The Applications Of Subtotal Cholecystectomy Via Intracholecystic Route In Difficult Laparoscopic Cholecystectomy

ObjectiveThe purpose of this study was to explore the subtotal cholecystectomy via intracholecystic route in difficult laparoscopic cholecystectomy in the related application feasibility,safety,efficiency,key points of operation and clinical value in the actual clinical work.In this study,laparoscopic subtotal cholecystectomy and total cholecystectomy were compared in difficult type of laparoscopic cholecystectomy.Aiming to provide reference and basis for making scientific and reasonable treatment plan and further improving treatment strategy for laparoscopic cholecystectomy for clinically difficult type of patients.MethodA total of 593 patients performed laparoscopic cholecystectomy for the treatment of benign gallbladder diseases were choose out from Qianfoshan hospital of Shandong Province of the department of hepatobiliary surgery from September 2015 to September 2018 and the clinical data were collected for retrospective analysis.Among them,95 cases were diagnosed as difficult type of laparoscopic cholecystectomy in the process of surgery,which were divided into two groups by different types of surgery including subtotal cholecystectomy via intracholecystic route(subtotal cholecystectomy group)and total cholecystectomy(total cholecystectomy group),with a total of 69 cases in the subtotal cholecystectomy group and 26 cases in the total cholecystectomy group.The determination of difficult laparoscopic cholecystectomy depends on the actual technical level of the chief physician of our center and the determination of the local pathological changes and severity of the gallbladder during the operation.Compare the data of two groups such as gender,age,BMI,abdominal surgery history,history of diabetes,liver cirrhosis history,operation method,operation time,intraoperative blood loss,preoperative and postoperative changes in AST,ALT,TBIL,time to get out of bed after surgery,time of recovery of gastrointestinal function after the operation,drainage tube indwelling time,days in hospital,and the postoperative complications,collate and analyze them.By analyzing and comparing the above data and recording the results of regular follow-up,the actual clinical effects of the two surgical methods for the treatment of benign gallbladder diseases in our hospital were evaluated.ResultsA total of 69 patients are in the subtotal cholecystectomy group,including 42 male patients and 27 female patients,ranging from 28 to 84 years old,with an average age of(61.8±12.7)years old.A total of 26 patients were in the total cholecystectomy group,in which there is 15 male patients and 11 female patients,ranging from 30 to 85 years old,with an average age of(61.2±13.2)years old.There was no significant difference in gender and the composition of age between the two groups.And there are 57 patients of male and38 cases are female in the two groups,and the male patients have a higher proportion.There were 498 LC patients in total,including 178 male patients and 320 female patients respectively,with an average age of(55.6±13.4)years old.Compared with LC,both P<0.001 tn gender and age,with statistical significance,subtotal resection group and the total resection group(DLC)had obvious advantage in gender and age.Advanced age and male gender were related to the difficulty of laparoscopic cholecystectomy.Respectively,the number of obese patients in the majority resection group and the total resection group was7 cases and 2 cases According to the standard comparison table of BMI,P=0.716,P>0.05,without statistical significance.The number of obese patients with DLC and LC was 9cases and 13 cases respectively,P=0.003,P<0.05,with statistical significance.Obesity was related to the difficulty in laparoscopic cholecystectomy.Patients with previous history of upper abdominal surgery in the subtotal cholecystectomy group accounts for 8(8/69),and patients with previous history of upper abdominal surgery in the total cholecystectomy group accounts for 3(3/26),P=0.914,P>0.05,without statistical significance.The number of previous history of upper abdominal surgery patients with DLC and LC was 11 cases and 1 cases respectively,P<0.001,with statistical significance.Previous history of upper abdominal surgery was related to the difficulty in laparoscopic cholecystectomy.In the subtotal cholecystectomy group,patients with a history of liver cirrhosis accounts for 2(2/69),while in the other group the patients with a history of liver cirrhosis accounts for 1(1/69),P=0.814,P>0.05,without statistical significance.The number of previous history of upper abdominal surgery patients with DLC and LC was 3 cases and 9 cases respecttively,P=0.467,P>0.05,without statistical significance.Subtotal cholecystectomy combined with a history of diabetes accounts for 7(7/69),while total excision combined with a history of diabetes accounts for 4(4/69),P=0.564,P>0.05,without statistical significance.The number of history of diabetes patients with DLC and LC was 11 cases and 42 cases respectively,P=0.357,P>0.05,without statistical significance.The average operative time of the two groups is(109.84±14.44)min and(124.54±22.90)min,respectively,P=0.004,and the average intraoperative blood loss is(34.57±10.46)ml and(43.85±16.75)ml,P=0.013.There were differences between the two groups in operative time and intraoperative blood loss,both P<0.05,which has significance in statistics.Compared with the total resection group,the subtotal excision group is significantly superior in terms of postoperative time to get out of bed(1.91±0.96、2.04±1.08,P=0.594),time of recovery of gastrointestinal function after the operation(1.62±0.62、1.85±1.01,P=0.043),drainage tube indwelling time(3.13±0.84 、 3.88±1.68,P=0.037),and length of hospital stay(5.79±1.13 、6.46±1.68,P=0.027).The success rate of the two groups are all 100%,and no patients were transferred to open surgery or death.In terms of surgical complications,1 case(1/69)of the subtotal cholecystectomy group occurred biliary fistula complications after laparoscopic surgery,and 3 cases(3/26)appeared biliary fistula complications in the total resection group.There was a significant difference between the two groups,which has significance in statistics.Patients with biliary fistula in the two groups were cured by continuous drainage through the abdominal drainage tube,1 case(1/69)of postoperative incision infection was found in the subtotal resection group,and complications such as severe bleeding and residual biliary calculi were not found in the two groups.Followup ranged from 3 to 39 months,eight people were lost to follow-up,the missing rate was8.42%.There were 2 cases appeared upper abdominal pain and 5 cases of abdominal distension in the subtotal resection group,while in the total resection group there are 1 case appeared upper abdominal pain and 3 cases of abdominal distension.Two groups did not appear long-term complications such as diarrhea,long-dated bile duct residual stones.Long-term residual mucosal lesions did not occur in the subtotal cholecystectomy group.Conclusions1.In the practical clinical work of hepatobiliary surgery,subtotal cholecystectomy via intracholecystic route is a widely used method in difficult laparoscopic cholecystectomy.It has the advantages of less collateral damage,rapid postoperative recovery and less severe postoperative complications.Laparoscopic subtotal cholecystectomy via intracholecystic route can be a safe,feasible and effective method for difficult type of cholecystectomy.2.Complex anatomy of Calot’s triangle and gallbladder bed area was avoided during laparoscopic subtotal cholecystectomy via intracholecystic route,so as to better control the injury of the operation,accelerate the recovery of patients and reduce the incidence of postoperative complications.3.Although Laparoscopic subtotal cholecystectomy via intracholecystic route in the treatment of difficult gallbladder excision have certain advantages,surgery can’t ignore the postoperative complications.A comprehensive examination should be conducted before the operation to predict the degree of surgical difficulty.During the operation,accurate operation and patient identification should be achieved to optimize surgical main points and techniques,and strengthen postoperative management of patients.