CHOLECYSTECTOMIA (Greek chole bile + kystis a bubble - f-ektome excision, removal) — operation of removal of a gall bladder.
For the first time in a wedge, practice the cholecystectomia was executed in 1882 by Langenbukh (Page J. A. Langenbuch), and in Russia — in 1886 Yu. F. Kos-sinsky.
As the most frequent indication to operation serves calculous cholecystitis (see) or the cholesterosis (see), is more rare — malignant or benign tumors of a gall bladder and its damage. At hypodermic ruptures of a gall bladder (see. A gall bladder, damages) the issue
of need of this operation is resolved individually, depending on a damage rate of body and the general condition of the patient. Besides, this intervention is carried out at various forms of acalculous (not calculous) cholecystitis in cases of inefficiency of conservative treatment.
A cholecystectomia — the difficult surgery demanding from the surgeon of good knowledge of topographical anatomy, orientation in quite often found anomalies and options of an arrangement of blood vessels and extrahepatic bilious ways in a zone of operation (see. Gall bladder, Bilious channels).
The cholecystectomia can be made in a planned order or according to the emergency indications in connection with the developed peritonitis, gangrene or phlegmon of a wall of a gall bladder. At planned intervention surely previously along with it is general clinical inspection of the patient to specify character patol. changes of a gall bladder by implementation of the cholecystography (see), and also ultrasonic investigation.
During the performance of operation it is necessary to consider that, in connection with features of anatomic relationship of bodies of the biliopankreati-chesky area and their character patomorfo l. changes operation in some cases should be made atypically that can be followed by emergence of unexpected heavy complications — damage of large vessels or the general hepatic channel. Besides, in patol. process also other bodies of this zone can be involved. Quite often it cannot be expected to a laparotomy therefore before each operation the surgeon shall be ready to performance of the interventions which were more expanded on volume.
The cholecystectomia is made under an endotracheal anesthesia using muscle relaxants (see. Inhalation anesthesia). The patient is in situation on spin with the roller enclosed at the level of XII of a chest vertebra. At the expense of a bend of a backbone of a kpereda the bodies which are in an upper part of an abdominal cavity that creates conveniences to carrying out operation get significantly closer to a front abdominal wall.
Most often use right subcostal and upper median accesses (see the Laparotomy). The last is less traumatic, however demands use of special dilators, and corpulent patients have extensions of a section from top to bottom that can lead to formation of postoperative hernia further.
The gall bladder can be allocated from a neck (retrogradno) or from a bottom (antegradno). The first way is more difficult, however is preferable as it allows to tie up a vesical channel at the beginning of operation that interferes with extremely undesirable moving to time of intervention of small concrements from a gall bladder and a vesical channel to the general bilious canal. Allocation of a vesical channel at the beginning of operation gives the chance to execute necessary is-
Fig. 1. Diagrammatic representation of some stages of a retrograde cholecystectomia:
and — the moment of allocation of a vesical artery (/) and a vesical channel (2) after opening of the peritoneum covering them; — the vesical artery (/) is tied up and crossed, the vesical channel (2) is taken on ligatures and prepared for introduction of a cannula.
followings of bilious channels: a ho-langiografiya (see), a holangiomanomet-riya (see), sounding of a faterov of a nipple (a big nipple of a duodenum, T.). Bandaging of a vesical artery at the beginning of operation allows to delete a gall bladder almost without blood.
The antegrade cholecystectomia is made in cases when retrograde allocation of a gall bladder is impossible because of anatomic features or inflammatory changes in area of a neck of a gall bladder and hepatoduodenal sheaf that interferes with accurate identification of a vesical channel and the artery of the same name. The attempt of their allocation in similar conditions can lead to heavy complications (see. Bilious channels, damages). As at an antegrade cholecystectomia the best conditions for consecutive allocation of the main anatomic educations in a zone of a neck of a gall bladder are created, this method should be recommended to less experienced surgeons.
In some cases the cholecystectomia is carried out a combined method: at first retrogradno (allocate and bring a ligature under a vesical channel in a neck), and then in connection with the found technical difficulties pass to antegrade removal of a gall bladder. Similar tactics allows to avoid damage of the main bilious channels and to prevent developing of bleeding from a vesical artery and its branches.
At a retrograde cholecystectomia after opening of an abdominal cavity the gall bladder is taken closer to a neck a fenestrated forceps
and tightened up its longitudinal axis (at the same time the vesical channel and a vesical artery become more available); open the peritoneum covering a vesical channel and a vesical artery and stupidly allocate them from a friable fatty tissue (fig. 1, a). Puzyrny Canal tie up near an otkhozhdeniye it from a neck of a gall bladder, and the distal department surrounds with thick thread, the ends pass a cut through a tourniquet. Then allocate a vesical artery, tie up it and cross between two ligatures (fig. 1, b). After that open with scissors a gleam of a vesical channel, enter into it a cannula for a holangiografiya and fix it by means of a tourniquet or a ligature. After the X-ray contrast research the cannula is deleted, and the vesical channel is tied up two ligatures at distance of 5 — 6 mm from its connection with the general bilious channel and crossed. After that the gall bladder is deleted, bringing up him for a neck in the direction of a bottom. The bed of a gall bladder is taken in a continuous catgut suture that allows to liquidate bleeding from the small superficially located vessels and the expiration of bile from small bilious channels. The abdominal cavity is drained a rubber or plastic tube. Tampons enter into an abdominal cavity only in case of not stopped bleeding or at impossibility to remove nekrotizirovan-ny fabrics from a zone of operation.
At an antegrade cholecystectomia allocation of a gall bladder is made subserozno, beginning from its bottom. Scalpel or scissors make cuts the peritoneum covering a gall bladder. Then an acute and stupid
way (scissors and a small rigid gauze ball) it is careful not to damage a parenchyma of a liver and walls of a gall bladder, separate it from a liver. The bleeding arising at the same time from branches of a vesical artery is stopped by their bandaging or coagulation. The vesical artery is tied up usually after full separation of a gall bladder from a liver (fig. 2). Puzyrny Canal is tied up at first near an otkhozhdeniye from a gall bladder, and after a holangiografiya — its distal end. The gall bladder is deleted after crossing of a vesical channel between the imposed ligatures.
Quite often the cholecystectomia should be carried out atypically. So, at significant increase ^елчного a bubble, caused it" by an edema or an empyema, detection of a neck of a bubble is extremely complicated, and allocation of walls is unsafe because of a possibility of their damage and break of the infected contents in an abdominal cavity. Make a puncture of a gall bladder for the prevention of it the thick needle connected to a suction and evacuate its contents. Tension of a bubble is liquidated after that, it considerably decreases in sizes that allows to remove it without special difficulties.
In cases when the gall bladder is closely soldered to a reinforced and infiltrirovanny big epiploon, intervention begin with department it with a stupid or acute way, and if necessary resect a part of an epiploon. In a similar situation it is necessary to show care since between a gall bladder and a duodenal or large intestine there can be bilious fistulas (see). Fistula shall be timely revealed and liquidated.
Fig. 2. Diagrammatic representation of a stage of an antegrade cholecystectomia:
the gall bladder is allocated and the ligature under a vesical artery is brought.
Fig. 3. The diagrammatic representation of an atypical cholecystectomia at the expressed cicatricial and infiltrative changes in area of a neck of a gall bladder: under
control of the bubble of a finger entered into a gleam allocate his neck from unions.
At considerable inflammatory infiltration or powerful cicatricial unions in a neck of a gall bladder when walls it cannot almost be otdifferentsirovat from the surrounding fabrics and bodies soldered to them, there is a real threat of damage of the last, and also elements of a hepatoduodenal sheaf. In these cases the gleam of a gall bladder is opened between two clips imposed in the field of a bottom (see the Cystifellotomy.), also delete its contents (bile, pus, stones). Then cut a bubble on a front wall lengthways, towards a neck. Bleeding is stopped by means of clips. After that from a cavity of a bubble make tool audit of its cervical department, an a'pra of an opportunity — Cholanum-giog a raffia, then consistently delete the remained its walls (fig. 3) under control of the gall bladder of a finger entered into a gleam.
If this reception does not allow to excise a wall of a gall bladder because of a dense union with surrounding fabrics, it is left on site, and the mucous membrane is coagulated. This intervention received the name «mucoclasis across Pribram». Koagulirovanny walls of a bubble are sewed among themselves tightly or to the drainage entered into a cavity. The mucoclasis is applied also during removal of the wrinkled, sclerosed gall bladder located deeply in a parenchyma of a liver.
The cholecystectomia at malignant tumors of a gall bladder has a number of features. First, it is necessary to be convinced of reliability of the diagnosis by means of an urgent gistol. researches of a piece of a tumor and lack of metastasises in a liver and surrounding bodies. Secondly, allocation of a wall of a gall bladder from oncological positions shall be made together with the site of an adjacent parenchyma of a liver. In nek-ry cases at the same time make a wedge-shaped resection of a liver together with a gall bladder after bandaging vesical a channel and an artery. On tissue of a liver in these cases previously put continuous haemo static sutures (see the Liver, operations). V. V. Vinogradov with success uses at this intervention a mechanical seam the devices UKL-40 and UKL-60.
During operation conduct a complex research of bilious channels, a liver and pancreas with use rentgenol. methods that allows to reveal and korrigirovat timely patol. changes of these bodies.
The immediate results of a cholecystectomia in most cases good. In the remote terms 5 — 10% of the operated patients have more or less expressed dispeptic frustration (see P ostkholetsistekty and chesk of ii a syndrome).
Bibliography: The multivolume guide to surgery, under red * B. V. Petrovsky, t. 8, page 86, M., 1962; Operational surgery, under the editorship of I. Littmann, the lane with Wenger., Budapest, 1982;
Fedorov S. P. Gallstones and surgery of bilious ways, Pg., 1918; Shalimov A. A., etc. Surgery of a liver and bilious channels, Kiev, 197 5; To eh of N. of Chirurgie der Gallenwege, Stuttgart, 1913; Nouveau traite de technique chirurgicale, publ. par J. Patel et L. Leger, t. 12, fasc. 2, P., 1969. O. B. Milonov.