Laparoscopy of the gallbladder

Laparoscopy is one of the methods of surgical intervention in the abdominal cavity. The procedure can be carried out both for the purpose of diagnosis, and for the removal of organs partially or completely, and for the extraction of stones contained in them. So, for example, the removal of stones from the gallbladder, or the removal of the organ itself occurs, most often, during laparoscopic intervention. Organ laparoscopy is considered to be a safer surgical intervention for the patient than a full-fledged abdominal operation, and the accuracy and success of its implementation directly depend on the skill level of the surgeon.

How does the gallbladder work, what are the dangers of diseases and pathologies of the organ

The gallbladder is a hollow, pear-shaped organ. It is located in the abdominal cavity, in a special recess on the surface of the liver, with which it forms a close functional relationship. The organ is directly involved in the process of digestion of food: it is responsible for the accumulation of bile. In turn, bile is produced by the hepatic parenchyma. While the liver structures are producing bile, it is collected in the bladder.

When food enters the body, the gallbladder ejects the collected fluid into the duodenum, where it, together with the enzymes of the intestine and pancreas, begins the process of digesting the food bolus from the stomach. In addition, the walls of the bladder produce mucus and produce anticholecystokinin, a hormone responsible for relaxing the muscular muscles of the bladder walls. The capacity of the body is about 60-80 milliliters.

Structurally, the gallbladder is represented by the bottom, walls (middle part) and neck. The latter passes into a narrow cystic duct. There is a functional inflection in the region of the neck of the organ, so the neck is located at a certain angle with respect to the body.

An irregular diet, congenital structural disorders and general abnormalities in the digestive tract often become a catalyst for the development of a number of gallbladder diseases. Their consequences are dangerous not only by failures in the processes of digestion of food. Since all elements of the digestive system are closely interconnected, disturbances in the functioning of the bladder, first of all, negatively affect the liver. In some cases, stagnant processes in the organ cause inflammation of the liver tissue, up to biliary cirrhosis.

The gallbladder and bile ducts are prone to the development of such diseases:

• cholelithiasis: cholelithiasis, when stones-calculi are formed in the cavity of the bladder or ducts;
• dyskinesia: violations of the contractile function of the muscular musculature of the organ and ducts;
• cholecystitis: inflammatory and necrotic processes in the walls and cavity of the bladder;
• cholangitis: acute or chronic inflammation of the bile ducts;
• cancerous tumors, benign neoplasms.

The essence of the laparoscopy method: how and why it is performed

Doctors, describing the operation of laparoscopy, focus on the fact that it is less traumatic, safe, effective and fast enough when compared with abdominal operations in the abdomen.

Laparoscopy, in this case, can be understood as an operation to remove the bladder, or as the process of removing stones located in its cavity and ducts, which is carried out in the process of laparoscopic access to the abdominal cavity. It is the peculiarity of the access that the physician uses in the process that distinguishes this operation from other types of surgical interventions. Such access becomes possible through the use of a specific instrument – a laparoscope.

Ordinary abdominal operations are performed through an incision in the anterior abdominal wall, made with a scalpel or other special instrument, that is, by laparotomy. At the same time, the size of the dissection can be quite significant, up to a dozen or more centimeters. After such an operation, surgical sutures are applied to the incision, and a noticeable scar remains.

The laparoscope is a miniature video camera equipped with a light, which is inserted into the patient’s abdomen. To do this, the surgeon does not need to make large incisions in the abdominal wall – a few small punctures are enough. The picture captured by the camera is displayed on the monitor of the device. The doctor gets the opportunity to perform the operation, focusing only on this image. The length of the puncture is usually no more than 20 millimeters. In addition to the laparoscope, special tubes are inserted into the abdominal cavity – trocars or manipulators. Through the cavities of these tubes, the surgeon introduces medical instruments into the abdominal cavity, and can control them.

Trocars have special devices that allow the doctor to cut adhesions, cauterize blood vessels, apply clamps, and perform other necessary surgical procedures.

In general, to perform a laparoscopy, the surgeon will need 3 small punctures. The operations themselves, their methodology and essence, both with laparoscopy and with laparotomy, do not differ in any way.

Why can laparoscopy of stones and gallbladder be prescribed? The attending physician directs the patient for surgery, if necessary:

• remove the gallbladder;
• peel the stones-concretions that are in it;
• control the quality of the previous operation.

Recently, the term “laparoscopy of the gallbladder” is more often used in the meaning of the removal of the organ. According to doctors, if there are too many stones in the cavity and they are small in size, it makes sense to remove the entire organ, since it has already undergone pathological changes and will no longer be able to work normally. Moreover, if only stones are removed, there is a high probability that the bladder will periodically become inflamed in the future, provoking other diseases. If there are few stones and they are small in size, it makes sense to use other methods of getting rid of them, for example, crushing with ultrasound or resorption with drugs with ursodeoxycholic acid.

Advantages of laparoscopy over laparotomy

General abdominal surgery is prescribed mainly in cases where it is not possible to solve the patient’s problem with the help of laparoscopy.

Laparoscopy is the preferred method of invasive treatment because:

• in the process of its implementation, a slight violation of the integrity of the tissues of the anterior wall of the abdomen is required, usually three or four punctures up to 20 millimeters long;
• pain after laparoscopy subsides within a day, provided that the operation was performed skillfully;
• the patient can walk and move 4-6 hours after the end of the procedure (we are not talking about physical activity or complex movements);
• hospital stay after laparoscopy lasts from 1 to 10 days;
• the rehabilitation period lasts much less than after laparotomy;
• scars remaining from punctures are hardly noticeable;
• the risk of postoperative hernia is minimal.

Indications for the procedure: in what cases is laparoscopy prescribed?

Surgical intervention, even if of such a sparing level, must necessarily be justified by objective reasons. The attending physician may prescribe an operation if the patient has such indications for it:

• in the presence of stones in the cavity of the bladder, without accompanying symptoms;
• in case of exacerbation of cholecystitis, in the first two days of an attack;
• if the patient has stones in the bile ducts, and mechanical jaundice is diagnosed;
• established chronic calculous cholecystitis;
• identified polyps and neoplasms in the bladder.

When is it forbidden to perform gallbladder surgery

Contraindications for laparoscopy are specific, due to the atypical technique of the operation itself. So, for example, for patients who have already undergone abdominal operations in the abdominal cavity, laparoscopy is not prescribed, since there is a high risk of touching and damaging adhesions on internal organs with instruments, which can lead to damage to the organs themselves.

Among other contraindications:

• violations of respiratory function, respiratory failure: during the injection of air into the abdominal cavity, the diaphragm may shift, which creates additional difficulties with breathing;
• severe cardiac and pulmonary pathologies;
• peritonitis;
• pregnancy in the third trimester;
• obesity of the second and third stages;
• violation of the function of blood coagulation, if it cannot be corrected;
• acute pancreatitis;
• the presence of fistulas between the intestines and bile ducts;
• installed pacemaker.

Procedure preparation requirements

Surgical intervention of this nature requires special preparation of the patient.

2 weeks before the date of the operation, it is necessary to pass a whole list of tests:

• general blood analysis;
• coagulogram;
• blood biochemistry;
• analysis to determine the Rh factor and blood type;
• women – a smear on the flora of the vagina;
• PCR for HIV, syphilis, hepatitis A, B, C.

In addition, the doctor who will perform the operation will definitely require the results of an electrocardiogram.

All tests should be within normal limits. If any indicators have deviations, the operation cannot be performed until the patient has undergone a course of treatment. If repeated analyzes show the norm, then the patient can be allowed to the next stages of preparation.

A person should inform the doctor about all chronic diseases he has, especially diseases of the respiratory organs, endocrine and digestive systems. Taking any medications 2-3 weeks before the scheduled operation must be agreed with the surgeon. 10 days before the appointed date, the use of vitamin E, anticoagulants, Aspirin is stopped.

On the day before the operation, after 18 hours it is forbidden to eat, and after 22 – to drink liquids. Within 3-4 days before the procedure, you should refuse fatty, fried, spicy and spicy foods, smoked meats and pickles. Before going to bed, you need to do a cleansing enema, in the morning – repeat the manipulation.

The operation is performed strictly on an empty stomach, so it is forbidden to have breakfast or drink liquid in the morning.

Prior to the procedure, the surgeon tells the patient in general terms how the laparoscopy will take place, how long the operation will take. On average, the removal of stones takes from 40 minutes to an hour, the removal of the bladder – 1,5-2 hours.

How is the removal of stones from the cavity of the bladder

The procedure is carried out under general anesthesia – thanks to this, it is possible not only to ensure the absence of pain in the patient, but also to achieve maximum relaxation of the abdominal muscles.

After introducing the patient into a state of medical sleep, the anesthesiologist places a special probe into his stomach, which allows removing the contents of the organ – liquid or gases. This step is mandatory, as it eliminates the possibility of accidental vomiting, in which the contents of the stomach can enter the respiratory tract and cause suffocation.

After the probe is installed, a mask is applied to the patient’s mouth and nose, which is connected to the ventilator system – throughout the operation, he will breathe with it. Carrying out laparoscopy without the use of artificial ventilation is almost impossible, since the gas injected into the abdominal cavity presses on the diaphragm, and it, in turn, compresses the lungs, and the patient’s independent breathing becomes difficult.

Having successfully completed all the preparatory measures described, the surgeon with assistants begin laparoscopic stone removal. A puncture is made in the fold of the navel, through which sterile gas is first injected into the abdominal cavity to straighten the folds of the organs and expand the volume of the cavity, and then a laparoscope is inserted.

2-3 more punctures are made along the line of the right hypochondrium, where trocars with instruments are inserted. Then the doctor examines the location and appearance of the bladder, if necessary, dissects the adhesions between it and the surrounding organs. Next, the wall of the bladder is dissected, the tip of the suction is inserted into it, with which the contents of the organ are withdrawn. The wall is sutured, the abdominal cavity is washed with an antiseptic. The doctor removes the trocars and the laparoscope, sutures the incisions in the skin.

Laparoscopy of the gallbladder: how the organ is removed

The operation to remove the bladder requires compliance with similar preparatory measures before starting – the patient is also immersed in a medical sleep, a probe is inserted into his stomach, he is connected to an artificial respiration apparatus.

Through an incision in the area, a laparoscope is inserted into the abdominal cavity, and 2 or 3 trocars are inserted through the punctures along the line of the right hypochondrium. Having determined the location of the bubble, the doctor, in the presence of adhesions, dissects them. Next, the surgeon evaluates the degree of tightness and fullness of the organ. If it is very tense, the surgeon first cuts through its wall and, using a special suction, removes part of the fluid from the bladder cavity.

A clamp is applied to the bladder, after which the bile duct – choledoch, is released from the tissues and cut. The next of the tissues is the cystic artery. Clamps are applied to it, between which the vessel is cut. The lumen of the artery is closed by the surgeon.

Having freed the organ from the duct and artery, the doctor proceeds to separate it from the hepatic cavity. All bleeding vessels, as the organ is cut off from them, are cauterized. After complete separation from the surrounding tissues, the physician removes the gallbladder through a puncture in the navel.

The surgeon carefully examines the abdominal cavity so as not to miss the remaining bleeding vessels, bile or other pathological structures. When all the vessels are coagulated and the altered tissues are removed, an antiseptic flushing fluid is injected into the abdominal cavity. Then it is sucked off, the laparoscope, trocars, instruments are removed from the punctures. The incisions made are sutured, except for one – a special drainage tube remains in it for the next 1-2 days so that the remnants of the antiseptic can freely leave the abdominal cavity.

If at some point the surgeon realizes that it is impossible to successfully remove the bladder using laparoscopy, the operation can go into laparotomy.

What happens after the operation

Upon completion of all surgical procedures, the anesthesiologist takes the patient out of anesthesia. Within 4-6 hours, the patient cannot move at all, and only after 6 hours will he be allowed to roll over, sit down, stand up and walk. From this moment on, it is allowed to drink liquid – so far only non-carbonated clean water. On the first day after the operation, food is prohibited. The next day, the patient is given fruits, low-fat cottage cheese, light meat broths, minced meat in the diet. At the same time, you need to eat often, 5-7 times a day, but in small portions. After the first two days, on the third one can already gradually return to a more familiar menu, however, the patient should not consume foods that increase the secretion of bile and gas formation.

Already from the third or fourth day, the patient switches to diet 5. The diet after the operation excludes onions, garlic, many spices, and fatty foods.

The postoperative period usually lasts until the tenth day. In the first two days, the patient may feel pain at the puncture sites, above the collarbone and in the right hypochondrium. By the fourth day, they usually pass, otherwise it is necessary to tell the doctor about the discomfort.

Physical activity of any nature in the first 10 days after the operation is prohibited. Approximately on the eleventh day, in a polyclinic, sutures are removed from the punctures.

A sick leave must be opened for a person – it includes a period of stay in a hospital, and about 10-12 more days that need to be spent at home, in bed rest, to recover from the operation. The total sick leave is up to 20 days.

Patient life after gallbladder removal

Rehabilitation after surgery is generally fast. A person fully recovers after about half a year, taking into account the mental aspects of the rehabilitation period.

The general normalization of well-being occurs within 2-3 weeks after the procedure, however, the patient must strictly adhere to all the requirements of rehabilitation. The first month after bladder laparoscopy, sports training should be avoided. The first half of the year it is forbidden to lift weights. Strict diet number 5 is indicated for 3-4 months.

If necessary, to speed up the process of tissue repair and wound healing, the doctor may recommend physiotherapy.

Nutrition after removal of the gallbladder has some restrictions. For the first 3-4 months, the patient strictly observes table number 5, after which raw vegetables, as well as unground fish and meat, can be introduced into his diet.

This stage lasts 2 years, after which the patient is gradually allowed to eat previously prohibited foods, but in moderation.

Consequences and possible complications after surgery

Most often in patients after removal of the gallbladder, the so-called postcholecystectomy syndrome occurs. Due to the absence of a bladder, the bile produced by the liver is directly thrown into the duodenum, causing severe abdominal pain, nausea, vomiting, flatulence, diarrhea, heartburn, jaundice, and fever.

Unfortunately, it is impossible to get rid of this problem completely, once and for all. The patient during the period of exacerbation is recommended to follow a strict diet 5, while taking antispasmodics to relieve the pain symptom.

Borjomi or Essentuki mineral water should be introduced into the diet.

In the process of laparoscopy, there is a possibility of some complications, for example, perforation of the walls of the stomach, damage to blood vessels in the abdominal wall, damage to surrounding organs.

Any of these manifestations are the basis for transferring laparoscopy to laparotomy, and providing the patient with the necessary medical care.

Complications that manifest themselves some time after the operation include peritonitis, inflammation of the tissue in the umbilical region, as well as the ingress of bile from a poorly sutured segment of the cystic duct into the abdominal cavity.

Laparoscopy of gallbladder stones or the organ itself is considered a relatively safe operation, but at the same time it requires jewelry precision from the surgeon. All his actions are carried out through several small incisions using trocars, a laparoscope and special surgical instruments. Removal of the gallbladder is most preferably carried out in this way – this provides a faster process for the patient’s recovery after surgery.