THE VASILE GOLDIȘ WESTERN UNIVERSITY OF ARAD [305121]

THE “VASILE GOLDIȘ” WESTERN UNIVERSITY OF ARAD

THE FACULTY OF GENERAL MEDICINE IN ENGLISH

BACHELOR THESIS

SCIENTIFIC SUPERVISOR

Lect. Univ. Dr. Papiu Horațiu

GRADUATE

Dr. Edoardo Giannotta

THE “VASILE GOLDIȘ” WESTERN UNIVERSITY OF ARAD

THE FACULTY OF GENERAL MEDICINE IN ENGLISH

Considerations on the surgical procedure in acute lithiasic colecystithis

INDEX

Introduction………………………………………………………………………………………………………….4

General Part……………………………………………………………………………………..5-8

Gallbladder positioning and anatomy……………………………………………5-7

Physiology……………………………………………………………………………..7

Para-Clinical signs…………………………………………………………………..7

1.1.4 Clinical Investigations………………………………………………………………8

1.2 Summary of the technique of VLC intervention…………………………………………….8-13

1.2.1 Generality…………………………………………………………………………….8

1.2.2 Preparation of the access…………………………………………………..……..8-9

1.2.3 Isolation of structures in Calot triangle and the procedure………………….9-12

1.2.4 Dissection of Gallbladder from liver bed…………………………………………12

1.2.5 Extraction of Gallbladder………………………………………………………….12

1.2.6 Final maneuvers……………………………………………………………………..13

Summary of the technique of cholangiography with VLC……………………………….14-16

Generality……………………………………………………………………………14

Preparation of the access…………………………………………………………..14

Isolation of structures in Calot triangle ………………………………………14-16

Injuries of the abdominal wall……………………………………………………………… 16-18

1.4.1 Incisional hernias………………………………………………………………..16-17

1.4.2 The parietal bleeding …………………………………………………………..17-18

1.5 The Nerve Damage……………………………………………………………………………….18

1.6 Neoplastic recurrence on the Abdominal Wall………………………………………………….18-19

1.7 Vascular Injuries…………………………………………………………………………….……20

1.7.1 The large vessel injury……………………………………………………..……….20

Iatrogenic injuries of the bowel ……………………………………………………….……20-21

The lesions of the duodenum………………………………………………………..30

[anonimizat]……………..20-21

1.9 Iatrogenic injuries of the biliary tract………………………………………………………21-22

1.9.1 The epathic injury and bile duct……………………………………………………21

1.9.2 The Mirizzi syndrome……………………………………………………………21-22

1.10 Bile spill………………………………………………………………………………….…..22-23

1.10.1 The dislocations of the clips ………………………………………………….……22

Lithiasis on a foreign body………………………………………………………….23

1.11 Complication liked to the perforation of the gallbladder and the lithiasic spill….…23-24

Abscess of the wall

Imagining methods…………………………………………………………………………….24

2.1 Special part…………………………………………………………………………………….….25

Aim and motivation of the study ……………………………………………………………25

2.2 Material and methods……………………………………………………………………………..26

2.3 Results………………………………………………………………………………………………27

2.3.1 Gender…………………………………………………………………………………..27

2.3.2 Age of the patients……………………………………………………………….28-29

2.3.3 Operator approaches and conversions…………………………………………..…30

2.3.4 Dimension of the gallstones……………………………………………………….31-32

2.3.5 Acute or Chronic Acutized………………………………………………………..33-34

2.3.6 Association with adherence syndrome (with\without)……………….……35-36

Men……………………………………………………………………….…35

Women………………………………………………………………………36

2.3.7 Associated Pathologies………………………………………………………..37

2.3.8 Intra operative incidence and complication (accidents)…………………..….38

2.4 Discussion……………………………………………………………………….………39

2.4.1 Gender…………………………………………………………………………………..39

2.4.2 Age of the patients……………………………………………………………………..40

2.4.3 Operator approaches and conversions………………..……………………………41

2.4.4 Dimension of the gallstones…………………………………………………………..41

2.4.5 Acute or Chronic Acutized……………………………………………………..…41-42

2.4.6 Association with adherence syndrome (with\without)………………….…42-43

2.3.7 Associated Pathologies………………………………………………………..44

2.3.8 Intra operative incidence and complication (accidents)………………………44

2.5 Conclusions………………………………………………………………………….45-46

2.6 Bibliography………………………………………………………………………….46-47

Introduction

The gall bladder stones are small solid agglomerates that consist mainly of cholesterol and calcium salts. Often they do not cause any symptoms and do not require any treatment (asymptomatic); other times they move from their original locations, blocking the bile flow and causing a condition known as acute cholecystitis (biliary colic), accompanied by intense, intermittent abdominal pain. About 15% of the adult population in each country is suffering from gallstones, with a higher prevalence in old women; the difference between the sexes tends to flattening, increasing the age. It is a common problem and often surgery is performed as a preventive measure.

The purpose on this work is to analyze all the aspect of this procedure, and evaluate its pros and cons.

General Part

1.1.1 Gallbladder positioning and anatomy

The gallbladder is a pear-shaped, hollow viscus that connected to the extrahepatic biliary tree by the cystic duct. There is considerable variations in dimension; approximate length and diameter of the fully distended gallbladder are 10 and 4 cm, respectively. The gallbladder’s capacity is up to 45ml.1

The gallbladder is divided in three parts:

The Fundus forms the antero-inferior margin with his hemispherical ending

The neck connects to the cystic duct and define the postero-superior limit

The lumen is the widest at the junction of the body and the fundus tighten towards the neck ;

The gallbladder is located in a concavity of the inferior surface of the liver called “the gallbladder fossa” and generally marks the caudal limit of the interlobar fissure.

The variability with which the cystic duct fits on the principle bile duct is considerable, even though,

some of the most frequent insertion method are recognizable.

– – – – – – – – – – – –

The cystic duct can (image 1):

run parallel to the biliary tract for a tract more or less long

cross on front the principal bile duct with an outlet on the left

cross on behind the principal bile duct with an outlet on the left

have a short course with hypertrophic or atrophic gallbladder

have a short course with melted gallbladder neck with the principal bile duct

have a long course with on outlet in the low biliary tract or in the papilla

The gallbladder is sprayed by the Cystic artery originated from the right hepatic artery and move to the organ’s neck passing both sides of the cystic duct; on the lower face originate a right and a left branch running on the sides of the lower face of the body. The veins get together in a common trunk tributary of the right branch of the portal vein; the most numerous are brought directly from the gallbladder wall in the liver parenchyma (accessory port veins). [7]

Also, the course of cystic artery has many anatomical variants; the artery can:

Originate from the right hepatic artery and cross the bile duct at the rear (70%)

Originate from the left hepatic artery and cross the bile duct on the front (20%)

Originate from the gastroduodenal artery and cross the bile on the front (2%)

Originate from the gastroduodenal artery, cross and run on the rear of the gallbladder to the bottom and, from there, towards the neck

All the above can be combined and show intermediate case

Lymph gather in three or four main trunks; they flock to:

lymph node of the cystic

Morgagni’s lymph node

Superior pancreatic-duodenal lymph nodes

Posterior pancreatic-duodenal lymph nodes

common hepatic duct

Choledochus duct

These structures define major topographical areas for the surgeon including (image 2):

Epato-cistic triangle, formed by the gallbladder and the cystic duct on the right, common hepatic duct on the left and hepatic margin superiorly

Calot triangle, a portion of the previous, bounded by the same lateral and medial structures, but with the top margin represented by cystic artery

Moosman area, defined by a circumference of about 30 mm in diameter, centered on the corner of the common hepatic duct and cystic duct. [8]

Physiology

Bile from the hepatocytes is stored and concentrated in the gallbladder and ultimately ejected into the gastrointestinal (GI) tract, under the influence of the parasympathetic nervous system and circulating hormones:

Cholecystokinin: is a molecule that promotes the secretion of pancreatic hormones and the contraction / emptying of the gallbladder.

Secretin: promotes an increase in volume and concentration of bicarbonate that results in a greater flow of bile fluid, an increase PH and bile osmolality favoring its outflow.

Gastrin: regulates the release of hydrochloric acid in the stomach

VIP (Vasoactive Intestinal Peptide): Cholecystokinin antagonist

PP (Polypeptide Pancreatic): determinate a release from the gallbladder

Somatostatin: Inhibits all pancreatic and gastrointestinal secretions

1.1.3 Para-clinical signs

Symptoms (Segni e sintomi della medicina d'urgenza Di S. R. Votey,M. A. Davis)

Acute pain in the upper right quadrant or epigastric pain.

nausea and vomit

Sometimes fever

Signs

Localized peritonitis

Murphy sign

1.1.4 Clinical investigation

Laboratory examinations:

VES,

complete emocromium, (Alfa 2 globulin salt)

bilirubinemia,

transaminases,

cholesterolemy,

Instrumental investigations:

hepatocellular ultrasound

colic and cologne radiography,

TAC and nuclear magnetic resonance imaging

1.2 Summary of the technique of VLC intervention

1.2.1 Generality

The surgery is performed under general anesthesia with the aid of an oximeter and a capnometer in order to quickly balance and prevent possible variations in PCO2 resulting from the absorption of CO2 from the abdominal cavity, where the pneumoperitoneum is induced, by blowing approximately 2 – 4 liters of CO2 up to a pressure of 10-14 mm Hg to allow the abdominal distension. A nasogastric tube is placed, which will be removed at the end of the intervention, in order to relax the stomach.

The patient is in supine position with lower limbs abducted, between which is placed the first operator. The second and the third operator are arranged to the sides of the operating table. [3]

1.2.2 Preparation of the access

The induction of pneumoperitoneum is carried out via the Veress needle that is perpendicularly introduced through a right periumbilical incision. Another "open" mode is with Hanson cannula.

The operation begins with the induction of pneumoperitoneum. Then proceeds to the introduction of the trocar according to the diagram (image 3):

In the diagram are shown in the order of introduction the four access sites in the peritoneal cavity: (1) umbilical, (2) under the left costal arch, (3) between the right mid-clavicular and umbilical transverse, (4) between the left mid-clavicular and umbilical transverse.

The first, with a diameter of 10 mm, through the same umbilical incision. Through this trocar the optical system connected to the camera is passed. From now on, under careful visual inspection, are introduced the other trocars;

The second, inserted on the apophyses ensiforme’s left, 2 cm below the costal arch, for the introduction of the aspirator / irrigator. This tool is also used to lift the liver and the round ligament,

The third trocar inserted to the right, at the intersection of the umbilical transverse and the right mid-clavicular line; allows the use of a clamp to stretch the infundibulum of the gallbladder and better highlight the vascular and biliary elements of Calot triangle.

The fourth trocar, placed to the left, at the intersection between the left mid-clavicular line and the umbilical transverse, allows the introduction of all the tools necessary to perform the cholecystectomy (laser probe and / or dissector with associated electric scalpels, scissors, pliers pose clips, etc. ).

1.2.3 Isolation of structures in Calot triangle and the procedure [3]

The operation continues with the incision of the peritoneum covering the infundibulum and the cystic duct up to completely isolate the latter and to render the entire circumference well visible. In the diagram (image 5) it is shown how, while with the grasper is underlay the gallbladder, the dissector and the palpatoresis opens the peritoneum and isolate the cystic and cystic artery.

.

The procedure could begin with the lysis of adhesions, result of inflammatory processes that often cover the gallbladder (image 6)

The peritoneum covering the infundibulum and cystic are opened and is isolated the cystic that is subtended by the stylus while with the dissector is isolated the cystic artery. (Image 7)

Four clips on the cystic are visible (image8)

The cystic is cut with scissors between the clips. (Image 9)

The cystic is dissected (image10) between the clips and is visible the proximal stump (arrow 1). Similarly also the cystic artery was sectioned between two series of clips (arrow 2).

Is positioned, therefore, a titanium clip close to infundibulum and two more clips at about 5 mm from the first in the direction of the common bile duct (CBD). Subsequently the surgeon identifies the cystic artery and make hemostasis with metal clips. [3]

1.2.4 Dissection of Gallbladder from liver bed

Completely sectioned the biliary-vascular pedicle, it proceeds with the dissection of the gallbladder from the liver bed.

The gallbladder was completely detached from the liver bed checking the hemostasis. (Image 11)

At this stage, a complete hemostasis of the hepatic bed is necessary, checking carefully after repeated washing and aspiration.

(The aspiration of the fumes produced by the electric scalpel or laser may represent a transitory problem for those nearby the operating field.)

1.2.5 Extraction of Gallbladder

The gallbladder, now dissected, is placed temporarily on the right lobe of the liver and is extracted through the trocar placed in the umbilical breach. If the gallbladder is lying or gallstones of large dimensions the 10 mm umbilical trocar is replaced with one of a larger diameter (20 mm Kleiber trocar) in order to avoid the need to empty the gallbladder and therefore, the contamination of the peritoneal cavity (image 12).

If the gallbladder is distended by numerous gallstones larger than 20 mm, it could be brought directly under the umbilical breach and carefully extracted with traction/rotation mixed movements. In some cases, may be necessary to expand the umbilical breach of one or two centimeters.

Then the optics is moved in the left umbilical trocar in order to control the phases of extraction of the gallbladder. In case of “check” interventions for the inflammation of the tissues, is positioned a sub-hepatic drainage. Some operators always put a drainage, to keep for 12-24 hours, in order to allow the complete elimination of the pneumoperitoneum, which can be the cause of pains radiated to the back and shoulders (image 13)

1.2.6 Final maneuvers

The tools are extracted; the four trocars are removed and the small surgical wounds are sutured, closing also, the Fascia (muscular bundle) and this especially if used a 20 mm trocar.

1.3 Summary of the technique of cholangiography with VLC

1.3.1 Generality

They are completely similar to those described for VLC.

The patient is supine with legs adducted, on a radiolucent operating table. The first operator is on the left.

1.3.2 Preparation of the access

Almost identical to that described for the VLC but a fifth right subcostal access is necessary to introduce the cholangiographic catheter. This access can also be very small (14-16G needle of a central subclavian venous access kit).

1.3.3 Isolation of the structures in Calot triangle

Identical to that described for the VLC.

A clip is positioned near the infundibulum and the cystic is partially dissected with scissors. After follow the insertion of the cholangiography catheter into the cystic. If there is not a specific kit for intraoperative VL cholangiography, can be used a subclavian venous catheter with Seldinger guide (image 15). In this case, the introduction can be easier if you do not draw back the guide wire. Eliminate all air bubbles from the catheter is extremely important. The injection of iodinated contrast and the recovery of radiograms is the last step. Retired the catheter, the cystic stump is closed with two clips and it is totally dissected.

The catheter, very flexible, is made more rigid by leaving inside the Seldinger guide. The arrow point the cystic (image 14).This technique is generally used in everyday clinical practice.

The semi-rigid catheter, at an angle of about 90°, required to reach the cyst. (Image 16)

A clamp with soft grip secures the gap between the cystic and the catheter. (Image 17)

After performing the radiographic examination, the cystic is closed with a metal clip while the semi rigid catheter is removed. [3]

1.4 Injuries of the abdominal wall

1.4.1 Incisional hernias [4]

In conventional “open” surgery after months or years, hernias appear on the laparotomy wound. Factors predisposing to the formation of these hernias are:

wound infection;

the use of inadequate suture materials: diameter, porosity and resorption time;

inadequate surgical technique;

certain diseases of the patient who require strong medications (cortisone, chemotherapy,…) in the immediate postoperative period;

Chronic bronchitis with cough (smoking with abundant bronchial secretion and cough…);

Obesity.

The video-laparoscopic surgical techniques have emerged precisely because they are more respectful of the patient (patient-friendly surgery); doctors and patients all have immediately agreed that most of the pain and complications of minor and medium interventions originate from the abdominal wall. For this reason, the possibility of having wall complications seemed immediately as "impossible”. The reality is that the presence of hernial complications is in the order of 0.2% in most series. This very low value means, however, that patients need to be followed in search of this complication.

The site where more frequently postoperative hernia should be noted is the one through which was extracted the gallbladder, this for the following reasons:

The gallbladder may contains gallstones with size even higher than 3-4 cm and this requires to expand the gap through which passed the trocar (usually 10 mm) to allow the passage of the gallstone. In some cases, the 10 mm trocar is replaced with a 20 mm trocar (Kleiber), but in some situations to extract the gallstone must be practiced a mini-laparotomy;

The gallbladder may contain infected bile that contaminates the wound;

Suturing of the breach is all the more uncomfortable the more it is small especially in overweight patients.

To these reasons already listed for open surgery, we have to add some specific aspects of video-laparoscopic technique:

During the extraction of the trocars the abdominal contents is pushed by the residue pneumoperitoneum in the direction of the breach in the wall and there remains “stuck” due to the pressure;

if the trocar’s valve is not open, the cannula itself may exert an aspiration (suction cup effect) on the abdominal contents dragging till near the wall;

the muscle relaxation, often modest or completely absent in the terminal stages of the interventions, helps to "fix" the omentum or handles (organic tissue that folds back on itself) that have come in contact with the abdominal wall.

Not all operators suture the fascial gaps. Almost everyone agrees that the breaches result from 5mm instruments do not require sutures unlike those from 20 mm, but for those from 10 mm opinions are divided. [4]

1.4.2 The parietal bleeding [9]

The abdominal wall is richly vascularized by small diameter vessels that originate at the top and front from the intercostal thoracic branches and inferiorly from the lumbar and hypogastric branches. The flow of these vessels is modest, but if an accurate hemostasis is not practiced, can also cause massive bleeding. Even the wall of the muscle can be a source of bleeding.

Generally, the bleeding is limited to the thickness of the sheet of the wall with the formation of a hematoma. In other cases, the hematoma makes its way between the parietal layer of the peritoneum and the muscle-fascial outer layer with possible rupture later. Much more rarely the bleeding occurs in the peritoneum, even with the formation of collections of several tens of ml.

These hemorrhages are sneaky in formation: during the operation are covered by the presence itself the trocar’s cannula and the backpressure of pneumoperitoneum. When the pneumoperitoneum and the trocar’s cannula are removed, the vessel is in a state of spasm and the bleeding may be minimal or even absent. In the hours after the resolution of the vascular spasm, the bleeding can appear. [9]

1.5 The nerve damage [2]

The frequency of damages to the nerve trunks that innervate the wall is not known in literature and are reported individual cases. In the presence of a nervous damage is useful to conduct a differential diagnosis with:

In particular, regarding cholecystectomy, we consider the right subcostal, para-rectal, right, and median trans-rectal accesses. Except the median access, surely the most "inconvenient" for the surgeon, all the others have in common the risk of damaging the nerves that provide the tropism of the muscles masses of the abdominal wall. The trunks that innervate the abdominal wall are the following:

n. intercostal T5 – T11

n. under-costal T12

n. ileum-ipogastric T12 – L1

The course of all these trunks is oblique from top to bottom and therefore a too deep vertical access, exposes to iatrogenic injury; if you need to expand the access, it is preferable rather do a horizontal incision. [2]

1.6 Neoplastic recurrence on the abdominal wall

The neoplastic facility [1]/ [11]

The number of cholecystectomies for the treatment of cholelithiasis increased since when was introduced in 1987; going from a percentage of about 29% before the introduction to the situation nowadays in which the classic “open” surgery is used just in extreme cases.

At the same time, there has been an increase in reported cases of gallbladder carcinoma passing from 0.28% in the “open” era to the actual 0.6%. This situation is common to almost all international case studies and show only minor regional variations.

The increase in gallbladder cancer seems to be only apparent if considered that the diagnostic tools are unchanged, mainly ultrasound and Computerized Axial Tomography, and increase only in cases with a gallbladder removed for other reasons (essentially for a cholelithiasis). The problem is that the random finding of a gallbladder malignancy during VLC preclude a therapy according to the canons of conventional open surgery and it seems that is accompanied by a large number of intraperitoneal and along the route of the port recurrences. These recurrences seem unrelated to the manipulation of the tumor or to the surgical technique, but rather to specific yet unknown aspects of laparoscopic procedures. [1]

It follows that it is very necessary to look for new diagnostic tools that have greater sensitivity and specificity for this type of disease in order to reduce the number of cancers of the gallbladder incidentally retrieved. At the same time, it is necessary to identify the risk factors that lead to exclude from VL technique patients with a suspicion of gallbladder carcinoma.

These criteria currently appear to be the following:

porcelain gallbladder wall or also only focally calcified (img. 19)

patient age> 70th;

clinical history of cholelithiasis, even asymptomatic, longstanding;

presence of gallbladder polyps (if the polyp has a size> 15 mm accommodates a neoplasm in 45% of cases);

Thickened gallbladder wall even only locally.

These criteria could indicate to perform a histological examination to confirm a diagnosis that could lead to a more radical oncological intervention, if the age of the patient, the risks of the intervention and his life expectation make it possible.

The palpation of the gallbladder, which in the “open” intervention allows the surgeon to have an idea, even if partial, of the disease is not possible with VL technique except for a mediated palpation that does not allow any assumptions. [11]

1.7 Vascular injuries

1.7.1 The large vessel injury [12]

Vascular lesions are extremely rare, but their severity can be devastating. Their gravity is such as to constitute the second leading cause of death during surgery in laparoscopy (the first cause are the anesthetic complications).

Some reviews [18], involving more than 100,000 interventions in VL, have shown that the percentage of vascular lesions amount to 0, 1 – 0, 25% with a mortality of 8.8% approximately. In the case of vascular injury to the triangle of Calot (portal vein and branches, hepatic artery and branches) the mortality drops to 4.1%. The majority of the lesions usually occur in the early stages of the intervention during the induction of pneumoperitoneum with a Veress needle and due to the blind introduction of the 1 ° trocar.

1.8 Iatrogenic injuries of the bowel

1.8.1 The lesions of the duodenum [14]

The duodenum injuries are very rare. However, emerge a small percentage of lesion of duodenum in the order of 0.2% that is comparable to iatrogenic lesions of the biliary tract. From an anatomical point of view, the duodenum lesions may involve the upper, lower knee and the posterior portion of the duodenum (retroperitoneal).

The pathogenesis of these injuries can be attributed to the following causes:

presence of strong adhesions that modify the anatomy anchoring the antral-pyloric-duodenal complex to the gallbladder;

the use of an inadequate instrument (sharp and sharp dissectors, pointed feelers, …);

the use of monopolar dissectors with consequent electro-thermal damage even at a distance and without direct contact.[14]

1.8.2 The lesions of the small intestine, colon and other organs

The pathogenesis of these injuries can be attributed to the following causes:

Presence of adhesions, not necessarily tenacious, but also weak, which adhere the intestine to the abdominal wall and / or other viscera;

The use of “closed” techniques for the introduction of the first port (pneumoperitoneum with Veress needle or Hasson cannula).

Typically when introducing the camera there will be immediate cognition of the lesion as it sees bubbling the intestinal contents mixed with gas; sometimes the pressure of pneumoperitoneum can mask the spot, however, the enteric mucosa fungus is appreciated. In other cases, there is no evidences. From a clinical point of view, the enteric material causes an immediate peritoneal reaction like in peritonitis.

1.9 Iatrogenic injuries of the biliary tract

1.9.1 The injury of liver and bile duct

The injury of the common liver, the right epathic branch, and common bile duct are extremely serious. The lesion is usually caused by a partial dissection of the elements to the Calot triangle with a consequent incorrect assessment of the relation between hepatic duct, cystic duct and common bile duct.

To avoid injury of the bile duct is necessary to be extremely cautious and may be useful:

isolate the elements of the triangle of Calot by pulling laterally the gallbladder on the infundibulum,

open two windows, one for the cystic and one for the cystic artery, and not dissect the duct until it is not clarified the anatomy of the region;

Intraoperative cholangiography may help to clarify the situation;

retrograde dissection of the gallbladder, if possible, after artery dissection between clips;

Don’t try the dissection of a Calot triangle if appears appear deformed by fibrotic tissue, edema and inflammation;

Accept a conversion "more" rather than a lesion of the bile duct. [5]

1.9.2 The Mirizzi syndrome [10]

From the anatomic-pathological point of view the syndrome is characterized by the presence of wedged gallstones in the infundibular region (in the Hartmann's pocket) or in the distal cystic in proximity of the hepatic duct common with the common bile duct junction with the presence of a dense tissue scar caused by a “sleepy” inflammation. It can be clinically accompanied by compression of the lithiasic formations on the bile duct with obstructive jaundice.

Two forms are classified:

The inflammation and the resulting anatomical change combined with the brevity of the cystic or in some cases even his complete absence, implies that the risk of damaging the main bile duct is extremely high. The risk is so high that a VLC is absolutely contraindicate in case the Mirizzi syndrome if identified preoperatively.

The preoperative diagnosis is made, most of the times, by ultrasound (15-20% of cases), but only the percutaneous cholangiography can provide certain images of a fistula between the bile duct and gallbladder. The incidence of the syndrome fluctuates between 0.05% and 1%, while the percentage of conversion of a VLC intervention to open one is 70% for the syndrome type 1 and 100% in type 2. [10]

1.10 Bile spill

1.10.1 The dislocations of clips [15]

The postoperative clinical symptomatology that leads to the suspicion of a lesion of the bile duct is characterized by cholestasis, jaundice, and sepsis all to be put in relation with also the septic bile peritonitis.

One of the most frequent causes, and luckily the one with the easiest treatment, is the loss of bile from the cystic stump. Usually, during VLC, the cyst is cut between clips making sure to leave at least two clips on the stump.

The causes of displacement of the clips are not clear; but pay the most attention to the positioning of the clips, which must be parallel to each other, and to the method of section of the cystic can be helpful. The cystic must be dissected leaving a few millimeters margin of tissue beyond the edge of the last clip and the section must be practiced with scissors rather than with the monopolar coagulator because it generates a large amounts of heat that damage the. The treatment of biliary fistulas supplied by the cystic can be very simple: it is to decompress the bile duct with a drain to keep for at least 7-14 days. The drainage follows a diagnostic ERCP that has the purpose to exclude the presence of an iatrogenic lesion of the bile duct.

In conclusion to avoid bile leaks from the clips dislocation, it is imperative to implement the following measures:

position the clips (at least 2) parallel to each other

dissect the cystic using scissors and not the monopolar dissector to prevent the possible formation of scars

leaving a portion of the cystic a few millimeters beyond the edge of the last clip

If there is concern about the tightness of the clips, use only of different size or a different manufacturer; alternatively bind the cystic. [15]

1.10.2 Lithiasis on a foreign body [16]

It is well established that non-absorbable suture material may migrate into the lumen of the bile duct and deliver the condensation nucleus on which presents a biliary lithiasis. There are reported cases where the metal clips have displaced up to penetrate the bile duct from where they were recovered, in the course of ERCP, on the center of lithiasic formations. It is a very rare situation whose reports are sporadic. Currently seems that the prevention must go through the correct position (parallel clips between them and not crossed) carefully avoiding the thermal and ischemic damage to the bile duct. Perhaps the genesis of this complication is linked to the necrosis of a portion of the cystic stump or of the biliary tract with the clips migration, subsequent the growth of the calculation and finally the obstruction of the bile duct [16]

1.11 Complication liked to the perforation of the gallbladder and the lithiasic spill

Abscesses of the wall [17]

In the international literature it is reported a perforation of the gallbladder with loss of the content material with a variable percentage between one and 40%. This situation is usually evaluated by surgeons as benign and does not deserve a specific treatment. In fact, are reported septic complications, also delayed by several months compared to the intervention of VLC.

The perforation of the gallbladder typically takes place in four stages:

During the dissection from the liver bed for drilling with the dissector,

As a result of the displacement of a clip,

As a result of tractions (true and proper tear) on the organ during surgery and

During the 'extraction of the gallbladder through the abdominal wall.

Of course, the quantity of gallstones and bile released into the peritoneum depends from the nature of the perforation and, presumably, also the frequency of these complications. An important role in the pathogenesis could be the bile infection present in approximately 15-30% of cases.

The presence of an acute inflammation of the organ is associated with an increased incidence of perforation, mainly linked to a greater fragility of the wall, which more easily can be damaged during normal surgical maneuvers.

The infectious complications can be divided into two main categories:

The first, with less severe clinical implications, encloses the abscesses of the abdominal wall linked to the loss of calculations during the extraction of the gallbladder from the wall itself;

The second, clinically more important, refers to systemic infections up to: septicemia, adhesions, fistulas and especially to the formation of intraperitoneal abscesses, mainly in the sub-hepatic or sub-phrenic space but also in the pelvis, omental and paracolic space.

The most important means to prevent these complications is prevention; the surgeon must avoid as much as possible the lesions of the gallbladder, recovering, however, all calculations also those of minimum size. Furthermore, it is necessary perform an accurate cleaning by abundantly flushing and subsequently aspirating all the liquid. The use of aids, such as endobag, can be useful but secondary to the care to put in avoiding injuries.

In conclusion, we can say:

gallstones in the peritoneum can cause illness;

complications also severe, as rare, may occur and may cause diagnostic doubts;

every possible precaution must be put into practice to prevent the spreading of gallstones and bile into the peritoneum during the VLC surgery

If a lot of calculations, including those discharged into the peritoneum, cannot be found during the laparoscopic inspection, in the presence of BC (bacterial cholangitis) must be performed a laparotomy conversion given the high incidence of infectious complications;

the abdominal cavity should be regularly irrigated after a perforation of the gallbladder in order to dilute the infected bile;

in any case, perform chemical and bacteriological examination of the gallstones;

The bile should be placed in culture to provide any information about the possible bacterial colonization and an eventual antibiogram that will be useful in case of complications;

treating an intra-abdominal abscess with a simple drainage is often ineffective and requires a “open” surgical approach;

Consider a “high risk of perforation of the gallbladder” the patients with hydrops (dimensions gallbladder> 8x4x4 cm) and those suffering from acute cholecystitis (with wall thickness > 7 mm). [17]

1.12 Imagining methods

In medicine diagnostic imaging methods allow you to view an anatomical structure, verify the functionality and the presence of any disease. Fifty years ago, diagnostic imaging in medicine was based on x-ray fluoroscopy, and inventions that are more recently new have revolutionized the diagnostic methods with the introduction of ultrasound, nuclear medicine and computed tomography (the first imaging technique computer-aided). Then were introduced the techniques of nuclear medicine, tomographic PET (Positron Emission Tomography), SPECT (Single Photon Emission Computed Tomography) and magnetic resonance imaging (MRI). The methods currently considered advanced level ( "Advanced Imaging") are thus computed tomography, ultrasonography, color Doppler ultrasound imaging, MRI, PET, SPECT. [19]

Special Part

2.1 Aim and motivation of the study

This study wants to show pros and cons of the Video Laparoscopic surgery method and tries to find some pattern of incidence of this inflammation among the patients of Arad.

Finding recurrences like: Age and sex can also help on determining who is at risk and why.

In literature, the reason of why a lithiasis occur is still a little mystery and analyzing the pattern of recurrences of our patients can may be help in understanding some algorithm of appear.

I choose this study because is a problem that is easily found in surgery, it has root in diet, hormones involved and lifestyle. If we can understand how and why an inflamed gallbladder reach this state may be avoiding some life behavior that we all have, we can easily avoid the hill itself.

2.2 Material and methods

The study is based on the analysis of the clinical records of 197 patients with cholecystitis (acute or chronic acutized) recovered at Spital municipal of Arad.

From the analysis of these clinical records, I took in consideration various parameters, useful for the study. These cases refers to the year 2016.

The parameters checked are the following:

Gender

Age

Conversions

Dimension of the Gallstones

Acute or Chronic Acutized

Association with adherence syndrome

Associated Pathologies

Intra-operative incidence and complications

Duration of the operation

These parameters are organized and represented in tables and graphics to show statistic studies and percentages. Statistics evicted by this study are also comparated with those are yet present in the medicine literature using the appropriate references.

2.3 Results

2.3.1 Gender

From our 197 patients 42 were male and 155 were female. As the pie chart (Chart 1) shows, the predominance of Cholecystitis is in women.

In the table below patients and percentage:

2.3.2 Age of the patients

From the analysis of the cases (chart.2/chart 3):

33.5% of the patients were over 60 years old

26.4% of the patients were between 51 and 60 years

20.3% of the patients were between 41 and 50 years

15.2% of the patients were between 31 and 40 years

4.6% of the patients were between 25 and 30 years

No cases under 25 years (0%)

2.3.3 Operative approaches and conversions

In our cases, 12 times the operation has been converted from the VL to Classic “Open” due to complications and 10 started as classic “open” from the beginning due to patient issue (chart4):

175 laparoscopic approach

12 conversions

10 classics “Open”

The episodes that needed a conversion represent less than 7% of the total operations. In our cases the issues where (chart 5):

Adherence block: 4 cases

Main biliary duct lesion: 2 cases

Gallbladder bed hemorrhage: 3 cases

Hemorrhages from the cystic artery branches: 3 cases

2.3.4 Dimension and quantity of the gallstones

Is obvious that the gallstone comes in different dimension and quantity (chart 6):

23 single gallstone

175 multiple

2.3.5 Acute or chronic acutized

We can find difference, also taking in analysis acute or acutized episodes, and compare them based on sex (chart 9, 10, 11):

2.3.6 Association with adherence syndrome (with\ without)

Men

Women

2.3.7 Associated Pathologies

I could noticed (chart 16) that the most common associated pathology is the Umbilical hernia, in the literature the conversion of the operation to an “open” one is due to a previous abdominal operation The ones the we encountered are (chart 17):

Ovarian cystectomy 0.6% of the total cases

Sub-umbilical hernia 1.5% of the total cases

Umbilical hernia 2.5% of the total cases

2.3.8 Intra operative incidence and complication (accidents)

Accidents always occurs, during the year toke in consideration, we had 23 accidents:

2 cases of main biliary duct lesion

9 cases of gallbladder bed hemorrhage

12 hemorrhages from the cystic artery branches

23 case on 197 represent 11.7% incidence of accidents.

2.4 Discussion

2.4.1 Gender

Taking in consideration the Sex of the patients, we can easily say that the women of Arad are more susceptible to this inflammation representing almost the 80% of the total cases (chart 20, 21).

Cholelithiasis is a widespread condition characterized by the presence of calculations in gallbladder and / or biliary tract; Women are more interested, with a female / male ratio of 2 to 1.

Acute cholecystitis is an acute inflammation of the gall bladder wall, accompanied by cholelithiasis in 95% of cases; chronic form is often characterized by recurrent colic and a contracted, fibrotic gallbladder, thickened walls

We know that the gallstones are divided into 2 sub-genres:

Cholesterol Stones: composed mainly of cholesterol (the most frequent)

Pigment Stones: composed of calcium bilirubinate, or calcified bilirubin. Black or brown in color.

Knowing that the estrogen encourages the cholesterol production, we can understand why the cholelithiasis is mostly present in women. [23]

2.4.2 Age of the patients

Gallbladder (or gall bladder) calculations affect about 80% of people after 40 years and frequency tends to increase with age. In most cases, they do not give any symptoms. This is why laparoscopic cholecystectomy (removal of the gall bladder), today a first-rate intervention, should only be reserved for specific cases. [22]

In our study:

33.5% of the patients were over 60 years old

26.4% of the patients were between 51 and 60 years

20.3% of the patients were between 41 and 50 years

15.2% of the patients were between 31 and 40 years

4.6% of the patients were between 25 and 30 years

No cases under 25 years (0%)

So the pattern of our study follow the pattern found in literature, because also most of our patients were over 40 years old (chart22).

2.4.3 Operator approaches and conversions

One of the complications of cholecystectomy is the lesions of the bile ducts, which occur, in the case of laparoscopic surgery, in 0.5-1% of cases.

The episodes that needed a conversion represent less than 1% of the total operations. In our cases the issues where:

Adherence block: 2 cases

Hemorrhage: 1 case

Conversion of laparoscopic technique to traditional laparotomy technique is performed when the surgeon judges that continuation of laparoscopic surgery increases the risk of complications for the patient. The conversion rate varies in international literature from 0.6 to 13% and is greatly influenced by the experience of the surgical team. The most common reason for conversion is adhesions, and the majority of these patients had prior abdominal surgery. [24]

So also on the conversions rate our study does not differ much from the literature.

2.4.4 Dimension and quantity of the gallstones

Our study shows that when the gallstone is single, it mostly will be a big one or any way in the order of >1 cm.

Taking in consideration the data we can understand that the single gallstone is rarer (23 cases out of 197), in fact in the most cases there were multiple micro-gallstones smaller than 0, 5 cm (174 cases out of 197)

2.4.5 Acute or chronic acutized

We can find difference, also taking in analysis acute or acutized episodes, and compare them based on sex:

Our study shows a perfect balance between acute and chronic acutized colecystithis. In fact, without taking the gender in consideration we have:

52% chronic acutized episodes

48% acute colecystithis

The main differences comes out if we base on the gender:

In men:

62% were Acute

38% were Chronic acutized

In women, we have quite the opposite:

56% were Chronic Acutized

44% were Acute

May be we can assume that the frequent acutiziation of the colecistithis in women is always due to estrogen.

2.4.6 Association with adherence syndrome (with\without)

The adherence syndrome is most common with a chronic colecystithis (75% of the cases) but from our study is obvious that the gender has a great influence on the appearance of the adherence syndrome, in fact in our case (chart 23, 24):

In man with acute colecystithis 65% of them showed lysis of adherences, in women instead, just the 41%

For what concern the Chronic Acutized syndrome there is a surprising equivalence of data bot 25% without and 75% with lysis

2.4.7 Associated Pathologies

In literature, the associated pathologies are various and are showed with a very variable percentage among the worldwide population. In Our particular study, we had 9 cases with an associated pathology:

Ovarian cystectomy 1 case

Sub-umbilical hernia 3 cases

Umbilical hernia 5 cases

We could assume that the Umbilical hernia is the most frequent but the cases are so few that is hard to extrapolate a plausible conclusion.

2.4.8 Intra operative incidence and complication (accidents)

A report of a similar study of the department of surgery science in the University of Pavia says: Regarding complications related to VLC interventions from 1993 to 2010, we found 44 cases in 1,047 patients (4.56%), of, which (chart 25):

18 were bleeding (12 of them were because of the Trocars),

15 subjected to conversion

11 lesions at different levels of biliary tract.[23]

We can compare their cases with complications and ours (Chart 26):

Considering that, some our cases requested a conversion we had (chart27):

12 conversions

21 hemorrhages

2 lesions

Therefore, in our year of study most of the complications have been hemorrhages like in the Italian study. But we encountered less lesion and the conversions ratio is almost the same.

CONCLUSIONS

The Video-laparoscopic surgery has emerged thanks to the undoubted advantages offered over conventional open surgery: Surgery traditionally known as "the brutal craft" finally became a bit 'more "patient friendly". Next to this, the VL surgery allows, if well practiced, to reduce the social costs of the diseases subject to surgical treatment.

This works shows that in laparoscopic surgery are highly important three aspects:

Who: the surgeon who is interested in Video surgery must be gone through special training. The training begins with a theoretical phase followed by several hours of application to the simulator and then move on to clinical phase that still provides for a learning curve far from immediate. In this phase, under the supervision of a tutor, however there is a risk of causing serious damage. Even after the end of the learning period, the risks are not over: surgery is a profession full of pitfalls and who is not well prepared and cautious sooner or later pay the consequences;

When: the timing of Video surgery is different from that of “open” surgery. Interventions that once could be postponed today should be treated immediately with less risk for the patient and lower costs for society;

Where: the Video surgery requires a series of equipment that must all be available simultaneously to work in safety.

The patient thanks to the VL techniques certainly undergoes a minor surgical trauma compared to conventional open surgical therapies, but still requires an adequate period of recovery and control. The request for a short stay in hospital often prevents clinical control with all the serious medical and legal implications that may arise; in other words, an intervention in VL is still a surgery with many advantages, but also many risks.

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