Managing the “difficult” gallbladder

#CVS

The gold standard for the surgical treatment of symptomatic cholelithiasis is conventional laparoscopic cholecystectomy (LC). The “difficult gallbladder” is a scenario in which a cholecystectomy turns into an increased surgical risk compared with standard cholecystectomy. The procedure may be difficult due to processes that either obscure normal biliary anatomy (such as acute or chronic inflammation) or operative exposure (obesity or adhesions caused by prior upper abdominal surgery). So, when confronted with a difficult cholecystectomy, the surgeon has a must: to turn the operation into a safe cholecystectomy, which can mean conversion (to an open procedure), cholecystostomy, or partial/ subtotal cholecystectomy. The surgeon should understand that needs to rely on damage control, to prevent more serious complications if choosing to advance and progress to a complete cholecystectomy.

When to Predict a Difficult Laparoscopic Cholecystectomy

A difficult cholecystectomy may be predicted preoperatively based on patient characteristics and ultrasound and laboratory findings. This is probably a very important step in mitigating the high risk associated with a difficult procedure and may serve either to reschedule the procedure or design intraoperative strategies of management to guarantee a safe performance of the surgical procedure.

The following situations are associated with a higher chance of a difficult cholecystectomy:

• Acute cholecystitis (more than 5 days of onset)
• Previous cholecystitis episode
• Male sex
• Obesity
• Cirrhosis
• Sclero-atrophic gallbladder
• Thick walls (>5 mm)
• Previous signs of canalicular dwelling (clinical and laboratory)

Through multivariate analysis, Bourgoin identified these elements of predictive help to identify difficult LC: male sex, previous cholecystitis attack, fibrinogen, neutrophil, and alkaline phosphatase levels. Another important point is the fact of conversion from a laparoscopic procedure to an open and traditional cholecystectomy, usually through a right subcostal incision. Conversion should not be considered as a personal failure, and the surgeon needs to understand the concept of “safety first,” considering that conversion is performed in order to complete the procedure without additional risks and preventing complications and not solving intraoperative complications. It is also useful to define a time threshold to aid in the decision to convert. It is not worth taking an hour and a half and still dissecting adhesions, preventing the correct visualization of the cystic pedicle. This time limit represents a method to prevent inefficiencies in the operating room (OR) schedule as well as additional expenditures.

A smart surgeon should rely to conversion in the following situations:
• Lack of progress in the procedure
• Unclear anatomy/any grade of uncertainty
CVS not achieved
• Bleeding/vascular injury
BD injury
Lack of infrastructure, expertise, and support

Final Remarks

The primary goal of a laparoscopic cholecystectomy in the treatment of symptomatic cholelithiasis is the safe remotion of the gallbladder and the absence of common bile duct injury. Some tips to take into account:
– Never perform a laparoscopic cholecystectomy without a skilled surgeon close by.
– Beware of the easy gallbladder.
– Slow down, take your time.
Knowledge is power, conversión can be the salvation!
Do not repair a bile duct injury (unless you have performed at least 25 hepaticojejunostomies).
– Do not ignore postoperative complaints (pain, jaundice, major abdominal discomfort, fever)

Other options when confronted with a difficult laparoscopic cholecystectomy are:
– A percutaneous cholecystostomy, if the risk was identified preoperatively or the patient is a poor surgical candidate;
– An intraoperative cholangiography, which may aid in identifying an injury to the bile duct and solve it, if you are an experienced surgeon;
A subtotal or partial cholecystectomy;
Ask for help;
– Conversion to an open procedure;

References here




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