Application Of Single Incision Laparoscopic Cholecystectomy In Different Types Of Biliary Tract Variation

Objective:With the increasing maturity of endoscopic technology and the continuous improvement of surgical level of surgeons,endoscopic surgery is developing towards a more refined and non-invasive direction on the premise of ensuring surgical safety.Single-incision laparoscopic cholecystectomy(SILC)in single-incision technique is widely carried out in China due to its characteristics of high postoperative incision satisfaction and rapid recovery.It provides a new choice for cholecystectomy.However,compared with traditional surgery,SILC has limited intraoperative space and exposure ability,leading to higher requirements for the practitioner and his assistants.Since biliary tract injury is characterized by high concealment and difficult treatment,different types of biliary tract variation will greatly increase the probability of biliary tract injury.Therefore,it is necessary to study the influence of different types of biliary tract variation on SILC surgery and the effectiveness and safety of SILC in different situations,as well as the operator’s operational ideas and the judgment of possible intraoperative situations.As well as the safety of patients,have very important significance.The purpose of this paper is to explore how the surgeon can improve the effectiveness and safety of SILC by corresponding operations before and during the operation,so as to avoid the occurrence of surgical changes and biliary tract injuries during the operation,in order to provide guidance for clinical work.Methods:The clinical data and surgical videos of 180 laparoscopic cholecystectomy(120cases of single-port laparoscopic cholecystectomy and 60 cases of multi-port laparoscopic cholecystectomy)completed by the same group of physicians in the Department of Hepatobiliary and Pancreatic Surgery of the First Clinical Medical College of Shanxi Medical University from January 2021 to June 2022 were retrospectively analyzed to divide them into 60 cases each in the single-port biliary normal group,single-port biliary variant group and three-port biliary variant group.Among them,the single-port biliary duct variant group included 15 cases of short cystic duct,10 cases of lengthy spiral cystic duct,16 cases of low confluence of cystic duct,and19 cases of extrahepatic bile duct variation(16 cases of pararight hepatic duct and 3cases of vagus bile duct).The triporous biliary duct variant group included 13 cases of short cystic duct,12 cases of lengthy spiral cystic duct,14 cases of low confluence of cystic duct,and 21 cases of extrahepatic bile duct variation(19 cases of pararight hepatic duct and 2 cases of vagus bile duct).The clinical data of each group of patients included operation time,intraoperative blood loss,biliary tract injury,discharge time,porous increase rate,transit laparotomy rate and catheter placement rate,postoperative inflammation level,postoperative complications,etc.Results:The operation time of the normal biliary group was 35～130min,the average(61.8±14.8)min,the average intraoperative blood loss was(13.9±3.7)ml,and the postoperative hospital stay was(2.0±0.9)days,of which 57 cases successfully completed SILC,2 cases of transit SLMC,1 case of transit open LC,and 2 cases of postoperative indwelling drainage tube.The operation time of biliary variant group was 46～200min,the average(69.7±20.5)min,the average intraoperative blood loss was(15.9±6.7)ml,and the postoperative hospital stay was(2.1±0.9)days,of which 54 cases successfully completed SILC,4 cases of transit SLMC,2 cases of transit open LC,7 cases of postoperative indwelling drainage tube,and 1 case of biliary tract injury.Among them,the biliary variant types of transit SLMC were 1 case of lengthy spiral cystic duct and low confluence of cystic duct,2cases of vagus bile duct,and 1 case of short cystic duct and 1 case of low confluence of cystic duct(which caused biliary injury)in transiting open LC.The operation time of the three-hole biliary variant group was 36～170min,the average(58.7±14.6)min,the average intraoperative blood loss was(9.2±1.4)ml,and the postoperative hospital stay was(1.9±0.8)days,of which 59 cases successfully completed SILC,1 case of trans-abdominal open LC,5 cases of postoperative indwelling drainage tube,1 case of biliary tract injury,and 1 case of abdominal wall injury.Among them,the type of biliary variant of transduction open LC is short cystic duct.All patients did not experience uncontrollable bleeding or biliary leakage during the postoperative hospitalization observation,and there were no cases of readmission within30 days.Patients who successfully undergo LC will eat liquid diet the next day after surgery and can get out of bed and move freely.Patients with intraoperative catheterization were observed for no abnormal drainage after surgery.Patients who successfully underwent SILC at the time of discharge had a concealed incision after removing the dressing,no redness and swelling and exudation,and the cosmetic effect was better(Figure 1).The statistical results showed that there were no significant differences in the operation time,blood loss,transfer rate,catheter placement rate and postoperative hospital stay of SILC for different biliary types of SILC,and there was no significant difference in the effectiveness of SILC(successful completion of SILC,no catheter insertion or other surgical procedures)(P>0.05).Patients with biliary variation who underwent three-port laparoscopic cholecystectomy had less operation time and bleeding,but patients who underwent SILC had lower postoperative pain levels,shorter recovery time of bowel sounds,and there were no significant differences in intraoperative catheter placement rate,transfer rate,injury rate,postoperative inflammation level,and postoperative complications.Conclusion:The operation time of SILC in patients with biliary variation is longer than that of patients undergoing conventional laparoscopic cholecystectomy,but there is basically no difference in effectiveness and safety.When patients with different biliary tract types underwent SILC,there were no significant differences in operation time,blood loss,and postoperative hospital stay.Preoperative evaluation of MRCP,increased vigilance during the operation,and careful treatment of suspicious intraoperative pipes are helpful to improve surgical safety and avoid the occurrence of surgical transfer and biliary tract injury.However,the transfer indication should be strictly controlled,and SILC should not be forcibly performed in pursuit of aesthetic effect.Surgeons with mature single orifice technique can effectively solve the corresponding intraoperative conditions caused by different types of biliary tract variation,which can be recovered after surgery.Besides,it is worthy to be popularized in clinical work because of its good cosmetic effect and light postoperative pain.