Planned removal of the gallbladder. Postoperative complications and consequences. Indications and restrictions for the operation

In what cases is surgery performed?

The gall bladder is an organ of the digestive system that serves as a reservoir for bile and lies on the lower surface of the liver in the right hypochondrium. Bile, located in gallbladder, is important for the digestion process and increased peristalsis. If gallbladder dysfunction occurs, surgical intervention to remove it is necessary. This operation is called cholecystectomy. Cholecystectomy is not a complex operation and the patient does not stay long in the clinic.

This operation is performed in the following cases:

• Finding stones in the gall bladder;
• Finding stones in the bile duct;
• Cholecystitis (calculous, non-calculous);
• Empyema and hydrocele;
• Neoplasms.

The operation is indicated when internal therapy has been unsuccessfully carried out: pharmacotherapy, regimen, diet, duodenal tube, mineral waters; with frequent and painful colic that interferes with work.

There are several types of this operation, but the main ones are:
- open cholecystectomy;
- removal of the gallbladder using a laparoscope.
The attending surgeon decides which type to use.

Is it possible to avoid surgery?

If the stones in the gall bladder do not bother you or interfere with your life, if the gall bladder performs its function properly, then there is no need to cut it off. But you need to know that by postponing surgery after the first colic, the number of attacks will increase, and the chances of a complete recovery after surgery will decrease. The liver and pancreas will be at risk, but they are vital for the body. Their removal can lead to the death of the organism as a whole. Therefore, the question of surgery to cut off the gallbladder will remain open and its belated decision may no longer give the desired positive result. If a person is undergoing surgery late dates, That inflammatory process has already spread to other organs: stomach, duodenum, head of the pancreas. Such patients will require additional treatment even after discharge.

What can you expect

If you decided to have surgery, and it was successfully performed, then now you need to slightly change your usual routine. But only a few. The period of gallbladder disease occurred gradually, and your body has already adapted a little to the new conditions. Therefore, deleting it will not cause serious violations. And, thanks to the operation, the inflammatory process will be eliminated, which will facilitate the secretion of bile.

But there is something you must understand. After removal of the gallbladder, the flow of bile occurs more slowly, and its bactericidal effect is not fully manifested. As a result, the microflora in the intestines may be disrupted, and It's a dull pain abdomen, flatulence, constipation or diarrhea may occur.

But don’t let this scare you, since this is all a matter of time. The body will recover quite quickly and, using the appropriate nutrition system, gastrointestinal tract will continue to perform its functions normally. There is diet No. 5, which involves limiting the consumption of high-calorie foods, easily digestible carbohydrates, fatty foods. This diet will stimulate the production moderate amount bile, improve it chemical composition, speed up and facilitate the digestion of food. Of course, the period of use of this diet varies from patient to patient and may vary, but nutritionists recommend its use for at least a year.

What should the diet be like?

And the following should be excluded from your diet: baked goods, all sweets, fatty, fried, canned foods. For obese people, pay attention to the amount of carbohydrates, the daily amount of which is no more than 200 grams. From fresh milk you will also have to abstain, as lactase becomes less active. Avoid consumption of legumes (beans, peas, lentils); greens with high content essential oil(onion, garlic, wild garlic); offal (kidneys, liver); mushrooms, nuts, alcohol, carbonated drinks, hot spices.

But it is necessary and necessary to include in the diet: wheat bran, cereals, vegetable salads, fruits and berries. Will be useful spoiled milk, lean meat, fish, seafood. Soups should not be made with meat. The bread is only white, it is better to dry it in the oven.
Overeating is unacceptable! Portions should be small, which will facilitate normal absorption and digestion of food.

For those who want to be healthy

In order to prevent gallbladder diseases, I would like to recommend the following measures: constant physical exercise; periodic procedures to cleanse the gallbladder; avoid stress; drinking special choleretic mineral water without gas; proper nutrition, which should contain magnesium and zinc.

In addition, be careful and beware of contacting unknown healers. There is a whole army of charlatans with dubious licenses and certificates that promise complete cure, and as a result, your illness remains with you. Use traditional medicine. Good health to you!

The review was prepared by journalist Vera Aleksandrovna Andreeva (on our instructions).

Cholecystectomy by laparoscopic method is the most in a safe way removal of the gallbladder or stones from it or its ducts. The operation is accompanied by minimal blood loss and tissue damage, which makes it easier recovery period. The intervention is carried out through several small incisions in the anterior abdominal wall, so there are practically no scars left. With high quality preliminary diagnostics There are practically no complications observed, and after 8-10 days the patient is discharged from the hospital.

Carrying out laparoscopy

In what cases is laparoscopic access preferable?

The doctor decides how to perform the operation - the patient’s wishes are taken into account, but are always taken into account possible risks, which may prevent the completion of the operation using the laparoscopic method. The main indications for laparoscopic intervention were:

• an attack of acute cholecystitis, from the onset of which less than 2 days have passed;
• calculous cholecystitis in the acute period;
• blockage of the gallbladder ducts and obstructive jaundice - in this case, only removal of stones is indicated;
• asymptomatic cholecystitis in the presence of stones.

This operation has many advantages, but there are also contraindications.

It will not be performed if there is a history of laparotomy interventions on organs abdominal cavity, at pulmonary insufficiency and the availability of extensive adhesive process. In these cases, standard abdominal surgery is performed.

What determines the operation time?

How long the operation will last can only be said approximately. The minimum duration of gallbladder laparoscopy is about half an hour. This is how much the surgeon will need to remove the bubble in ideal conditions, which are quite rare. The first thing that increases total time interventions - putting the patient under anesthesia. For many patients this may take 15-30 minutes.

If the patient is obese, the operation will take longer - getting to the operated area in this case is not so easy. The presence of even small adhesions also makes access difficult, and the surgeon may need to make additional punctures in the abdominal wall to ensure complete and comfortable access - this also takes additional time. But this will allow you to complete the operation using the chosen method and avoid damage to internal organs.

If during the operation there is a threat of bile leakage, the duration of the procedure increases and can be up to 1.5 hours without taking into account the time of anesthesia. Any complications that are diagnosed during the operation lead to an increase in its duration. In some cases, it is not possible to complete the intervention laparoscopically. If there is a possibility dangerous complications that cannot be eliminated through a thoracoscope, a decision is made on laparotomy. As a result, the question of how long a laparoscopy operation to remove the gallbladder lasts can only be answered after its completion.

How long does the recovery period last?

Woman after laparoscopic cholecystectomy

If the operation is completed without complications, the recovery period is easy, and after a week the patient is discharged from the hospital. Within 5-6 hours after the person is transferred from the operating room, compliance with bed rest, after which it is allowed to sit up in bed, and then get out of bed. Eating on the day of surgery is excluded. A small amount of still water is allowed.

You need to move after surgery as actively as your condition allows.

The best thing is to walk. This will allow the gas introduced during surgery to leave the body faster. In addition, movement will quickly restore normal peristalsis.

On the second day you are allowed to eat, giving preference to light foods. Be sure to drink enough water - at least 1.5-2 liters. After laparoscopic removal of the gallbladder, lifelong diet is required. It is based on treatment table №5. Pain syndrome after laparoscopy, unexpressed - analgesics are required for 1-2 days, and on days 4-5 discomfort They practically stop bothering me.

If rehabilitation period does not become complicated, after two weeks the patient returns to his usual lifestyle, but taking into account new dietary restrictions. Light physical labor and sports are allowed. It is recommended to lift weights over 5 kg no earlier than six months after surgery; if complications are present, this period may be longer. During recovery, it is important to listen to your feelings, especially in the first days. The appearance of uncharacteristic symptoms should alert you, and they should be reported to your doctor, since some complications may develop after discharge from the hospital.

Anatomy of the gallbladder

The gallbladder is a hollow organ located in the abdomen, on the right, under the liver. Its volume is approximately 50-70 ml, and its shape resembles a pear. Its main purpose is the accumulation and concentration of bile, which is synthesized by liver cells, and its subsequent release into the duodenum, periodically, mainly in connection with food intake. Bile helps in the digestion and absorption of fats, absorption fat-soluble vitamins, cholesterol, amino acids and calcium salts, as well as bile is involved in the activation of parietal digestion in the intestine, enhances secretion and motor activity small intestine.

When is the gallbladder removed? Indications for cholecystectomy

Cholecystectomy is performed to treat gallbladder diseases, mainly from the formation of gallstones in the gallbladder (cholelithiasis). The stones may be hard and small, like pebbles inside the gallbladder. The rocks can be as small as grains of sand or as large as a golf ball.

General indications to cholecystectomy is:

Obstruction normal outflow bile leading to severe abdominal pain (biliary colic)
- Infection or inflammation of the gallbladder (cholecystitis)
- Blockage biliary tract leading to the duodenum (biliary tract obstruction)
- Blockage of the duct leading from the pancreas to the duodenum (pancreatitis)

Indications for cholecystectomy also include exacerbation of chronic cholecystitis, calculous cholecystitis, acute cholecystitis that is not amenable to conservative therapy, and cholesterosis.

How to prepare for cholecystectomy, surgery to remove the gallbladder?

- To prepare for a cholecystectomy, your surgeon may ask you to take a laxative 3-4 days before surgery to cleanse your bowels.
- Do not eat anything the night before surgery. You should not drink or eat at least, four hours before surgery, but you can take a sip of water with your medication.
- It is necessary to stop taking certain medications and food additives that affect blood clotting because they may increase the risk of bleeding. In any case, tell your doctor about all the medications and supplements you take.
- Hygiene procedures before surgery, for example, shower with antibacterial soap.
- Plan ahead for your hospital stay. Most patients are able to go home the same day after their cholecystectomy, but complications may occur that require one or more nights in the hospital. If the surgeon must make a long cut in your abdomen to remove your gallbladder, you may have to stay in the hospital longer. It is not always possible to know in advance which procedure will be used. Plan ahead, in case you have to stay in hospital, what personal items you might need, e.g. Toothbrush, comfortable clothes, and books or magazines to pass the time.

Most surgeries to remove the gallbladder today are performed using laparoscopic surgical methods, in which thin surgical instruments - trocars - are inserted into the abdominal cavity through small incisions. The operation is performed under general anesthesia, so that the patient sleeps and does not feel any pain.

During a laparoscopic cholecystectomy, the surgeon makes four small incisions in the abdomen, two of which are 5 millimeters long and the other two are 10 millimeters long. A tube containing a tiny video camera is inserted into the abdomen through one of the incisions. During insertion, the trocars do not cut the tissue, but only move it apart. The patient, who is under anesthesia, inflates the abdomen with carbon dioxide. The remaining instruments are inserted through 2 more incisions. Then, once the gallbladder is found, it is removed.

Next, cholangiography, a special x-ray, is performed to check the bile duct for abnormalities. If your doctor thinks there are other problems in the bile ducts, they can be treated. After this, the incisions are sutured. Laparoscopic cholecystectomy takes one or two hours.

However, laparoscopic cholecystectomy is not suitable for everyone. In some cases, a large incision must be made, for example due to scar tissue from previous surgeries or complications, or very large stones. In this case, an open cholecystectomy is performed.

If the gallbladder is extremely inflamed, infected, or has large stones, another surgical approach called open cholecystectomy is used.

During an open cholecystectomy, the surgeon makes a 15-centimeter incision in the abdomen just below chest and ribs with right side. Muscles and tissues are retracted to allow easier access to the liver and gallbladder. Next, the liver is dislodged to expose the gallbladder. The vessels, cystic ducts and arteries of and from the gallbladder are cut out, and the gallbladder is removed. The common bile duct, which drains bile from the liver to small intestine, is also checked for the presence of stones. A small drainage tube may be left in place for several days to drain fluid if there is inflammation or infection in the abdomen. The incision is then sutured.

An open cholecystectomy lasts one or two hours.

Recovery after gallbladder removal (cholecystectomy)

After surgery, you will be taken to the intensive care unit to recover from anesthesia. When the anesthesia wears off, you will be taken to your room. Further recovery varies depending on your procedure:

After laparoscopic cholecystectomy, patients are often sent home the same day after surgery, although a one-night hospital stay is sometimes required. After discharge, you can return to your normal diet and activities almost immediately.

After open surgery, you can expect to be allowed to go home as soon as you are able to eat and drink without pain and are able to walk without assistance. This usually takes from two to three days to a week. The ability to return to a normal diet occurs after 1 week and return to normal activities after 4 to 6 weeks.

You may experience some of these symptoms during recovery:

Abdominal pain. You may experience pain in one or both shoulders for several days after surgery. This occurs due to gas in the abdomen after surgery. Your doctor will prescribe pain medications to use at home. If you take pain pills 3 or 4 times a day, try taking them at the same time every day for 3 to 4 days. Try getting up and walking around if you have some abdominal pain. This may relieve your pain.
- Pain in the incision area for 1 to 2 weeks. This pain should decrease every day. Press on the area over the incision when you cough or sneeze to relieve discomfort and protect your stitch from tearing.
- Sore throat from the breathing tube. Sucking on ice cubes or gargling may have a soothing effect.
- Nausea and vomiting. Your doctor may prescribe medications if needed.
- Loose stools after eating. This can last from 4 to 8 weeks.
- Bruises and hematomas around the wound. They will go away on their own.
- Redness of the skin around the wound. This is fine.
- A small amount of watery or dark bloody fluid from the incision. This is normal for several days after surgery. The surgeon may leave 1 or 2 drainage tubes in the abdomen: one will help drain any fluid or blood that remains in the abdomen. The second tube will drain the bile during recovery. This tube will be removed by your surgeon after 2 to 4 weeks. Before it is removed, a special X-ray test called cholangiography will be performed. You will receive instructions on how to care for these tubes before you go home.

Activities after gallbladder removal (cholecystectomy)

You should be able to carry out most of your regular activities within 4 to 8 weeks. Before:

Do not lift anything heavier than 4.5 - 7 kg until your doctor gives you permission.
- Avoid strenuous activities. This includes strenuous exercise, weightlifting, and other activities that force you to breathe heavily or strain yourself.
- Take short walks regularly.

Wound care after surgery

Change the bandages over yours surgical wound once a day, or sooner if it gets dirty. Your doctor will tell you when you do not need to use the bandages. Keep the wound clean by washing it with mild soap and water. You can also shower after removing the bandages if your incisions were closed with stitches, staples, or special glue.

If the seams were closed using seam strips skin wound or adhesive skin suture Steri-Strip, cover the incision with plastic wrap before showering for the first week. Don't try to wash these strips off; let them fall off on their own.

Diet after gallbladder removal (cholecystectomy)

You can return to your normal diet almost immediately, but it is usually recommended to limit your intake of fatty or spicy foods and eat small, frequent meals.

If you have hard stools:

Try to walk more and be more active, but don't overdo it.
-Try to reduce the dosage of painkillers, some of them can cause constipation.
- You can use a mild laxative. But don't take any laxatives without checking with your doctor.
- Ask your doctor about products with high content fiber.

Forecast after gallbladder removal(cholecystectomy)

A cholecystectomy can relieve pain and discomfort from gallstones. Conservative treatments, such as dietary changes, usually fail to stop the formation of gallstones, and symptoms may recur. Cholecystectomy is the only way to prevent the formation of gallstones.

Some people experience mild diarrhea after a cholecystectomy, although this usually goes away with time. Most people do not experience digestive problems after cholecystectomy, since the gallbladder is not necessary for healthy digestion.

Complications and risks of cholecystectomy

Cholecystectomy carries a small risk of complications. The risk of complications depends on your general condition health and reasons for cholecystectomy. It could be:

Bile leakage during surgery
- Bleeding
-Vascular thrombosis in the area of ​​surgery
- Heart problems
- Infection
-Injuries nearby organs, such as the bile ducts, liver and small intestine
- Pancreatitis
- Pneumonia

Call your doctor or nurse if:

You have a fever and a temperature above 38°C.
- From the wound there's blood coming out, red or warm to the touch.
- The edges surgical wound have thick edges and yellow, green, or milky discharge from the drain.
- You have pain that is not relieved by painkillers.
- It's difficult to breathe.
- You have a cough that does not go away.
- You can’t help but drink and eat.
- Your skin or the whites of your eyes turn yellow.
- Your stool is gray and clayey in color.

Laparoscopy of the gallbladder is an endoscopic surgical procedure performed to remove the gallbladder. More than 90% of cholecystectomies today are performed using this method. This article will discuss the features and benefits of laparoscopy.

Even 20 years ago, all operations to remove the gallbladder, cholecystectomy, were performed openly. The doctor made a large incision for access, which increased the risk of infection and bleeding. The first laparoscopy of the gallbladder was performed in 1987. In less than 15 years, almost all surgeons have mastered this method.

The reason for this is the advantages of laparoscopy such as:

1. Low patient trauma.
2. Low risk of bacterial infection.
3. Low blood loss, unlike open surgery, with laparoscopy the risk of damage to large vessels is minimal.
4. Shorter hospital stay. The patient is allowed to go home for 2-3 days after laparoscopy.
5. Fast recovery. You can return to work in a week.
6. No large postoperative scar. After open cholecystectomies, a scar measuring about 20 cm may remain, and with endoscopic intervention, several inconspicuous scars of 1-5 cm remain.
7. Reducing the operation time, which leads to a decrease in the duration of the patient's stay under general anesthesia.

Types of endoscopic operations on the gallbladder, and indications for their performance

Several types of operations are performed using laparoscopy. Each of them has its own indications. Types of operations and indications for their performance are presented in the table:

Despite the advantages of this method, there are situations when a patient is indicated for open strip surgery:

• Peritonitis. The surgeon requires a large incision to irrigate the abdominal cavity.
• Severe obesity. In stage 3 and 4 obesity, endoscopic interventions are difficult to perform.
• Malignant neoplasms. The surgeon needs a large incision to remove large amounts of tissue.
• Cirrhosis of the liver. With cirrhosis, the risk of extensive bleeding is increased, and endoscopy cannot stop it.
• Acute inflammation of the pancreas, pancreatitis.

In more than 80% of cases, laparoscopy of the gallbladder is performed as planned. Preparation for it should begin a week in advance, it includes:

1. Cancel anticoagulants and drugs that affect blood clotting 7 days in advance. These include: acetylsalicylic acid (aspirin), heparin, non-steroidal anti-inflammatory drugs (indomethacin, diclofenac, paracitamol, ibuprofen).
2. Intake of light foods that do not cause gas formation for 3 days before the intervention. The diet should exclude fried and spicy foods and legumes. 12 hours before - fasting, even water is excluded.
3. Carrying out cleansing enemas or taking special laxative solutions in the evening before the operation.

But besides these actions, preparation for laparoscopy of the gallbladder includes a number of examinations that will determine the scope of the operation, health status and presence chronic diseases. The figure shows the sequence of the operation (a, b, c, d).

Basic diagnostic methods:

1. General blood analysis– will show the presence of anemia, various inflammatory processes in the body, helminthic infestations.
2. General Analysis of urine – excludes kidney pathology.
3. Blood chemistry for bilirubin, cholesterol, transaminases, C-reactive protein.
4. Blood sugar test. Very often, during routine examinations, latent forms are discovered diabetes mellitus, which are not yet clinically manifested.
5. Ultrasound examination of the abdominal organs. The size of the gallbladder, the thickness of its walls, its position in the peritoneum, the condition of the ducts, and the pancreas are assessed.
6. MRI– prescribed if the presence of a tumor is suspected, or if there is a need to detail the patency of the ducts.
7. Electrocardiography and echocardiography. These two examinations are required. They will help identify heart diseases in which endoscopic intervention becomes impossible.

This list can be expanded by the attending physician, depending on the presence of chronic diseases or previous diseases.

Only general anesthesia is always used. It can be masked or intravenous. The choice of drugs that are suitable for the patient is made by the anesthesiologist, based on the results of the examination conducted in the preoperative period.

After induction of anesthesia, the surgeon makes the first incision through which he inserts a laparoscope with a camera at the end and pumps air into the abdominal cavity, which improves the visibility of the internal organs. Then three more small incisions are made through which the rest are inserted. necessary tools. Under camera control, the gallbladder is removed or the ducts are cut.

Typically, the duration of such an intervention does not exceed half an hour. But there are times when the surgeon, after inserting the camera and assessing the condition of the organs, decides to perform an open strip operation. Then the time increases.

The postoperative period is no less important than the intervention itself. Thanks to him, you can avoid the formation adhesive disease, and restore the flow of bile from the liver to the duodenum.

The postoperative period consists of more than just diet. This period also includes lifestyle changes and the formation of new habits.

Basic principles of the postoperative period include:

1. Diet. You can read about it in detail in the next part of the article;
2. Change in physical activity. The day after surgery you should start walking. In the thirty-day period after the operation, it is better to take care of yourself and avoid heavy physical activity. But you need to walk every day. The more you go through this period, the lower the risk of adhesions will be. Then, after a month, doctors recommend doing morning exercises every day, and also walking a lot. This way you can improve the passage of food. The period when you need to do exercises and move is not limited to a few months; an active lifestyle should be constant.
3. Eating habits. Many patients who have undergone cholecystectomy note that they feel better when they eat while standing. There is an explanation for this: when a person stands, it is easier for bile to leave the liver. Another habit is to take a teaspoon of flaxseed or olive oil on an empty stomach. It stimulates the production and discharge of bile.
4. Drug therapy. In the postoperative period, it includes the following drugs:
   • Antibiotics are needed to prevent possible purulent complications. Typically, the duration of their use is 3-7 days.
   • Antispasmodics - taken for 10-14 weeks, in order to simplify the outflow of bile;
   • Ursofalk is prescribed to prevent the formation of new stones.
5. Treatment of seams with antiseptics. It is carried out in a hospital for 3 days.

The diet in the period after cholecystectomy should last a lifetime. It is thanks to diet that you can avoid the formation of stones in the liver itself and ensure normal and complete outflow of bile.

First of all, the diet involves changing drinking regime. You need to drink often, slowly. The volume of liquid is calculated individually. For 1 kilogram of weight you need to drink 30 ml of water per day. The first intake of liquid should be in the morning on an empty stomach. It's better to drink a little warm water, cold will cause spasms of the ducts.

In the first days after cholecystectomy, the diet should include water and mucus porridge. Then you need to gradually expand your diet and introduce one product every few days.

When following a diet, you need to exclude:

• fried, spicy and smoked foods;
• fatty meats and fish;
• semi-finished products;
• alcohol;
• carbonated drinks;
• mayonnaise, full-fat sour cream;
• meat soups;
• sour berries and fruits.

The diet should be formed from the following products and dishes:

• vegetable soups;
• porridge;
• lean meat, steamed, boiled or baked;
• low-fat varieties of fish;
• boiled vegetables;
• sweet berries and fruits;
• dairy products;
• stale white bread;
• sweet compotes;
• steamed protein omelette;
• pumpkin juice.

Also, you need to know about such general principles diets:

• the volume of food eaten at a time should not exceed the size of the patient’s fist;
• It is better to eat often, at least 5 times a day;
• food should not be cold or very hot;
• You need to eat slowly and chew your food carefully.

You must always adhere to such a diet, and try not to break it. After a sudden departure from the diet or feast, acute pain may occur in the right hypochondrium, which may indicate a violation of the outflow of bile, which is dangerous for the development of hepatitis or cirrhosis.

Laparoscopy of the gallbladder is a safe and good method. By following a diet and exercise regimen, complications can be avoided. Within a week, after cholecystectomy, the patient regains his ability to work and returns to a full life.

Many of us have encountered pain and colic in the right hypochondrium near the stomach, however, we did not always pay attention to the unusual symptom, attributing the discomfort to a stomach ulcer, gastritis, neuralgia, liver problems, or anything but problems with the stomach. gallbladder. However, not everyone knows that it is in this place that the above-mentioned organ is located, which can also become inflamed and painful. The cause of acute pain in the gallbladder is quite often stones formed in the organ itself, and restoration of its normal functioning is possible only after removal of the stones. The operation to remove them is in most cases performed laparoscopically and is called laparoscopy of gallstones.

Where do gallstones come from?

The gallbladder is a small organ in the form of a sac with a capacity of 50 to 80 ml, which is a storage facility for bile. Bile is an aggressive liquid that actively participates in the digestion process, because it is with its help that fats are digested. Bile also helps maintain normal microflora in organism.

Bile produced in the liver enters the gallbladder located near it, and from there, as needed, it is sent to the duodenum, where it performs its main function. If a person leads an active lifestyle and adheres to the principles of proper nutrition, the gallbladder functions normally and the fluid inside it is constantly renewed. Physical inactivity and abuse of fried, fatty and spicy foods, on the contrary, lead to stagnation of bile inside the organ.

Bile is a liquid with a heterogeneous composition. As a consequence of stagnation, precipitation of individual components of this liquid can be observed. From this sediment, stones are formed, which can have different shapes and compositions.

Some stones are formed from cholesterol and its derivatives (cholesterol). Others (oxalate or calcareous) are calcium formations based on calcium salts. And the third type of stones is called pigment stones, because their main component is the pigment bilirubin. However, the most common stones are those that have a mixed composition.

The size of the stones formed in the depths of the gallbladder can also vary. Initially they are small in size (0.1 - 0.3 mm) and can easily exit into the intestine through the bile ducts along with the liquid component. However, over time, the size of the stones increases (stones can reach a diameter of 2-5 cm), and they can no longer leave the gallbladder on their own, so you have to resort to an effective and low-traumatic surgical intervention, which is considered to be laparoscopy of gallstones.

Indications

Gallstones are not a rare occurrence. Such deposits inside the body can be found in 20 percent of the world's population. Moreover, women suffer from pathology more often than men. And it's all to blame female hormone estrogen, for reasons known only to it, inhibits the outflow of bile from the gallbladder.

The presence of gallstones does not necessarily have to be accompanied by pain. For a long time, a person may not even suspect that the bile in his body has liquid and solid components, until at some point alarming symptoms appear in the form of bitterness in the mouth, pain in the right hypochondrium, intensifying with exercise and in the evening, and nausea after eating.

Acute pain (colic) occurs when stones from the gallbladder try to escape through a special duct. If the stone is microscopic in size, it can pass almost painlessly. A large stone is not able to do this due to the limited diameter of the bile ducts. It stops at the very beginning of the duct or gets stuck along the way, thereby blocking the path of bile. A new portion of bile, entering the organ, stretches its walls, provokes the development of a strong inflammatory process, which is accompanied by severe pain. And if you also take into account that some stones have sharp corners and edges, then the pain when they unsuccessfully try to leave the gallbladder becomes simply unbearable.

The duration of colic can vary: from 15 minutes to 6 hours. In most cases, patients note the appearance of this symptom in the evening or at night. Painful colic may be accompanied by bouts of vomiting.

The development of cholecystitis (inflammation of the gallbladder) against the background of the formation of stones in it leads to the appearance of systematic severe pain in the area of ​​the right hypochondrium, nausea and episodes of vomiting not associated with the consumption of poor quality food. Pain can radiate to the back, collarbone or stomach, and even to the shoulder of the right arm.

If such symptoms are detected, doctors conduct a diagnostic study and positive result, confirming the diagnosis of gallstone disease, they think about the need for laparotomy or laparoscopy of gallstones.

Gallstones can be detected completely by accident during an ultrasound of the abdominal organs. But the fact that there are already stones in the gall bladder does not mean at all that it is time to go under the surgeon’s knife. Small stones do not cause concern and can leave the organ at any time without outside help, but larger stones in the absence of pain and severe symptoms You can try to crush cholecystitis with the help of medications. Medicines that are also used for kidney inflammation (pyelonephritis) and urolithiasis(“Urolesan”, “Ursosan”, “Ursofalk”, etc.).

This conservative treatment called litholytic therapy. True, its effectiveness depends on the size of the stones. For large gallstones, this treatment is rarely effective.

In the treatment of cholelithiasis in the presence of small stones, ultrasound can also be used, with the help of which the stones are crushed into small parts, which can independently leave the gallbladder and, together with chyme, and then feces, come out.

TO surgical treatment Doctors prefer to resort to gallstone disease only if the stones in the gall bladder are large in size, in which drug therapy and ultrasound are considered ineffective and give a person painful sensations. In other words, the indications for surgery to remove stones from the gallbladder using laparoscopy are:

• ineffectiveness of conservative and physical therapy,
• the presence of small sharp stones that can injure the walls of the organ and cause even greater inflammation,
• development of obstructive jaundice and the presence of stones in the bile ducts,
• as well as the patient’s desire to get rid of gallstones and painful colic with the least possible losses.

The fact is that there are two ways to remove stones from the gallbladder:

• Traditional (laparotomy), when the operation is performed using a scalpel without special equipment. The doctor evaluates the progress of the operation visually, because through a fairly large incision in the abdominal cavity he can see internal organs and carry out manipulations to remove stones from the gallbladder or remove the organ itself, which is practiced much more often.
• Laparoscopic. In this case visual assessment organ and tracking of manipulations carried out with it is carried out using a special device (laparoscope), resembling a probe (endoscope) with a flashlight and a camera at the end. From the mini-camera, the image is displayed on a monitor, where it is seen by the medical staff performing the surgical operation.

Of interest is the operation itself, in which the surgeon acts as an operator without holding a surgical instrument in his hands. Laparoscopic access to organs is carried out using a laparoscope and 2 manipulator tubes (trocars). It is through these tubes that surgical instruments are delivered to the operation site and the surgical removal of stones or the gallbladder itself is performed.

We can say that in terms of effectiveness, the methods of laparoscopy and laparotomy of the gallbladder are not much different from each other. However, the first innovative method is considered more preferable because it has significantly fewer disadvantages.

The advantages of laparoscopic surgery include:

• Low trauma to the skin and soft tissues at the surgical site. During laparotomy, the doctor makes a fairly large incision (sometimes up to 20 cm) so that it is convenient for him to see the gallbladder and the surrounding tissues and organs, as well as to create sufficient freedom of movement during the operation. After the operation, the incision site is sutured, and a noticeable scar subsequently remains at the site of the suture. Laparoscopic intervention is limited to several punctures of no more than 0.5-2 cm, after healing of which there is practically no trace left. Aesthetically, such pinpoint scars look much more attractive than huge scars after laparotomy.
• Pain after laparoscopy is less intense, easily relieved with conventional analgesics and subsides within the first day.
• Blood loss during laparoscopy is almost 10 times less than during laparotomy. The loss of about 40 ml of blood is practically imperceptible for a person.
• A person gets the opportunity to move and perform simple actions already on the first day after the operation, after several hours have passed, which are necessary to recover from anesthesia and recover a little. The patient can take care of himself without resorting to the help of a nurse.
• Short period of stay inpatient treatment. If the operation is successful, the patient can leave the hospital one day after the operation. Typically, such patients stay in hospital for no more than a week. A longer stay is indicated if some complications arise after the procedure.
• Rehabilitation after surgery does not take much time. Sick leave can last up to 3 weeks, after which the person can resume his professional duties.
• A not so rare complication after laparotomy is a hernia. With laparoscopy, the risk of developing an incisional hernia is incredibly low.
• Good cosmetic effect. Small, inconspicuous scars, especially on female body, look less repulsive than large purple scars. Scars adorn only men, and even then, if we are not talking about post-operative marks, but about marks received in battle and are evidence of courage, not illness.

Despite its comparative novelty, the laparoscopic method has already gained the trust of doctors and patients and has become much more popular than traditional surgical intervention. Doctors resort to the latter only if serious complications arise during the operation, which can only be corrected by gaining full access to the organs.

Preparation

The patient receives a referral for laparoscopy after diagnostic tests for pain in the right hypochondrium. In this case, it is possible to establish a final diagnosis ultrasound diagnostics(ultrasound) of the abdominal organs, which, in addition to stones in the gall bladder, can also detect more dangerous neoplasms in it - polyps, which are considered a precancerous condition.

Laparoscopy of the gallbladder, despite small incisions on the body and a small number of complications, is still a serious surgical operation, and, therefore, requires some preparation for the procedure.

Such preparation includes:

• Physical examination of the patient by a therapist or gastroenterologist, clarifying the medical history, existing symptoms, time of onset of pain, etc.

• Lab tests:
  1. general analysis urine,
  2. general blood test, which pays special attention to ESR indicator,
  3. biochemical blood test (the content of various mineral components, bilirubin pigment, urea, protein, cholesterol, glucose, etc. is taken into account),
  4. analysis to clarify blood type and Rh factor,
  5. blood clotting test (coagulogram),
  6. test for syphilis,
  7. virological tests for the presence of hepatitis viruses and HIV infection.
• Electrocardiogram showing the condition of cardio-vascular system.
• An x-ray or ultrasound helps to assess the condition of the gallbladder, its size and the degree of filling with stones.
• Fibrogastroduodenoscopy (FGDS) to clarify the state of the digestive system.
• Doctor's report with final diagnosis.
• Referral for examination by a surgeon.

After the surgeon studies the examination data and examines the patient, he decides on the method and type of operation (whether it is worth removing the gallbladder or limiting it to removing stones from it). After this, the patient receives instructions on how best to prepare for the operation in order to avoid unpleasant consequences. general anesthesia. Under local anesthesia laparoscopy of gall bladder stones is not performed due to the fact that such anesthesia allows the patient to remain conscious, which means that a person is unlikely to be able to completely relax and relax the abdominal muscles to facilitate access to the gallbladder.

Preparation begins the day before the operation in the evening. After 18.00, doctors do not recommend eating food, and after 22-24 hours, water. Must be done this evening cleansing enema. The morning before the operation, the cleansing procedure is repeated.

There is a certain group of drugs, the use of which affects blood clotting parameters. Anticoagulants, non-steroidal anti-inflammatory drugs (NSAIDs), vitamin E preparations help thin the blood, which leads to large blood loss during the operation. Taking such medications should be stopped ten days before the planned date of surgery.

In a conversation with the surgeon, the patient learns about the likelihood of various complications during surgery. For example, in case severe inflammation when the gallbladder is tightly attached to other organs by numerous adhesions, or large quantities For large stones that cannot be removed by suction, laparoscopy for gallstones will not be effective. And even removing such an organ laparoscopically is very problematic. In this case, they resort to laparotomy. The patient may initially be prepared for laparoscopy, but during the operation, after visualization of the organ, the tube is removed and the operation is performed in the traditional way.

On the eve of the operation, the anesthesiologist conducts a conversation with the patient, clarifying information about tolerability various types anesthesia, as well as the presence of diseases respiratory system. For example, when bronchial asthma endotrachial anesthesia, in which the anesthetic enters the body through the respiratory system, is dangerous to use. In this case, the anesthetic is introduced into the body using an intravenous infusion.

On the eve of the operation, the patient is scheduled for an appointment in the evening or morning. sedatives. Additionally, the patient is given an injection already in the preoperative room or directly on the operating table to relieve excessive anxiety before the operation and fear of the device. artificial ventilation lungs used for anesthesia, fear of death, etc.

Restriction of fluid intake from 10-12 o'clock at night the previous day is a definite trauma for him. Ideally, there should be no liquid or food in the gastrointestinal tract, but the body should not suffer from dehydration. To replenish the lack of fluid in the body immediately before surgery, infusion therapy. Those. a catheter is inserted into the vein, to which a system (dropper) containing the necessary medicinal solutions, preventing dehydration and possible complications during surgery, as well as providing high-quality anesthesia when administering anesthesia through the respiratory tract is ineffective.

Before the operation, a probe is inserted into the patient’s stomach to pump out liquid and gases from it, thus preventing vomiting and the entry of gastric contents into the respiratory system and preventing the danger of asphyxia. The probe remains inside the gastrointestinal tract throughout the operation. A ventilator mask is placed over it, which is used even in the case of intravenous anesthesia.

The need to use the device artificial respiration during laparoscopy of gall bladder stones, it is due to the fact that to facilitate the surgeon’s work and prevent injury to nearby organs, gas is pumped into the abdominal cavity, which, squeezing the diaphragm, compresses the lungs. The lungs cannot perform their functions in such conditions, and without oxygen the body will not survive for long and will not undergo surgery, which can last from 40 to 90 minutes.

Which operation should I choose?

The word "laparoscopy" consists of two parts. The first part of the word denotes an object - the stomach, the second implies an action - to see. In other words, using a laparoscope allows you to see the organs inside the abdomen without opening it. The surgeon sees the image provided by the camera on a computer monitor.

Using a laparoscope, you can perform 2 types of surgery:

• laparoscopy (removal) of stones from the gallbladder and its ducts.

As practice shows, the effectiveness of the latter operation is much higher than simple removal of stones. The fact is that the gallbladder itself is not a vital organ; it is, as it were, a transit point for bile leaving the liver and intended for the stage of the digestive process taking place in the duodenum. Basically, this is a bladder for storing bile, which our body can do just fine without.

Removing stones from the gallbladder does not in itself solve the problem of inflammation of the organ and stone formation in general. Without changing your lifestyle and diet, it is impossible to stop the process of stone formation. And in people with a hereditary predisposition to gallstone disease, even these measures are not always able to solve the problem of gallstone formation.

The above-described disadvantages of surgery to remove gallstones made this procedure unpopular. Doctors resort to it mainly in cases where it is necessary to remove single stones. large sizes, blocking the bile ducts, if cholelithiasis not complicated by cholecystitis (inflammatory process in the gallbladder). Most often, doctors are inclined to remove the entire gallbladder and stones in its ducts.

Technique for laparoscopy of gallbladder stones

After appropriate preparation for the operation has been made, the patient is attached to a ventilator and is subject to anesthesia, the surgeon can proceed directly to the operation. Regardless of whether the entire gallbladder is removed or just the stones inside it, sterile carbon dioxide is pumped into the abdominal cavity using a special needle, which increases the clearance between the abdominal organs, improves their visualization and prevents the possibility of damage to other organs during surgery .

After this, a small semicircular incision is made in the area just above the navel, through which a laparoscope (a tube with a flashlight and a camera) is inserted. Next, in the area of ​​the right hypochondrium, 2 or 3 more punctures are made in certain places, through which the corresponding number of trocars is inserted. If the laparoscope is needed to visualize the progress of the operation, then the remaining trocars are used to supply instruments directly to the organ and control these instruments using special mechanisms as part of the manipulator.

First, the surgeon examines the condition of the gallbladder and the tissues around it. If there is an inflammatory process in the abdominal cavity, the gallbladder may be surrounded by adhesions, which also cause discomfort in patients. These adhesions must be removed.

Now let's see how stones are removed from the gallbladder using laparoscopy. An incision is made in the wall of the gallbladder, into which a special suction is inserted, with the help of which the stones, along with bile, are removed from the organ and its ducts. The incision site is sutured with self-absorbing materials. The peritoneal cavity must be washed with antiseptics to prevent complications such as the development of peritonitis, after which the instrument is removed and sutures are applied to the puncture sites.

A slightly different operation is performed to remove the gallbladder along with the stones in it. After releasing the organ from adhesions, the surgeon assesses its condition, the degree of overflow and tension. At high voltage In the gallbladder, it is recommended to make an incision and partially pump out the contents of the organ to avoid its rupture and spillage of bile into the lumen of the abdominal cavity. After pumping out a certain volume of bile, the suction is removed and a clamp is applied to the incision site.

Now it’s time to find the bile duct and artery, onto which special clips are applied (two for each vessel), after which the gallbladder is cut off from them (an incision is made between the clips, the lumen of the artery must be carefully sutured).

Finally, the time has come to release the gallbladder from its special socket in the liver. This must be done carefully, without haste. During this procedure, bleeding small vessels are periodically cauterized using an electric current.

The gallbladder with stones is removed through a small hole in the navel area, which does not damage it in any way. appearance belly. Any pathologically altered tissue found during surgery is subject to removal.

After removing the bubble, the surgeon once again evaluates the condition of the severed vessels and, if necessary, cauterizes them again. After this, an antiseptic solution is injected into the abdominal cavity, which washes and disinfects the internal organs. At the end of the procedure, the antiseptic is removed outside, again using suction.

To remove residual fluid in case the suction does not remove all the solution, after removing the trocars, a drainage tube is inserted into one of the incisions, which is removed after one or two days. The remaining incisions are sutured or sealed with medical tape.

Whatever the operation to remove stones from the gallbladder using the laparoscopic method, if serious difficulties arise, the doctor resorts to a traditional solution to the problem.

Contraindications for carrying out

Laparoscopy of gallbladder stones, like any other serious intracavitary operation, requires preliminary comprehensive diagnostic examination, including the study of anamnesis from the patient’s words and information contained in medical documents (patient’s medical record). This is not a simple reinsurance, but a necessity, because the operation has a number of contraindications. If they are not taken into account, serious harm to the patient's health can be caused.

It is worth mentioning right away that such a wide list of diagnostic studies is not accidental, because it helps to identify hidden pathologies that either do not allow resorting to laparoscopy or require preliminary treatment. All tests prescribed before surgery must be normal. Otherwise, the doctor will first prescribe treatment for the existing disease, and then, when the condition normalizes, determine the date of the operation.

In what cases can a doctor refuse surgery for a patient:

• with the development of an abscess in the area of ​​the gallbladder,
• in case of exacerbation serious illnesses cardiovascular system, especially if wearing a pacemaker,
• for decompensated pathologies of the respiratory system,
• with an anomaly in the location of the gallbladder, when it is located not next to the liver, but inside it,
• on acute stages of pancreatitis,
• if a malignant process in the gallbladder is suspected,
• in the presence of severe scar changes in the area of ​​connection of the gallbladder, liver and intestines,
• in the presence of fistulas between the gallbladder and duodenum,
• with acute gangrenous or perforated cholecystitis, as a result of which bile or pus may pour into the abdominal cavity,
• with a “porcelain” gallbladder with deposition of calcium salts in its walls (removal of the organ is indicated classical method, since there is a high probability of cancer).

Laparoscopic surgery on the gallbladder is not performed in the third semester of pregnancy, with the development of obstructive jaundice caused by blockage of the bile ducts, or a blood clotting disorder due to the risk of bleeding. It is dangerous to carry out such operations if diagnostic studies do not provide a clear picture of the location of organs. Patients who have undergone intracavitary operations in the past using the traditional method may also be denied laparoscopy.

Some contraindications are related to the anesthesia used during the operation. Others can be considered relative, since they relate only to a specific method of performing the operation. In the presence of such pathologies, the operation can be performed traditionally. As for pregnancy, conservative treatment is temporarily prescribed, and after childbirth we can talk about surgery to remove the gallbladder. The limitation regarding pacemakers is associated with electromagnetic radiation, which can negatively affect both the functioning of the cardiac apparatus and the functionality of the laparoscope.

Consequences after the procedure

Despite the fact that the laparoscopic method of surgery is considered the least traumatic and has fewer complications than the traditional approach to surgical removal gallstones, it is still not possible to completely avoid discomfort after surgery. We are talking about a pain syndrome, which, although of low intensity, still requires the use of analgesics (Tempalgin, Ketoral, etc.) for the first 2 days.

Usually, after a couple of days, the pain subsides and you can safely stop taking painkillers. After a week, patients usually forget about pain and discomfort.

After the stitches are removed (approximately a week after surgery), patients can live peacefully active life. Pain syndrome can only remind itself when physical activity and tension in the abdominal muscles. To prevent this from happening, you should take care for at least a month.

Sometimes pain appears if a person begins to strain during bowel movements. It's better not to do this. If there are difficulties with passing stool, the doctor will prescribe suitable laxatives that will help you pass the toilet without effort.

If during laparoscopy of gallbladder stones it was decided to remove the bladder completely, a fairly common consequence of such an operation can be considered postcholecystectomy syndrome caused by the reflux of bile directly into the duodenum.

Symptoms of postcholecystectomy syndrome are considered: pain in the epigastrium of moderate intensity, attacks of nausea and vomiting, dyspeptic symptoms(bloating and rumbling in the stomach, the appearance of heartburn and belching with a bitter aftertaste). Less commonly observed is yellowness of the skin and fever.

The syndrome described above, unfortunately, will accompany a person after surgery to remove the gallbladder throughout his life. Symptoms will occur periodically. When they appear, it is enough to adhere to the diet indicated for liver diseases, take antispasmodics and antiemetics, and drink small amounts of alkaline mineral water.

As for pain outside of attacks of postcholecystectomy syndrome, they may indicate the development of various complications, especially if the intensity of pain gradually increases.

Complications after the procedure

We have already mentioned that complications during laparoscopy of gallstones are extremely rare. The reason for this may be insufficient preparation for surgery, which happens in cases of emergency procedures (for example, taking anticoagulants on the eve of surgery can lead to bleeding during surgery). Other complications may arise as a result of insufficient competence of the medical staff or simple carelessness of the surgeon.

Complications can occur both during surgery and several days after it.

Complications that arise during intracavitary manipulations:

• Improper administration of anesthesia can cause severe anaphylactic reactions,
• bleeding due to disruption of integrity blood vessels, running along the abdominal wall;

bleeding can occur if the cystic artery, which was to be cut off, is not sufficiently clamped or poorly sutured;

sometimes bleeding accompanies the release of the gallbladder from the liver bed,

• perforation various organs located near the gallbladder, including the bladder itself (the reasons may be different),
• damage to nearby tissues.

What can happen after laparoscopy? Some complications may appear not at the time of surgery, but after some time:

• damage to tissues inside the abdominal cavity due to the ingress of bile from a poorly sutured incision in the gallbladder;

if the gallbladder is removed, bile may leak from the remnant bile duct or liver bed,

• inflammation of the peritoneum (peritonitis) due to the entry of the contents of the gallbladder or other organs damaged during surgery into the abdominal cavity;

an identical situation is observed when the abdominal cavity is insufficiently treated with antiseptics at the end of the operation, as a result of which some elements remain (blood, bile, etc.) that cause inflammation,

• reflux esophagitis, in which food from the stomach and duodenum, richly flavored with enzymes, is thrown back into the esophagus,
• omphalitis is a pathology characterized by inflammation of the soft tissues in the navel area, which can be caused by contact with wound infection,
• hernia is one of the rarest complications after laparoscopy, usually occurs in people with overweight or as a consequence of an urgent operation with a short preparatory period.

In general, complications after laparoscopy of gallstones are very rare if doctors are sufficiently competent, which is also an advantage of this method.

Post-procedure care

At the end of the operation, the anesthesia is stopped, and the anesthesiologist tries to bring the patient out of the state of artificial sleep. If anesthesia was administered intravenously, the patient regains consciousness within one hour after the operation. An unpleasant consequence General anesthesia is considered a high probability of dizziness, nausea and vomiting mixed with bile. Buy similar symptoms you can use Cerucal. In any case, after a short time, the effects of anesthesia disappear.

Laparoscopy of gallbladder stones, like any other surgery, cannot exclude tissue damage. The places of incisions and sutures will remain visible for some time after the anesthesia has come off. painful sensations. This is inevitable, but quite tolerable. At the very least, you can always relieve pain with analgesics.

IN in rare cases, if an organ was perforated during surgery, as well as in the case of acute cholecystitis, antibiotics may be additionally prescribed.

The patient's awakening from anesthesia only marks the end medical manipulations, but not freedom of action for the patient. He will have to remain on bed rest for about 4-5 more hours to avoid various complications. After this time, the doctor examines the patient and gives the go-ahead for the patient to try to turn over on his side, get out of bed, and walk around. Patients are also allowed to sit and perform simple activities that do not require tension in the abdominal muscles. It is forbidden to perform active sudden movements and lift heavy objects.

As soon as the patient is allowed to get out of bed, he can gradually drink purified or mineral water without gas. Patients are not allowed to eat on the first day after surgery.

Patients begin to feed on the second day after laparoscopy of gallstones. Food during this period should be easily digestible, non-solid, low-fat and non-spicy. You can try eating weak vegetable broth, yogurt or yogurt, pureed skim cheese, boiled dietary meat crushed in a blender, soft varieties of fruit, etc.

You need to take food in small portions, following the principle of fractional meals prescribed for various diseases digestive system. You need to eat little by little at least 5-6 times a day. But doctors recommend drinking a lot to replenish the volume of fluid in the body.

Starting from the third day, you can switch to your usual diet. The exceptions are:

• products that promote gas formation (brown bread, peas, etc.),
• hot spices (black and red hot pepper, onion, ginger, garlic), stimulating bile excretion.

From this moment on, you need to accustom yourself to eat according to diet number 5, prescribed after removal of stones from the gallbladder by laparoscopy. Using this diet, you can normalize liver function and minimize the risk of complications associated with the reflux of bile into the duodenum between meals due to the lack of a vessel for its storage.

According to this diet, food served to the table should be crushed. You can only eat warm dishes (not hot!), prepared by boiling, baking or stewing various foods.

The diet contains a specific list of prohibited foods that will have to be excluded from the diet altogether. Liquid and semi-liquid porridges, light soups without frying, low-fat dairy and fermented milk products, heat-processed vegetables (not fried), sweet fruits and berries, and honey are considered healthy.

Patients will have to strictly adhere to diet No. 5 for 3 or 4 months after surgery. Then you can gradually add fresh vegetables to your diet. From now on, it is no longer necessary to chop meat and fish. And only 2 years after the procedure to remove the gallbladder, you can return to your normal diet if you wish.

The duration of the postoperative period ranges from 1 to 1.5 weeks, during which physical activity remains limited due to the risk of suture dehiscence. It is prohibited to lift any weights or engage in physical labor or sports. It is recommended to wear soft underwear made from natural fabrics to avoid irritating the puncture sites located in the navel and right hypochondrium.

The end of the postoperative period is marked by the procedure for removing sutures at the sites of skin incisions. From this moment on, a person can live a normal life, do light work, and his health will return to normal over the next 3-5 days. However, before full recovery still far. It will take about 5-6 months until the body can fully recover from the operation, both psychologically and physically, while at the same time regaining its strength.

In order for the recovery period to go smoothly and without complications, you will have to adhere to some restrictions:

• refusal of active sexual activity for at least 2 weeks (ideally, you should abstain for a month),
• proper nutrition with sufficient fluids, vegetables and fruits, preventing the development of constipation,