Difference between revisions of "Cholecystectomy"

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{{Infobox surgical case reference
{{Infobox surgical case reference
| anesthesia_type = General
| anesthesia_type = General
| airway = Endotracheal tube
| airway = ETT
| lines_access = Peripheral IV
| lines_access = Peripheral IV
| monitors = Standard ASA<br />
| monitors = Standard
5-lead EKG
| considerations_preoperative = PONV prophylaxis
| considerations_preoperative = NG Tube
| considerations_intraoperative = General considerations for laparoscopic surgery
| considerations_intraoperative = Rapid sequence intubation
| considerations_postoperative = PONV
| considerations_postoperative = PONV
± TAP block
}}Cholecystectomy is performed to treat symptomatic cholelithiasis and its complications (e.g., cholecystitis, pancreatitis, cholangitis), and other gallbladder conditions (e.g., polyps, porcelain gallbladder). This is one of the most common procedures performed in hospitals in the United States. Of the more than 20 million people in the US with gallstones, about 30% will eventually require cholecystectomy to relieve symptoms or treat complications. Cholecystectomy is most commonly performed laparoscopically, though there are specific indications for open surgery. The rate of conversion to an open operation is 2-3% for elective surgery and ~10% for acute cholecystitis<ref>{{Cite book|last=Jaffe|first=Richard A|url=http://public.ebookcentral.proquest.com/choice/publicfullrecord.aspx?p=3418805|title=Anesthesiologist's manual of surgical procedures|last2=Schmiesing|first2=Clifford A|last3=Golianu|first3=Brenda|date=2014|isbn=978-1-4963-0594-7|language=English|oclc=888551588}}</ref>.   
}}Cholecystectomy is performed to treat symptomatic cholelithiasis and its complications (e.g., cholecystitis, pancreatitis, cholangitis), and other gallbladder conditions (e.g., polyps, porcelain gallbladder). This is one of the most common procedures performed in hospitals in the United States. Of the more than 20 million people in the US with gallstones, about 30% will eventually require cholecystectomy to relieve symptoms or treat complications. Cholecystectomy is most commonly performed laparoscopically, though there are specific indications for open surgery. The rate of conversion to an open operation is 2-3% for elective surgery and ~10% for acute cholecystitis<ref>{{Cite book|last=Jaffe|first=Richard A|url=http://public.ebookcentral.proquest.com/choice/publicfullrecord.aspx?p=3418805|title=Anesthesiologist's manual of surgical procedures|last2=Schmiesing|first2=Clifford A|last3=Golianu|first3=Brenda|date=2014|isbn=978-1-4963-0594-7|language=English|oclc=888551588}}</ref>.   
==Preoperative management==
==Preoperative management==
===Patient evaluation===
===Patient evaluation===
{| class="wikitable"
Most patients are healthy presenting for elective surgery, though others with acute cholecystitis may be critically unwell (e.g., patients with critical illness who develop acalculous cholecystitis).
|+
!System
!Considerations
|-
|Respiratory
|
* Acute abdominal pain can cause respiratory impairment (respiratory splinting) resulting in atelectasis
|-
|Cardiovascular
|
* Sepsis can result in hypotension, tachycardia
|-
|Renal
|
*
|-
|Gastrointestinal
|
|-
|Hematologic
|
* Sepsis can result in leukocytosis/leucopenia
|-
|Endocrine
|
|-
|Other
|
|}


=== Labs and studies ===
=== Labs and studies ===


* CBC
* No procedure-specific considerations for otherwise healthy patients.
* Chemistry Panel
 
*


===Operating room setup<!-- List any special, non-standard equipment, medications, fluids, or other preparations that should be made prior to surgery. If none, this section may be removed. -->===
===Operating room setup<!-- List any special, non-standard equipment, medications, fluids, or other preparations that should be made prior to surgery. If none, this section may be removed. -->===


* NG tube
*No procedure-specific equipment required.


*
===Patient preparation and premedication===


*  
*Laparoscopy and cholecystectomy specifically are minor risk factors for PONV<ref>{{Cite journal|last=Apfel|first=C. C.|last2=Heidrich|first2=F. M.|last3=Jukar-Rao|first3=S.|last4=Jalota|first4=L.|last5=Hornuss|first5=C.|last6=Whelan|first6=R. P.|last7=Zhang|first7=K.|last8=Cakmakkaya|first8=O. S.|date=2012-11|title=Evidence-based analysis of risk factors for postoperative nausea and vomiting|url=https://pubmed.ncbi.nlm.nih.gov/23035051|journal=British Journal of Anaesthesia|volume=109|issue=5|pages=742–753|doi=10.1093/bja/aes276|issn=1471-6771|pmid=23035051}}</ref>, consider the need for pre-operative prophylaxis (e.g., scopolamine, aprepitant)
 
*Anxiolysis as indicated by patient characteristics and local practices.
=== Patient preparation and premedication ===
 
* Midazolam


===Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. -->===
===Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. -->===


* Consider epidural for open approach
*Open<ref>{{Cite journal|last=Savas|first=Jeannie F.|last2=Litwack|first2=Robert|last3=Davis|first3=Kevin|last4=Miller|first4=Thomas A.|date=2004-11|title=Regional anesthesia as an alternative to general anesthesia for abdominal surgery in patients with severe pulmonary impairment|url=https://pubmed.ncbi.nlm.nih.gov/15546579|journal=American Journal of Surgery|volume=188|issue=5|pages=603–605|doi=10.1016/j.amjsurg.2004.07.016|issn=0002-9610|pmid=15546579}}</ref> and laparoscopic<ref>{{Cite journal|last=Sinha|first=Rajeev|last2=Gurwara|first2=A. K.|last3=Gupta|first3=S. C.|date=2009-06|title=Laparoscopic cholecystectomy under spinal anesthesia: a study of 3492 patients|url=https://pubmed.ncbi.nlm.nih.gov/19522659|journal=Journal of Laparoendoscopic & Advanced Surgical Techniques. Part A|volume=19|issue=3|pages=323–327|doi=10.1089/lap.2008.0393|issn=1092-6429|pmid=19522659}}</ref><ref>{{Cite journal|last=Bessa|first=Samer S.|last2=Katri|first2=Khaled M.|last3=Abdel-Salam|first3=Wael N.|last4=El-Kayal|first4=El-Saed A.|last5=Tawfik|first5=Tarek A.|date=2012-07|title=Spinal versus general anesthesia for day-case laparoscopic cholecystectomy: a prospective randomized study|url=https://pubmed.ncbi.nlm.nih.gov/22686181|journal=Journal of Laparoendoscopic & Advanced Surgical Techniques. Part A|volume=22|issue=6|pages=550–555|doi=10.1089/lap.2012.0110|issn=1557-9034|pmid=22686181}}</ref><ref>{{Cite journal|last=Agrawal|first=Malti|last2=Verma|first2=A. P.|last3=Kang|first3=L. S.|date=2013-01|title=Thoracic epidural anesthesia for laparoscopic cholecystectomy using either bupivacaine or a mixture of bupivacaine and clonidine: A comparative clinical study|url=https://pubmed.ncbi.nlm.nih.gov/25885719|journal=Anesthesia, Essays and Researches|volume=7|issue=1|pages=44–48|doi=10.4103/0259-1162.113988|issn=0259-1162|pmc=4173493|pmid=25885719}}</ref><ref>{{Cite journal|last=Das|first=Writuparna|last2=Bhattacharya|first2=Susmita|last3=Ghosh|first3=Sarmila|last4=Saha|first4=Swarnamukul|last5=Mallik|first5=Suchismita|last6=Pal|first6=Saswati|date=2015-04|title=Comparison between general anesthesia and spinal anesthesia in attenuation of stress response in laparoscopic cholecystectomy: A randomized prospective trial|url=https://pubmed.ncbi.nlm.nih.gov/25829908|journal=Saudi Journal of Anaesthesia|volume=9|issue=2|pages=184–188|doi=10.4103/1658-354X.152881|issn=1658-354X|pmc=4374225|pmid=25829908}}</ref> cholecystectomy can be performed under neuraxial anesthesia with a sensory level of T4-T6.
* Transversus abdominis plane (TAP) block likely provides improved analgesia compared to local wound infiltration<ref name=":0">{{Cite journal|last=Grape|first=Sina|last2=Kirkham|first2=Kyle Robert|last3=Akiki|first3=Liliane|last4=Albrecht|first4=Eric|date=2021-07-06|title=Transversus abdominis plane block versus local anesthetic wound infiltration for optimal analgesia after laparoscopic cholecystectomy: A systematic review and meta-analysis with trial sequential analysis|url=https://pubmed.ncbi.nlm.nih.gov/34243030|journal=Journal of Clinical Anesthesia|volume=75|pages=110450|doi=10.1016/j.jclinane.2021.110450|issn=1873-4529|pmid=34243030}}</ref>.


==Intraoperative management==
==Intraoperative management==
===Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. -->===
===Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. -->===


* Standard ASA monitors
*No procedure-specific considerations for otherwise healthy patients.
* 5-lead EKG
* Urinary catheter
* NG tube
* 1-2 peripheral IVs (16-18 gauge)
* In unstable patients or if open cholecystectomy, consider arterial line and central access


===Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. -->===
===Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. -->===


* Standard induction
*Rapid-sequence induction and intubation (RSII) may be required for unfasted patients undergoing emergency surgery.
* In unstable patients, consider etomidate (BP control) and rapid sequence intubation (RSI)
*Endotracheal intubation is most common for laparoscopic surgery, though supraglottic airways (preferrably with an inbuilt drain channel) can be used<ref>{{Cite journal|last=Belena|first=J. M.|last2=Nunez|first2=M.|last3=Vidal|first3=A.|last4=Gasco|first4=C.|last5=Gilsanz|first5=C.|last6=Alcojor|first6=A.|last7=Anta|first7=D.|last8=Lopez|first8=A. E.|date=2016|title=Use of second generation supra-glottic airway devices during laparoscopic cholecystectomy: a prospective, randomized comparison of LMA Proseal™, LMA SupremeTM and igel™|url=https://pubmed.ncbi.nlm.nih.gov/29873467|journal=Acta Anaesthesiologica Belgica|volume=67|issue=3|pages=121–128|issn=0001-5164|pmid=29873467}}</ref>.
*Orogastric or nasogastric tube should be inserted and suction applied shortly after induction and before trocar insertion.


===Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. -->===
===Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. -->===


* Supine, Trendelenburg
*Supine (USA) or lithotomy (Europe).
* Secure and tuck arms
* Reverse Trendelenburg (head up), often steep. Roll ("airplane") to patient's left.
**Ensure patient secured and well padded.
*Both arms or left arm only tucked (primary surgeon on left).


===Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. -->===
=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. -->===


* Intraoperative insufflation may cause
*General considerations for laparoscopic surgery.
** Resp: atelectasis, decrease FRC, increase PIPs, and increase CO2. May also cause endobronchial intubation
** GI: gastric content regurgitation
** Cardiac: decreased cardiac output


===Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. -->===
===Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. -->===


* PONV prophylaxis
*PONV prophylaxis, otherwise no procedure-specific considerations.


==Postoperative management==
==Postoperative management==
===Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. -->===
===Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. -->===
*PACU, often same-day discharge


===Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. -->===
===Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. -->===


* NSAIDs and acetaminophen for mild pain
*NSAIDs and acetaminophen often adequate for laparoscopic cases
* Opioids for breakthrough pain. Consider PCA for open cases
*Transversus abdominis plane (TAP) block likely provides improved analgesia compared to local wound infiltration<ref name=":0" />.


===Potential complications<!-- List and/or describe any potential postoperative complications for this case. -->===
===Potential complications<!-- List and/or describe any potential postoperative complications for this case. -->===


* PONV
*General complications of laparoscopic surgery
* Subcutaneous emphysema (from insufflation)
* Bowel injury


==Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). -->==
== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). -->==




Line 117: Line 78:
''*PACE: Perioperative Adverse Cardiac Event''
''*PACE: Perioperative Adverse Cardiac Event''
!
!
!Open Cholecystectomy
! Open Cholecystectomy
!Laparoscopic Cholecystectomy
!Laparoscopic Cholecystectomy
|-
|-
|Unique considerations
|
|
|
|
|
Line 133: Line 94:
|-
|-
|EBL
|EBL
|250mL  
|250mL
|Minimal  
 
|Minimal
|-
|-
|Postoperative disposition
|Postoperative disposition

Latest revision as of 22:20, 4 April 2022

Cholecystectomy
Anesthesia type

General

Airway

ETT

Lines and access

Peripheral IV

Monitors

Standard

Primary anesthetic considerations
Preoperative

PONV prophylaxis

Intraoperative

General considerations for laparoscopic surgery

Postoperative

PONV ± TAP block

Article quality
Editor rating
Certified
User likes
1

Cholecystectomy is performed to treat symptomatic cholelithiasis and its complications (e.g., cholecystitis, pancreatitis, cholangitis), and other gallbladder conditions (e.g., polyps, porcelain gallbladder). This is one of the most common procedures performed in hospitals in the United States. Of the more than 20 million people in the US with gallstones, about 30% will eventually require cholecystectomy to relieve symptoms or treat complications. Cholecystectomy is most commonly performed laparoscopically, though there are specific indications for open surgery. The rate of conversion to an open operation is 2-3% for elective surgery and ~10% for acute cholecystitis[1].

Preoperative management

Patient evaluation

Most patients are healthy presenting for elective surgery, though others with acute cholecystitis may be critically unwell (e.g., patients with critical illness who develop acalculous cholecystitis).

Labs and studies

  • No procedure-specific considerations for otherwise healthy patients.

Operating room setup

  • No procedure-specific equipment required.

Patient preparation and premedication

  • Laparoscopy and cholecystectomy specifically are minor risk factors for PONV[2], consider the need for pre-operative prophylaxis (e.g., scopolamine, aprepitant)
  • Anxiolysis as indicated by patient characteristics and local practices.

Regional and neuraxial techniques

  • Open[3] and laparoscopic[4][5][6][7] cholecystectomy can be performed under neuraxial anesthesia with a sensory level of T4-T6.
  • Transversus abdominis plane (TAP) block likely provides improved analgesia compared to local wound infiltration[8].

Intraoperative management

Monitoring and access

  • No procedure-specific considerations for otherwise healthy patients.

Induction and airway management

  • Rapid-sequence induction and intubation (RSII) may be required for unfasted patients undergoing emergency surgery.
  • Endotracheal intubation is most common for laparoscopic surgery, though supraglottic airways (preferrably with an inbuilt drain channel) can be used[9].
  • Orogastric or nasogastric tube should be inserted and suction applied shortly after induction and before trocar insertion.

Positioning

  • Supine (USA) or lithotomy (Europe).
  • Reverse Trendelenburg (head up), often steep. Roll ("airplane") to patient's left.
    • Ensure patient secured and well padded.
  • Both arms or left arm only tucked (primary surgeon on left).

Maintenance and surgical considerations

  • General considerations for laparoscopic surgery.

Emergence

  • PONV prophylaxis, otherwise no procedure-specific considerations.

Postoperative management

Disposition

  • PACU, often same-day discharge

Pain management

  • NSAIDs and acetaminophen often adequate for laparoscopic cases
  • Transversus abdominis plane (TAP) block likely provides improved analgesia compared to local wound infiltration[8].

Potential complications

  • General complications of laparoscopic surgery

Procedure variants

*PACE: Perioperative Adverse Cardiac Event
Open Cholecystectomy Laparoscopic Cholecystectomy
Position Supine Supine
Surgical time 2-4 hours 0.5-2 hours
EBL 250mL Minimal
Postoperative disposition PACU PACU
Mortality
Morbidity Elevated PACE vs laparoscopic[10]
Pain 5-7 3

References

  1. ↑ Jaffe, Richard A; Schmiesing, Clifford A; Golianu, Brenda (2014). Anesthesiologist's manual of surgical procedures. ISBN 978-1-4963-0594-7. OCLC 888551588.
  2. ↑ Apfel, C. C.; Heidrich, F. M.; Jukar-Rao, S.; Jalota, L.; Hornuss, C.; Whelan, R. P.; Zhang, K.; Cakmakkaya, O. S. (2012-11). "Evidence-based analysis of risk factors for postoperative nausea and vomiting". British Journal of Anaesthesia. 109 (5): 742–753. doi:10.1093/bja/aes276. ISSN 1471-6771. PMID 23035051. Check date values in: |date= (help)
  3. ↑ Savas, Jeannie F.; Litwack, Robert; Davis, Kevin; Miller, Thomas A. (2004-11). "Regional anesthesia as an alternative to general anesthesia for abdominal surgery in patients with severe pulmonary impairment". American Journal of Surgery. 188 (5): 603–605. doi:10.1016/j.amjsurg.2004.07.016. ISSN 0002-9610. PMID 15546579. Check date values in: |date= (help)
  4. ↑ Sinha, Rajeev; Gurwara, A. K.; Gupta, S. C. (2009-06). "Laparoscopic cholecystectomy under spinal anesthesia: a study of 3492 patients". Journal of Laparoendoscopic & Advanced Surgical Techniques. Part A. 19 (3): 323–327. doi:10.1089/lap.2008.0393. ISSN 1092-6429. PMID 19522659. Check date values in: |date= (help)
  5. ↑ Bessa, Samer S.; Katri, Khaled M.; Abdel-Salam, Wael N.; El-Kayal, El-Saed A.; Tawfik, Tarek A. (2012-07). "Spinal versus general anesthesia for day-case laparoscopic cholecystectomy: a prospective randomized study". Journal of Laparoendoscopic & Advanced Surgical Techniques. Part A. 22 (6): 550–555. doi:10.1089/lap.2012.0110. ISSN 1557-9034. PMID 22686181. Check date values in: |date= (help)
  6. ↑ Agrawal, Malti; Verma, A. P.; Kang, L. S. (2013-01). "Thoracic epidural anesthesia for laparoscopic cholecystectomy using either bupivacaine or a mixture of bupivacaine and clonidine: A comparative clinical study". Anesthesia, Essays and Researches. 7 (1): 44–48. doi:10.4103/0259-1162.113988. ISSN 0259-1162. PMC 4173493. PMID 25885719. Check date values in: |date= (help)
  7. ↑ Das, Writuparna; Bhattacharya, Susmita; Ghosh, Sarmila; Saha, Swarnamukul; Mallik, Suchismita; Pal, Saswati (2015-04). "Comparison between general anesthesia and spinal anesthesia in attenuation of stress response in laparoscopic cholecystectomy: A randomized prospective trial". Saudi Journal of Anaesthesia. 9 (2): 184–188. doi:10.4103/1658-354X.152881. ISSN 1658-354X. PMC 4374225. PMID 25829908. Check date values in: |date= (help)
  8. ↑ 8.0 8.1 Grape, Sina; Kirkham, Kyle Robert; Akiki, Liliane; Albrecht, Eric (2021-07-06). "Transversus abdominis plane block versus local anesthetic wound infiltration for optimal analgesia after laparoscopic cholecystectomy: A systematic review and meta-analysis with trial sequential analysis". Journal of Clinical Anesthesia. 75: 110450. doi:10.1016/j.jclinane.2021.110450. ISSN 1873-4529. PMID 34243030.
  9. ↑ Belena, J. M.; Nunez, M.; Vidal, A.; Gasco, C.; Gilsanz, C.; Alcojor, A.; Anta, D.; Lopez, A. E. (2016). "Use of second generation supra-glottic airway devices during laparoscopic cholecystectomy: a prospective, randomized comparison of LMA Proseal™, LMA SupremeTM and igel™". Acta Anaesthesiologica Belgica. 67 (3): 121–128. ISSN 0001-5164. PMID 29873467.
  10. ↑ Liu, Jason B.; Liu, Yaoming; Cohen, Mark E.; Ko, Clifford Y.; Sweitzer, Bobbie J. (2018-02-01). "Defining the Intrinsic Cardiac Risks of Operations to Improve Preoperative Cardiac Risk Assessments". Anesthesiology. 128 (2): 283–292. doi:10.1097/ALN.0000000000002024. ISSN 0003-3022.

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