American Journal of Medicine and Medical Sciences

p-ISSN: 2165-901X    e-ISSN: 2165-9036

2022;  12(9): 897-899

doi:10.5923/j.ajmms.20221209.09

Received: Aug. 15, 2022; Accepted: Aug. 29, 2022; Published: Sep. 15, 2022

 

Minimally Invasive Technologies in the Correction of Intraoperative Bile Ducts Injuries

Kadirov Rustam Nadirovich, Nurillaev Hasan Jamshidovich, Yarashev Sultonbek Saloxiddinovich, Abdukadirov Ulug’bek Qaxramonovich

Samarkand Branch of the Republican Scientific Center for Emergency, Medical Care

Correspondence to: Kadirov Rustam Nadirovich, Samarkand Branch of the Republican Scientific Center for Emergency, Medical Care.

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Copyright © 2022 The Author(s). Published by Scientific & Academic Publishing.

This work is licensed under the Creative Commons Attribution International License (CC BY).
http://creativecommons.org/licenses/by/4.0/

Abstract

The paper analyzes the results of surgical treatment of 3266 patients for various forms of cholelithiasis. Bile leakage in the postoperative period was observed in 34 patients due to damage to the peripheral bile ducts (aberrant hepatocystic ducts of the gallbladder bed - Luschka passages, leakage of the cystic duct stump, dislocation of the installed drainage in the hepaticocholedochus). The developed surgical tactics, based on the data of ultrasound and RPCH, can improve the results of treatment and avoid laparotomy in 94.2% of patients with bile leakage from the peripheral bile ducts.

Keywords: Cholecystectomy, Bile leakage, Surgical tactics

Cite this paper: Kadirov Rustam Nadirovich, Nurillaev Hasan Jamshidovich, Yarashev Sultonbek Saloxiddinovich, Abdukadirov Ulug’bek Qaxramonovich, Minimally Invasive Technologies in the Correction of Intraoperative Bile Ducts Injuries, American Journal of Medicine and Medical Sciences, Vol. 12 No. 9, 2022, pp. 897-899. doi: 10.5923/j.ajmms.20221209.09.

Article Outline

1. Relevance
2. Purpose of the Study
3. Materials and Methods
4. Results and Discussion
5. Conclusions

1. Relevance

The leading place in the structure of postoperative complications after cholecystectomy (CE) is occupied by external or intra-abdominal bile leakage (BI) in the early postoperative period, which should be considered as an independent problem, since it can have serious consequences and be life-threatening [1,2,3,10,11,14,16,17]. The main causes of postoperative GI are damage to the peripheral bile ducts (aberrant hepatocystic ducts of the gallbladder bed - Luschka's ducts, leakage of the cystic duct stump) and "large" - iatrogenic damage to the main bile ducts [5,19,21].
The outflow of bile through the drainage contributes to the early diagnosis of biliary complications, but even a small bile leakage into the abdominal cavity can lead to serious complications [4,6,7,13,20]. Diagnosis of intra-abdominal bile leakage is a difficult task, the presence of safety drainage in the subhepatic space contributes to early diagnosis and prevention of biliary peritonitis [8,9,12,15,18].

2. Purpose of the Study

To improve the results of surgical treatment of patients with cholelithiasis (GSD) who developed external or intra-abdominal GI by standardizing the indications and technical improvement of the use of relaparoscopy, transduodenal endoscopic interventions, ultrasound-guided puncture methods to reduce the number of repeated laparotomic operations.

3. Materials and Methods

The analysis of the results of surgical treatment of 3266 patients operated on in the period 2012-2021 was carried out. regarding various forms of cholelithiasis, which underwent CE: - laparoscopic access - 1947, mini-access - 1093, wide laparotomy - 216.
The diagnostic program included a standard general clinical examination, ultrasound, endoscopy, according to the indications of ERCP, MSCT, MRCP. All interventions were completed by draining the abdominal cavity with one or two drains.
In the early postoperative period, 49 patients had FI. Women - 37, men - 12, the average age of patients was 49±5.1 years. In 34 patients, the cause of VE was peripheral damage, in 15 - damage to the main bile ducts. The cause of bile leakage in 34 (69.3%) patients (i.e., in more than 2/3 of cases) was damage to the peripheral bile ducts - aberrant hepatic - cystic ducts of the gallbladder bed (Lushka's passages) - 8, failure of the stump of the cystic duct - 6 and dislocation of the established drainage in hepaticocholedochus - 3. However, in 17 patients, the source was not identified due to independent cessation of bile leakage. This study did not include patients with iatrogenic lesions of the main bile ducts.

4. Results and Discussion

GI was observed in 16 (47.1%) patients operated on for chronic cholecystitis and in 18 (52.9%) patients with acute cholecystitis. In 22 patients, the flow of bile through the drainage was noted, and in 12 patients, the accumulation of bile in the abdominal cavity was diagnosed according to ultrasound data.
To assess postoperative GI, we took into account both the daily flow of bile from the abdominal cavity drains and ultrasound data - we determined the volume of delimited fluid accumulation in the projection of the removed gallbladder bed, as well as the localization and volume of free fluid in the abdominal cavity.
In 24 patients with GI with bile discharge through the drainage in a volume of 150-200 ml per day and in the absence of signs of peritonitis, a satisfactory condition of patients, no changes in blood tests, dynamic monitoring was performed with obligatory ultrasound control and conservative treatment (antispasmodics, infusion, anti-inflammatory and antibacterial therapy). In 9 patients, the treatment was effective, bile leakage through the drainage progressively decreased and completely stopped within 5-7 days, so no other diagnostic and therapeutic procedures were required.
3 patients required punctures of the biloma under ultrasound control in order to evacuate the accumulation of fluid in the subhepatic space, and in 1 patient the cause of bile leakage was the loss of drainage from the choledochus (Fig. 1).
Figure 1. Puncture of the Biloma under ultrasound control
In 2 more patients, conservative treatment was also ineffective, and they underwent RPCH and EPST. In 1 patient, the cause of bile leakage was the failure of the stump of the cystic duct, in another 1 patient, the source of FI was not established. After endoscopic drainage of the biliary system, bile leakage in these patients stopped on days 2 and 5.
In the presence of FI in the control drainage of more than 200 ml within 2-3 days after surgery, 12 (46.1%) patients underwent abdominal ultrasound, ERCP, and, if necessary, decompression of the biliary tract by endoscopic papillotomy or the establishment of nasobiliary drainage. In 6 patients, EPST with nasobiliary drainage (NBD) proved to be effective and GI was stopped within 5-7 days. In case of failure or ineffectiveness of NBD, persistence or intensification of abdominal pain, symptoms of intoxication and irritation of the peritoneum, 4 patients underwent relaparoscopy with additional electrocoagulation of the gallbladder bed, clipping of Luschka ducts or an incompetent stump of the cystic duct, adequate sanitation and drainage of the abdominal cavity (Fig. 2).
Figure 2. Relaparoscopy, additional clipping of the cystic duct stump
Laparotomy, choledochostomy, sanitation and drainage of the abdominal cavity with diffuse bile peritonitis were performed in 2 patients. Complications were noted in 2 (7.6%) patients (repeated bile leakage - 1, acute pancreatitis after EPST - 1).

5. Conclusions

1. Ultrasound examination contributes to the choice of adequate surgical tactics for bile leakage.
2. With the appearance of bile discharge through the control drainage in a volume of not more than 200 ml per day with a tendency to decrease and the absence of accumulation of bile intraperitoneally and the clinic of bile peritonitis, conservative therapy can be limited.
3. The use of minimally invasive endoscopic transduodenal interventions, diapeutical methods and relaparoscopy, as well as active conservative therapy allowed patients with peripheral bile duct injuries after CE to avoid laparotomy in 94.2% of patients.
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.

References

[1]  Abdurakhmanov D.Sh. et al. Analysis of surgical treatment options for different types of Mirizzi syndrome // Bulletin of science and education. – 2021. – №. 5-1 (108). – P. 71-76.
[2]  Abdurakhmanov D.Sh. et al. Biliary peritonitis as a complication of chronic calcular cholecystitis // Bulletin of science and education. – 2021. – №. 5-1 (108). – P. 77-80.
[3]  Akhmedov B. A. et al. Surgical approach to the treatment of patients with posttraumatic scar structures of the main bile ducts // VolgaMedScience. – 2021. – P. 341-342.
[4]  Altiev B.K., Rakhimov O.U., Asamov Kh.Kh. // Diagnosis and treatment of intra-abdominal complications in biliary tract surgery. // Shoshilinch tibbiot axborotnomasi. -2012. - No. 4 - P.73-78.
[5]  Balla A., Quaresima S., Corona M. et. al. ATOM Classification of Bile Duct Injuries During Laparoscopic Cholecystectomy: Analysis of a Single Institution Experience. J Laparoendoscop Adv Surg Tech 2019. -No. 29(2). - P. 206-212.
[6]  Boyko V.V., Tishchenko A.M., Smachilo R.M. et al. // Treatment of bile leakage after laparoscopic cholecystectomy. // Kharkiv surgical school. - 2009. - No. 2. - S. 75 - 77.
[7]  Bretucu E., Straja D, Marincae M. et al. // Late choledochal pathology after choltcystectomy for cholelithiasis. // Chirurgia (Bucur). -2006. -May-Jun., Vol. 101(3). -R. 289-295.
[8]  Bystrov S.A., Zhukov B.N. //Surgical tactics for bile leakage after minimally invasive cholecystectomy. // Medical Almanac. -2012. -No.1. -P.90-93.
[9]  Ekmakcigil E., Unalp O., Hasanov R. et.al. Management of iatrogenic bile duct injuries: Multiple logistic regression analysis of predictive factors affecting morbidity and mortality. Turk J Surg 2018. -№28. - R.1-7.
[10]  Kasymov S. Z., Davlatov S. S. Hemoperfusion as a method of homeostasis protection in multiple organ failure syndrome // Academic Journal of Western Siberia. – 2013. – Т. 9. – №. 1. – P. 31-32.
[11]  Katanov E.S., Anyurov S.A., Maskvichev E.V. and others.// Biliary complications after cholecystectomy. // Acta medica Eurasica. -2016. -№1. -S.14-22.
[12]  Kolesnikov S.A., Pakhlevanyan V.G., Kopylov A.A. et al. // Surgical tactics for damage to the extrahepatic and main intrahepatic bile ducts as a result of minimally invasive cholecystectomy. // Scientific statements. -2015. -№10. -Issue 30. -p.39-43.
[13]  Kotecha K., Kaushal D., Low W. et.al. Modified Longmire procedure: a novel approach to bile duct injury repair. ANZ J Surg 2019. -89(11): E554-E555.
[14]  Krasilnikov D.M., Mirgasimova D.M., Abdulyanov A.V. et al. // Complications of laparoscopic cholecystectomy. // Practical medicine. 2016. -№4. -p. 110-113.
[15]  Kurbaniyazov Z. B. et al. Surgical treatment of patients with intraoperative damages of the main cholic ducts // Academic Journal of Western Siberia. – 2013. – Т. 9. – №. 1. – P. 32-32.
[16]  Martinez-Mier G., Luna-Ortiz H.J., Hernandez-Herrera N. et.al. Factores de riesgo asociados a las complicaciones y a la falla terapeutica en las reconstrucciones de lesions de via biliar secundarias a colecistectomia. Cir 2018. -86(6). - R. 491-498.
[17]  Nazirov F.G., Devyatov A.V., Babadzhanov A.Kh., Baibekov R.R. // Damage to aberrant bile ducts during laparoscopic cholecystectomy. // Shoshilinch tibbiyot axborotnomasi. - 2019. - No. 12. - P. 11 - 15.
[18]  Rakhmanov K. E. et al. The treatment of patients with major bile duct injuries // Academic Journal of Western Siberia. – 2013. – Т. 9. – №. 1. – P. 33-34.
[19]  Saydullaev Z. Y. et al. Minimally invasive methods of treatment of patients with acute cholecystitis //Annals of the Romanian Society for Cell Biology. – 2021. – P. 1956-1961.
[20]  Sokolov A.A., Kuznetsov N.A., Artemkin E.G., Naji Hussein // Diagnosis and treatment of bile leakage in the early stages after cholecystectomy. // Siberian Medical Journal. - 2009. - No. 6. -FROM. 143-146.
[21]  Song S., Jo S. Peritonitis from injury of an aberrant subvesical bile duct during laparoscopic cholecystectomy: A rare case report. Clin Case Rep 2018. - 6(9). - Р. 1677-1680.