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

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 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

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[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. 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.