Tài liệu Hội thảo Quốc tế về Nội soi và Phẫu thuật nội soi

• generally avascular and may be lysed bluntly by grabbing attachment to gallbladder wall and gently stripping them down toward the. infundibulum[r]

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Gallstone with Cholecystitis and CBD stone

Assoc.Prof.Sukij Panpimanmas MD Rajavithi Hospital

Disease of Gallbladder

• Gallstones

• Acute or subacute cholecystitis

• Empyema or gangrenous cholecystitis

• Chronic cholecystitis

3/3/2014

Contraindications to LC

Absolute

• Unable to tolerate general anesthesia

• Refractory coagulopathy

• Suspicion of gallbladder carcinoma? (Lap Hepatec) Relative

• Previous upper abdominal surgery

• Cholangitis

• Diffuse peritonitis

• Cirrhosis and/or portal hypertension

• Chronic obstructive pulmonary disease

• Cholecystoenteric fistula

• Morbid obesity

• Pregnancy

Criteria for Difficult LC

Clinical problem

• Acute or subacute cholecystitis

• Previous upper abdominal operation

3 Imaging criteria

• Thick walled gallbladder

• Contracted or calcified gallbladder

• Retraction of gallbladder into hepatic bed

• Impacted stones with mark distended GB

• Cholecystoduodenal fistula

• Mirizzi’s syndrome

Operative finding criteria

• Severe adhesion around gallbladder

• Anterior abdominal wall bowel adhesion

• Empyema or gangrenous cholecystitis

3/3/2014

Gallstone with CBD stone

• ERCP  LC (Rajavithi and gen.standard)

• ERCP+LC (same setting- difficult)

• LC+IOC+Lap.explore CBD *****

• LC  ERCP (Take risk)

3/3/2014

Timing for LC in Ac.Cholecystitis

Early VS Delayed

• Early is better

• Golden period, 72hrs history

• 6-8 weeks -complications, conversion—not different

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Complications of LC

• Bile duct injury/leak (0.1-1%)

• Hemorrhage

• Retained stones (CBD, intraperitoneal)

• Pancreatitis

• Wound infection

• Incisional hernia

• Pneumoperitoneum related:

– CO2 embolism

– Vaso-vagal reflex

– Arrhythmias

– Hypercarbic acidosis

• Trocar related:

– Bleeding:vascular injury/abdominal wall injury

– Visceral injury

How to for SAFE LC

• Training, Hands-on model, animal and as surgeon under experienced trainer

• Ports- 1,2,3,4 safe technique

• Fundus, Hartmann grasping, dissection

• Needle aspiration

• Retrograte/fundus down—endoloop

• Partial/subtotal cholecystectomy

• Nasobiliary (ERCP), IOC [ Mirizzi’s, fistula ]

3/3/2014

Gallbladder Adhesions

• Adhesions between the gallbladder and

–hepatic flexure

–and/or duodenum

–omentum

• generally avascular and may be lysed bluntly by grabbing attachment to gallbladder wall and gently stripping them down toward the

infundibulum

Intraoperative Gallbladder Perforation

• Perforation of the gallbladder with bile or stone leakage should not ordinarily require conversion to OC

• Perforation may occur

– secondary to traction

– electrosurgical thermal injury during dissection

• Patients with a bile leak

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Spilled Gallstone

• Incidence - 10-30%

• Low morbidity of spilled stones

– conversion to open not justified

• Complications:

– Mostly seen with pigmented stones

•postulated to be due to the release of

bacteria from within the stones

– Intra-abdominal abscess

– Abd wall infection or permanent sinus

Bleeding

• Uncontrolled bleeding incidence - 0.1 - 1.9 %

• Sites:

– Liver

• Usually occurs during final removal of gallbladder from fossa

• requires conversion to open if uncontrolled

– Arterial

– Port insertion sites

3/3/2014

DO NOT

• Clip or cauterize in the lake

• Cauterize-Unseen tip of instrument

Conclusion

Difficult LC is still challenging, it can be done safely by experienced surgeon who always keeps carefulness in all steps

Gallstone with CBD stone- options of treatment depend on

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