Targeted ultrasound examination of the edges of the abdominal cavity in patients with gallstones and concomitant bile duct diseases as a method of preventing intraoperative complications during laparoscopic cholecystectomy
Authors: Tsivenko O.I. , Bychkov S.O. , Hrynyov R.M. , Dushyk L.M. 
Published: November 2024

Background. Statistical data from the last three decades indicate that gallstone disease (GSD) occupies a dominant position among all gastroenterological pathologies requiring surgical intervention. Despite the widespread implementation of modern minimally invasive surgical techniques, the increase in the number of operations for this condition has been accompanied by a rise in intra- and postoperative complications and unsatisfactory treatment outcomes. Patients with a history of previous abdominal surgeries, leading to the development of adhesions, are at higher risk of persistent pain syndrome, abdominal discomfort, and intra- and postoperative complications. This necessitates a very cautious approach to the initiation, execution, and conclusion of laparoscopic cholecystectomy. The current protocol for instrumental diagnosis of adhesion disease and especially adhesive bowel obstruction includes: abdominal ultrasound (US), plain and contrastenhanced radiography of the abdomen, and computed tomography (CT) and magnetic resonance imaging (MRI), respectively. The development and implementation of an accessible program addressing these issues based on evidence-based medicine principles will improve treatment outcomes for this patient group.

Purpose. The objective of this study is to investigate and substantiate the necessity of targeted abdominal ultrasound in the preoperative period as an effective method for visualizing adhesive processes and preventing intraoperative and postoperative complications in patients with concurrent intra-abdominal adhesions (IAA).

Materials and мethods. This study presents An analysis of surgical treatment outcomes was conducted for 11.549 patients with various forms of gallstone disease (GSD). Among these, 2.736 patients with a history of previous abdominal surgeries underwent LC along with various simultaneous procedures, accounting for 23.69% of all LCs performed. The cohort included 2.209 women and 527 men, with ages ranging from 16 to 78 years. Among the 2.736 patients with a history of abdominal surgeries, only 343 (12.54%) were diagnosed with intra-abdominal adhesions (IAA) during preoperative evaluation, necessitating simultaneous adhesiolysis. In 172 (6.29%) patients, IAA was definitively diagnosed intraoperatively (with high sonographic probability of adhesions preoperatively), and adhesiolysis was required to facilitate port placement, adequate revision, and visualization necessary for performing LC. Overall, adhesiolysis was performed in 515 (18.83%) patients. Preoperative Diagnostic Program: The preoperative diagnostic program included clinical and biochemical tests of blood and urine, electrocardiography (ECG), chest and abdominal radiography or fluoroscopy with and without contrast as indicated, targeted abdominal ultrasound (US) following a developed methodology, and, as needed, computed tomography (CT) and magnetic resonance imaging (MRI) of the abdomen. Abdominal ultrasound was performed using Sonoace 4800 devices from Medison, Toshiba Nemio, and Philips HDI 4000 in real-time mode. Linear, sector, and convex transducers with frequencies ranging from 2 to 5 MHz, as well as Doppler and energy transducers, were employed. Surgical Procedure: Laparoscopic cholecystectomy (LC) was carried out using standard techniques. During adhesion lysis, scissors, bipolar coagulation, and ultrasonic dissection/coagulation were used.

Results. When assessing the likelihood of adhesions in the abdominal cavity, factors considered included patient history, clinical presentation, the nature and location of postoperative scars, and results from abdominal ultrasound (US). The clinical presentation of adhesion disease varied in intensity and duration, with patients experiencing either constant or intermittent aching abdominal pain. Occasionally, the pain assumed cramp-like characteristics, often linked to the type and quantity of ingested food, and was typically diffuse, though it could change with body position. Symptoms were accompanied by periodic abdominal bloating, unstable stool, and, in most cases, patients reported delayed gas and stool passage during exacerbations. These manifestations were alleviated by dietary adjustments or the use of antispasmodics. Thus, in most cases, the clinical course aligned with forms predominantly featuring pain syndrome or gastrointestinal discomfort, resembling perivesiculitis. Given these complaints and the specific clinical manifestations, which were not entirely characteristic of GSD and considering the presence of pathogenic factors for the development of adhesion processes in the abdominal cavity, we developed and analyzed methods and sonographic signs that objectively indicate the presence, extent, and severity of motor function disturbances and, consequently, gastrointestinal physiology associated with adhesive bowel obstruction (ABO). Based on preoperative examination, adhesion disease was not diagnosed in 6 (1.75%) patients, and it emerged as a predicted intraoperative finding, which indicated the need for simultaneous adhesion lysis. These adhesions were isolated, localized, with lengths ranging from 10 mm, explaining their non-visualization on abdominal US and the generally absence of symptoms typical of ABO in these cases. Regardless of their location within the abdominal cavity, adhesions exhibited a nearly identical echographic pattern. This pattern was characterized by the degree of infiltrative and scar changes, as well as the thickening and alteration in the density of the parietal and visceral peritoneum, which exhibited focal lesions of varying extent. These characteristics were diagnosed in all patients with preoperative adhesive bowel obstruction (ABO). The ultrasound semiotics of adhesions were distributed as follows: 123 (47.12%) patients had adhesions localized as echopositive inclusions in elongated (linear or oval) forms or as fine, point-like formations. In 31 (11.87%) patients, multiple adhesions fused or combined to form small, deep conglomerates with irregular oval or round configurations. In 21 patients (8.02%), the adhesive process was represented by an echopositive, heterogeneous band. Scarring of various forms was identified in 31 (11.87%) patients. Overall, the positive echographic sign of «spring» was found in 93 (35.63%) patients, and the positive echographic sign of «curtain» was found in 46 (17.62%) patients. It was noted that adhesions have distinct features depending on their location: in the lower abdominal regions, they appeared as linear and fine-point forms, while in the upper and middle regions, deep inclusions or scar changes in the form of echopositive, heterogeneous bands were more common. Linear and oval adhesions typically exceeded their transverse diameter, ranging from 5 to 15 mm. The diameter of fine-point inclusions ranged from 3 to 10 mm. Deep formations and echopositive, heterogeneous bands of scar tissue were more than 15 mm in diameter. The echogenicity of scar changes was high or very high, sometimes with the formation of acoustic shadowing distally (behind the adhesions). Changes in peristalsis, internal contour of the bowel, presence of deformation, degree of dilation, and passage disruption of bowel contents were identified as direct and indirect signs of ABO. In previously operated patients, particular attention was given to the clinical manifestations of the disease to detect bowel passage disturbances, the pathology for which the patient was previously operated on, with a focus on the postoperative course, the nature and location of postoperative scars, and, crucially, the data obtained from targeted abdominal ultrasound according to the developed methodology to determine the location for Veress needle insertion and placement of the first trocar.

Conclusions. Adhesive Disease of the Abdominal Organs: Adhesive disease, with its specific semiotics, can significantly affect the course of gallstone disease. Depending on the extent, intensity of the connective tissue component, and disturbances in bowel motility, it can result in a high risk of intraoperative and postoperative complications. Frequency and Extent of Adhesion Formation: The frequency and extent of adhesive processes in operated patients are directly related to the number of laparotomy procedures, the type, size, and location of the laparotomy access, the volume of the surgical intervention, the nature of the pathology being treated, the type and duration of abdominal drainage, the specifics of the postoperative course, and the presence and nature of postoperative complications. Diagnostic Value of Targeted Ultrasound: The data obtained highlight the high diagnostic value of targeted ultrasound for visualizing adhesions. This approach allows for the verification of the location, extent, and characteristics of the adhesive process in the abdominal cavity and helps identify early signs of acute adhesive bowel obstruction. Comparison with Radiological Examination: Targeted abdominal ultrasound, when used according to the developed algorithm, provides a detailed diagnosis with nearly 100% accuracy in a shorter time compared to radiological examination. It helps determine safe trocar insertion sites and prevents intraoperative and postoperative complications.