Preoperativna identifikacija i kvantifikacija parametara za predviđanje tehnički komplikovane laparoskopske holecistektomije

Abstract

Laparoskopska holecistektomija(LC) je najĉešća endoskopska operativna procedura u svakodnevnom hirurškom radu i zlatni standard u lijeĉenju simptomatske holelitijaze zbog manje operativne traume, manjeg operativnog reza i problema vezanih za zarastanje operativne rane, manjeg postoperativnog morbiditeta i postoperativnog bola, kraće hospitalizacije i odsustvovanja sa posla, manjih troškova lijeĉenja i neuporedivo boljeg estetskog efekta . Danas se u razvijenim i bogatim zemljama više od 90% bolesnika sa kalkulozom ţuĉne kese operiše laparoskopskim putem. Bezbjednost LC je usko povezana sa iskustvom hirurga i makroskopskim izgledom ţuĉne kese. Sa sticanjem iskustva i prevazilaţenjem krivulje uĉenja, selekcija kriterijuma za LC kod laparoskopskih hirurga je sve liberalnija pa laparoskopski hirurzi nailaze na brojne probleme koji oteţavaju bezbjedno izvodjenje operacije. Apsolutne kontraindikacije su bolesnici sa teţim poremećajem koagulacije, karcinom ţuĉne kese i bolesnici koji ne tolerišu opštu anesteziju. Većina ranije opisanih kontraindikacija, kao što su morbidna gojaznost, prethodne operacije u gornjem abdomenu i akutni holecistitis su danas faktori rizika za konverziju u referentnim centrima za endoskospku hirurgiju a relativna kontraindikacija u nereferentnim ustanovama za laparoskopsku hirurgiju i hirurzima u fazi uĉenja. Kao relativnu kontraindikaciju za LC treba smatrati i nedovoljno iskustvo laparoskopskog hirurga, nepostojanje uslova za rješavanje intraoperativnih komplikacija i postojanje prediktivnih faktora koji ukazuju da će LC biti komplikovana sa većom uĉestalošću intraoperativnih komplikacija. U nereferentnim ustanovama za laparoskopsku hirurgiju i manjim regionalnim bolnicama sekundarna prevencija biliovaskularnih povreda je suština operativnog rada zbog ĉesto diskutabilnog naĉina zbrinjavanja nastalih povreda...

Laparoscopic cholecystectomy (LC) is most common endoscopic surgical procedure in everyday surgical work and golden standard in medical treatment of symptomatic cholelithiasis. This is due to smaller surgical trauma, smaller surgical incision and less issues connected to the healing of the incision, decreased postoperative mortality and pain, shorter hospitalisation and sick leave, smaller costs of the medical treatment and more incomparably better estetical effects. Presently in developed and rich countries, more than 90% of the patients with cholelithiasis are operated in laparoscopic surgery. Safety of LC is close connected with the experience of the surgeon and macroscopic look of the gallbladder(GB). With gain of the experience and overcoming of the locus of learning, selection of the criteria for LC in the case of the laparoscopic sergeant is becoming more liberal – therefore laparoscopic sergeants encounter numerous issues which make difficult for laparoscopic surgeon to safely perform the surgery. Absolute contraindications are the patients with serious disorder of coagulation, GB carcinoma and the patients who are intolerant to general anesthesia. Most of the previously described contraindications, such as morbid obesity, previous surgeries in upper abdomen and acute cholecystitis which are the risk factors for conversion in referential centers for endoscopic surgeries and relative contraindication in non-referential centers for laparoscopic surgery and for surgeons in a learning phase. As relative contraindications for LC should be taken into account insufficient experience of laparoscopic surgeon, non-existence of the conditions for solution of intraoperative complications and existence of predicative factors which indicate that LC will be complicated with higher occurrences of intraoperative complications. In non-referential centers for laparoscopic surgeries and smaller regional hospitals, secondary prevention of injury of biliary and vascular structures is the essence of the surgical work due to often questionable medical care of the incurred injuries...