Rational Approach to the Management of Calculous Cholecystitis and Standardized Technique of Laparoscopic Cholecystectomy as a Basis for the Prevention of Postoperative Complications
The objective — to improve the outcomes of laparoscopic treatment of cholelithiasis using endoscopic ultrasonography in preoperative examination, method of critical view on safety in identification of Calot’s triangle, meticulous dissection of gallbladder and minimally invasive methods in treatment of bile leak.
Material and methods. We studied the outcomes of laparoscopic cholecystectomy in 4,880 patients. Patients were divided into 2 groups. The first group included 3,036 patients who were operated using infundibular technique for identification of Calot’s triangle elements. Patients with suspicion of common bile duct stones according to ultrasound examination were subjected to endoscopic retrograde cholangiopancreatography and extractions of stones, if necessary.
The second group included 1,844 patients with the identification of the elements of Calot’s triangle in whom we used technique critical view of safety. For suspected choledocholithiasis and negative ultrasound findings we used endoscopic ultrasonography.
Upon confirmation of choledocholithiasis wу carried out endoscopic lithoextraction. In negative result of endoscopic ultrasonography the patients underwent laparoscopic cholecystectomy without further endoscopic examination.
Results and discussion. Mean operative time was 50.5 ± 13.3 min in the second group, and 66.2 ± 14.1 min — in the first group
(p = 0.02). Large bile duct damage were observed in 2 patients (0.06 %) from the first group. Bile leak due to minor damage of bile ducts were observed in 13 patients (0.42 %) of the first and 5 (0.27 %) — of second group. All complications were treated minimally invasively. Reduction in the incidence of minor damage of bile ducts, especially the lack of cystic duct stump insolvency, is explained by improved due to endoscopic ultrasonography of choledocholithiasis diagnosis, which is the main cause of failure of the stump of the bile duct, and meticulous dissection. Residual choledocholithiasis was diagnosed in 18 (0.6 %) patients in the first group and was not observed in second group. Endoscopic ultrasonography enabled in 65 (51.5 %) patients to rule out common bile duct stones and to avoid carrying out diagnostic endoscopic retrograde cholangiopancreatography. The sensitivity, specificity, and accuracy of endoscopic ultrasonography was 100.0; 97.0; 98.4 %, respectively.
Conclusions. The use of endoscopic ultrasonography in patients with suspected choledocholithiasis, meticulous dissection using a technique of critical view on safety and minimally invasive treatments of bile leak can improve the outcomes of laparoscopic cholecystectomy.
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