【 Abstract 】 Objective To investigate the cause, management and prevention of biliary fistula with un-typical after laparoscopic cholecystectomy (LC). Methods Twenty-one cases of biliary fistula with un-typical after LC were reviewed retrospectively. Results All patients displayed with un-typical expression and had no obvious signs of peritonitis. Lump of right upper quadrant (6 cases) ， vague pain of epigastric zone (11 cases) ， abdominal distention (3 cases) and bowel obstruction (1 case) after operation were main manifestations. Abdominal paracentesis (14 cases) ， bile exuded from incisional opening of trocar (6 cases) and exploratory laparotomy (1 caes) were the methods of final diagnosis. The cause of biliary fistula included cystic stump fistula (2 cases) ， aberrant bile-duct fistula (9 cases) ， and accessory hepatic duct fistula (4 cases). Laparoscopic approach and puncturation and drainage under ultrasound were the main therapeutic methods. All patiens were discharged successfully with no death case. Nineteen cases were followed up for 3 months to 2 years, and all patients recovered very well. Conclusion The biliary fistula with un-typical after LC is scarce ， and it can lead to missed diagnosis and treatment. Strengthening recognition of biliary fistula after LC ， and paying attention to chief complaint and abdominal sign can help discover biliary fistula early. Laparoscopic approach and puncturation under ultrasound are the recommended therapeutic methods.
Objective To explore whether the intraoperative cholangiography （IOC） should be applied in laparoscopic cholecystectomy routinely or selectively. Methods Data of routine IOC group （1 520 patients）and selective IOC group （457 patients）in laparoscopic cholecystectomy were collected and analyzed， including cholangiography time， success rate， common bile duct stones rate， open cholecystectomy rate， and hospital stay after operation. All IOC cases were performed by home-made cholangiography appliance or infusion needle. Results There were no significant differences between routine IOC group and selective IOC group on cholangiography time， success rate， open cholecystectomy rate， and hospital stay after operation （P＞0.05）. However， compared with routine IOC group， the common bile duct stones rate， anatomic variation rate， and iatrogenic damage rate were significantly higher in selective IOC group （28.25% vs. 13.43%， 10.71% vs. 7.43%， 2.05% vs. 1.02%， P＜0.05）. Conclusions For avoiding iatrogenic bile duct damage and residual stones， routine IOC should be applied in early-stage of laparoscopic cholecystectomy， and IOC should be applied selectively when the surgeon have LC technique at their finger ends.
ObjectiveTo investigate and compare the advantages and disadvantages of laparoscopic cholecystolithotomy and laparoscopic cholecystectomy for patients with gallbladder stone. MethodsThe eligible patients with gallbladder stones hospitalized in our department between January 2007 and December 2011 were included, and all of them received either laparoscopic cholecystolithotomy (observation group) or laparoscopic cholecystectomy (control group) minimally-invasive surgery. The operation time, bleeding volume, enterokinesia recovery time, hospital stay, post-operative complication and follow-up results were compared between the two groups. ResultsA total of 148 patients were included, with 68 patients in the observation group and 80 patients in the control group. In this cohort, the success rate of surgery for the observation group and the control group was 100.0% (68/68) and 98.8% (79/80), respectively; and the success rate of complete stone removal was 100% for both two groups. B-ultrasound examination after 2 weeks of treatment showed that gallbladder wall was normal and gallbladder contraction rate was more than 30% for all patients with laparoscopic cholecystolithotomy. The operation time was (49.6±5.2) minutes for the observation group and (50.5±6.2) minutes for the control group, and bleeding volume was (9.5±1.4) mL for the observation group and (50.2±8.1) mL for the control group; the difference in bleeding volume was significant between the two groups (P<0.05). The difference in enterokinesia recovery time[(33.9±2.2) and (34.4±2.6) minutes] or hospital stay[(3.4±1.0) and (3.6±1.2) days] between the observation group and the control group was not significant (both P >0.05). The post-operative complications of bleeding, bile leakage and wound infection were not observed in both two groups, and all patients were followed up for 6 to 12 months with no stone recurrence; and only 2.7% of patients (1/37) had stone recurrence after 3-year follow-up. ConclusionBoth laparoscopic cholecystolithotomy and laparoscopic cholecystectomy procedures are safe and efficient. However, laparoscopic cholecystolithotomy not only reserves gallbladder but also has superiority of less bleeding volume.
Objective To investigate the possibility of laparoscopic cholecystectomy （LC） on porcelain gallbladder. Methods Twenty-four cases of porcelain gallbladder， who were operated in China Medical University， including 13 LC cases， from 2006 to 2008 were retrospectively reviewed. Results Of 24 porcelain gallbladder cases (0.48%) in 4964 cholecystectomy patients， calcification of gallbladder in 87.50%(21/24) patients was diagnosed by ultrasonography. Of 13 patients who were cured by LC, one suffered from postoperative leak bile, no metastasis were found by following up 12 or 14 months in two gallbladder carcinoma cases. Conclusion There’s specificity of ultrasonographic image in porcelain gallbladder, in which LC is safe to be performed and routine frozen pathology during operation is necessary.
ObjectiveTo investigate the value of magnetic resonance (MR) imaging in the assessment of bile duct complications after cholecystectomy. MethodsFifty patients of having bile duct complications after cholecystectomy underwent MR imaging and had some positive manifestations. The indication for cholecystectomy was symptometic cholelithiasis in all cases. MR imaging was performed with a 1.5T clinical imager including all of the sequences of: ①T1 weighted imaging (T1WI) was performed in transverse and coronal plane before and after gadolinium-enhanced. ②T2 weighted imaging (T2WI) was performed in transverse plane. ③A true fast imaging with steadystate precession sequence (True fisp) was performed in coronal plane. ④MR cholangiopancreatography was also obtained. ResultsThe bile duct complications after cholecystectomy including: 22 cases of cholelithiasis, 15 cases of chronic cholangitis with or without bile duct abscess. Bile duct strictures or abruption at the confluence of hepatic and common bile duct in 6 and 3 cases respectively. Tumors of bile duct or pancreas in 9 cases. The other complications after cholecystectomy including bile leak with choleperitonitis and/or biloma and acute pancreatitis.ConclusionMR imaging was a valuable method for the assessment of bile duct complications after cholecystectomy. MR imaging could assess the etiology of bile duct complications. If there were bile duct obstruction, MR imaging could assess the location and the severe of obstruction. For bile duct or pancreatic tumors, MR imaging could assess the areas of tumor infiltration and resection and was helpful to select treatment methods. Before lapatoscopic cholecystectomy, the overall and careful imaging assessment for bile duct and gallbladder and its adjacent hepatic tissue and pancreas so to avoid missing the relative tumors.
ObjectiveTo investigate the feasibility and advantages of general laparoscopic cholecystectomy and gynecologic uterus and attachment surgery at the same time. MethodsSixty patients with gallbladder stones combined with ovarian cysts, benign gynecological disease or fallopian tube adhesions aged between 35 and 55 were chosen from the department of General Surgery and Gynecology and Obstetrics to be the study subjects between January 2009 and December 2013. The inclusion criteria included: gallbladder stones; gallbladder wall thickness <0.5 cm; non-acute inflammation; symptomatic gynecological diseases; and tumor size between 5.0 and 10.0 cm. Based on similar age, body mass, and histological type, the patients were divided into laparoscopic surgery (GLS) group and staging surgery group (control group) according to the will of the patients. The anesthesia time, surgery time, the number of abdominal perforations, length of hospital stay, and total costs were detected for comparison between the two groups. ResultsThe first-time operation was successful in all the patients in the CLS group, with two cases of abnormal liver function, which were cured within 5-6 days. In the control group, 2 cases of reoperation were transferred to laparotomy due to umbilical and peritoneal adhesions, and both of them were cured and discharged from hospital without incision infection or iatrogenic tissue and organ damage. CLS group had significant advantages in anesthesia time, surgery time, the number of abdominal perforations, length of hospital stay, and total costs over the control group (P<0.05). ConclusionThe combined gynecologic laparoscopic surgery is feasible, safe, mini-invasive, and economical.
【Abstract】ObjectiveTo evaluate the injury of common bile duct in immediate removal of the ligation in cholecystectomy. MethodsEighteen healthy Japanese rabbits were selected and divided into three groups randomly: A group treated with simple cholecystectomy, B group with cholecystectomy plus common bile duct crossligation and C group with cholecystectomy plus hepatic bile duct conjunction “Y”type ligation. The ligation was removed after 5 min in B and C groups. The levels of serum transaminase and bilirubin and pathological changes of bile duct and liver in each group were observed respectively. ResultsThere were no statistic difference in the levels of GPT, GOT, total bilirubin (TB), direct bilirubin (DB) and DB/TB on 12 hours before operation and the 1st and 7th day after operation between A and ligation groups (Pgt;0.05). But there were statistic difference in the those indexes and pathological changes of bile duct and liver between A and ligation groups on the 30th and 90th day after operation (Plt;0.05). ConclusionDuring cholecystectomy, immediate removal of common bile duct ligation doesn’t affect shortterm results, but the long-term results are bile duct stricture and obstruction.
Objective To study the suitable operation method of elderly patients with acute cholecystitis. Methods The clinical data of 149 elderly patients with acute cholecystitis were retrospectively analyzed. All patients were divided into two groups according to the operation: open cholecystectomy group (OC group, n=76) and laparoscopic cholecystectomy group (LC group, n=73). Some clinical data were compared in this paper such as operation time, blood loss, length of hospital stay, time of resumption of food, time of intestinal function recovery and complications. Results No marked difference was found between OC group and LC group about basic data except WBC count and examination of gallbladder by B ultrasound（P＞0.05）. But there were significant difference in operation time, blood loss, time of resumption of food, time of intestinal function recovery, length of hospital stay and complications between OC group and LC group （P＜0.01）. Conclusion Individualized treatment should be emphasized on elderly patients with acute cholecystitis. Selection of OC or LC to these patients should be based on the clinical condition and taken the safety as the first principle.
ObjectiveTo evaluate the security and feasibility of transumbilical laparoendoscopic single-site cholecystectomy (TULESC) with conventional laparoscopic instruments. MethodsThe clinical data of 62 adult patients undergoing TULESC between October 2011 and June 2013 were analyzed retrospectively. There were 13 males and 49 females aged between 22 and 70 years old averaging 40±15. Forty-nine patients suffered from chronic cholecystitis with cholelithiasis, 10 from asymptomatic cholelithiasis and 3 from cholecystic polyposis. A single arc incision was cut on the edge of the umbilicus, and two 10 mm Trocars and one 5 mm Trocar were placed by puncture. Cholecystectomy was performed with conventional laparoscopic instruments and equipment. ResultsAll the 62 patients underwent TULESC successfully without severe complications such as bile leakage or biliary injury. The operation time was 20-70 minutes with the average of (40±15) minutes; The blood loss was 5-40 mL with the average of (15±10) mL. All the patients were discharged from the hospital within 3 to 7 days after surgery, averaging 4.0±1.0. During the 1 to 12-month follow-up (averaging 3 months), there was no obviously visible scars on the abdominal wall and the aesthetic effect was significant. ConclusionTULESC with conventional laparoscopic instruments and equipment is safe, feasible and cosmetic.
Objective To systematically review the effectiveness and safety of single-incision laparoscopic cholecystectomy (SILC) versus conventional multiport laparoscopic cholecystectomy (CMLC). Methods We electronically searched PubMed, EMbase, The Cochrane Library (Issue 1, 2013), CBM, CNKI, VIP and WanFang Data for randomized controlled trials (RCTs) on SILC versus CMLC from inception to January 1st, 2013. According to the Cochrane methods, the reviewers screened literature, extracted data, and assessed the methodological quality. Then, meta-analysis was performed using RevMan 5.2 software. Results Finally, 17 RCTs involving 1 233 patients were included. The results of meta-analysis showed that, compared with CMLC, SILC was lower in 24 h postoperative pain score (visual analogue scale, VAS) (SMD= –0.40, 95%CI –0.76 to –0.04, P=0.03), higher in cosmetic results score (SMD=1.56, 95%CI 0.70 to 2.43, P=0.000 4), and longer in operative time (MD=13.11, 95%CI 7.06 to 19.16, Plt;0.000 1). However, no significant difference was found in 6 h postoperative pain scores (VAS), postoperative complications, port-site hernia and hospital stay between the two groups. Conclusion SILC is a safe and effective technique for the treatment of uncomplicated benign gallbladder diseases, and it has certain advantages compared with CMLC, which is recommended in clinical application.