Difference between revisions of "Cholecystectomy"

From WikiAnesthesia
m (Added to the procedure risk summary table regarding elevated perioperative cardiac risk with open procedures compared to laparoscopic. I added a 2018 citation with this edit.)
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| airway = Endotracheal tube
| airway = Endotracheal tube
| lines_access = Peripheral IV
| lines_access = Peripheral IV
| monitors = Standard ASA /
| monitors = Standard ASA<br />
5-lead EKG
5-lead EKG
| considerations_preoperative = -
| considerations_preoperative = NG Tube
| considerations_intraoperative = -
| considerations_intraoperative = Rapid sequence intubation
| considerations_postoperative = -
| considerations_postoperative = PONV
}}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.  
}}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<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==
===Preoperative evaluation<!-- Provide a brief overview of the preoperative evaluation and optimization of patients for this case. Also list relevant labs, studies, or physical exam findings. If none, this section may be removed. -->===
===Patient evaluation===
{| class="wikitable"
{| class="wikitable"
|+
|+
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|Cardiovascular
|Cardiovascular
|
|
* Sepsis can result in hypotension, tachycardia
|-
|-
|Renal
|Renal
|
|
*
|-
|-
|Gastrointestinal
|Gastrointestinal
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|Hematologic
|Hematologic
|
|
* Sepsis can result in leukocytosis/leucopenia
|-
|-
|Endocrine
|
|
|-
|Other
|
|
|}
|}
=== Labs and studies ===
* CBC
* Chemistry Panel
*  
*  


===Operating room preparation<!-- 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


*  
*  


*  
*  
=== 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


==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
* 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
* In unstable patients, consider etomidate (BP control) and rapid sequence intubation (RSI)


===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
* Secure and tuck arms


===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
** 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


==Postoperative management==
==Postoperative management==
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===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
* Opioids for breakthrough pain. Consider PCA for open cases


===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
* 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). -->==
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{| class="wikitable"
{| class="wikitable"
|+
|+
''*PACE: Perioperative Adverse Cardiac Event''
!
!
!Variant 1
!Open Cholecystectomy
!Variant 2
!Laparoscopic Cholecystectomy
!Variant 3
|-
|-
|Unique considerations
|Unique considerations
|
|
|
|
|
|-
|-
|Position
|Position
|
|Supine
|
|Supine
|
|-
|-
|Surgical time
|Surgical time
|
|2-4 hours
|
|0.5-2 hours
|
|-
|-
|EBL
|EBL
|
|250mL
|
|Minimal
|
|-
|-
|Postoperative disposition
|Postoperative disposition
|
|PACU
|
|PACU
|
|-
|-
|Mortality
|Mortality
|
|
|
|
|
|-
|-
|Morbidity
|Morbidity
|
|Elevated PACE vs laparoscopic<ref>{{Cite journal|last=Liu|first=Jason B.|last2=Liu|first2=Yaoming|last3=Cohen|first3=Mark E.|last4=Ko|first4=Clifford Y.|last5=Sweitzer|first5=Bobbie J.|date=2018-02-01|title=Defining the Intrinsic Cardiac Risks of Operations to Improve Preoperative Cardiac Risk Assessments|url=https://pubs.asahq.org/anesthesiology/article/128/2/283/17742/Defining-the-Intrinsic-Cardiac-Risks-of-Operations|journal=Anesthesiology|language=en|volume=128|issue=2|pages=283–292|doi=10.1097/ALN.0000000000002024|issn=0003-3022}}</ref>
|
|
|
|-
|-
|Pain
|Pain
|
|5-7
|
|3
|
|}
|}


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<references />
<references />


[[Category:Surgical case reference]]
[[Category:Surgical procedures]]
[[Category:General surgery]]
[[Category:Biliary tract surgery]]

Revision as of 10:51, 5 April 2021

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

Article quality
Editor rating
Certified
User likes
1

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

  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.