocar 3, the bladder is punctured. After the bile is evacuated, the needle is removed and the bladder is grabbed at the puncture site. After this, the entire bladder is gradually released up to the neck.

The main problems at this stage are bleeding and damage to internal organs. To prevent this, it is necessary to carry out all manipulations almost along the wall of the bladder. If, despite this, the omental vessel is damaged, it can be coagulated. To do this, it is captured by a dissector and coagulated. It is necessary to caution against coagulation “blindly”, as this can cause more serious complications. The bleeding site is washed and dried with an aquapurator, and only under visual control is captured with a dissector.

Damage to internal organs occurs when working in conditions of poor visibility and when using coagulation. If there is an adhesive process with the intestine or stomach, it is necessary to separate them either bluntly or without using coagulation with cuticles.

3. Mobilization of the gallbladder neck

After separating the adhesions, an instrument inserted through 3 trocars grasps Hartmann's pouch and retracts it laterally, opening Calot's triangle. A hook-shaped electrode is inserted through the epigastric trocar to mobilize the neck of the gallbladder. It is safest to use a 3mm tool. First, the peritoneum is dissected in the neck area along both the anterior and posterior surfaces of the bladder. After this, the adipose tissue is separated step by step, using the cutting mode. Minor bleeding in this area can be controlled with coagulation. Isolation of the cystic artery and duct is carried out to the point of their connection with the gallbladder. In this case, it is necessary to clearly ensure that these structures go to the bubble. The artery and duct are clipped separately, placing 2 clips on the proximal segment and one on the distal segment. The artery and duct are crossed with scissors between the clips. Clipping and crossing begin with the artery, since if the cystic duct is crossed, the artery can easily be torn. When crossing structures, coagulation is not used, since the clips heat up and this can cause necrosis of the wall of the duct or artery with the development of corresponding complications.

4. Isolation of the gallbladder from the bed

Further isolation of the gallbladder from the bed is carried out using a hook-shaped electrode subserosally. In this case, bleeding usually does not occur. Bleeding is possible if the discharge occurs through the liver tissue, or if there is an atypical location of a large vessel. Having almost completely isolated the gallbladder from the bed, it is necessary to leave a “bridge” of the peritoneum, the bladder is tilted upward and the bed is examined. If necessary, we coagulate bleeding areas. For coagulation, an electrode in the form of a spatula or ball is used. For diffuse bleeding from the gallbladder bed, argon-enhanced coagulation is of great help.

After this, the bed and subhepatic space are washed and thoroughly dried (in case of “dry” discharge of the bladder, we do not wash). The bridge connecting the gallbladder to the liver is crossed and the bladder is placed in the subphrenic space.

5. Removing the gallbladder from the abdominal cavity

Removal of the bladder from the abdominal cavity is usually performed through an umbilical wound. To do this, the laparoscope is moved into the epigastric trocar, and under its control, a “rigid” clamp is inserted through the umbilical trocar. The gallbladder is grabbed by the neck (preferably by the cystic duct with a clip) and brought to the trocar and, if possible, drawn into it. Together with the trocar, the bladder (or part of it) is brought out onto the abdominal wall. The bubble is captured with a Mikulicz clamp and, if large, is emptied. After this, the wound is expanded if necessary and the bladder is removed from the abdominal cavity.

6. End of operation

After removing the bladder, the umbilical wound is sutured. In this case, it is necessary to apply sutures to the aponeurosis. After suturing the wound, pneumoperitoneum is applied again, the subhepatic space and the gall bladder bed are examined. For convenience, the liver is elevated with an instrument inserted through the fourth trocar. If necessary, the bed is additionally coagulated. The third and fourth trocars are removed under visual control. After removal of the pneumoperitoneum, the epigastric trocar is removed along with the laparoscope, and all layers of the abdominal wall are examined to monitor hemostasis. The wounds are sutured. Possible intervention options associated with the development of endoscopic technology. The appearance of a 5 mm clipper allows the installation of a 5 mm trocar in the epigastrium. The most interesting is the use of tools with a diameter of 2 mm. Their use is possible in not very obese patients without acute inflammation of the gallbladder, in the absence of infiltrates. In this case, trocars (and instruments) of 2 mm are used at points 3 and 4, and a trocar of 3.5 mm is used at point 2. Mobilization of the gallbladder is carried out as usual, after which a 2 mm laparoscope is installed through the epigastric trocar, and a clipper is inserted through the umbilical trocar. In this situation, it is preferable to use a multi-charge clipper. The duct and artery of the gallbladder are clipped. After this, a 10 mm laparoscope is re-installed and, under its control, the artery and duct are intersected, mobilization of the bladder is completed. Removal of the bladder through the umbilical wound is carried out again under the control of a 2 mm laparoscope. With this technique, only the umbilical wound needs to be sutured. No stitches are applied to other punctures.