PREVENTION OF INTRAOPERATIVE COMPLICATIONS DURING LAPAROSCOPIC CHOLECYSTECTOMY IN PATIENTS WITH CONCOMITANT ABDOMINAL SEBACEOUS DISEASE
Authors: Tsivenko O. , Bychkov S. , Hrynyov R. , Dushyk L. , Cherkova N. 
Published: June 2024

Abstract. Aim of the research is to study the reasons for the unsatisfactory results of treatment of patients with gallstone disease combined with adhesive disease of the abdominal cavity, to substantiate the need for a targeted ultrasound examination as an effective method of preoperative diagnosis of adhesive disease of the abdominal cavity, to develop and implement in clinical practice a safe technique for introducing trocars and performing adhesiolysis in patients on housing and communal services with accompanying adhesive disease of the abdominal cavity.
Research methods. An analysis of the results of surgical treatment of 11,549 patients for various forms of gastrointestinal tract was carried out. All patients underwent LHCE as a method of surgical treatment of the underlying disease. In 2,736 patients who previously underwent surgical interventions on the organs of the abdominal cavity, LHCE and simultaneous operations were performed, which is 23.69% of the total number of LHCE. Of them, 283 patients were operated twice and 51 three times. There were 2,209 women, 527 men. The age of the patients ranged from 16 to 78 years.
Out of 2,736 patients who had a history of operations on abdominal organs, only 343 (12.54%) patients required a simultaneous operation - adhesiolysis. That is, they had established clinical manifestations of CKD at the stage of preoperative diagnosis, accordingly, it was formulated as a concomitant pathology that required surgical correction during surgery. However, in 172 (6.29%) patients, it was diagnosed intraoperatively, and the performance of adhesiolysis was necessary for the introduction of ports, adequate revision of the abdominal cavity and visualization - to ensure the conditions for performing LHCE. In total, adhesiolysis was performed in 515 (18.83%) patients.
Laparoscopic cholecystectomy was performed according to the generally accepted technique, during adhesiolysis, scissors, bipolar coagulation and ultrasonic dissection / coagulation were used. The electrosurgical unit worked in monopolar and bipolar modes.
Results. When determining the probability of the presence of abscesses in the abdominal cavity, the data of the anamnesis, clinical picture, the nature and localization of postoperative scars, and the results of ultrasound examination of the abdominal cavity were taken into account. The clinical picture of celiac disease was manifested by varying degrees of intensity and duration, constant or periodic aching pains in the abdomen, sometimes they took on a paroxysmal character, which in most cases patients associated with the nature and volume of food consumed and were mainly without a clear localization, but changed their character when changing position of the body, were accompanied by periodic bloating, unstable stool, but the vast majority of patients noted during the period of aggravation of constipation and delay in passing gases. These manifestations were bought by correcting and reducing the food load or by taking antispasmodics. That is, in the vast majority of observations, the clinical course corresponded to forms with a predominance of pain syndrome or gastrointestinal discomfort - perivisceritis. In connection with these complaints and features of clinical manifestations - not entirely typical for housing and communal services and the presence
in the anamnesis of pathogenetic factors for the development of sebaceous posses in the abdominal cavity with characteristic clinical manifestations, we developed and analyzed techniques and sonographic signs that objectively indicate the presence, prevalence and the severity of disturbances in motor function and, accordingly, the physiology of the gastrointestinal tract.
Based on preoperative examination, the adhesive process was not diagnosed in 82 (23.91%) patients and it became a predicted operative finding, which served as an indication for simultaneous surgery. But these adhesions were isolated, local, had no prevalence and their length varied within 10 mm., which explains the lack of visualization of the adhesions during the ultrasound examination of the abdominal organs and, in most cases, almost no complaints characteristic of the adhesive disease of the abdominal cavity.
The most important stage of laparoscopic surgery in patients with a history of laparotomy operations is the imposition of pneumoperitoneum and the introduction of the first trocar, which is due to the impossibility of visual control of these actions. The possibility of reducing the risk of complications at this stage of laparoscopic surgery in this contingent of patients depends on the correct choice of the place of insertion of the Veresh needle and the first trocar. &quot;Blind&quot; puncture of the abdominal cavity near postoperative scars is unacceptable. When determining the place of puncture with a Veresha needle and inserting the first trocar in previously operated patients, the peculiarities of the clinical manifestations of the disease were taken into account in order to identify disorders of the passage of intestinal contents through the gastrointestinal tract, the pathology for which the patient was operated on with an emphasis on the course of the postoperative period, the nature and localization of postoperative scars, and the main thing is the results of ultrasound of the abdominal organs.
The correct intraoperative use of dissectors based on different types of physical energy, certainly taking into account the peculiarities of their traumatic effect on tissues, ensured the absence of intra- and postoperative complications. The average duration of simultaneous surgery during adhesiolysis increased by 15 to 35 minutes and amounted to (59.4 ± 5.9) minutes. An increase in the duration of LHE due to adhesiolysis during the early postoperative period was not reflected, but it allowed to avoid the negative consequences of laparotomy. Patients were discharged from the clinic on the 4th to 6th day after surgery. Recurrences of adhesive disease of the abdominal cavity were not observed in patients operated on by us within 12-36 months after the operation.
Conclusions. As a result of the conducted research, it was established that:
The reasons for the persistence of preoperative complaints of pain syndrome and functional digestive disorders are related to undiagnosed concomitant diseases of the abdominal organs (CHF, GERD, and others).
The full use of the extended diagnostic program, first of all, the improved technique of conducting ultrasound of the abdominal organs with targeted verification of the splenic process, especially in patients with characteristic clinical signs and an appropriate history, made it possible to correctly establish a preoperative diagnosis and choose a pathogenetically justified surgical strategy.
The obtained data testify to the high diagnostic possibilities of ultrasound of the abdominal organs according to the developed technique in the diagnosis of the sebaceous process in the abdominal cavity. The frequency and prevalence of the malignant process in operated patients are directly dependent on the number of laparotomy interventions, the type and size of the laparotomy access, the scope of the surgical intervention and the nature of the operated pathology.
Ultrasonic dissection is characterized by a relatively gentle effect on biological tissues, which is accompanied by the formation of much less widespread areas of necrosis and necrobiosis than with electrosurgical exposure. In addition, biological welding of the edges of the wound, reliable hemostasis is achieved; there are no charring of fabrics, their sticking to the surface of the manipulator, smoke, sparks and other adverse effects.
The correct intraoperative use of electrosurgical and ultrasonic dissectors ensured the absence of intra- and postoperative complications and recurrences of adhesive disease of the abdominal cavity in operated patients for 36 months.