Management of common bile duct stones. Gallbladder Stone Removal What to Expect During and After the Procedure

All materials on the site are prepared by specialists in the field of surgery, anatomy and specialized disciplines.
All recommendations are indicative and are not applicable without consulting the attending physician.

“Cholelithiasisthe disease is one of the most common chronic diseases in adults, ranking third after cardiovascular disease and diabetes,” – writes Doctor of Medical Sciences Ilchenko A.A., one of the leading experts on this issue in the country. The reasons for its development are a number of factors, in particular heredity, women taking oral contraceptives, obesity, eating a lot of cholesterol.

Conservative therapy can be effective only at the pre-stone stage of the disease, which at this stage is diagnosed only with the help of ultrasound. The next steps are surgical intervention. The operation for stones in the gallbladder can be reduced to the complete removal of the gallbladder, the removal of stones invasively or naturally (after crushing, dissolution).

Types of surgery, indications for carrying out

At the moment, there are several options for surgical intervention:

• Cholecystectomy- removal of the gallbladder.
• Cholecystolithotomy. This is a minimally invasive type of intervention that involves preserving the gallbladder and removing only deposits.
• Lithotripsy. This procedure involves crushing the stones with ultrasound or laser and removing the fragments.
• Contact litholysis- dissolution of stones by direct injection of certain acids into the cavity of the gallbladder.

In most cases, cholecystectomy is the removal of the gallbladder. A sufficient indication is the detection of stones and the characteristic symptoms of the disease. Mainly, it is severe pain and disturbances in the work of the gastrointestinal tract.

Important! Definitely, the operation is performed with acute cholecystitis (purulent inflammation) or choledocholithiasis (presence of stones in the bile ducts).

In the asymptomatic form, the operation may not be performed unless polyps are found in the gallbladder, its walls are calcified, or stones exceed 3 cm in diameter.

While preserving the organ, there is a high risk of recurrence - according to some reports, up to 50% of patients experience recurrent stone formation. Therefore, cholecystolithotomy is prescribed only if the removal of the organ is an unjustified risk to the patient's life.

Cholecystolithotomy and cholecystectomy can be performed through an incision or laparoscopically. In the second case, there is no violation of the tightness of the body cavity. All manipulations are carried out through punctures. This technique is used more often than the usual, open one.

Lithotripsy can be indicated for single small stones (up to 2 cm), the stable condition of the patient, the absence of complications in history. In this case, the doctor must ensure the preservation of the functions of the gallbladder, its contractility, the patency of the outflow tract of liquid secretion.

Contact litholysis is used as an alternative method when other methods are ineffective or impossible. It is developed and used mainly in the West, in Russia you can find only a few reports of a successful operation. It allows you to dissolve only stones of a cholecysteric nature. A big plus is that it can be used for any size, quantity and location.

Preparing for the operation

If the patient's condition allows, it is better to extend the time before surgery to 1 - 1.5 months. During this period, the patient is prescribed:

1. special diet.
2. Reception of funds with antisecretory activity and antispasmodics.
3. A course of polyenzymatic preparations.

Before the operation, the patient must pass general blood tests, urine tests, EEG, fluorography, and undergo a study for the presence of a number of infections. Mandatory is the conclusion of medical specialists who are registered with the patient.

Cavity (open) cholecystectomy

The operation is performed under general anesthesia. Its duration is 1-2 hours. A contrast agent is injected into the bile duct for better visualization. It is necessary to control the absence of stones in it. The incision is made either under the ribs or along the midline near the navel. First, the surgeon clamps with metal clips or sews up all the vessels and ducts that are connected with the gallbladder with self-absorbable threads.

The organ itself in a blunt way (to avoid cuts) is separated from the liver, adipose and connective tissue. All ligated ducts and vessels are excised, and the gallbladder is removed from the body. A drainage tube is placed in the wound to drain blood and other body fluids. This is necessary so that the doctor can monitor whether a purulent process has developed in the body cavity. With a favorable outcome, it is removed in a day.

All fabrics are sutured in layers. The patient is transferred to the intensive care unit. Until the action of anesthesia is over, you need strict control over his pulse and pressure. When he wakes up, he will have a tube in his stomach and a drip in his vein. Important! It is necessary to relax, not to try to move, to get up.

Laparoscopy

The cholecystectomy operation is also performed under general anesthesia, its duration is somewhat less than with open surgery - 30-90 minutes. The patient is placed on his back. After the onset of anesthesia, the surgeon makes several punctures in the wall of the abdominal cavity and introduces trocars there. Holes are created in different sizes. The largest one is used for visualization with a camera attached to the laparoscope and organ extraction.

Note. A trocar is a tool that can be used to gain access to the body cavity and maintain the tightness of its walls. It is a tube (tube) with a stylet (pointed rod) inserted into it.

The patient is injected with carbon dioxide into the body cavity with a needle. This is necessary to create sufficient space for surgical procedures. At least twice during the operation, the doctor will tilt the table with the patient - first, to move the organs in order to reduce the risk of damage, and then to move the intestines down.

The bubble is clamped by an automatic clamp. The duct and the organ itself are isolated using instruments inserted into one of the punctures. A catheter is inserted into the duct to prevent its compression or ejection of its contents into the abdominal cavity.

Explore the functions of the sphincter. Examine the duct to make sure that there are no stones in it. Make an incision with microscissors. The same goes for blood vessels. The bubble is carefully removed from its bed, while monitoring for damage. All of them are sealed with an electrocautery (an instrument with an electrically heated loop or tip).

After complete removal of the gallbladder, aspiration is performed. All fluids accumulated there are sucked out of the cavity - secrets of the glands, blood, etc.

With cholecystolithotomy, the organ itself is opened and stones are removed. The walls are sutured, and the damaged vessels are coagulated. Accordingly, the transection of the ducts is not carried out. Operative removal of stones without removal of the gallbladder is practiced quite rarely.

Lithotripsy

The full name of the procedure is extracorporeal shock wave lithotripsy (ESWL). It says that the operation is carried out externally, outside the body, and also that a certain type of wave is used, which destroys the stone. This is due to the fact that ultrasound has a different travel speed in different media. In soft tissues, it spreads quickly without causing any damage, and when it passes into a solid formation (stone), deformations occur that lead to cracks and destruction of the calculus.

This operation can be indicated in approximately 20% of cases with cholelithiasis. Important! It is not carried out if the patient has any other formations in the direction of the shock wave or if he must constantly take anticoagulants. They inhibit the formation of blood clots, which can complicate the healing of possible injuries, recovery after surgery.

The operation is performed under epidural anesthesia (injection of an anesthetic into the spine) or intravenous. Before the ultrasound, the doctor selects the optimal position of the patient during the ultrasound and brings the device-emitter to the selected place. The patient may feel slight jolts or even pain. It is important to remain calm and not move. Often, several approaches or sessions of lithotripsy may be needed.

The operation is considered successful if there are no stones and their parts larger than 5 mm. This happens in 90-95% of cases. After lithotripsy, the patient is prescribed a course of bile acids, which help dissolve the remaining fragments. This procedure is called oral litholysis (from the word per os - through the mouth). Its duration can be up to 12-18 months. Removal of sand and small stones from the gallbladder is carried out through the ducts.

The option of dissolving stones with a laser is possible. However, this new technique is still under development and there is little information about its implications and effectiveness. The laser as a shock wave is conducted to the stone through the puncture and is focused directly on it. Evacuation of sand occurs in a natural way.

Contact litholysis

This is an operation to remove stones with the complete safety of the organ. When the underlying disease is cured, she has a very good prognosis. In Russia, the technique is under development, most of the operations are carried out abroad.

It includes several stages:

• Imposition of a microcholecystotomy. This is a drainage tube through which the contents of the gallbladder are removed.
• Assessment by injection of a contrast agent of the number and size of stones, which allows you to calculate the exact amount of litholytic (solvent) and avoid it from entering the intestines.
• The introduction of methyl tert-butyl ether into the cavity of the gallbladder. This substance effectively dissolves all deposits, but can be dangerous for the mucous membranes of neighboring organs.
• Evacuation through the drainage tube of bile with litholytic.
• The introduction of anti-inflammatory drugs into the cavity of the gallbladder to restore the mucous membrane of its walls.

Complications

Many surgeons believe that cholecystectomy eliminates not only the consequences of the disease, but also its cause. The doctor Karl Langenbuch, who performed this operation for the first time in the 19th century, said: “It is necessary [to remove the gallbladder] not because it contains stones, but because it forms them.” However, some modern experts are sure that with an unexplained etiology, surgical intervention will not solve the problem, and the consequences of the disease will bother patients for many years.

Statistics confirm this in many respects:

The following factors increase the risk of complications:

• Excess weight of the patient, his refusal to comply with the doctor's prescriptions, diet.
• Errors during the operation, damage to neighboring organs.
• The elderly age of the patient, the presence of a history of other diseases of the gastrointestinal tract.

The main danger of operations that do not involve the removal of the gallbladder is the recurrence of the disease, and, accordingly, all its unpleasant symptoms.

Recovery period after surgery

For several months, patients will have to follow certain recommendations, and the doctor's instructions regarding nutrition will have to be followed for life:

1. In the first months after surgery (even minimally invasive), physical activity should be limited. Exercises such as “bicycle”, swinging arms from a prone position are useful. Exact gymnastics can be recommended by the attending physician.
2. The first weeks you need to wash only in the shower, preventing the wound from getting wet. After hygiene procedures, it must be treated with an antiseptic - iodine or a weak solution of potassium permanganate.
3. Within 2-3 weeks, the patient must adhere to diet No. 5 (excluding fried, salty, fatty, sweet, spicy), take choleretic drugs. After the expiration of this period, it is allowed to take such products only in very limited quantities.
4. It is advisable to get used to eating fractionally, 5-6 times a day with breaks in the first month after the operation at 1.5-2 hours, later - 3-3.5 hours.
5. An annual visit to sanatoriums is recommended, especially preferably 6-7 months after the operation.

The cost of surgical intervention, the operation under the compulsory medical insurance policy

The most frequent operations described are open and laparoscopic cholecystectomy. Their price when contacting a private clinic will be approximately the same - 25,000 - 30,000 rubles in medical institutions in Moscow. Both of these varieties are included in the basic insurance program and can be carried out free of charge. The choice in favor of a public or private company lies entirely with the patient.

Lithotripsy of the gallbladder is not carried out in every medical center and only for money. The average cost is 13,000 rubles per session. Contact litholysis is not yet carried out in large quantities in Russia. Cholecystolithotomy can cost from 10,000 to 30,000 rubles. However, not all medical institutions provide such services.

Instead of a traditional incision in the abdominal cavity, the diseased organ was “pulled out” to the woman through her mouth. An operation to remove the gallbladder using a new technique was performed in California.

In traditional appendicitis or gallbladder surgery, patients make small incisions in the abdominal wall, and then a miniature camera and instruments are inserted into the abdominal cavity to remove the organ. The new procedure, called NOTES, involves surgery through the mouth or vagina. In surgery, there has long been a tendency to perform the least traumatic operations that do not leave scars. If the most modern operations involve the smallest incisions, then the new technique will avoid them. The tools needed to remove the diseased organ are passed through the mouth and esophagus into a small hole that is made in the stomach.

During the operation, which was carried out by scientists from the University of California, the patient still had to make a small incision in the abdominal wall to insert a camera for observation, but the gallbladder itself was removed through the mouth. The operation was part of a study that will evaluate the safety and effectiveness of an innovative technique in comparison with the traditional method of removing the gallbladder. Also, scientists are going to compare the degree of pain, cosmetic consequences, the cost of surgery, etc. Santiago Horgan, director of the university's Center for Future Surgery, who led the procedure, hopes that surgery through the body's natural openings will help reduce the risk of infection and avoid ugly scars. His center also performed the first operation to remove appendicitis through the mouth.

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Most of us, who care about our health, mainly pay attention to the heart, brain, lungs and liver, forgetting about other organs necessary for the normal functioning of the body. One of these organs is the gallbladder.

Biliary interventions are minimally invasive procedures that are performed to treat a blockage or narrowing of the bile ducts. In addition, these techniques are used in the treatment of inflammatory or infectious lesions of the gallbladder.

Bile is a biological fluid that is involved in the processes of digestion. It is produced by liver cells, and then, through the system of bile ducts and passages, it is stored in the gallbladder. When needed, the gallbladder contracts and the bile passes into the small intestine.

When the biliary tract is blocked, the flow of bile into the duodenum is disrupted, which leads to the development of jaundice, in which the content of bile acids in the blood increases. With severe jaundice, there is a change in the color of the skin and sclera (white membrane of the eye), which acquire a yellow tint.

When blockage of the final sections of the bile ducts (for example, the common bile duct), which is possible with cholelithiasis, inflammation or infection of the gallbladder occurs, that is, cholecystitis. The treatment for this condition is the surgical removal of the gallbladder: using a gentle laparoscopic technique or traditional open surgery. However, in some cases, the severe condition of the patient does not allow for surgical cholecystectomy. In such situations, percutaneous cholecystostomy is possible, which is performed by an interventional radiologist.

Interventions on the biliary tract include:

• Percutaneous transhepatic cholangiography (PTCH): An X-ray procedure that involves injecting a contrast material directly into the bile ducts inside the liver to make them look clear. The examination is usually performed by an interventional radiologist. If a blockage or narrowing of the ducts is detected, additional procedures may be performed:
• Endoscopic retrograde cholangiopancreatography (ERCP): A diagnostic procedure that combines the capabilities of endoscopic examination with the use of optical instruments for examining the internal organs and X-ray examination. As a rule, ERCP is performed by a gastroenterologist. If a blockage or narrowing of the ducts is detected, additional procedures may be performed:
  • Insertion of a catheter to remove excess bile.
  • Removal of gallstones that may form in the gallbladder or bile ducts.
  • Sphincterotomy: a small incision in the area of ​​the external opening of the common bile duct, which ensures the normal outflow of bile and the exit of small gallstones.
  • Placement of a stent in the lumen of the bile duct: a small plastic or metal tube that restores the patency of the duct or forms a bypass for the normal outflow of bile.
• Laparoscopic cholecystectomy, or removal of the gallbladder. The operation is performed by a surgeon.
• Percutaneous cholecystostomy: A minimally invasive procedure in which a drain tube is inserted under image guidance into a distended, inflamed, or infected gallbladder to relieve pressure within the gallbladder. Usually this procedure is indicated in a serious condition of the patient, which does not allow for cholecystectomy. Typically, treatment is performed by an interventional radiology specialist.

An interventional radiologist is a specialist who performs minimally invasive, image-guided surgical procedures. The doctor has sufficient skills and experience in the use of fluoroscopy / fluoroscopy, CT and ultrasound, which allows him to perform such percutaneous procedures as biopsy, insertion of catheters and drainage tubes to remove excess fluid or drain abscesses, and place stents for vasoconstriction or any ducts .

In what areas are interventions on the biliary tract used?

Blockage or narrowing of the biliary tract occurs in a number of diseases, which include:

• Inflammatory conditions: pancreatitis (inflammation of the pancreas), sclerosing cholangitis (inflammation of the bile ducts), cholecystitis (inflammation of the gallbladder)
• Tumors: cancer of the pancreas, gallbladder, liver, bile ducts, as well as swollen lymph nodes against the background of various oncological and other diseases
• Gallstone disease involving the gallbladder and/or bile ducts
• Bile duct injury during surgery
• infections

In general, PTCG and ERCP can be used for all of the above conditions that are accompanied by narrowing or blockage of the biliary tract. An exception is the need to remove the gallbladder (cholecystectomy), which is performed surgically.

How should you prepare for the procedure?

Before the procedure, the doctor prescribes a short course of antibiotics to the patient. Usually, before treatment, a series of blood tests are also performed, which allow you to evaluate the function of the liver and kidneys, as well as the work of the blood clotting system.

It is very important to tell the doctor about all medications the patient is taking, including those of herbal origin, as well as any allergies, especially to local anesthetics, anesthesia drugs or iodine-containing contrast materials. Some time before the procedure, you should stop taking aspirin or other drugs that thin the blood, as well as non-steroidal anti-inflammatory drugs.

You should also tell your doctor if you have any recent illnesses or other conditions.

Women should always inform their physician and radiologist of any possibility of pregnancy. As a rule, studies using X-ray radiation during pregnancy are not carried out in order to avoid negative effects on the fetus. If X-ray examination is necessary, all possible measures should be taken to minimize the effect of radiation on the developing child.

The doctor should provide the patient with detailed instructions for preparing for the procedure, including any necessary changes to the usual drug regimen.

In addition, a few hours before the procedure, you should stop eating and drinking.

For the duration of the procedure, it is necessary to remove some or all of the clothes and put on a special hospital gown. In addition, remove all jewelry, eyeglasses, and any metal or clothing items that may interfere with the x-ray image.

It is advisable to come to the hospital with a relative or friend who will help the patient get home.

Some interventions on the biliary tract require short-term hospitalization.

What does the equipment for the procedure look like?

For interventions on the biliary tract, X-ray or ultrasound equipment, as well as a CT scanner, can be used. In addition, the physician may require devices such as endoscopes, laparoscopes, catheters, and/or stents.

X-ray equipment:

For this type of procedure, an X-ray tube, a patient table and a monitor located in the radiologist's office are usually used. To monitor the process and to control the doctor's actions, a fluoroscope is used, which converts x-rays into a video image. To improve the quality of images, a special amplifier is used, suspended above the patient table.

Ultrasonic equipment:

The ultrasound scanner consists of a console that includes a computer and electronic equipment, a video display and an ultrasound sensor used to scan internal organs and blood vessels. The sensor is a small handheld device that resembles a microphone and is connected to the scanner with an electrical cord. The ultrasound transducer sends high-frequency sound signals and picks up the echo reflected from the internal structures of the body. The principle of operation of the device is similar to sonars, which are used on submarines.

At the same time, an image instantly appears on a monitor resembling a television or computer screen. Its appearance depends on the amplitude (strength), frequency and time it takes for the sound signal to return from the patient's body to the transducer.

CT Scanner:

A CT scanner is a massive rectangular machine with a hole, or tunnel, in the middle. During the procedure, the patient is placed on a narrow table that slides inside a tunnel. The X-ray tube and electronic X-ray detectors are located opposite each other inside a ring-shaped structure called a gantry. In a separate office there is a computer workstation, where the processing of the received image is carried out.

There is also a doctor or technologist who controls the operation of the tomograph and the course of the examination. The CT scanner produces x-ray images or "sections" of tissues and organs with a thickness of 0.1 to 1 cm.

Optional equipment:

• Catheter: a long thin plastic tube of extremely small diameter
• Balloon catheter: a long thin plastic tube with a small balloon at the end
• Stent: a small plastic tube or mesh frame design
• Endoscope: an optical instrument with a light that is used to examine the internal organs
• Laparoscope: a thin, tube-shaped instrument with a light and a lens that allows you to view the inside of the abdomen

What is the procedure based on?

At percutaneous transhepatic cholangiography(ChCHG) contrast material is injected into the bile ducts under image control, which allows you to get an x-ray image of the bile ducts and gallbladder.

Endoscopic retrograde cholangiopancreatography(ERCP) combines endoscopic and x-ray examination of the bile ducts, gallbladder and pancreatic ducts and allows you to get their x-ray image.

At percutaneous cholecystostomy imaging control is used to place a drain tube into an infected or inflamed gallbladder. This ensures the normal outflow of bile from the gallbladder.

Laparoscopic cholecystectomy This is a procedure during which a laparoscope is inserted into the abdominal cavity through a small incision in the navel, which is a thin instrument in the form of a tube with a light bulb and a lens at the end. This allows you to see the state of the abdominal cavity from the inside on the monitor screen. The surgeon then exposes the gallbladder under imaging control and removes it through a small incision in the anterior abdominal wall. If it is impossible to perform a laparoscopic operation, the doctor uses the traditional removal of the gallbladder by open access.

How is the procedure carried out?

In some cases, the procedures are performed on an outpatient basis, while other situations require a short-term hospitalization of the patient. About the features of the treatment should be consulted with your doctor.

Before the procedure, the doctor prescribes an examination: ultrasound, computed tomography (CT) and / or magnetic resonance imaging (MRI).

Antibiotics are used to prevent infection; nausea and pain syndrome can be controlled by special drugs.

The doctor helps the patient to sit on the operating table. To monitor the heartbeat, pulse and blood pressure during the procedure, devices are used that are connected to the patient's body.

The nurse sets up an intravenous infusion system, with which the patient will be sedated. In other cases, general anesthesia is possible.

Endoscopic retrograde cholangiopancreatography (ERCP):

The endoscope is inserted into the initial sections of the small intestine through the mouth, esophagus and stomach, after which a thin catheter is passed through it, and the contrast material enters directly into the bile ducts. Then an x-ray is taken.

Percutaneous transhepatic cholangiography (PTCHG):

The skin at the injection site of the needle or laparoscope is thoroughly cleaned of hair, disinfected and covered with a surgical sheet.

A pinpoint skin incision or a small puncture is performed.

Under x-ray control, a thin needle is inserted into the liver through the skin in the area below the ribs, through which a contrast material enters the liver tissue and bile ducts. After that, x-rays are taken. If a blockage of the bile ducts is detected in the patient's body, a special catheter may be temporarily left, which ensures the outflow of bile into the small intestine or an external reservoir.

The stent is placed under imaging control. A stent is placed in the narrowing of the bile duct to keep it open. A special balloon catheter can be used to widen the narrowed duct.

During the procedures, self-expanding stents are used, which expand on their own after placement. There are also stents that require a balloon to deploy. Such stents are usually combined with a balloon catheter, therefore, after the expansion of the balloon, the stent opens and is located on the inner surface of the bile duct. After the balloon is collapsed and removed, the stent remains in place and helps keep the duct open. Removal of gallstones: If the x-ray shows the presence of a stone in the common bile duct, the doctor makes a small incision in its wall and removes the foreign object.

Laparoscopic cholecystectomy:

A laparoscope, which is a thin tube-shaped instrument with a light and a lens at the end, is inserted into the abdominal cavity through a small incision near the navel. For the best view in the area of ​​the proposed surgical intervention, carbon dioxide is pumped into the abdominal cavity. Near the insertion site of the laparoscope, the surgeon makes three additional incisions through which special surgical instruments are inserted.

The gallbladder is removed under the control of images that are projected onto the monitor screen from the lens at the end of the laparoscope.

After the operation is completed, the nurse removes the intravenous catheter for infusion of drugs.

What should I expect during and after the procedure?

Devices are connected to the patient's body to monitor heartbeats and blood pressure.

When setting up the system for intravenous infusion, as well as with the introduction of a local anesthetic, you can feel a slight prick.

When using general anesthesia during the procedure, the patient is unconscious, and his condition is monitored by an anesthesiologist.

If the procedure is performed under local anesthesia, then sedative (sedative) drugs are administered intravenously, which is accompanied by drowsiness and a feeling of relaxation. Depending on the degree of sedation, the patient's consciousness may or may not be preserved.

The introduction of a contrast material is often accompanied by a feeling of warmth or heat.

Until full recovery of consciousness after the completion of the procedure, the patient remains in the intensive care unit.

In general, after all the described procedures, a complete return to normal life is possible within the next few days. In some cases, the doctor leaves a drainage tube in the patient's body, through which the bile flows into a special external reservoir. The duration of the drainage tube stay depends on each specific case of the disease. For more information, please contact your physician.

Who studies the results of the procedure and where can they be obtained?

The analysis of the results of the procedure is carried out by an interventional radiologist, who prepares and signs a report for the attending physician.

After completion of the procedure or other treatment, the specialist may recommend to the patient a follow-up dynamic examination, during which an objective examination, blood tests or other tests and instrumental examination are performed. During such an examination, the patient can discuss with the doctor any changes or side effects that have appeared after the treatment.

Benefits and risks of interventions on the biliary tract

Advantages:

• PTCG and similar procedures do not require surgical incisions: the doctor makes only a small puncture of the skin, which does not even need to be closed with sutures. Surgical incisions are also not required for ERCP and similar procedures. Very small incisions are only necessary for laparoscopic interventions.
• The described procedures avoid the risks of open access surgery.
• The duration of hospitalization is reduced.
• The rehabilitation period is significantly reduced compared to open surgery.

Risks:

• Any procedure that involves breaking the integrity of the skin carries the risk of infection. However, in this case, the likelihood of developing an infection that requires antibiotic therapy is less than 1 in 1000 cases.
• There is a very small risk of developing an allergic reaction to the contrast material.
• In rare cases, the procedure is accompanied by bleeding, which, however, almost always stops on its own. If necessary, treatment is carried out arterial embolization, which is a low-traumatic procedure.
• There is a very small risk of damage to internal organs, such as perforation of the intestinal wall.

Restrictions during interventions on the biliary tract

Minimally invasive procedures such as biliary interventions are not suitable for all patients. Therefore, the decision on the possibility of using a particular technique in a particular case of the disease is made jointly by the attending physician and a specialist in interventional radiology.

In general, minimally invasive techniques are preferable to open surgery, but in some situations they cannot be used. In such cases, the doctor chooses open access surgery.

Sometimes there is a recurrence of the disease, such as blockage of the installed stent or the development of cholecystitis. In such situations, repeated intervention on the biliary tract is required. If the doctor does not consider it possible, then an open surgical operation is performed.

The CYBERKNIFE Center is located at the Grosshadern University Hospital Munich. It is here that since 2005, patients have been treated using the latest development in the field of medicine called CYBERKNIFE (Cyberknife). This unique equipment is the safest and most effective of all methods of treating benign and malignant neoplasms.

Gallstone disease (GSD) is a very common pathology throughout the world, today the removal of stones from the gallbladder can be done in several ways.

GSD is most common in developed industrial regions, where people eat more protein and fatty foods.

In addition, the disease is 3 to 8 times more likely to affect women than men. About how to treat pathology with medication, surgery and folk remedies - in this article.

Features of the disease

The gallbladder is located near the liver. Its role is to store the bile that comes there from the liver.

Bile is a complex fluid containing bilirubin and cholesterol that helps the digestive tract to digest food.

The main reason for the occurrence of stones in the bladder is called excessive cholesterol in the bile, its stagnation and improper outflow, infection of the organ.

If bile stagnates in the bladder for a long time, cholesterol settles and turns into “sand”, grains of sand grow over time and calculi form.

The volumes of stones can be very different - from two to three millimeters to several centimeters. In some cases, the calculus extends to the entire organ and stretches it.

Small formations 1-2 mm in diameter move freely along the ducts, but larger ones cause a clinic of the disease.

Most often, the disease occurs without any symptoms. If clinical symptoms suddenly appear, then urgent action should be taken.

Typical manifestations of cholelithiasis are sudden colic, in which a person feels pain under the ribs on the right, heartburn, nausea, fever, bloating, and jaundice are present.

If the disease has been going on for a long time, then over time the bile ducts narrow, the bladder becomes infected, and chronic inflammation occurs.

If the patient had stones in the gallbladder, then the doctor first of all studies their composition and determines the type of calculus - cholesterol, calcareous, pigment or mixed.

Modern medicine offers several ways to remove gallstones - this is dissolution with the help of special preparations, crushing with a laser or ultrasound, and dissolving residues with acids. But the main method of removing formations is cholecystectomy.

In recent years, abdominal operations have faded into the background, and endoscopic removal is increasingly being used.

dissolving stones

Crushing and dissolution of stones are methods that allow you to get rid of formations in the bladder with the least loss while preserving the organ itself and its ducts.

Indications for the dissolution of calculi are cholesterol formations up to 2 cm. Pigment and calcareous stones cannot be dissolved in this way.

To dissolve calculi, doctors use the drugs Ursosan, Henohol, Ursofalk.

At the same time, they can stimulate organ contractions and bile secretion, for which Allochol, Holosas, Zixorin are used.

This method of treatment has some contraindications. This:

• various pathologies of the digestive tract;
• taking oral contraceptives with estrogens;
• pregnancy;
• obesity;

In addition, the method has many disadvantages, so it is not used so often.

So, after the dissolution of stones in 10 - 70% of cases, relapses may occur, because after the end of the medication, the cholesterol in the patient's body begins to grow again.

The course can last from 6 months to several years and be accompanied by diarrhea, impaired liver function tests. In addition, the cost of drugs is quite high.

crushing stones

In some situations, doctors offer the patient other ways to grind stones. For example, crushing formations with ultrasound grinds them with the help of a shock wave.

This effect allows you to grind stones up to 3 mm, after which they calmly move along the ducts and exit into the intestines.

This method is prescribed in cases where the patient has up to 4 large stones (up to 3 cm) that do not have lime in their composition.

Grinding stones with ultrasound is contraindicated in case of poor blood clotting, pathologies of the gastrointestinal tract of a chronic type, pregnancy.

In addition, the method has its drawbacks - after the procedure, duct blockage may occur due to vibration, and the sharp edges of stone fragments can damage the walls of the bladder.

Another way to crush stones while preserving the bile and ducts is a laser beam.

For the procedure, the doctor makes a puncture in the anterior wall of the peritoneum and the laser beam acts directly on the stones and splits them. Crushing stones with a laser lasts about 20 minutes.

This technology cannot be used by people over 60 years old, people who weigh more than 120 kg, as well as patients in serious condition.

Laser fragmentation has some disadvantages. So, during the procedure, there is a high probability of burning the organ, as a result of which an ulcer may form.

The sharp edges of stone fragments can damage the bladder and clog the ducts. In addition, this procedure is not carried out in every clinic.

Surgical treatment

Laparoscopy is an operation performed under general anesthesia using special metal conductors.

The peritoneum is filled with gas, a chamber is inserted inside, and stones are removed from the organ using the picture on the screen. The laparoscopy operation takes about an hour. The patient is in the hospital for about a week.

Laparoscopy is usually prescribed for calculous cholecystitis. Has laparoscopy and contraindications.

So, it is impossible to perform an operation for obesity, with large calculi, with adhesions after other operations, suppuration of the bile, problems with the heart and breathing.

Cholecystectomy is a treatment in which the stones are removed along with the bladder itself.

Indications for surgery are large stones, regular recurrences of the disease with severe attacks of pain, fever and other complications.

Doctors use both laparoscopy and abdominal surgery to remove the gallbladder.

With laparoscopy, the doctor makes several incisions in the abdomen: through one, the laparoscope is inserted, and through another small incision, the organ is removed.

After such an operation, the patient recovers quite quickly, in addition, it is relatively inexpensive.

As for the open abdominal surgery, the indications for its implementation are very large stones, various complications and inflammation in the organs.

With this method of treatment, the doctor makes an incision of 15 - 30 cm, which is located from the hypochondrium to the navel.

Such an operation has some disadvantages - this is a high invasiveness, the risk of infection or internal bleeding after treatment, the likelihood of death in emergency treatment.

Another minimally invasive, but at the same time rather painful method of treatment is the removal of stones through the mouth.

Unlike laser or ultrasound, the removal of stones through the mouth brings a lot of discomfort to the patient.

People with a strong gag reflex are especially affected, since a special tube must be inserted into the mouth for the operation.

Before removing the stones through the mouth, the patient is given anesthesia, then a special tube is inserted into the mouth and advanced to the place where the stones accumulate.

It should be noted that before the advent of laser therapy, the removal of stones through the mouth was used quite often.

Treatment with folk methods

Many people suffering from gallstone disease prefer to use folk remedies to remove stones. It must be understood that alternative methods of treatment can be carried out only after the permission of the doctor.

For the treatment of gallstone disease, only fresh vegetable juices should be used, since pasteurized or canned juices already lose all their beneficial properties.

For treatment with folk remedies, you can take the juice of one lemon, dilute it in a glass of water and drink 1 glass several times a day for about a month.

The following mixture helps to fight stones: 7 - 10 parts of carrot juice, 3 parts of cucumber and beet juice.

GSD can be treated with herbal infusions. For example, take 5 parts of celandine, wormwood, sweet clover and 3 parts of chicory, valerian, gentian and dandelion.

Everything is mixed, pour a spoonful of the mixture with a cup of boiling water. Infusion drink ¼ cup twice a day.

Although in some cases folk recipes help get rid of gallstones, doctors recommend using other methods to treat this problem.

Inna Lavrenko

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The operation is called cholecystectomy, and this type of surgery is one of the most common. Such an operation can be performed using various surgical techniques.

The gallbladder, which forms the biliary system with the liver, is an important organ of the digestive system. Its main functions are to accumulate the bile produced by the liver, bring it to the desired concentration and release this secret in portions into the digestive system when food enters the gastrointestinal tract. Bile is involved in the breakdown of food components (especially heavy types of fats and protein), and also has an antibacterial effect, preventing the reproduction of pathogens.

Many pathologies of this organ, alas, can only be cured by surgery.

They are often accompanied by severe pain, stool disorders, nausea, heartburn and other negative symptoms that do not allow a person to lead a full life and cause him severe discomfort. In addition to emergency cholecystectomy operations designed to save the patient's life, this surgical intervention is also carried out as planned, when gallbladder pathologies can lead to very serious complications over time.

Cholecystectomy is usually prescribed in cases of:

• the presence of calculi (stones) in the gallbladder that cannot be removed without surgery;
• cholecystitis (inflammation of the walls of this organ) in acute or chronic form;
• with cholesterosis, which causes disruption of this organ and interferes with normal bile flow;
• with polyps;
• in some cases of functional disorders, when the body is no longer able to fully work.

Contraindications to this operation are general and local.

If the case is an emergency and there is a real threat to the patient's life, doctors may neglect some of them, because in such situations the benefits of the operation outweigh the possible risks.

General contraindications for cholecystectomy:

• terminal states;
• severe decompensation of internal organs;
• metabolic disorders that complicate surgical intervention.

Laparoscopic intervention is contraindicated in cases of:

Local contraindications are relative and are directly dependent on the condition of a particular patient.

Methods for this operation

Currently, cholecystectomy is performed in three ways:

• traditional abdominal intervention;
• using the laparoscopy method;
• mini-access technique.

The choice of the method of performing the operation directly depends on the current condition of the patient, the type of pathology being operated on, the opinion of the attending physician, and also on how well this or that medical institution is equipped. Regardless of the method of intervention, cholecystectomy is always performed under general anesthesia.

If we talk about traditional abdominal surgery, then its main disadvantages are:

• large size of the surgical wound;
• postoperative cosmetic discomfort in the patient;
• a high degree of risk of postoperative complications caused by internal organs remaining in the body;
• long rehabilitation period (up to two months).

Such an intervention is performed, as a rule, in emergency cases and in the presence of contraindications to the use of other surgical techniques.

Considering all the above disadvantages of an open operation (laparotomy), the main method of cholecystectomy (in the absence of contraindications) is laparoscopy, the main advantages of which are:

1. small size of postoperative scars;
2. short rehabilitation period;
3. minimal risk of complications;
4. low pain after surgery.

The essence of this technique lies in the fact that the intervention is carried out through small (up to one centimeter) punctures using a special tool. The surgeon controls the process by means of a video camera inserted along with the instruments. After laparoscopic cholecystectomy, as a rule, the patient is discharged from the hospital on the second or third day (if there are no complications). The average duration of such an operation is one hour.

Of course, between abdominal and laparoscopic surgery, most patients will choose a less traumatic laparoscopy. However, if it is contraindicated, there is a third method for such an intervention. It is called the mini-access technique (something between laparoscopy and abdominal surgery).

Such an operation consists of the same sequence of actions as the other two, but, unlike the traditional one, access to the gallbladder is provided through a relatively small (from 3 to 7 centimeters) incision just below the right costal arch.

Medical science does not stand still, and continues to search for minimally invasive surgical techniques.

So, an American surgeon named Lee Swanstrom in an Oregon clinic performed a removal of the gallbladder through the mouth.

He gained access to the organ to be removed by introducing miniature surgical instruments into the patient's stomach through her mouth opening, after which he made a small incision in the gastric membrane, cut off the gallbladder and removed it outward in the same way that the instrument had inserted.

According to this American surgeon, such a technique for removing this organ is associated with some risk of infection of the abdominal cavity with bacteria contained in the gastrointestinal tract, but he believes that this risk is very small.

This technique is the most sparing of all existing ones, since no scars and scars remain on the patient's body at all, and the rehabilitation period is also greatly reduced. In addition, Lee Swanstrom claims that such an intervention can be performed even under local anesthesia, which makes it possible to discharge the patient in a day.