Websurg, e-Surgery 關於腹腔鏡手術

CHOLELITHIASIS: POSTOPERATIVE MANAGEMENT

B Millat, MD , Hôpital Saint Éloi, Montpellier, France
D Mutter, MD, PhD , Hôpitaux Universitaires de Strasbourg, Strasbourg, France

1. Postoperative pain management

2. Operative complications

3. Early complications

4. Late complications

5. General complications and death

6. References

1. Postoperative pain management

Goals:

treat the pain before its onset;
avoid nausea and vomiting (additional source of pain and potentially detrimental to the surgical repair)

-> use of Droperidol (Inapsine®) at anti-emetic dosage

Note: Doses are standardized for a healthy 70 kg patient (when not specified as dose/kg).

An analgesic ketamine dose (0.5 mg/kg, KETALAR®) is injected during the anesthesiologic induction in order to antagonize the NMDA receptors. (NOTE: there is no effect on the patient’s level of consciousness at these doses).
Excellent curarization and analgesia during the operative procedure. Injection of 1 mg of Droperidol (DROLEPTAN®).
Non-opioid analgesics used about 30 min. before the end of the anesthesia:
- NSAID (e.g. Ketoprofen, 50 to 100 mg) (there are no side effects at these doses, notably on hemostasis);
- 1 g of paracetamol per rectum or 2 g of paracetamol PO.
Tramadol hydrochloride administered (postoperative pain, 100 mg initially then 50 mg every 10-20 min. if necessary during first hour to total maximum 250 mg (including initial dose) in first hour, then 50-100 mg every 4-6 hours; maximum 600 mg daily) with 0.5 mg of Droperidol for every 100 mg of Tramadol hydrochloride to prevent nausea
For breakthrough pain, morphine titration (2 to 3 mg IV morphine every 5 to 10 min. until the visual analogue scale for the assessment of pain <= 3 is reached) in the recovery room:
- to anticipate nausea/vomiting, Droperidol is given with morphine (0.5 mg of Droperidol for 10 mg of morphine),
- the Patient Controlled Analgesia (PCA) is rarely used: if it is, Droperidol is associated with morphine in the PCA reservoir at the dosage indicated above.
As soon as liquid intake is resumed and if no nausea or vomiting occur, soluble paracetamol is administered: 1 g every 4-6 hours.
Continue regular NSAIDs (eg, Ketoprofen 50 mg every 8 hours orally).

This analgesic protocol has proven to be effective in our services.
Effective relief of postoperative shoulder pain has not yet been found (currently under study).

1. Postoperative pain management

2. Operative complications

3. Early complications

4. Late complications

5. General complications and death

6. References

2. Operative complications of laparoscopic cholecystectomy

The complications linked to laparoscopic cholecystectomy have been extensively studied. Two such studies present the major complications as reported by a wide sampling of surgeons: Deziel et al., 1993 (77 604 patients) and Shea et al., 1996 (30 052 patients).
Operative complications are divided into three classifications. The results are comparable in each of the 2 series (see Table 2.a). A list of the complications ( Deziel et al., 1993 ) is presented in Table 2.b.

Table 2.a: Biliary, vascular and digestive complications

Biliary complications	( Deziel et al., 1993 )	0.59%
Biliary fistulae	( Shea et al., 1996 )	0.3% to 0.6%
Hemorrhage	( Deziel et al, 1993 )	0.25%
	( Shea et al., 1996 )	0.5% to 1%
Bowel injuries	( Deziel et al., 1993 )	0.14%
	( Shea et al., 1996 )	0.06% to 0.3%

Common bile duct injuries, often thought to occur frequently in laparoscopy, are reported in 0.35% to 0.5% of cases.

Table 2.b: Complications of laparoscopic cholecystectomy,
reported for 77 604 cases ( Deziel et al., 1993 ).

Location of the injury	Number of patients	Need to convert to laparotomy
Biliary tract
Common bile duct	271	239
Common hepatic duct	38	38
Right hepatic duct	8	7
Aberrant duct	48	25
Cystic duct	94	38
Total	459 (0.59%)	347

Vascular injuries
Retroperitoneal vessels
Aorta	13	12
Inferior vena cava	5	3
Iliac artery	11	10
Iliac vein	7	6
Total	36 (0.05%)	31
Portal vessels
Hepatic artery	44	36
Cystic artery	73	63
Portal vein	5	4
Total	122 (0.16%)	103
Other vessels	35 (0,05%)	24
Total	122 (0.16%)	103
Total vasculaire	193 (0.25%)	158

Bowel injuries
Small intestine	57	42
Colon	35	26
Duodenum	12	12
Stomach	5	5
Total	109 (0.14%)	85

The other complications reported in this series (77 604 cases) are considered insignificant enough not to be mentioned. Nevertheless, some of these complications may be a cause for conversion. They are as follows:

intraoperative loss of stones – 35 conversions; 6 postoperative abscesses;
minor biliary leaks – 40 conversions;
bleeding at a trocar insertion site – 29 conversions;
bleeding of the gallbladder bed – 80 conversions (0.10%);
subcutaneous emphysema;
pneumothorax – 10 cases;
air embolism – 1 case;
punctures of intra- and retroperitoneal organs: gravid uterus, uterus, kidney, horseshoe kidney, bladder, diaphragm, ovarian cyst.

1. Postoperative pain management

2. Operative complications

3. Early complications

4. Late complications

5. General complications and death

6. References

3. Early complications of laparoscopy

Complications of laparoscopic cholecystectomy can be treated conservatively by means of endoscopic, laparoscopic or open procedures, depending on the type of complication and on the experience and availability of the medico-surgical teams.

3.1. Postoperative hemorrhage

3.1.1. Frequency
Hemorrhage can occur in the postoperative period (58 out of 77 604 cases – 0.08%) ( Deziel et al., 1993 )).

3.1.2. Diagnosis
Typically established due to hemodynamic instability or due to a drop in the hematocrit count.

3.1.3. Origin
Usually due to one of several mechanisms:

poor visualization of the operative field;
failure to ligate the cystic artery – 13%;
hemorrhage of the gallbladder bed – 25%;
par un orifice de trocart – 5 % ;
by a trocar insertion site – 5%.

3.1.4. Management
In case of severe symptoms, such as hypotension or a significant drop in the hemoglobin count, the patient must undergo re-operation in order to identify the origin of the hemorrhage and to control it (by clips, compression, monopolar and/or bipolar coagulation, Argon beam). Surgery must be performed again in 80% of cases ( Deziel et al., 1993 ).

3.2. Biliary fistula

45% of cases of common bile duct injuries are detected during the procedure. The others are usually discovered due to an external fistula (12%), by bile collections localized in the right hypochondrium (5%), or by bile peritonitis (29%) ( Deziel et al., 1993 ).

3.2.1. Incidence
Biliary tract injuries frequently occur at an early stage of the procedure. 223 cases are mentioned in the series reported by Deziel et al., 1993 (77 604 cases).

3.2.2. Origin
It may have several causes :

leakage from the cystic stump – 25%, (which may be linked to a CBD stone – 1%);
leak from the gallbladder bed – (Luschka’s accessory duct – 10%);
division of the bile duct (common or right) unrecognized, partial or total – 8%;
injury of an accessory duct – 2%;
in a significant number of cases, the origin of this leak is not identified (47%).

3.2.3. Diagnosis
When an intra-abdominal drain has been placed, the bile leak may first manifest via the drain. In all cases, a biliary fistula may be discovered by the onset of symptoms of an acute abdomen, in connection with bile peritonitis. An endoscopic retrograde cholangiopancreatography (ERCP), with or without viewing of the video recordings of the procedure and of the intraoperative cholangiography, can help to determine the source of the lesion.

3.2.4. Management
Several therapeutic options are possible (see chapter dealing with “biliary tract injuries”), depending on the type of lesion found:

3.2.5. Minor leak (from the gallbladder bed or from the cystic duct)
A minor leak may be treated by simple drainage, which may be combined with an endoscopic sphincterotomy to improve bile drainage.
A nasobiliary drain may be used.

3.2.6. Leak due to a common bile duct injury
When the lesion is detected postoperatively, its repair will require either:

a primary repair over a T-tube drain;
a Roux-en-y hepatico-jejunal anastomosis;
a temporary total biliary diversion.

In certain cases, the origin of the leak cannot be determined. In most of these cases, a simple external drainage in the absence of a distal obstruction will put a stop to the leak.

3.3. Other complications

early jaundice due to an obstruction of the common bile duct by a clip;
early jaundice due to the obstruction of the common bile duct by an unrecognized stone (0.2% to 0.8% for Shea, 1996 );
hepatic necrosis due to accidental clipping of the hepatic artery ( Wachsberg, 1994 ).

1. Postoperative pain management

2. Operative complications

3. Early complications

4. Late complications

5. General complications and death

6. References

4. Late complications of laparoscopy

4.1. Late jaundice

4.1.1. Origin
Jaundice which appears progressively, can be a late complication of laparoscopic cholecystectomy. The onset interval ranges from 1 to 150 days postoperatively. It can be linked to:

intraoperative burn injury due to prolonged cautery performed close to the CBD. This type of burn causes progressive stenosis of the CBD from scar tissue;
blind application of a clip causing CBD obstruction;
late jaundice due to the obstruction of the CBD by an unrecognized stone.

4.1.2. Diagnosis
Usually based on clinical and biological findings, but requires a radiological imaging study of the biliary tract. The first choice imaging study, after ultrasonography, is a MRCP.

4.1.3. Management
Residual stones are ideally treated using an endoscopic approach. If this fails, reoperation and choledochotomy are required (by either laparoscopic or conventional approach).
Secondary CBD stenosis is treated by a hepatico-jejunostomy with Roux-en-Y sutured in a healthy zone of the CBD above the stenotic zone.

4.2. Intraperitoneal abscesses

4.2.1. Origin
Stones can escape from the gallbladder if ruptured during surgery. If they are not retrieved in entirety and extricated, they may be the cause of abdominal abscesses. In rare cases, they can provoke an abscess which drains spontaneously via various routes (example: stones lost under the diaphragm causing a pulmonary fistula) ( Lee, 1993 ).

4.2.2. Management
In most cases, this type of complication requires re-operation to remove these foreign bodies.

1. Postoperative pain management

2. Operative complications

3. Early complications

4. Late complications

5. General complications and death

6. References

5. General complications and death

Table 5: Frequencies reported in the study carried out by Shea et al., 1996 .

Urinary infection	0.1%
Ileus	0.3%
Myocardial infarction	0.05%

5.1. Death
The mortality rate reported in the series of Deziel et al., 1993 is 0.04%; according to Shea et al., 1996 it varies between 0.06% and 0.2%. Half of these deaths are related to technical problems possibly linked to the laparoscopic approach itself. The other half are related to general medical problems (infarction, pulmonary embolism, respiratory problems).

1. Postoperative pain management

2. Operative complications

3. Early complications

4. Late complications

5. General complications and death

6. References

6. References

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