Cholecystectomy: types, methods and complications

Since the first application in 1882 (S. Langenbuch) until 1987, cholecystectomy remained the only effective treatment for cholelithiasis. The technique of the operation over these years has reached its perfection.

[1], [2]

Traditional cholecystectomy

Traditional cholecystectomy and the results of its application are devoted to a large number of publications in periodicals and well-known authoritative monographs. Therefore, let us recall briefly the main points of the problem under consideration.

Indications: any form of CSF, requiring surgical treatment.

Anesthesia: a modern multicomponent endotracheal anesthesia.

Access: upper median laparotomy, oblique and oblique subcutaneous incisions of Kocher, Fedorov, Biven-Herzen, etc. At the same time, there is wide access to HP, extra-hepatic ways, liver, pancreas, duodenum. It is possible to examine and palpate almost all organs of the abdominal cavity and retroperitoneal space.

The whole program of intraoperative revision of extrahepatic bile ducts is performed:

• examination and measurement of the external diameter of the common hepatic duct and the heart valve;
• palpation of supraduodenal and (after use of Kocher's method) retroduodenal and intrapancreatic parts of the OZP;
• transillumination of the supraduodenal department of the heart;
• IOKHH;
• IHEPS;
• choledochotomy with GIHG, investigation of the terminal department of the CAP by calibrated bougie, cholangiomanometry; Any options for completing the choledochotomy depending on the specific clinical situation and the indications resulting from it are possible;
• When using traditional access, it is possible to perform combined (simultaneous) surgical interventions;
• traditional cholecystectomy is the safest method of surgery in the presence of pronounced inflammatory or cicatricial changes in the subhepatic region, in the region of the Kalo triangle and the hepatoduodenal ligament.

Disadvantages of the method:

• operational injury of moderate severity, leading to the development of the catabolic phase of the postoperative period, intestinal paresis, impaired function of external respiration, restriction of physical activity of the patient;
• significant injury to the structures of the anterior abdominal wall (in some cases, access to blood supply and innervation of the muscles of the anterior abdominal wall), a significant number of early and late wound complications, in particular postoperative ventral hernias;
• a significant cosmetic defect;
• a long period of post-surgery and postoperative rehabilitation and disability.

Video laparoscopic cholecystectomy

In principle, the indications for laparoscopic cholecystectomy should not differ from the indications for traditional cholecystectomy, because the task of these operations is the same; removal of the gallbladder. However, the use of laparoscopic cholecystectomy has a number of limitations.

Indications:

• chronic calculous cholecystitis;
• Cholesterosis of the liver, polyposis of the liver;
• asymptomatic cholecystolithiasis;
• acute cholecystitis (up to 48 hours from the onset of the disease);
• chronic acalculous cholecystitis.

Contraindications:

• severe cardiopulmonary disorders;
• uncorrectable blood clotting disorders;
• diffuse peritonitis;
• inflammatory changes in the anterior abdominal wall;
• late pregnancy (II-III trimester);
• obesity of the IV degree;
• acute cholecystitis after 48 hours from the onset of the disease;
• marked cicatricial-inflammatory changes in the neck of the gallbladder and hepatic duodenal ligament;
• mechanical jaundice;
• acute pancreatitis;
• bilio-digestive and bilio-biliary fistulas;
• cancer of the gallbladder;
• the operations carried on the upper floor of the abdominal cavity.

It should be said that the above contraindications are sufficiently relative: contraindications to superposition of pneumoperitoneum are leveled by performing laparoscopic cholecystectomy with low intra-abdominal pressure or lifting gas-free technologies; perfection of operating technique allows to operate safely enough with pronounced cicatricial and inflammatory changes, Mirizi syndrome, bilio-digestive fistulas. More and more there is information about the possibilities of video laparoscopic operations on the heart. Thus, the improvement of surgical techniques and the emergence of new technologies and instruments significantly reduce the list of possible contraindications. Very important is the subjective factor: the surgeon himself must make a decision, answering the question, is it possible for him and how justified is the use in this particular clinical situation of laparoscopic cholecystectomy or is it safer than other variants of surgery?

During the implementation of laparoscopic cholecystectomy, there may be a need for a transition to a traditional operation (conversion). Such operations are most often used in cases of inflammatory infiltrate, tight fusion, internal fistulas, ambiguity in the arrangement of anatomical structures, inability to perform choledocholithotomy, intraoperative complications (damage to the vessels of the abdominal wall, bleeding from the vesical artery, perforation of the hollow organ, damage to the common hepatic duct and OZhP, etc.), the elimination of which is not possible during laparoscopic surgery. There are also technical malfunctions of the equipment that require a transition to a traditional operation. The conversion frequency ranges from 0.1 to 20% (planned surgery - up to 10%, emergency - up to 20%).

Prognostic factors are highly useful in terms of the possible conversion of laparoscopic cholecystectomy into a traditional one. It is believed that the most reliable risk factors are acute destructive cholecystitis, a significant thickening of the walls of the HP according to ultrasound, pronounced leukocytosis and an increase in the level of alkaline phosphatase. If the patient does not have any of the four listed risk criteria (risk factors), then the probability of a possible transition to a traditional operation is 1.5%, but it increases to 25% or more if all of the above-listed prognostically unfavorable factors are present.

At the same time, careful pre-operative examination, correct identification of indications for surgery, careful consideration of possible contraindications in each specific case, as well as high qualification of surgeons performing laparoscopic interventions, lead to a significant reduction in the proportion of inverted operations.

Anesthesia is an extremely important moment in laparoscopic cholecystectomy. Use general anesthesia with intubation of the trachea and the use of muscle relaxants. An anesthesiologist must understand that throughout the intervention, a good muscle relaxation and proper level of anesthesia is required. Reducing the depth of the neuromuscular block and the level of anesthesia, the appearance of independent movements of the diaphragm, the restoration of peristalsis, etc. Not only hinders visual control in the operating area, but can also cause severe damage to the abdominal organs. It is mandatory to insert a probe into the stomach after intubation of the trachea.

Organization and technique of the main stages of laparoscopic cholecystectomy

The list of basic instruments used to perform laparoscopic cholecystectomy includes:

• monitor with color image;
• a lighting source with automatic and manual adjustment of the intensity of the light flux;
• automatic insufflator;
• electrosurgical unit;
• device for aspiration and liquid injection.

The following tools are usually used to perform the operation:

• trocars (usually four);
• laparoscopic clamps ("soft", "hard");
• scissors;
• electrosurgical hook and spatula;
• applicator for applying clips.

The operating team consists of three surgeons (an operator and two assistants), an operating sister. It is desirable to have an operating sister to control the light source, electric block, insufflator, washing system.

The main stages of the operation are performed with the head end of the table raised at 20-25 °, tilting it to the left by 15-20 ". If the patient is lying on his back with legs joined together, the surgeon and the camera are to his left. If the patient is lying on his back with legs apart, the surgeon is located on the side of the perineum.

Most operators use four main points of introduction of trocar into the abdominal cavity:

1. "Umbilical" directly above or below the navel;
2. "Epigastric" 2-3 cm below the xiphoid process along the middle line;
3. on the anterior axillary line 3-5 cm below the costal arch;
4. on the mid-succinic line at 2-4 cm below the right costal arch.

The main stages of laparoscopic cholecystectomy:

• creation of pneumoperitoneum;
• the introduction of the first and manipulative trocars;
• separation of the bladder artery and bladder duct;
• clipping and intersection of the bladder duct and artery;
• separation of the liver from the liver;
• removal of the HP from the abdominal cavity;
• control of hemo- and bile duct, drainage of the abdominal cavity.

Videolaparoscopic operation allows to perform examination and instrumental palpation of the abdominal cavity organs, to perform a cholecystectomy at a sufficient level of safety. In the conditions of highly qualified and well-equipped surgical hospital in the presence of indications it is possible to realize the program of intraoperative examination and sanation in the non-hepatic biliary tract:

• perform inspection and measurement of the outer diameter of the supraduodenal department of the LC;
• to fulfill IOKHG;
• to conduct the EHIS;
• carry out intraoperative revision of extrahepatic bile ducts and fibrocholedochoscopy through a cystic duct, removal of stones;
• perform a choledochotomy, examination of the heart and liver ducts with special biliary balloon catheters and baskets, fibrocholedochoscopy, removal of stones;
• to produce antegrade transprotective sphincterotomy, an ampullar balloon dilatation.

Videolaparoscopic techniques allow to complete the choledochhotomy with the primary suture of the duct, external drainage or the imposition of holedoduodenoanastomosis. It should be emphasized that laparoscopic operations on LMW are feasible, but far from simple in execution and can not be regarded as generally available. They should be performed only in specialized offices.

Laparoscopic cholecystectomy has firmly won a leading place in the surgery of extrahepatic biliary tract, while the number of operations in some surgical teams exceeds several thousand. At the same time, it is very revealing that almost all recent international and Russian surgical forums included complications of laparoscopic cholecystectomy as one of the issues on the agenda.

The main causes of complications of laparoscopic cholecystectomy

The reaction of the body to the intense pneumoperitoneum:

• thrombotic complications - phlebothrombosis in the lower limbs and small pelvis with the risk of pulmonary embolism. Any surgical intervention leads to hypercoagulability, but with laparoscopic cholecystectomy, the increased abdominal pressure, the position of the patient with the raised head end, in a number of cases the long duration of the operation, is of additional pathological importance;
• limitation of lung excursions with pneumoperitoneum;
• reflex inhibition of the motor function of the diaphragm in the postoperative period due to its hyperextension;
• the negative effect of the absorbed carbon dioxide;
• decrease in cardiac output due to a decrease in venous return to the heart due to the deposition of blood in the veins of the lower extremities and pelvis;
• disturbance of microcirculation of abdominal cavity organs due to compression with pneumoperitoneum;
• disturbances of the portal blood flow.

The listed pathological reactions of the body to increase intra-abdominal pressure when applying carboxyperitoneum with standard LCE within 60 min are expressed minimally or easily corrected by an anesthesiologist. However, their severity and danger significantly increase with prolonged operation. Therefore, laparoscopic cholecystectomy lasting more than two hours should hardly be considered a minimally invasive intervention.

Complications caused by the need to superimpose pneumoperitoneum can be divided into two main groups:

• associated with extra-peritoneal gas injection;
• associated with mechanical damage of various anatomical structures.

Insufflation of gas into the subcutaneous tissue, preperitoneal, into the tissue of the large omentum does not present a serious danger. With accidental puncture of the vessel and the ingress of gas into the venous system, massive gas embolism may follow.

Among the mechanical damages, the most dangerous are damage to large vessels and hollow organs. Their frequency with laparoscopic cholecystectomy ranges from 0.14 to 2.0%. Injury of the vessels of the anterior abdominal wall and formation of a hematoma or intra-abdominal bleeding are diagnosed with laparoscopy and do not pose a threat to the patient's life, a trauma of the aorta, vena cava, iliac vessels is much more dangerous when delay with active actions can lead to death.

Most often, such complications occur with the introduction of the first trocar, less often the Veresh needle. In our practice, aortic injury with the introduction of the first trocar took place in a young patient who underwent laparoscopic examination and possible surgery for gynecological indications Immediately after the introduction of the first trocar, massive bleeding into the abdominal cavity, and the anesthesiologist recorded a critical drop in blood pressure. In the next operating room, one of the authors of these lines, together with another experienced surgeon, was preparing to perform another operation, which made it possible to perform a large median laparotomy without any delay, to detect parietal aortic injury and to stitch it. The patient recovered.

Specialists developed a number of rules for superimposing pneumoperitoneum:

• aortic palpation test allows to determine the localization of the aorta and iliac arteries;
• the horizontal position of the scalpel when the abdominal wall is cut above or below the navel;
• test needle springs Veresha;
• vacuum test;
• aspirating test.

After the laparoscope is inserted, the abdominal cavity should be inspected before the main stages of the operation are performed. Of considerable interest is ultrasonic mapping of the adhesive process in the anterior abdominal wall, especially when performing laparoscopic operations in previously operated patients. The most effective method of prevention is the method of "open" laparocentesis.

Laparoscopic cholecystectomy is the most frequent video-laparoscopic operation, which, according to the literature, is accompanied by average complications in the range of 1-5%, and the so-called "large" complications in 0.7-2% of cases. In some authors, the number of complications in the group of persons of the elderly age is 23%. There are a number of classifications of complications of laparoscopic cholecystectomy, as well as the causes of their occurrence. From our point of view, the most frequent cause of complication development is the surgeon's reassessment of the possibilities of the method in his performance and the desire to certainly complete the operation laparoscopically. Bleeding during the performance of laparoscopic cholecystectomy occurs with lesions of the cystic artery or from the hepatic lobe of the HP. In addition to the threat of massive blood loss, bleeding from the cystic artery is dangerous additional trauma to the bile ducts when trying to stop bleeding in conditions of insufficient exposure and reduced visibility. Experienced surgeon in most cases copes with bleeding from the vesicle artery without switching to laparotomy. Beginning surgeons, as well as unsuccessful attempts at hemostasis should be recommended without hesitation to perform a wide laparotomy.

Possible cause of damage to hollow organs in the stage of cholecystectomy is most often a pronounced adhesive process and non-compliance with the rules of coagulation and visual control during the introduction of instruments into the zone of operation. The greatest danger is the so-called "scanned" damage. In case of timely detection of the wound of the hollow organ, suturing the defect endoscopically does not cause great difficulties.

The most serious complication of laparoscopic cholecystectomy is the trauma of extrahepatic bile ducts. The statement that, with LHE, the frequency of lesions of extrahepatic bile ducts is 3-10 times greater than with conventional surgery, it has unfortunately become common. True, some authors believe that the frequency of lesions of extrahepatic bile ducts with LHE and the traditional method of surgery is the same. Apparently, the establishment of a true state of affairs on this important issue is possible as a result of further prospective multicentric (interclinical) studies.

A fairly clear correlation was found between the number of operations performed and the frequency of bile duct traumas. This fact testifies to the insufficient control of the training of surgeons for LHE and, unfortunately, the ineradicable practice of training on "own" mistakes of crossing the "foreign" bile duct.

The absence of the possibility of manual revision of the allocated structures, anatomical variants of the configuration of the biliary tract and vessels, the desire for high-speed surgery, the intersection of tubular structures to their full identification - this is far from a complete list of causes of serious complications.

The causes leading to the development of intraoperative complications can be divided into three groups.

1. "Dangerous Anatomy" - a variety of anatomical options for the structure of extrahepatic biliary tract.
2. "Dangerous pathological changes" - acute cholecystitis, scleroatrophic RA, Mirizzi syndrome, liver cirrhosis, inflammatory diseases of the hepatic-duodenal ligament and duodenum
3. "Dangerous surgery" - incorrect traction, leading to inadequate exposure, stopping bleeding "blindly," etc.

Prevention of intraoperative bile duct lesions is the most important task of laparoscopic surgery, which is due to the increasing prevalence of laparoscopic cholecystectomy.

Open laparoscopic cholecystectomy

In 1901 the Russian surgeon-gynecologist Dmitry Oskarovich Ott surveyed the abdominal cavity through a small incision of the posterior vaginal foramen with long mirror hooks and a head reflector as a source of illumination. By 1907, he had performed some operations on pelvic organs with using the described technique. It is this principle - a small incision of the abdominal wall and the creation of a much larger zone in the abdominal cavity, accessible to adequate examination and manipulation - is laid in the basis of the mini-laparotomy technique with "elements" of open "laparoscopy" according to M.I. To Prudkov.

The basis of the developed set of tools "Mini-Assistant" is a ring-shaped retractor, a set of interchangeable hooks-mirrors, a lighting system and special surgical instruments. The design features of the instruments (clamps, scissors, tweezers, dissector, fork for tying ligatures in the depth of the wound, etc.) are designed taking into account the features of the axis of the operation and have additional bends. A special channel is provided for outputting optical information to the monitor (open telelaparoscopy). By changing the angle of inclination of the mirror, fixed by means of a special mechanism, it is possible, when cutting an abdominal wall 3-5 cm long, to obtain in the subhepatic space an adequate examination and manipulation zone sufficient for performing cholecystectomy and interventions on the ducts.

The authors devoted a considerable number of publications to this variant of surgery, but nevertheless we consider it expedient to give a detailed description of the technique of cholecystectomy.

Long reflections on the name of the technique of operating by M.I. Prudkov using the "Mini-Assistant" tool kit led to the development of the term MAC - cholecystectomy.

The incision of the anterior abdominal wall is performed with an indentation of 2 transverse toes to the right of the middle pinnate, starting from the costal arch vertically downwards 3-5 cm long. Very small incisions should be avoided, since too much traction with mirrors is done, which increases the number of wound complications in postoperative period. The skin, subcutaneous tissue, the outer and inner walls of the vagina of the rectus muscle are dissected, and the muscle itself is stratified along the access axis by the same length. Careful hemostasis is important. The peritoneum, as a rule, is dissected together with the back wall of the vagina of the rectus muscle. It is important to enter the abdominal cavity to the right of the circular ligament of the liver.

The main stage of the operation is the installation of a system of hooks-mirrors and lighting systems ("open" laparoscopy). Most of the errors and unsatisfactory references about the method come from insufficient attention to this stage of the operation. If the mirrors are installed incorrectly, there is no complete fixation of the retractor, adequate visual control and illumination of the subhepatic space, manipulation is difficult and dangerous, the surgeon starts using additional tools that are not included in the kit, which often results in a transition to a traditional laparotomy at best.

First set two small hooks in a direction perpendicular to the axis of the wound. Let's call them "right" and "left" in relation to the operator. The main task of these hooks is to stretch the wound in the transverse direction and fix the annular retractor. The angle of inclination of the right hook should be chosen in such a way as not to interfere with the subsequent removal of the wound to the wound. The left hook is usually placed at an angle close to the right. In the subhepatic space, a large tissue is inserted. The longer third hook is inserted into the lower corner of the wound in the unfixed state, and then, together with the tissue, is set in the desired position and fixed. The movement of this hook resembles the function of the assistant's hand in a standard operation and opens the operator's handshake space.

Between the hooks, surgical napkins with long "tails" of thick lavsan ligatures are installed. Napkins are inserted into the abdominal cavity completely and placed between the mirrors as in TCE: left - under the left lobe of the liver, left and down - for the stomach and large gland, right and down - to fix the hepatic angle of the colon and loops of the small intestine. Most of all three mirrors and napkins between them are enough to create an adequate surgical zone, almost completely delimited from the rest of the abdominal cavity. A mirror with a light guide is installed in the upper corner of the wound; it simultaneously acts as a hepatic hook. In the case of a large "overhanging" right lobe of the liver, an additional mirror is required for its removal.

After the correct installation of the system of mirror hooks, napkins and light guide, the operator clearly sees the lower surface of the right lobe of the liver, the HP, when he is guided by Hartman's pocket - the hepatic-duodenal ligament and the duodenum. The stage of open laparoscopy can be considered to be held.

Isolation of elements of the triangle Kalo (cholecystectomy from the cervix) according to the technique of execution differs from TCE only by the necessity of "remote" operation and the inability to insert a hand into the abdominal cavity. A special feature of the tools is the angular displacement of their working part relative to the handle so that the surgeon's hand does not cover the operating field.

These features of manipulation require some adaptation, but in general the procedure is much closer to the usual TCE than to LHE, which greatly facilitates the training of surgeons.

The basic rules for performing open laparoscopic cholecystectomy:

• when separating the elements of the Kahlo triangle, one should clearly see the wall of the common hepatic duct and the LC;
• the allocated tubular structures can not be tied up and crossed until they are fully identified;
• if within 30 minutes from the beginning of the release of the HP from the inflammatory infiltrate or scarring, the anatomical relationships remain unclear, the transition to traditional cholecystectomy is advisable.

The last rule, developed by the authors on the basis of the study of the causes of complications and conversions, is very important. In practice, especially in the daytime, it is advisable to invite an experienced surgeon for advice and decide whether to continue the operation or to convert together.

After the separation of the cystic duct, the latter is distally re-bandaged, and at this time, intraoperative cholangiography can be performed through the vesicular duct, for which a special cannula is available in the kit.

Then the cystic duct is crossed, and the stump is ligated with two ligatures. The knot is knotted with the help of Vinogradov's wand: the knot is formed outside the abdominal cavity and is pulled down and tightened with a fork. Admission, as well as the instrument itself, are not new to an experienced surgeon, as they are used in traditional surgery in difficult situations.

The next stage is the isolation, intersection and bandaging of the vesicle artery. For the treatment of the stump of the vesicle artery and the cystic duct, the use of clipping is possible.

The stage of separating the HP from the bed should be performed as accurately as possible. As in classical surgery, the main condition: "get into the layer" and, moving from the bottom or from the neck (after the bladder duct and artery are crossed, it is not important), to gradually separate the HP from the bed. Usually, a dissector and scissors are used with careful coagulation (there is a special electrocoagulator in the kit). The quality and safety of the execution of the stage largely depend on the characteristics of the electric block.

Removing a remote RP with open laparoscopic cholecystectomy from a mini-access is never difficult. The operation is terminated by bringing the silicone perforated drainage to the HP box through the counter-control. The wound of the abdominal wall is sutured layer by layer.

Indications for open laparoscopic cholecystectomy:

• chronic calculous cholecystitis, asymptomatic cholecystolithiasis, polyposis, HP cholesterosis;
• acute calculous cholecystitis;
• Cholecystolithiasis, choledocholithiasis, unresolved endoscopically;
• technical difficulties with LHE.

Contraindications to open laparoscopic cholecystectomy:

• the need for revision of the abdominal cavity;
• diffuse peritonitis;
• not correctable blood clotting disorders;
• cirrhosis of the liver;
• cancer of HP. 

Anesthesia: multicomponent balanced anesthesia with IVL.

Advantages of open laparoscopic cholecystectomy from mini-access:

• minimal injury of the anterior abdominal wall;
• adequate access to the HP, the common hepatic duct, and the LUS;
• the possibility of performing an intervention in patients who have undergone previous operations on the abdominal cavity;
• the possibility of performing surgery in the second and third trimester of pregnancy;
• small traumatic surgery, lack of pneumoperitoneum;
• a significant reduction in the number of early and late wound complications;
• absence of disturbances in the function of external respiration, intestinal paresis, decreased need for analgesics, early recovery of motor activity, rapid recovery of work capacity;
• a short period of training in connection with the technology of operation, close to traditional;
• relatively low cost of equipment.

Mini-laparotomy with the elements of "open" laparoscopy, performed with the help of the "Mini-Assistant" tool kit, allows to perform cholecystectomy with a high degree of reliability and safety in almost all clinical forms of calculous cholecystitis, to perform intraoperative revision of extrahepatic bile ducts, including:

• inspection and measurement of the outer diameter of the LCA;
• trai-sullification of the supraduodenal department of the OZHP;
• IOHG through the cystic duct;
• IHEPS;
• IOHG through the cystic duct.

In the presence of indications, it is possible to ingra-operative choledochotomy, removal of concrements.

If necessary, choledochoscopy can be performed, examination of the terminal department of the MDC by calibrated bougies, carrying out a revision of the ducts with a catheter with an inflated cuff,

When combined with choledocholithiasis and stricture of the terminal department of the heart or large duodenal papilla, it is possible to perform fibroduodenoscopy during surgery and perform an endoscopically controlled antegrade or retrograde papillosphincterotomy, it is technically possible to superimpose choledochoduodeno- and choledochoenteroanastomosis.

Choledocholithotomy can be completed by the primary suture of the duct, drainage by Keru or Halstead, etc. In other words, in carrying out OLHE from mini-access, an adequate restoration of the outflow of bile can be realized in the vast majority of clinical situations.

The accumulation of the experience of operating according to the method described above allowed the authors to perform repeated and reconstructive operations on the bile ducts.

More than 60% of operations from mini-laparotomy access were performed in connection with complicated forms of GAD - acute destructive obstructive cholecystitis, choledocholithiasis, mechanical jaundice, bilio-digestive and bilio-biliary fistulas.

Open laparoscopic cholecystectomy with choledocholithotomy and subsequent variants of the completion of choledochotomy (from the primary suture of the LTR to the imposition of supraduodenal holedoduodenodoanastomosis) was performed in 17% of operated patients.

Repeated operations after previously transferred cholecystectomies (TCE or LHE), including excision of residual cervicalis with calculi, choledocholithotomy, choledochoduodenostomy, were performed by 74 patients. Reconstructive surgery for cicatricial strictures of hepatitis choledocha was performed in 20 patients.

A comparative evaluation of the immediate and long-term results of LHE and OLHE from mini-access allows us to speak about the comparability of both methods of operation, both in terms of the level of traumatism and the quality of life of operated patients in the long-term period. The methods not only are not competing, but also largely complement each other: so OLKE can be used in the event of technical difficulties with LHE and allows the operation to be completed in a minimally invasive manner.

Almost the same technical conditions of operation, excluding palpation, impossibility of examination of the entire abdominal cavity with open laparoscopic cholecystectomy, close indications and contraindications, allow us to recommend a general algorithm for preoperative examination of patients with SCI for operations of small access.

NOTES Natural Orifice Transluminal Endoscopic Surgery

This is a completely new direction of endoscopic surgery, when the introduction of a flexible endoscope into the abdominal cavity for performing operations is carried out through natural openings followed by viscerotomy. In animal experiments, accesses through the stomach, rectum, posterior vaginal vault and bladder were used. A complete absence or decrease in the number of punctures in the anterior abdominal wall provides a reduction in traumatic surgery and a high cosmetic effect. The idea of using a flexible endoscope for intra-abdominal operations through natural openings arose from the experience of Japanese surgeons who discovered the safety of perforation of the stomach wall during endoscopic removal of tumors. This led to a new original concept of transgastral access to such organs in the abdominal cavity, like the liver, appendix, liver, spleen, fallopian tubes, etc. Without incision in the anterior abdominal wall. In principle, access to the abdominal cavity can be carried out through natural openings - the mouth, vagina, anus or urethra. Recently, through the perforation of the gastric wall with a knife - needle, overgastric access has been used for relatively simple endoscopic aids, including drainage of pancreatic pseudocysts and abscesses. Complete removal of necrotic spleen with transgastric endoscopic access was performed by Siffert in 2000. Kantsevoy et al. Al. 2006 reports that the first descriptions of surgical interventions through natural openings occurred in 2000 during the Digestive Deseases Week.

The use of flexible endoscopy to perform transluminal operations through natural openings has many names, such as "operations without a cut", but the generally accepted term is NOTES (Rattner and Kalloo 2006). The term means the introduction of a flexible endoscopic device through natural openings, followed by viscerotomy to provide access to the abdominal cavity and perform surgical intervention. The prospective advantages of using this technique of surgery are, first of all, the absence of any scarring on the abdominal wall, a reduction in the need for postoperative analgesia. It is possible to use the technique in patients with morbid obesity and tumor obstruction, because they have access through the abdominal wall is difficult and the risk of wound complications is very high. There are prospects for use in pediatric surgery, mainly related to the absence of damage to the abdominal wall.

On the other hand, NOTES carries the risk of many complications associated with the difficulties of examination and manipulation in remote operation, even more pronounced than with video-laparoscopic techniques.

Analysis of the literature suggests that, despite the fairly extensive experience of operations in the countries of South America, the techniques are under development, and the comparative safety of the operation is still on the side of laparoscopic cholecystectomy.