Results of small laparotomy in the treatment of acute destructive cholecystitis
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https://www.eduzhai.net American Journal of Medicine and Medical Sciences 2021, 11(8): 593-597 DOI: 10.5923/j.ajmms.20211108.10 Results of Surgical Treatment of Patients with Acute Destructive Cholecystitis from Minilaparotomic Access Saydullayev Zayniddin Yaxshiboyevich1,*, Rakhmanov Kosim Erdanovich1, Davlatov Salim Sulaymonovich2, Gaziyev Karim Umarovich2 1Samarkand State Medical Institute, Samarkand, Uzbekistan 2Bukhara State Medical Institute, Bukhara, Uzbekistan Abstract Introduction. Acute destructive cholecystitis is a common complication of cholelithiasis; of great practical interest is the development of atypical methods for performing minilaparotomic cholecystectomy, which make it possible to avoid the transition to a wide laparotomy. The aim of the study is to improve the quality of treatment of patients with acute destructive cholecystitis by improving surgical tactics. Materials and research methods. The work is based on the assessment of the results of surgical treatment of patients with acute destructive cholecystitis who were treated in the surgical departments of the 1st clinic of the Samarkand State Medical Institute (clinical base of the departments of surgical diseases No. 1 and general surgery of the Samarkand State Medical Institute) for the period from 2018 to 2020. Research results. In order to study the results of treatment of atypical MLCE methods, we used the following indicators: duration of operations; the frequency of switching to laparotomy; the frequency of damage to hepaticoholedochus; the frequency of local complications; postoperative mortality. Conclusions. When performing standard MLCE in acute destructive cholecystitis, there remains a relatively high risk of damage to the hepatic choledochus. Therefore, the method of choice in the treatment of these patients is the use of MLCE "from the bottom", MLCE with "amputation" of the gallbladder or MLCE according to Fedorov and Pribram. Keywords Cholelithiasis, Cholecystitis, Cholecystectomy, Laparoscopy, Minilaparotomic cholecystectomy, Laparotomy, Conversion, Complication 1. Introduction Acute destructive cholecystitis is a common complication of the gastrointestinal tract, the development of atypical methods of performing MLCE that allow avoiding transitions to a wide laparotomy is of great practical interest [4,10]. It seems to us relevant and practically significant to determine the indications for each of the atypical methods of cholecystectomy within the framework of minilaparotomy access with the development of optimal technical support and the most rational surgical techniques for performing surgical intervention, as well as the study of the immediate and long-term results of their implementation [3,8,12]. The most dangerous complication of acute cholecystitis, which can lead to peritonitis and other intraabdominal problems, is purulent-destructive cholecystitis, including phlegmonous, gangrenous, perforated forms, as well as empyema of the gallbladder. It is this category of patients that attracts the greatest attention of surgeons and requires * Corresponding author: firstname.lastname@example.org (Saydullayev Zayniddin Yaxshiboyevich) Received: Aug. 12, 2021; Accepted: Aug. 25, 2021; Published: Aug. 30, 2021 Published online at https://www.eduzhai.net optimization of emergency care methods [1,5,9,13]. The conducted analysis of the literature indicates that at the present time, the therapeutic and diagnostic tactics for acute cholecystitis belongs to one of the urgent and completely unresolved problems of modern healthcare [2,6,10,14]. In this regard, there is a need to revise the criteria for radical surgical intervention in acute cholecystitis, depending on the information content of non-invasive medical imaging methods, which allow to assess the features of the clinical course of the disease at the preoperative stage and identify signs of aggression of the disease, and therefore, optimization of the diagnostic algorithm becomes especially relevant in order to choose the most radical tactics of surgical treatment in each specific case. The aim of the study is to improve the quality of treatment of patients with acute destructive cholecystitis by improving surgical tactics. 2. Materials and Methods of Research The work is based on the evaluation of the results of surgical treatment of patients with acute destructive cholecystitis who were treated in the surgical departments 594 Saydullayev Zayniddin Yaxshiboyevich et al.: Results of Surgical Treatment of Patients with Acute Destructive Cholecystitis from Minilaparotomic Access of the 1st clinic of the Samarkand State Medical Institute (clinical base of the departments of Surgical diseases №1 and general surgery of the Samarkand State Medical Institute) for the period from 2018 to 2020. During this period, 81 patients with acute destructive cholecystitis, taking into account the clinical signs of the course of acute cholecystitis, the existing concomitant somatic pathology and the data of the ultrasound study, cholecystectomy was performed through a minilaparotomy access. Minilaparotomic cholecystectomy (MLCE) was performed in terms of more than 72 hours from the onset of the disease, and at the beginning of the operation, attempts were made to use standard methods of surgery, and when technical difficulties arose, they tried to perform non-standard methods of MLCE. Of 81 patients with acute destructive cholecystitis, standard MLCE was performed in 43 (53.1%) patients; MLCE from the bottom – in 27 (33.3%) patients, of which 6 (22.2%) had gallbladder amputation and 8 (29.6%) had cholecystectomy performed according to the Fedorov method due to dense infiltration into the neck of the gallbladder and the risk of damage to hepaticocholedoch; MLCE according to Pribram-in 11 (13.6%) patients (Fig. 1). In the technique of performing MLСE from the bottom, the following stages were provided: opening the lumen of the gallbladder and removing its contents; crossing the gallbladder along the border of the body and neck; removing the walls of the body and the bottom of the gallbladder; removing the walls of the neck of the bladder and the cystic duct; completing the operation. bottom to the neck (Fig. 2). A particularly dangerous moment of the operation is the isolation of the neck of the gallbladder, sealed in the infiltrate. It must be remembered that large vessels are located behind it, and on the side, at the beginning of the cystic duct, hepaticocholedoch can be soldered. In this regard, the neck was isolated with extreme caution, as close as possible to the walls of the bladder and the cystic duct. All manipulations were performed under the control of the finger of the left hand inserted into the gallbladder cavity. Figure 2. Atypical cholecystectomy according to S.P. Fedorov In the main group of patients in 11 cases, the main difficulty was that it was impossible to identify not only the neck, but also the part of the gallbladder adjacent to the liver. Separate from the liver without significant damage to its parenchyma and as a result of intense bleeding. In order to avoid this complication, the operation of choice was considered MLCE with mucoclasia according to Pribram (1928). The following operation technique was used. Figure 1. Distribution of patients of the main group depending on the performed method of cholecystectomy from the minilaparotomy approach In particularly difficult situations, when there are significant technical difficulties in isolating the gallbladder from the surrounding tissues due to extensive fibrotic scar changes, radical isolation of the walls of the organ is fraught with iatrogenic damage to significant anatomical formations, a high probability of bleeding from the bed of the gallbladder. In such situations, cholecystectomy was completed by amputation of the gallbladder or CE was performed according to the method of S.P. Fedorov (1904). The essence of the operation according to S.P. Fedorov is the longitudinal opening of the lumen of the gallbladder, the introduction of a finger there and the gradual excision (with scissors or a scalpel) of the walls of the organ from the Figure 3. Atypical cholecystectomy according to Pribram Along the middle line at the border of the body and the bottom of the gallbladder, using straight scissors curved along the edge, its cavity was opened longitudinally. The length of the incision of the gallbladder wall, if necessary, was increased towards the neck. The concretions were captured with a compressed clamp and gradually removed. Then the walls of the gallbladder were excised along the American Journal of Medicine and Medical Sciences 2021, 11(8): 593-597 595 border of the splices. Excision of free sections of the gallbladder wall was performed along the border of the line at the level of which tissue differentiation was lost. Hemostasis, coagulation with stitching of the branches of the cystic artery. Next, mucoclasia was performed. The use of electrocoagulation was considered the best option. It was performed from the bottom up, by linear parallel movements of the ball electrode in the coagulation mode. The uniformity and depth of mucosal coagulation were visually controlled by conducting exposure to the subserous layer. The last stage of the cystic duct was carefully examined for the presence of nodules in it. A safety drainage tube according by Vishnevsky was installed in the subhepatic region according to the standard procedure (Fig. 3). 3. The Results of the Study In order to study the results of treatment of atypical methods of MLCE, we used the following indicators: the duration of operations; the frequency of transition to laparotomy; the frequency of hepaticocholedocha injuries; the frequency of local complications; postoperative mortality. When studying the frequency of local complications in our work, we took into account only those complications that were accompanied by a significant deterioration in the patient's condition, posed a threat to his life and required active conservative or surgical treatment (table 1). Local postoperative complications included damage to the biliary tract, bile leakage through the drainage of the abdominal cavity, massive bleeding from the abdominal cavity, infectious intra-abdominal complications. The frequency of hepaticocholedocha damage in acute cholecystitis complicated by dense infiltration during standard LCE was observed by us in 1 out of 23 patients (4.3%) of the comparison group. The comparative characteristics of other local complications after CE by various methods in the studied groups are presented in Table 2. As follows from the data in Table 2, the frequency of local complications after performing CE in the comparison group was observed in 11 (13.4%) of 82 patients. This indicator was significantly higher than in patients of the main group, i.e. in 2 (1.7%) of 119 patients. In the main group of patients after LCE, after standard and non-standard MLCE, such terrible complications as damage to the hepaticocholedoch were not observed. The analysis of methods of treatment of local complications in patients with acute destructive cholecystitis, after CE in various ways in the studied groups, is presented in Table 2. The shortest duration of the operation was observed in patients with acute destructive cholecystitis, when performing the standard method of MLCE-83.2±1.3 minutes. All atypical methods of MLCE required more time to perform them: MLCE «from the bottom» - 102.3±2.1 min; MLCE according to Fedorov-78.4±2.6 min; MLCE according to Pribram – 89.2±1.7 min. Table 1. The frequency of postoperative complications in patients after cholecystectomy Type of complication damage to hepaticocholedocha Bile flow through the drainage due to the slipping of clips from the stump of the cystic duct due to the failure of the stump of the cystic duct from Lyushko's moves Biloma in the subhepatic region Biliary peritonitis Bleeding Suppuration of a postoperative wound Total complications Number of patients with complications Criteria χ2 Group of patients Comparison group (n=82) Main group (n=119) condition after LCE (n=23) condition after TCE (n=59) condition after LCE (n=38) condition after MLCE, (n=81) absolute % absolute % absolute % absolute % 1 4,3 2 8,7 1 1,7 2 3,4 1 1,2* 1 4,3 1 2,6 1 1,7 1 4,3 2 3,4 5 21,7 6 10,2 1 2,6** 1 1,2 4 17,4 5 8,5 1 2,6 1 1,2 Df=1; χ2 = 4.954; p=0,027 Note: * - differences relative to the control group data are significant (*- P<0.05, * * - P<0.001) Total, n=201 absolute % 1 0,5 2 0,9 1 0,5 3 1,5 2 0,9 1 0,5 1 0,5 2 0,9 13 6,5 11 5,5 596 Saydullayev Zayniddin Yaxshiboyevich et al.: Results of Surgical Treatment of Patients with Acute Destructive Cholecystitis from Minilaparotomic Access Research groups Comparison group (n=82) Main group (n=119) Total Table 2. Methods of treatment of local complications after cholecystectomy in the study groups Type of complication Conservative damage to hepaticocholedocha after LCE (n=1) due to the slipping of clips from the stump Bile of the cystic duct after LCE (n=2) 1 discharge due to the failure of the stump of the cystic duct after TCE (n=1) 1 from Lyushko's moves after TCE (n=2) 1 Biloma in the subhepatic region after LCE (n=1) Biliary peritonitis after TCE (n=1) Bleeding after LCE (n=1) Suppuration of the postoperative wound after TСE (n=2) 2 Bile discharge from Lyushko's moves after MLСE (n=1) 1 Biloma in the subhepatic region after LCE (n=1) 6 Treatment method Conversion, external drainage of the GC stump Laparotomy Puncture drainage under ultrasound control 1 1 1 1 1 1 1 1 4 2 Conversion with standard MLCE was required in 7 (16.3%) patients; with MLCE «from the bottom»- in 1 (7.7%); with MLCE with «amputation» of the gallbladder, with MLCE according to Fedorov and Pribram – there were no conversions. The reasons for the conversion during the standard MLCE in acute destructive cholecystitis were: inability to identify the cystic duct and hepaticocholedoch in the infiltrate (2 patients), intense parenchymal bleeding from the vessels of the gallbladder bed (1 patient), inability to detect a crossed cystic duct in the infiltrate (1 patient), intense bleeding from the cystic artery (2 patients), damage to the hepaticocholedoch (1 patient). The transition to laparotomy during MLCE «from the bottom» in 1 patient was due to bleeding from the posterior branch of the cystic artery. Local postoperative complications included damage to the biliary tract, bile leakage through the drainage of the abdominal cavity, massive bleeding from the abdominal cavity, infectious intra-abdominal complications (abdominal abscesses). The frequency of damage to hepaticocholedocha in acute destructive cholecystitis, during standard MLCE, was observed by us in 1 out of 43 patients (2.3%). With MLCE «from the bottom» and atypical methods of MLCE, there was no damage to hepaticocholedocha. The frequency of local complications after standard MLCE was observed in 6 (13.9%) out of 43 patients and in 1 (2.6%) patient after atypical MLCE out of 38. In one case, bile discharge through drainage from the abdominal cavity was stopped due to EPST for decompression of the biliary tract, followed by a reminilaparotomy and sanitation of the subhepatic space in the phenomena of local peritonitis. The clinical picture of diffuse bile peritonitis developed in 1 patient with insufficiency of the cystic duct stump after performing standard MLCE, which required laparotomy, sanitation and drainage of the abdominal cavity with additional ligation of the cystic duct. In another case, after the standard MLCE, there was a transient bile discharge through the control drainage with a flow rate of no more than 50 ml per day, which was resolved conservatively. In 2 cases, the formation of a subhepatic abscess was observed, which was drained under the control of ultrasound and subsequently resolved conservatively. In 2 cases, a large amount of blood was released (more than 100 ml per day) through the drains of the abdominal cavity. A reminilaparotomy was performed with the removal of a subhepatic hematoma, in 2 cases a laparotomy was performed with ligation of the failed stump of the cystic artery. 4. Conclusions 1. The frequency of transitions to laparotomy in acute destructive cholecystitis, when performing atypical methods of MLCE is 7.7%, which is significantly lower compared to standard MLCE, in which the conversion rate reaches 16.3%. 2. The frequency of local complications after atypical methods of MLCE in acute destructive cholecystitis (2.6%) is lower than when performing standard MLCE (13.9%). 3. The frequency of hepaticocholedoch damage in acute destructive cholecystitis was 2.3% during standard MLCE. After the introduction of atypical methods of MLCE in acute cholecystitis, no damage to hepaticocholedoch was observed. 4. When performing standard MLCE in acute destructive cholecystitis, there is a relatively high risk of damage to the hepaticocholedocha. Therefore, the method of choice in the treatment of these patients is the use of American Journal of Medicine and Medical Sciences 2021, 11(8): 593-597 597 MLCE «from the bottom», MLCE with «amputation» of the gallbladder or MLCE according to Fedorov and Pribram. Information about the source of support in the form of grants, equipment, and drugs. The authors did not receive financial support from manufacturers of medicines and medical equipment. Conflicts of interest: The authors have no conflicts of interest. pancreatic necrosis, topical diagnostics and treatment of complications // Annals of surgical hepatology. – 2012. – Т. 17. – №. 2. – С. 42-49.  Rakhmanov K. E. et al. 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