Cholecystectomy: types, technique and complications

From its first use in 1882 (C. Langenbuch) until 1987, cholecystectomy remained the only effective method of treating gallstone disease. The technique of the operation has reached its perfection over the years.

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Traditional cholecystectomy

A large number of publications in periodicals and well-known authoritative monographs are devoted to traditional cholecystectomy and the results of its application. Therefore, we will only briefly recall the main provisions of the problem under consideration.

Indications: any form of cholelithiasis requiring surgical treatment.

Pain relief: modern multicomponent endotracheal anesthesia.

Accesses: upper midline laparotomy, oblique transverse and oblique subcostal incisions of Kocher, Fedorov, Beaven-Herzen, etc. This provides wide access to the gallbladder, extrahepatic bile ducts, liver, pancreas, duodenum. It is possible to examine and palpate almost all organs of the abdominal cavity and retroperitoneal space.

The entire program of intraoperative revision of the extrahepatic bile ducts is feasible:

• examination and measurement of the outer diameter of the common hepatic duct and CBD;
• palpation of the supraduodenal and (after using the Kocher maneuver) retroduodenal and intrapancreatic sections of the common bile duct;
• transillumination of the supraduodenal part of the common bile duct;
• IOHG;
• IOUS;
• choledochotomy with IOCG, examination of the terminal section of the common bile duct with calibrated bougies, cholangiomanometry; any options for completing choledochotomy are possible depending on the specific clinical situation and the indications arising from it;
• 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 area of the Calot triangle and the hepatoduodenal ligament.

Disadvantages of the method:

• moderate surgical trauma leading to the development of the catabolic phase of the postoperative period, intestinal paresis, impaired respiratory function, and limitation of the patient's physical activity;
• significant trauma to the structures of the anterior abdominal wall (with some access options, there is a disruption of the 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;
• significant cosmetic defect;
• a long period of post-anesthesia and post-operative rehabilitation and disability.

Videolaparoscopic cholecystectomy

In principle, the indications for performing laparoscopic cholecystectomy should not differ from the indications for traditional cholecystectomy, because the goal 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;
• gallbladder cholesterosis, gallbladder polyposis;
• 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 stages of pregnancy (II-III trimester);
• obesity stage IV;
• acute cholecystitis after 48 hours from the onset of the disease;
• pronounced cicatricial inflammatory changes in the area of the neck of the gallbladder and the hepatoduodenal ligament;
• mechanical jaundice;
• acute pancreatitis;
• bilio-digestive and bilio-biliary fistulas;
• gallbladder cancer;
• previous operations on the upper abdominal cavity.

It should be noted that the contraindications listed are quite relative: contraindications to the imposition of pneumoperitoneum are eliminated by performing laparoscopic cholecystectomy at low intra-abdominal pressure or lifting gasless technologies; improvement of surgical techniques allows for fairly safe operations in cases of severe cicatricial and inflammatory changes, Mirizzi syndrome, biliodigestive fistulas. More and more information is emerging on the possibilities of videolaparoscopic operations on the common bile duct. Thus, improvement of surgical techniques and the emergence of new technologies and instruments significantly reduce the list of possible contraindications. The subjective factor is very important: the surgeon himself must make a decision, answering the question of whether he is capable of and how justified is the use of laparoscopic cholecystectomy in a given clinical situation or whether other surgical options are safer?

During laparoscopic cholecystectomy, it may be necessary to switch to a traditional operation (conversion). Such operations are most often resorted to in case of detection of an inflammatory infiltrate, dense adhesions, internal fistulas, unclear location of anatomical structures, impossibility of performing choledocholithotomy, occurrence of intraoperative complications (damage to abdominal wall vessels, bleeding from the cystic artery, perforation of a hollow organ, damage to the common hepatic duct and CBD, etc.), the elimination of which is not possible during laparoscopic surgery. Technical malfunctions of the equipment are also possible, requiring a switch to a traditional operation. The frequency of conversion is from 0.1 to 20% (planned surgery - up to 10%, emergency - up to 20%).

Prognostic factors seem to be extremely useful in terms of possible conversion of laparoscopic cholecystectomy to traditional. It is believed that the most reliable risk factors are acute destructive cholecystitis, significant thickening of the gallbladder walls according to ultrasound data, pronounced leukocytosis and increased alkaline phosphatase levels. If the patient does not have any of the four listed risk criteria (factors), then the probability of a possible transition to traditional surgery is 1.5%, but it increases to 25% or more if all of the above prognostically unfavorable factors are present.

At the same time, a thorough preoperative examination, correct determination of indications for surgery, careful consideration of possible contraindications in each specific case, as well as the high qualifications of surgeons performing laparoscopic interventions, lead to a significant reduction in the proportion of inverted operations.

Anesthesia is an extremely important point in laparoscopic cholecystectomy. General anesthesia with tracheal intubation and muscle relaxants is used. The anesthesiologist must understand that good muscle relaxation and the proper level of anesthesia are required throughout the intervention. A decrease in the depth of the neuromuscular block and the level of anesthesia, the appearance of independent movements of the diaphragm, restoration of peristalsis, etc. not only complicates 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 tracheal intubation.

Organization and technique of performing the main stages of laparoscopic cholecystectomy

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

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

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), and a surgical nurse. It is desirable that a surgical nurse be present to control the light source, electrical unit, insufflator, and flushing system.

The main stages of the operation are performed with the head end of the table raised by 20-25° and tilted to the left by 15-20". If the patient lies on his back with his legs together, the surgeon and the camera are located to the left of him. If the patient lies on his back with his legs apart, the surgeon is positioned on the perineal side.

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

1. "umbilical" just above or below the navel;
2. "epigastric" 2-3 cm below the xiphoid process along the midline;
3. along the anterior axillary line 3-5 cm below the costal arch;
4. along the midclavicular line 2-4 cm below the right costal arch.

The main stages of laparoscopic cholecystectomy:

• creation of pneumoperitoneum;
• introduction of the first and manipulation trocars;
• isolation of the cystic artery and cystic duct;
• clipping and transection of the cystic duct and artery;
• separation of the gallbladder from the liver;
• removal of the gallbladder from the abdominal cavity;
• control of hemo- and cholestasis, drainage of the abdominal cavity.

Videolaparoscopic surgery allows for inspection and instrumental palpation of abdominal organs, and for cholecystectomy to be performed at a sufficiently safe level. In a highly qualified and well-equipped surgical hospital, if indicated, it is possible to implement a program of intraoperative examination and sanitation in non-hepatic bile ducts:

• carry out an examination and measurement of the outer diameter of the supraduodenal section of the common bile duct;
• perform IOC;
• conduct IOUS;
• perform intraoperative revision of the extrahepatic bile ducts and fibrocholedochoscopy through the cystic duct, removal of stones;
• perform choledochotomy, examination of the common bile duct and hepatic ducts with special biliary balloon catheters and baskets, fibrocholedochoscopy, removal of stones;
• perform antegrade transductal sphincterotomy and ampullary balloon dilation.

Videolaparoscopic techniques allow choledochotomy to be completed with primary duct suturing, external drainage, or choledochoduodenoanastomosis. It should be emphasized that laparoscopic operations on the CBD are feasible, but far from easy to perform and cannot be considered generally available. They should be performed only in specialized departments.

Laparoscopic cholecystectomy has firmly won a leading place in surgery of extrahepatic bile ducts, with the number of operations in some surgical teams exceeding several thousand. At the same time, it is quite indicative that at almost all recent international and Russian surgical forums, one of the issues on the agenda was complications of laparoscopic cholecystectomy.

Main causes of complications of laparoscopic cholecystectomy

The body's response to tension pneumoperitoneum:

• thrombotic complications - phlebothrombosis in the lower extremities and pelvis with the risk of developing pulmonary embolism. Any surgical intervention leads to hypercoagulation, but in laparoscopic cholecystectomy, increased intra-abdominal pressure, the patient's position with the head end raised, and in some cases a long duration of the operation have additional pathological significance;
• limitation of lung excursion in pneumoperitoneum;
• reflex inhibition of the motor function of the diaphragm in the postoperative period due to its overstretching;
• negative impact of absorbed carbon dioxide;
• decreased cardiac output due to decreased venous return to the heart due to blood deposition in the veins of the lower extremities and pelvis;
• disturbances of microcirculation of abdominal organs due to compression during pneumoperitoneum;
• portal blood flow disorders.

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

Complications resulting from the need to impose pneumoperitoneum can be divided into two main groups:

• associated with extraperitoneal gas injection;
• associated with mechanical damage to various anatomical structures.

Insufflation of gas into the subcutaneous tissue, preperitoneal, into the tissue of the greater omentum does not pose a serious danger. In case of accidental puncture of the vessel and gas entering the venous system, massive gas embolism may follow.

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

Most often, such complications occur when the first trocar is inserted, less often the Veress needle. In our practice, aortic damage when the first trocar was inserted occurred in a young patient, who underwent laparoscopic examination and possible surgery for gynecological reasons. Immediately after the first trocar was inserted, massive bleeding into the abdominal cavity was detected, and the anesthesiologist recorded a critical decrease in blood pressure. In the neighboring operating room, one of the authors of these lines, together with another experienced surgeon, was preparing to perform another operation - this allowed us to perform a wide median laparotomy almost immediately, detect parietal damage to the aorta and suture it. The patient recovered.

Specialists have developed a number of rules for the imposition of pneumoperitoneum:

• aortic palpation test allows to determine the location of the aorta and iliac arteries;
• horizontal position of the scalpel when making an incision in the abdominal wall above or below the navel;
• Veresh needle spring test;
• vacuum test;
• aspiration test.

After inserting the laparoscope, before the main stages of the operation, it is necessary to examine the abdominal cavity. Of significant interest is ultrasound mapping of the adhesion process in the anterior abdominal wall, especially when performing laparoscopic operations on previously operated patients. The most effective method of prevention is the "open" laparocentesis technique.

Laparoscopic cholecystectomy is the most common videolaparoscopic surgery, accompanied, according to the literature, by average complication rates of 1-5%, and the so-called "major" complications - in 0.7-2% of cases. In the works of some authors, the number of complications in the group of elderly people reaches 23%. There are a number of classifications of complications of laparoscopic cholecystectomy, as well as the reasons for their occurrence. From our point of view, the most common cause of the development of complications is the surgeon's overestimation of the capabilities of the method in its implementation and the desire to certainly complete the operation laparoscopically. Bleeding during laparoscopic cholecystectomy occurs with damage to the cystic artery or from the hepatic bed of the GB. In addition to the threat of massive blood loss, bleeding from the cystic artery is dangerous due to additional trauma to the bile ducts when trying to stop the bleeding in conditions of insufficient exposure and limited visibility. An experienced surgeon can manage cystic artery bleeding without resorting to laparotomy in most cases. Beginning surgeons, as well as those who have failed attempts at hemostasis, should be advised to perform a wide laparotomy without hesitation.

The most common possible cause of damage to hollow organs at the stage of cholecystectomy is a pronounced adhesion process and failure to comply with the rules of coagulation and visual control during the introduction of instruments into the surgical area. The greatest danger is posed by so-called "overlooked" injuries. In case of timely detection of a wound to a hollow organ, endoscopic suturing of the defect does not cause great difficulties.

The most serious complication of laparoscopic cholecystectomy is injury to the extrahepatic bile ducts. The statement that the frequency of injury to the extrahepatic bile ducts during LCE is 3-10 times higher than during traditional surgery has, unfortunately, become generally accepted. However, some authors believe that the frequency of injury to the extrahepatic bile ducts during LCE and traditional surgery is the same. Apparently, the true state of affairs in this important issue can be established as a result of further prospective multicentric (interclinical) studies.

A fairly clear correlation has been established between the number of operations performed and the frequency of bile duct injuries. This fact indicates insufficient control over the training of surgeons for LCE and, unfortunately, the ineradicable practice of learning from "one's own" mistakes in crossing a "foreign" bile duct.

The lack of the possibility of manual revision of the isolated structures, anatomical variations in the configuration of the bile ducts and vessels, the desire for high-speed surgery, the intersection of tubular structures before their complete identification - this is far from a complete list of the causes of serious complications.

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

1. "Dangerous anatomy" - a variety of anatomical variants of the structure of the extrahepatic bile ducts.
2. "Dangerous pathological changes" - acute cholecystitis, scleroatrophic gallbladder, Mirizzi syndrome, liver cirrhosis, inflammatory diseases of the hepatoduodenal ligament and duodenum
3. "Dangerous surgery" - incorrect traction leading to inadequate exposure, "blind" stopping of bleeding, etc.

Prevention of intraoperative bile duct injuries is the most important task of laparoscopic surgery, which is due to the increasingly widespread use of laparoscopic cholecystectomy.

Open laparoscopic cholecystectomy

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

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

The authors have devoted a significant number of publications to this type of surgery, but we still consider it appropriate to provide a detailed description of the cholecystectomy technique.

Long reflections on the name of the surgical technique according to M.I. Prudkov using the “Mini-Assistant” instrument set led to the development of the term MAC – cholecystectomy.

The anterior abdominal wall incision is made with an indentation of 2 transverse fingers to the right of the middle line, starting from the costal arch vertically downwards with a length of 3-5 cm. Very small incisions should be avoided, since this produces too much traction with mirrors, which increases the number of wound complications in the postoperative period. The skin, subcutaneous tissue, outer and inner walls of the rectus sheath are dissected, and the muscle itself is stratified along the access axis to the same length. Careful hemostasis is important. The peritoneum is usually dissected together with the posterior wall of the rectus sheath. It is important to enter the abdominal cavity to the right of the round ligament of the liver.

The main stage of the operation is the installation of the hook-mirror system and the lighting system ("open" laparoscopy). Most errors and unsatisfactory references about the method occur due to 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, manipulations are difficult and dangerous, the surgeon begins to use additional instruments not included in the kit, which often ends with a transition to traditional laparotomy at best.

First, two small hooks are installed in the direction perpendicular to the wound axis. 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 ring-shaped retractor. The angle of the right hook should be chosen so as not to interfere with the subsequent removal of the gallbladder into the wound. The left hook is usually installed at an angle close to a right angle. A large napkin is inserted into the subhepatic space. A longer third hook is inserted into the lower corner of the wound in an unfixed state, and then, together with the napkin, it is installed in the desired position and fixed. The movement of this hook resembles the function of the assistant's hand during a standard operation and opens the subhepatic space for the operator.

Surgical drapes with long "tails" made of thick lavsan ligatures are placed between the hooks. The drapes are inserted into the abdominal cavity completely and placed between the mirrors as in TCE: to the left - under the left lobe of the liver, to the left and down - to retract the stomach and greater omentum, to the right and down - to fix the hepatic angle of the colon and loops of the small intestine. Most often, just three mirrors and drapes between them are enough to create an adequate surgical area, almost completely separated from the rest of the abdominal cavity. A mirror with a light guide is placed in the upper corner of the wound; it simultaneously acts as a liver hook. In the case of a large "overhanging" right lobe of the liver, an additional mirror is required to retract it.

After correct installation of the system of hooks-mirrors, napkins and light guide the operator clearly sees the lower surface of the right lobe of the liver, the gallbladder, when it is retracted behind Hartman's pouch - the hepatoduodenal ligament and the duodenum. The stage of open laparoscopy can be considered completed.

The isolation of the elements of the Calot triangle (cholecystectomy from the neck) differs from TCE in technique only by the need for "remote" surgery and the impossibility of inserting a hand into the abdominal cavity. A feature of the instruments is the angular displacement of their working part relative to the handle, so that the surgeon's hand does not cover the surgical field.

These manipulation features require some adaptation, but in general the surgical technique is much closer to the usual TCE than to LCE, which significantly simplifies the training process for surgeons.

Basic rules for performing open laparoscopic cholecystectomy:

• when isolating the elements of Calot's triangle, the wall of the common hepatic duct and the CBD should be clearly visible;
• the isolated tubular structures must not be ligated or cut until they are fully identified;
• If within 30 minutes from the start of the isolation of the gallbladder from the inflammatory infiltrate or cicatricial adhesions the anatomical relationships remain unclear, it is advisable to switch to traditional cholecystectomy.

The last rule, developed by the authors based on a study of the causes of complications and conversion, is very important. In practice, especially during the daytime, it is advisable to invite an experienced surgeon for consultation and decide together on the continuation of the operation or the need for conversion.

After the cystic duct is isolated, it is ligated distally, and at this point intraoperative cholangiography can be performed through the cystic duct, for which the kit includes a special cannula.

Next, the cystic duct is crossed and its stump is tied with two ligatures. The knot is tied using a Vinogradov stick: the knot is formed outside the abdominal cavity and is lowered and tightened using a fork. The technique, as well as the instrument itself, are not new to an experienced surgeon, since they are used in traditional surgery in difficult situations.

The next step is to isolate, transect and ligate the cystic artery. Clipping may be used to treat the stump of the cystic artery and cystic duct.

The stage of separating the gallbladder from the bed should be performed with maximum precision. As in classical surgery, the main condition is to “get into the layer” and, moving from the bottom or from the neck (after the cystic duct and artery are crossed, this is not important), gradually separate the gallbladder from the bed. As a rule, a dissector and scissors with careful coagulation are used (the set includes a special electrocoagulator). The quality and safety of the stage largely depend on the characteristics of the electric unit.

Extraction of the removed gallbladder during open laparoscopic cholecystectomy from a mini-access never causes difficulties. The operation is completed by inserting a silicone perforated drainage to the bed of the gallbladder through a counter-opening. The abdominal wall wound is sutured tightly in layers.

Indications for open laparoscopic cholecystectomy:

• chronic calculous cholecystitis, asymptomatic cholecystolithiasis, polyposis, cholesterosis of the gallbladder;
• acute calculous cholecystitis;
• cholecystolithiasis, choledocholithiasis, unresolved endoscopically;
• technical difficulties during LHE.

Contraindications to open laparoscopic cholecystectomy:

• the need for revision of abdominal organs;
• diffuse peritonitis;
• uncorrectable blood clotting disorders;
• cirrhosis;
• gallbladder cancer. 

Pain relief: multicomponent balanced anesthesia with the use of artificial ventilation.

Advantages of open laparoscopic cholecystectomy from a mini-access:

• minimal trauma to the anterior abdominal wall;
• adequate access to the gallbladder, common hepatic duct and CBD;
• the possibility of performing the intervention in patients who have previously undergone abdominal surgery;
• the possibility of performing surgery in the second and third trimesters of pregnancy;
• low trauma of the operation, absence of pneumoperitoneum;
• significant reduction in the number of early and late wound complications;
• absence of disturbances in the function of external respiration, intestinal paresis, reduced need for analgesics, early restoration of motor activity, rapid restoration of working capacity;
• short training period due to the operating technology being close to traditional;
• relatively low cost of equipment.

Mini-laparotomy with elements of "open" laparoscopy, performed using the "Mini-Assistant" instrument set, allows for a high degree of reliability and safety in performing cholecystectomy in almost all clinical forms of calculous cholecystitis, and performing intraoperative revision of extrahepatic bile ducts, including:

• inspection and measurement of the outer diameter of the OZP;
• transillumination of the supraduodenal part of the common bile duct;
• IOCG through the cystic duct;
• IOUS;
• IOCG through the cystic duct.

If indicated, intraoperative choledochotomy and removal of stones are possible.

If necessary, it is possible to perform choledochoscopy, examination of the terminal section of the common bile duct with calibrated bougies, and revision of the ducts with a catheter with an inflatable cuff.

In the case of a combination of choledocholithiasis and stricture of the terminal section of the common bile duct or major duodenal papilla, it is possible to perform fibroduodenoscopy during surgery and perform endoscopically controlled antegrade or retrograde papillosphincterotomy; it is technically possible to impose choledochoduodeno- and choledochoenteroanastomosis.

Choledocholithotomy can be completed with primary duct suturing, drainage according to Kehr or Halsted, etc. In other words, when performing OLCE from a mini-access, adequate restoration of bile outflow can be achieved in the vast majority of clinical situations.

The accumulation of experience in operating using the above-described technique allowed the authors to perform repeated and reconstructive operations on the bile ducts.

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

Open laparoscopic cholecystectomy with choledocholithotomy and subsequent options for completing choledochotomy (from the primary suture of the common bile duct to the imposition of a supraduodenal choledochoduodenoanastomosis) was performed in 17% of operated patients.

Repeated operations after previously undergone cholecystectomies (TCE or LCE), including excision of the remnants of the gallbladder neck with stones, choledocholithotomy, choledochoduodenostomy, were performed in 74 patients. Reconstructive operations for cicatricial strictures of the hepaticocholedochus were performed in 20 patients.

Comparative assessment of the immediate and remote results of LCE and OLCE from a mini-access allows us to speak about the comparability of both surgical methods both in terms of the level of trauma and the quality of life of operated patients in the remote period. The methods are not only not competing, but also complement each other to a significant extent: thus, OLCE can be used in case of technical difficulties during LCE and allows the operation to be completed in a minimally invasive manner.

Almost identical technical conditions of surgery, excluding palpation, the impossibility of examining the entire abdominal cavity during open laparoscopic cholecystectomy, similar indications and contraindications, allow us to recommend a common algorithm for preoperative examination of patients with cholelithiasis for small-access operations.

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 with subsequent viscerotomy. In experiments on animals, approaches through the stomach, rectum, posterior vaginal fornix and urinary bladder were used. Complete absence or reduction of the number of punctures of the anterior abdominal wall ensures a decrease in the trauma of the operation 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 transgastric access to such organs in the abdominal cavity as the liver, appendix, gallbladder, spleen, fallopian tubes, etc. without an incision on 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, transgastric access by perforating the stomach wall with a knife-needle has been used for relatively simple endoscopic procedures, including drainage of pancreatic pseudocysts and abscesses. Complete removal of a necrotic spleen by transgastric endoscopic access was performed by Siffert in 2000. Kantsevoy et al. 2006 reported that the first descriptions of surgical interventions through natural openings took place in 2000 during the Digestive Diseases Week.

The use of flexible endoscopy to perform transluminal operations through natural orifices has many names, such as "incisionless surgery", but the generally accepted term is NOTES (Rattner and Kalloo 2006). The term refers to the introduction of a flexible endoscopic device through natural orifices, followed by viscerotomy to provide access to the abdominal cavity and perform the surgery. The supposed advantages of using this surgical technique are, first of all, the absence of any scars on the abdominal wall, a decrease in the need for postoperative analgesia. It is possible to use the technique in patients with morbid obesity and tumor obstruction, since access through the abdominal wall is difficult for them and the risk of wound complications is very high. There are prospects for use in pediatric surgery, mainly associated with 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 during remote surgery, which are even more pronounced than with videolaparoscopic techniques.

An analysis of the literature allows us to say that, despite the fairly extensive experience of operations in South American countries, the methods are still in the development stage, and the comparative safety of performing the operation is still on the side of laparoscopic cholecystectomy.