隐形胆囊取石

Laparoscope and fiber choledochoscope in combination for removing gallbladder stones

 

Abstract [Purpose] To evaluate the safety and feasibility of  sequential use of laparoscope and fiber choledochoscope for removing gallbladder stones. [Patients and Method] From March 2007 to Sept 2007, 21 patients with gallbladder stones, 17 females and 4 males, 47 years old in average, were hospitalized for the purpose of gallstone removal. In all, 12 patients had solitary stones, 6 patients had two stones and 3 patients had three stones. Measured in the greatest diameter,the average size of the stones was 12 mm.General anesthesia was adopted and the patient was rotated to the left with the head placed higher than the feet. 4 ports procedure was taken, one 2mm Trocars for fine instruments below right subcost, one 2mm subxyphoid and two 5mm by umbilicus for laparoscope and fiber choledochoscope in-out. The standard laparoscopic techniques were used to make a small incision on the bottom of the gallbladder, followed by extracting stones using the basket through choledochoscope. [Results] All patients had gallbladder stone removed successfully without any perioperative complications. The average operation time was 65 min (45-90 min ).  Post operation, only 3 patients requested painkiller by the reason of intolerable pain around the umbilicus. Followed-up for 1-7 months, no stone recurrence was observed. [Conclusion] Laparoscope and fiber choledochoscope used in combination for gallbladder stones removal is not only feasible but also with the advantages of  increased safety and effectiveness, and minimal invasion, However, the procedure is relatively complex and requires higher skill level. 上海东方医院胆石病专科胡海

[ Key words ] Laparoscope; Fiber choledochoscope; gallstone removal

 

It is generally accepted that the functional gallbladder, regardless of the symptom, must try to be reserved. In alignment with this view，many researchers devoted themselves to the research of  nonoperative treatment of gallbladder stones, and some effective approaches appeared, including dissolving biliary calculus by medication, removing biliary calculus by Chinese herb, extracorpereal shock-wave lithotripsy and cholecystolithotomy.Cholecystolithotomy had 100% cure rate for 100 patients who underwent percutaneous cholecystolithotomy (PCCL) 10 yeas ago. However, there are many drawbacks for the previous approaches, like large incision, trauma to abdominal wall muscle and being hard to reveal. We introduce an approach based on laparoscope technique for bladder stones, which has the ability to overcome the drawbacks mentioned above.

     Patients and methods

From March 2007 to Sept 2007, 21 patients with gallbladder stones, 17 females and 4 males, 47 years old in average, whose gallbladders had the function of contraction and concentration confirmed by ultrasound and/or oral cholecystography, were included in this study. 12 patients had solitary stones, 6 two stones and 3 three stones. The average size of the stones was 12 mm (8-17mm) in largest diameter. General anesthesia was adopted and patient was in anti-Trendelenburg position with rotation to the left. A 5mm trocar was introduced at the right edge of umbilicus and a 5mm 30°scope was introduced through this trocar, after the establishment of pneumoperitoneum, another 3 trocars were introduced under the view of laparoscope: a 5mm trocar at the left edge of umbilicus for surgical instruments and fiber choledochoscope, two 2mm trocars were introduced in right subcostal area and subxyphoid for using fine instruments. The bile was suctioned out by the transfixion pin through the bottom of the gallbladder, the fiber choledochoscope was inserted into the gallbladder after cutting a 10mm incision on the bottom, the stones were removed by the basket through fiber choledochoscope into a sack which had a extracorporeal retention suture linked on its end through a trocar. The incision on the bottom of gallbladder was sutured by absorbable leptonemaa after making sure that there were no stones remain. After the abdominal cavity was cleaned and the intraluminal fluid was suctioned, the two small umbilical wounds were united by cutting the bridge and the sack of stones was grasped and subsequently extracted through this incision. Other trocars were pulled out and intradermic sutures were done by absorbable leptonemaa,  woundplasters were pasted. Results

All operations were successful, with mean operative time was of 65min (45-90min). All patients could get out of bed on operation day, eat fluid diet on the second day and be discharged in 1-3 days after operation. Postoperative complication like bleeding, bile leakage, infection of the incision wound were not observed. Recurrence of stone was not observed during follow-up in the out-patient policlinic 1-7 month after operation.

Discussion

Compared with PCCL or in other words, minimally incision cholecystolithotomy, the approach of using Laparoscope and fiber choledochoscope in combination for gallbladder stones removal has the following advantages: (1) confirming the orientation of the gallbladder is not necessary, thereby decreasing the procedural time;   (2)the space for revealing and operating is large enough, therefore it is not necessary to consider the space relation between the gallbladder’s bottom and the right costal margin; (3)only the 2mm trocar below the right subcostal is through the muscle layer, not the other 3, therefore, postoperative pain is significantly decreased. However, there are some disadvantages linked with this procedure, like the need of filling abdominal cavity with CO2,  the multiplicity of the operative procedure and the high requirement of instruments .

A freshman might encounter the following difficulties: 1.establishing pneumoperitoneum safely, it is difficult to the operators who have not undergone the training of laparoscope techniques; 2. higher skill level is required for cutting and suturing of the gallbladder’s bottom through the laparoscope, otherwise the complications such as bleeding during surgery and postoperative bile leakage are possible;  3. it is difficult to remove the gallbladder stones because inserting the fiber choledochoscope transumbilical is different compared to through the subcostal incision

In our opinion, removing gallbladder stones transumbilically is hopeful and worthy of generalization if all the manipulations could be done through umbilicus. This however requires the improvement of instruments, standardization of procedures and facilitation of training.  Researches in this area has just started and definitely worth further exploration.