Cholecystectomy

Cholecystectomy
Anesthesia type	General
Airway	Endotracheal tube
Lines and access	Peripheral IV
Monitors	Standard ASA; 5-lead EKG
	Primary anesthetic considerations
Preoperative	NG Tube
Intraoperative	Rapid sequence intubation
Postoperative	PONV
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Editor rating	Certified
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A cholecystectomy is generally performed to treat symptomatic cholelithiasis and other gallbladder conditions. 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. A cholecystectomy can be performed laparoscopically or as an open procedure. Surgical practice has largely transitioned to the laparoscopic approach. The rate of conversion to an open operation is 2-3% for elective gallbladder surgery and ~10% for acute cholecystitis^[1].

Preoperative management

Patient evaluation


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

CBC
Chemistry Panel

Operating room setup

NG tube

Patient preparation and premedication

Midazolam

Regional and neuraxial techniques

Consider epidural for open approach

Intraoperative management

Monitoring and access

Standard ASA monitors
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

Standard induction
In unstable patients, consider etomidate (BP control) and rapid sequence intubation (RSI)

Positioning

Supine, Trendelenburg
Secure and tuck arms

Maintenance and surgical considerations

Intraoperative insufflation may cause
- Resp: atelectasis, decrease FRC, increase PIPs, and increase CO2. May also cause endobronchial intubation
- GI: gastric content regurgitation
- Cardiac: decreased cardiac output

Emergence

PONV prophylaxis

Postoperative management

Disposition

Pain management

NSAIDs and acetaminophen for mild pain
Opioids for breakthrough pain. Consider PCA for open cases

Potential complications

PONV
Subcutaneous emphysema (from insufflation)
Bowel injury

Procedure variants

*PACE: Perioperative Adverse Cardiac Event
	Open Cholecystectomy	Laparoscopic Cholecystectomy
Unique considerations
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^[2]
Pain	5-7	3

References

↑ Jaffe, Richard A; Schmiesing, Clifford A; Golianu, Brenda (2014). Anesthesiologist's manual of surgical procedures. ISBN 978-1-4963-0594-7. OCLC 888551588.
↑ 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.

Top contributors: Stuart van der Greeff, Barrett Larson, Tony Wang, Nirav Kamdar and Chris Rishel

[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] 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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