Cholecystectomy

Etiology

15-20 million adults in the US have biliary disease, evidenced by gallstones.

Stone disease

• Young, female, obese, parity

The operation is performed for symptomatic gallstones or acute cholecystitis.

The laparoscopic approach is preferred for earlier recovery and return to normal activities.

The laparoscopic approach is contraindicated in pts with uncorrectable coagulopathy, severe COPD, or cardiac disease, as they are unable to tolerate the increased intraabdominal pressure with CO2 insufflation.

Patients with prior abdominal surgery or acute cholecystitis are at higher risk for conversion to open surgery. 

Biliary tract

The intrahepatic ducts collect bile from the liver segments

The coalescence of the intrahepatic ducts and the right and left hepatic ducts

The common hepatic duct formed by the junction of the right and left hepatic ducts in the liver hilum

The gallbladder, which is the reservoir for bile

The cystic duct joining the gallbladder to the common bile duct

The common bile duct, terminating in the duodenum - shares a channel with the mina pancreatic duct. It ends in smooth muscle -the sphincter of Oddi - which functions as a barrier against intestinal bacteria. Empties via the ampulla of Vater into the duodenum

The gallbladder can hold 30-50 mL of fluid

Cholecystokinin regulates the release of bile. Stimulated by the presence of amino acids and fat in the duodenum. Vagal stimulation has a secondary role.

Bile functions

Emulsify and enhance absorption of ingested fats and fat-soluble vitamins (ADEK)

Excretory pathway for bilirubin, drugs, and toxins, and immunoglobulin A

Maintain duodenal alkalization

Cholecystitis

Obstruction of the cystic duct by gallstones results in acute, severe, midepigastric pain

Inspirational effort accentuates the pain (Murphy's sign)

At risk for Ileus. Leukocytosis and fever are often present

Jaundice indicates complete obstruction

Pt is often dehydrated due to intolerance of oral intake, vomiting, and possible NG drainage of gastric contents

If there is evidence of free air on KUB/rigid and painful abdomen, consider ruptured viscus and possible gallbladder rupture

Cholelithiasis

Recurrent bouts of cholecystitis can cause fibrotic changes in the gallbladder and impede the emptying of bile

Charcot triad (fever and chills, jaundice, upper quadrant pain) indicates acute ductal obstruction along with weight loss, anorexia, and fatigue

Anesthetic considerations

the pt may be dehydrated

Prevent PONV

If CO₂ insufflation occurs, the patient needs ETT to seal the airway and prevent passive aspiration of gastric contents

 Insufflation also leads to extra pressure on the LES, increasing aspiration risk

CO₂ insufflation leads to atelectasis, decreased FRC, increased PIP, increased PaCO₂, and decreased PaO₂

• Think respiratory or cardiac disease - pt may not be a candidate

CO₂ inflation > 15 mmHg will decrease venous return, increase SVR, and decrease CO

• Baroreceptor response

Pressure control ventilation should be adjusted to PIP to prevent any barotrauma

Reverse Trendelenburg may impede venous return and lead to hemodynamic instability

Maintain MAP to ensure adequate cerebral perfusion

If jaundice is present, consider hepatic dysfunction

Sphincter of Oddi and opioids - both morphine and Meperidene can be used. Research states that morphine gives pain relief longer than Meperidene. It may cause spasms.

An open procedure

Higher risk of complications due to preexisting medical conditions

Risk of severe post-op pain and respiratory splinting due to the site of the incision

Complications

Pneumoperitoneum

Endobronchial intubation due to change in position

Hemodynamic instability due to position change (Trendelenburg then reverse Trendelenburg - maintain MAP to ensure adequate cerebral perfusion)

PONV

Shoulder pain, usually left shoulder. Good to give three large breaths before sealing access holes

Medicate with Ketorolac 15-30 mg IV or other NSAIDS