Cholecystectomy

From WikiAnesthesia
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

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.