What About Laparoscopic Cholecystectomy?

(4) Surgical procedures

① Make pneumoperitoneum. An arc incision is made along the lower margin of the umbilical fossa, about 10mm long. If the lower abdomen has been operated on, the skin can be cut at the upper margin of the umbilical cord to avoid the original surgical scar.

The surgeon and the first assistant lift the abdominal wall from both sides of the umbilical fossa with towel forceps. The surgeon with the right thumb, index finger holding pneumoperitoneum needle (Veress needle), wrist force, vertical or slightly oblique pelvic cavity into the abdominal cavity.

In the process of puncture, the needle broke through fascia and peritoneum for two times. Determine if the tip has entered the abdominal cavity. It can be attached to a syringe with normal saline. When the tip is in the abdominal cavity, the pressure is negative. When the pneumoperitoneum machine is connected, if the inflating pressure does not exceed 1.73kPa, it indicates that the pneumoperitoneum needle is in the abdominal cavity. At the beginning of inflation should not be too fast, the use of low flow inflation, 1 ~ 2L per minute.

At the same time, observe the intraperitoneal pressure of the pneumoperitoneo machine, and the pressure should not exceed 1.73kPa when inflating. If the pressure is too high, the position of the pneumoperitoneo needle is incorrect or the anesthesia is too shallow and the muscle is not relaxed enough. Appropriate adjustment should be made. When the abdominal bulge begins and the liver dullness boundary disappears, it can be changed to the high flow automatic inflatable until the predetermined value (1.73-2.00kpa) is reached. At this time, the inflatable is 3 ~ 4L, the patient's abdomen is completely raised, and the operation can be started.

The abdominal wall was lifted with towel forceps at the umbilical pneumoperitoneum needle, and the 10mm trocar was used for puncture. The first puncture had certain "blindness", which was a dangerous step in laparoscopy, and extra care should be taken. Rotate the trocar slowly and enter the needle with uniform force. When it enters the abdominal cavity, there is a sensation of sudden disappearance of resistance. When the closed air valve is opened, gas can escape, which means the puncture is successful. Connect the pneumoperitoneum to maintain constant pressure in the abdominal cavity. Then the laparoscope was put in and the puncture was performed at each point under the supervision of the laparoscope.

Generally, the puncture was made 2cm below the xiphoid process, and 10mm cannula was placed to provide discharge hooks, clips and other instruments; A 5mm trocar puncture was made 2cm below the costal margin of the right midclavicular line or 2cm below the costal margin of the rectus abdominis and the anterior axillary line, respectively, for the insertion of a rinsed device and a gallbladder fixation clamp. At this point, the artificial pneumoperitoneum and preparation work have been completed.

Because the first trocar puncture and the production of pneumoperitoneum can accidentally injure the large blood vessels and intestines in the abdominal cavity, and it is not easy to find during the operation. Nowadays, many people make a small incision in the umbilical cord, find the peritoneum, and inflate the trocar directly into the abdominal cavity. After the pneumoperitoneum was successfully manufactured, the operation began.

② Anatomy of the Calot triangle. Grasp the neck of the gallbladder or Hartmann's sac with a grasping clamp and pull to the upper right. It is best to draw the cholecystalline duct perpendicular to the common bile duct in order to clearly distinguish the two, but be careful not to draw the common bile duct at an Angle. The serous membrane on the gallbladder duct was cut open with an electric coagulation hook, and the gallbladder duct and gallbladder artery were bluntly separated to distinguish the common bile duct and hepatic duct. Because this place is close to the common bile duct, try to minimize electric coagulation to avoid accidental injury to the common bile duct. The relationship between the gallbladder duct and the common bile duct can be seen clearly. The titanium clamp should be placed as close to the neck of the gallbladder as possible. There should be sufficient distance between the two titanium clips, and the titanium clip should be at least 0.5cm away from the common bile duct. Cut between two titanium clips with scissors. Do not cut or coagulate electrically to prevent damage to the common bile duct due to heat conduction. Then the gallbladder artery was found behind it and cut with titanium clipping. After cutting the gallbladder artery, do not pull hard, so as not to break the gallbladder artery, and pay attention to the posterior branch of the gallbladder. Carefully peel the gallbladder, electrocoagulation or titanium clamp to stop the bleeding.

③ Remove the gallbladder. Clamp the gallbladder neck upward traction, carefully peel along the gallbladder wall, the assistant should assist in pulling so that the gallbladder and liver bed have a certain tension. Remove the gallbladder intact and place it above the right side of the liver. The liver bed was treated with electrocoagulation and hemostasis, and carefully washed with normal saline to check for bleeding and bile leakage (a gauze block was treated at the hepatic portal, and bile staining was checked after removal). After the fluid in the abdominal cavity was sucked up, the laparoscope was transferred to the subxiphoid cannula and the umbilical incision was made free, so that the gallbladder containing stones larger than 1cm could be removed from the umbilical incision with relatively loose structure and easy expansion. If the stones were small, the gallbladder could also be removed from the puncture hole under the xiphoid process.

Take out the gallbladder. A toothed claw is sent into the abdominal cavity through the umbilical cannula. The remnant of the gallbladder duct is held under surveillance, and the gallbladder is slowly dragged into the cannula sheath and pulled out together with the cannula sheath. When grasping the gallbladder, it is necessary to put the gallbladder on the liver to avoid the injury of the intestinal tube by the sharp forceps. If the stone is large or gallbladder tension is high, must not force out, so as to avoid gallbladder rupture, stones and bile leakage into the abdominal cavity. At this time, vascular forceps can be used to enlarge the incision and remove it, or dilators can be used to expand the incision to 2.0cm. If the stone is too large, the incision can be extended. If there is bile leakage into the abdominal cavity, apply wet gauze through the umbilical incision into the bile suction.

When the stone is too large to be removed from the incision, the gallbladder can also be opened first, the bile in the gallbladder can be sucked dry with the suction device, and the stone can be removed one by one after crushing the stone. If the stone is found to fall into the abdominal cavity, it should be removed. After checking that there was no blood accumulation or fluid in the abdomen, the laparoscope was pulled out, the valve of the cannula was opened to discharge carbon dioxide gas in the abdomen, and then the cannula was pulled out. The incisions where 10mm cannula was placed were sutured with 1 ~ 2 stitches of fascial layer using fine lines, and each incision was closed with sterile adhesive film.

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