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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_725_Библиотеки_им_академика_М_И_Перельмана
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dissection,beforefibrosisensuesandmakesanatomyunclearand
surgerymoredifficultanddangerous.
Delayingcholecystectomy maybejustifiedalso inotherspecific
situations.If the patientpresentslate, after a fewdaysof disease, the
operationmayprovedifficult,withahigherrateofconversionandhigher
riskofcomplications.Youareprobablyfamiliarwiththe‘golden72hours’,
although you should not take it too literally — some patients have an
‘easy gallbladder’ even later, while others will have a horrendous,
gangrenous one after 24 hours. Medically unfit patients may also
benefit from delayed surgery, after optimization, proper evaluation and
preparation. However, this is a double-edged sword, as these frail
patients can also succumb more easily to an untreated septic
source. So use your judgment — good judgment comes from
experience;experiencecomesfrombadjudgment.Andsoitgoes.
Gallbladderdrainage
Gallbladder drainage is another option to temporize the acute
condition, by relieving the intra-gallbladder pressure and draining
theinfectedbile.It is aneffectivesolutionforthehigh-risk patient
(e.g.acutecholecystitisafewdaysafteranacuteMI),andforfailed
‘conservative’treatmentafewmoredaysintothediseaseprocess.
Performedpercutaneously,transhepatically,underimaging(USorCT)
by the interventional radiologist, or rarely — if the latter option is not
available—underlocalanesthesiaasanopenprocedurebyyou,itwill
usuallybringtheconditionundercontrol,withrapidclinicalimprovement.
In many cases it will also leadto dislodgmentof the obstructing stone,
andifbilestartstoflowdownthetube,andatubecholecystogramafew
dayslatershowsfreeflowofcontrasttothecommonbileduct(CBD)and
duodenum,youcansafelycorkthetubeuntilintervalcholecystectomy,68weekslater.Don’texpectittobeaneasycase!
As a ‘footnote’onehas to mentionhere that it is notwritten in the ‘Bible ofSurgery’that all
patients treated conservatively, or after successful percutaneous drainage, must undergo an
intervalLC.Beselective:youcanleavetheold,frail,highriskandasymptomaticalone!
Longitudinalstudiesandauditsrevealthatmanypatientsallowedto‘cooldown’nevercometo
surgery,foravarietyofreasons.Recurrentproblemsarenotinevitable.
Operativemanagement
Emergency cholecystectomy is rarely a true emergency, requiring
you to rush to the OR, unless you are dealing with the rare free
perforation with bile peritonitis, or with Clostridium-induced,
emphysematous cholecystitis. Remember that even with these
conditions,abriefresuscitationisamust.
Early cholecystectomy, as mentioned above, is the preferred
approach for mostcases of acute cholecystitis. The definition of ‘early’
may differ between surgeons and systems, but operating in the next
availableOR list,orafter-hours inthe ‘emergency’list,isacceptable as
longasit isdonewithinadayortwo.Operatingafter72hoursisnot
recommended—butstillpossible.Somepatientswillimprovequickly
after the initial non-operative therapy; this may mean that they had a
‘protractedbiliarycolic’andnotatrueinflammation,butnevertheless—if
youcangetridofthesourceandsendthemhomewithoutagallbladder,
theymaybenefit.
The algorithm on the facing page summarizes our recommended
approach( Figure20.1).
Figure20.1.Algorithmforthetreatmentofacutecalculouscholecystitis.
Theoperation
Laparoscopic cholecystectomy (LC) is the standard approach,
although the rate of conversion is higher than in elective cases.
Somestill preferanopen approachfromthestart foracutecases.
So,howshouldyoudecidehowtoproceed?
Itisrarenowadaystostartwithopensurgery,unlessthepatientisvery
unwellandyoudonotthinkitagreatideatopumphistummywithgas;
but then think again if surgery is what he needs now. The need to
convert a lap approach to an open procedure is related to local
inflammatory conditions and inversely related to your own
expertise,but what should reallyguide youisthe progress of the
operation.
Strugglingwithoutmakingprogress(45-60minutesofnorealprogressisanacceptable
rule of thumb) means that your chance of harming the patient increases, and you
shouldchangestrategy—callingforhelpisonesuchpossiblechange.
With the decreasing exposure of young surgeons to open
cholecystectomy, opening up is not always asafe option(what we call
the‘unlearningcurve’),andfindingagrey-hairedsurgeontoassistyouis
notabadidea.Yes,sometimesoneofthose‘oldfarts’mayproveuseful!
There are some technical ‘tricks’ that you may use to improve
yourchancesofsuccessfullyandsafelycompletingadifficultLC:
•
Decompressthedistendedgallbladder(youmayuse theVeress
needle inserted through the abdominal wall or a special ‘needletrocar’). After aspiration of the contents, grasping the ‘eggplant’
becomeseasier...
•
Addafifthorevensixthtrocartoimproveretractionofstructures
thatobliterateyourview,especiallyinobesepatients.
•
Use gravity: make sure, before the operation, the patient is well
secured to the OR table, and make your anesthetist give you a
steepreverse-Trendelenburgandleft-tiltposition.
•
Usethesuctiontipliberally;itisagooddissectiontool,especially
forthe‘wet’,edematousgallbladder.
•
Indifficult-to-graspgallbladderstrytomilkthestonebackupfrom
Hartmann’spouch into the fundus,or just push thegallbladder up
withanopeninstrument.
•
Adheringtotheprinciplesofa‘criticalviewofsafety’(CVS)is
evenmoreimportantinacuteconditions,whenanatomytendstobe
distorted.Ifit’snoteasy—gohigherandfindtheplanebetweenthe
liverandthegallbladder,andtrytocomebackdownfromthere.This
istheequivalentoftheopen‘fundus-down’technique,whichisless
suitableforlaparoscopicperformance.AchievingaCVSisprobably
more difficult when operating on a hot gallbladder, but not less
important,somakesureyoureallyhaveit.Dictatingthatyoudidis
notenough...
•
Whileuncontrolledbleedingshouldmakeyou convert quickly,
rememberthatyoudon’thavetopanic,asmosthemorrhagecanbe
controlled, at least partially, by pressure. Instead of frantic and
dangeroushemostaticattempts,insertagauzeandapplypressure,
waitafewminutesandreassess.
Wehopethatthereisnoneedtoexplainthe‘criticalviewofsafety’.Butifyouarenotfamiliar
with this term please do read Chapter 16 in Schein’s Common Sense Prevention and
Managementof Surgical Complications, foran in-depth discussionon how toavoid problems
(andmanagethem)ingallbladderandbiliarysurgery.TheEditors
Conversion,andopencholecystectomy
Apart from non-progression ( Figure 20.2), and difficulty in defining
anatomy,youmayneedtoconvertforbleeding,or—andthismeansyou
didnotconvertearlyenough—forbileductinjury(clearbileissuddenly
accumulatinginyoursurgicalfield?Somethingiswrong!).
Don’t expect the conversion toeasily solveyour problems, and
continue to be alert, suspicious and careful. You need the best
possibleworkingconditions—exposureandlighting,somakesureyou
have good assistance, proper retraction, and accessories such as a
head-light, if needed. The most important thing is changing your
mindset: this is no longer minimal access, so act accordingly. Forget
about ‘connecting the dots’ (if they do not fit) between your trocars,
resulting in a strange and inconvenient incision — make a proper
subcostal incision thatwill allow you to work comfortably.Forget about
‘mini-cholecystectomy’ unless you have your own experience with this
procedure—this isnotthe timetosaveafewcentimetersbuttomake
sureyoucompletetheprocedurequicklyandsafely.Unlikelaparoscopy,
afteryouhaveconverted,theretrograde‘dome-down‘cholecystectomyis
the one we recommend — staying near the gallbladder wall and
progressing toward the cystic duct and artery, to be disconnected last.
What about a drain? Probably not if you feel the cystic duct was well
secured,butleavingoneisnotasin.
Figure20.2.“Ineverconvert…”
Again,wehaveneverseenapatientdyingbecausehewasconvertedtoopen;wehaveseen
themdyingbecausetheywerenotconverted.
Alternativeapproachestoavoidzures
1
Insomecasesyouneedtoactdifferentlyinordersaveyou(and
the patient…) from big troubles. This is commonly the situation in
‘neglected’ cases, operated late in the disease process, with a lot of
pathology and little normal anatomy. Sometimes even ‘cooled down’
cases, operated weeks after the acute infection, may be surprisingly
challenging — with a chronically contracted, thick-walled gallbladder,
commonly described by the pathologist as ‘xanthogranulomatous’.
Interestingly,some‘chronicgallbladders’withaclearhydrops(mucocele)
or even frank empyema can be clinically silent. Your initial surprise
should be quickly transformed into a decision about how to
progresssafelywithalowriskofcomplications.
Subtotal(partial)cholecystectomy
Our old friend, Asher Hirshberg, summarized it aptly: “Itis better to
remove95%ofthegallbladder(i.e.subtotalcholecystectomy)than
101%(i.e.togetherwithapieceofthebileduct).”
Andyes,yes,yes—anyweatheredsurgeonwilltellyouthatthisis
the procedure to use, in order to avoid misery in problematic
situationssuchasascarred,‘impossible’triangleofCalot—when
inflammatorychangesobscuretheanatomyinsuchawaythatthe
riskofbileductinjuryissignificant.It is also useful in cases where
the risk of bleeding from the liver is significant, as in cirrhosis or
coagulopathy.
PartialorsubtotalcholecystectomyhasbeenpopularizedintheUnited
States by Max Thorek (1880-1960) and thus some call it the Thorek
procedure. Thorek, by the way, was a keen aphorist and also said:
“…howoldisournewestknowledge,howpainfullyandproudlywe
struggletodiscoveries,which,insteadofbeingnewtruth,areonly
rediscoveriesoflostknowledge.”
How should you perform a partial or subtotal cholecystectomy? It
seemstousthatthismostvaluabletechnique,whichhassavedourbutt
numerous times, is notwell known to the new generation of surgeons.
Hence,wewillgointodetailsbelow.
Duringopencholecystectomy
Open the gallbladder at the fundus, empty it from all contents. Now
startcarvingoutthegallbladder(wedoitwiththediathermy)leavingits
posteriorwallattachedtotheliver.Hemostasisoftherimoftheremnant
isachievedwiththediathermyandclipsorVicryl®3-0sutures.Whenyou
reach the level of the Hartmann’s pouch, make sure that all impacted
stoneshavebeenevacuated—nowyoucaninsertyourindexfinger,or
instrumenttip,allthewaydowntotheinternalopeningofthecysticduct,
whichcan beoftenvisualized fromwithin. Theaccurateplacement ofa
purse-stringsuturearoundthisopening,asdepictedbyartists’drawings,
isnotsatisfactory,becausethe suture tends to tear out of the inflamed
and friable tissues. A better option is to leave a 1cm rim of
Hartmann’spouchtissueandsuture-buttressitovertheopeningof
the cystic duct (we use 2-0 Vicryl®). The exposed mucosa of the
posteriorgallbladderwallisfriedwithdiathermy(somesayuntilyousmell
friedliver…)and the omentum is broughtintothe area. Finally, leave a
drainbelowthe gallbladderremnant;usually youwon’tseeevena drop
of bile in the drain because in such cases the cystic duct is obstructed
duetotheinflammatoryprocess.However,intherarecasewhenabile
leakdevelops,thedrainwillsolvetheproblem.
What to do if you find that it is impossible to close the cystic
duct/gallbladderremnant?Don’tpanic:itisabsolutelysafejustto
leaveasuctiondrainandbailout.Thedrainwill beproducingbile
forafewdays,upto2weeks,buteventuallyitwilldryout!
Duringlaparoscopiccholecystectomy
The gallbladder is opened at a ‘safe and comfortable’ location, at
Hartmann’s pouch or above, and the contents evacuated. Have your
suction ready, and place a specimen collection bag inside —
throughanaddedportifneeded—tocollectthestonesbeforethey
spill. At this point you can easily look inside towards the gallbladder
outlet and make sure you clear all stones obstructing the cystic duct.
Complete the transection of Hartmann’spouch, and close the remnant
(youcan suturethe cysticduct fromwithin,orsuture-closethe remnant
fromoutside,orsimplyplaceanEndoloop®aroundit).Nowcompletethe
removalofthe body and fundus — you can leavetheposteriorwall on
theliverandfulguratethemucosaiftheriskofbleedingishigh.Leavea
drain.Theendresultisdepictedin Figure20.3.
In conclusion: in this operation, the structures in Calot’s triangle are not dissected out and
bleedingfromthehepaticbedisavoided;itisafastandsafeprocedurehavingtheadvantages
ofbothcholecystectomyandcholecystostomy.
There is a caveat: arare (so rareas to deserve being published as
isolated case reports) complication of subtotal cholecystectomy is the
late enlargement of the gallbladder remnant presenting as
symptomatic cholelithiasis, with ultrasound reporting “stones within the
gallbladder”.Themost commoncauseis faultytechnique,andfailureto
evacuatethestonescompletely.Differentialdiagnosiswouldincludelate
enlargement of the cystic duct remnant and a duplication of the
gallbladder (one of which wasmissed during the initial operation).This
complicationhasbeenalsodescribedfollowing‘conventional’LC,where
thesurgeondividedandoccludedHartmann’spouchinsteadofthecystic
duct. Whatever the specific cause, the treatment is a ‘recholecystectomy’ (open or lap) with pre-operative bile duct imaging,
providingaroadmapforthebiliaryanatomy.Sowhendoingasubtotal
cholecystectomyalwaysmakeadetailedoperativereportjustifying
what was done andwhy,and explainit tothe patient — thuspreemptively suppressing any future lawsuit. (“He did not tell me that
partofmygallbladderisstillinside…”).
Figure20.3.Subtotal cholecystectomy.Theendresultofsubtotalcholecystectomy,beit
laparoscopicoropen.Thebluearrow points to the ‘rim’ofthe gallbladder remnant. The
blackarrowpointstotheinsideoftheremnantanddowntotheHartmann’spouch,which
isnowclearofstonesandtowardstheinneropeningofthecysticduct.Ifyoucanclose
theremnantwithsuturesthendoit;butsometimes,asinthiscase,itisimpossible...so
justleaveadrain.Donotworry—everythingwillbealright!ImagecourtesyofDr.Kristoffer
Lassen,Oslo,Norway.
Surgicalcholecystostomy
Another option to bail out in difficult situations is to do a
cholecystostomy. This procedure is rarely performed nowadays, as
percutaneoustechniquesprevail,butoccasionallyyoumay findyourself
alone with a patient in such an extreme condition, that he will be best
served by a short procedure under local anesthesia. Another plausible
situation can arise during a planned LC when the gallbladder appears
‘impossible’—say,anobliteratedgallbladderinamorbidlyobesepatient:
youdonotwanttoconvertandyouarenotcomfortablewithlaparoscopic
subtotal cholecystectomy. Whatever the situation, expose the fundus of
the gallbladder,place a purse-string suture, and incise it. Suck out the
contents;evacuatestonesifyoucanbutyourpurposeisdrainage,nota
complete surgical solution. Then insert a Foley catheter into the
gallbladder and inflate the balloon and tie the purse-string, which is
easierdoneduringanopenprocedure.
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