74 Questions
In what percentage of patients is the open cholecystectomy technique utilized?
Less than 10%
What is a benefit associated with the laparoscopic surgical technique compared to the traditional open technique?
Decreased postoperative pain
What is the function of the gallbladder in relation to bile?
To concentrate and store bile
What is the role of bile in the digestive process?
To aid in the absorption and breakdown of dietary fat
What connects the gallbladder to the common hepatic duct?
The cystic duct
What happens to the sphincter of Oddi when the gallbladder becomes full?
It relaxes
What is the primary method used to confirm correct needle placement during laparoscopic surgery?
Feeling and hearing a distinct 'pop' when the needle pierces the fascia and peritoneum
What is the primary purpose of the Hasson technique in laparoscopic surgery?
To create a small incision through the abdominal fascia for trocar placement
What is a common respiratory change associated with patients presenting with symptomatic cholecystitis?
Hypoventilation
What preoperative test is recommended for patients with pulmonary disorders?
Chest x-ray
What is a potential complication of preoperative administration of bile salts in patients with obstructive jaundice?
Postoperative renal insufficiency
What is the primary indication for preoperative administration of bile salts in patients with obstructive jaundice?
To alleviate symptoms of obstructive jaundice
What is the primary benefit of using laparoscopic surgery over traditional open techniques?
Less postoperative pain and faster recovery
What laboratory test is essential to evaluate liver function in patients presenting for cholecystectomy?
Liver function tests (LFTs) including bilirubin, AST, ALT, ALP, and albumin
What is the primary indication for fluid resuscitation in patients presenting for cholecystectomy?
Signs and symptoms of hemodynamic compromise
What is the primary method used to introduce a video laparoscope into the abdomen during laparoscopic surgery?
Through a cannula or trocar
What is the function of cholecystokinin?
Causing contraction of the gallbladder
What is the average volume of bile secreted per day?
500-1000 mL
What is the composition of gallstones?
Bile acids, bile pigments, cholesterol, and calcium
What is the characteristic pain associated with cholecystitis?
Severe right upper abdominal pain radiating to the right shoulder
What is the diagnostic evaluation used to assess for the presence of cholecystitis?
Murphy sign
What is the blood test result in patients with cholecystitis?
Increased plasma bilirubin, ALP, and amylase
What is the treatment for ileus in patients with cholecystitis?
Nasogastric tube
What is the estimated percentage of patients who develop cholecystitis and become symptomatic?
20%
What is the surgical approach used in less than 10% of cholecystectomy procedures?
Open
What is the purpose of insufflation of carbon dioxide in a laparoscopic cholecystectomy?
To create a pneumoperitoneum
What is the primary benefit of using general anesthesia for laparoscopic cholecystectomy?
To allow for airway protection and control of CO2 during artificial ventilation
Why is carbon dioxide preferred for insufflation during laparoscopic surgical procedures?
It is noncombustible and can be used with electro-cautery
What is the advantage of using muscle relaxation during laparoscopic cholecystectomy?
It minimizes abdominal insufflation pressures
Why is a significant amount of narcotic not warranted for laparoscopic cholecystectomy?
Because the degree of postoperative discomfort is rarely extreme
What happens to the CO2 absorbed during laparoscopic insufflation?
It is rapidly eliminated from the lungs by increasing minute ventilation
What is a potential complication of CO2 absorption during laparoscopic insufflation?
Increased end-tidal CO2
What is the primary effect of CO2 absorption during laparoscopic procedures on the heart rate?
Decrease
What happens to intracranial pressure during pneumoperitoneum?
Increases
What is the effect of increased vagal tone on the heart?
Decreased heart rate, contractility, and rate of cardiac impulse conduction
What is a potential complication of laparoscopic cholecystectomy?
Increased risk of regurgitation
What is the reason for decreased renal blood flow during laparoscopic surgery?
All of the above
What is the cause of subcutaneous emphysema in laparoscopic surgery?
Accidental extraperitoneal insufflation
Why is laparoscopic surgery contraindicated in patients with increased intracranial pressure?
Due to the risk of increased intracranial pressure
What is a rare but life-threatening complication of laparoscopic cholecystectomy?
Pneumothorax
What happens to hepatic and splanchnic blood flow during pneumoperitoneum?
Decreases
What is the treatment for carbon dioxide gas embolism?
All of the above
What is the cause of bradycardia and cardiac arrest during CO2 absorption?
Vagal nerve stimulation
What is the effect of steep reverse Trendelenburg positioning on lung and chest compliance?
Increases
What is the effect of a carbon dioxide gas embolism on the heart?
Decreased blood flow through the heart
What is the position of the patient during treatment of a carbon dioxide gas embolism?
Left lateral decubitus position with the head oriented downward
What is the primary reason for monitoring ETCO2 levels during laparoscopic surgery in patients with normal pulmonary physiology?
To monitor PaCO2 levels
What is the effect of subcutaneous emphysema on the CO2 levels?
Increased CO2 levels
What is the cause of the sudden decrease in heart rate from 82 to 36 beats per minute during insufflation?
Stretching of the abdominal cavity
What is the cause of pneumothorax during laparoscopic cholecystectomy?
All of the above
What is the effect of abdominal insufflation on renal blood flow and glomerular filtration rate?
Decreases renal blood flow and glomerular filtration rate
What is a potential complication of open cholecystectomy?
All of the above
What is the primary mechanism by which a pneumoperitoneum affects the cardiovascular system during laparoscopic cholecystectomy?
All of the above
What is the typical gradient between PaCO2 and ETCO2 in healthy patients?
3-5 mmHg
What occurs when intraabdominal pressure exceeds 20 Torr during laparoscopic cholecystectomy?
Venous return to the heart decreases
What is the effect of a pneumoperitoneum on pulmonary function during laparoscopic cholecystectomy?
All of the above
What is the primary purpose of maintaining normocapnia during laparoscopic cholecystectomy?
To prevent coronary and cerebral vascular dilation
What is the effect of a pneumoperitoneum on cardiac workload and myocardial oxygen requirements?
Increases cardiac workload and myocardial oxygen requirements
Why are laparoscopic procedures relatively contraindicated for patients with severely limited cardiac reserve?
Due to the increased cardiac workload and myocardial oxygen requirements
What is the effect of the reverse Trendelenburg position on venous return to the heart during laparoscopic cholecystectomy?
Decreases venous return to the heart
What is the effect of CO2 absorption on the PaCO2-ETCO2 gradient during laparoscopic cholecystectomy?
Increases the PaCO2-ETCO2 gradient
What is the effect of insufflation of CO2 on the pericardium and mediastinum during laparoscopic cholecystectomy?
CO2 accumulates in the pericardium and mediastinum
What is the primary factor that stimulates the sympathetic nervous system during the postoperative period?
Pain
What is the primary purpose of elevating the head of the patient's bed during the postoperative period?
To promote respiratory excursion
What is the primary effect of abdominal splinting on respiratory function?
Decreased tidal volume
What is the primary reason for administering analgesic medications during the postoperative period?
To alleviate discomfort
What is the primary treatment for extreme hypertension and tachycardia during the postoperative period?
Vasodilators and beta-blockers
What is the primary factor that determines the severity of postoperative pain?
Individual patient variability
What is the primary cause of shoulder tip pain during laparoscopic cholecystectomy?
Diaphragmatic irritation caused by CO2 gas
Which medication decreases postoperative pain without inhibiting ventilation or causing sedation?
Ketorolac
What is the incidence of nausea and vomiting for patients after the administration of anesthesia?
30% to 70%
What type of medication is aprepitant?
Neurokinin type 1 receptor antagonist
What is the benefit of using multimodal drug therapy for treating nausea and vomiting?
It is more effective than monotherapy
What is the primary mechanism of pain relief in patients undergoing laparoscopic cholecystectomy?
Decrease in postoperative pain
Study Notes
Cholecystectomy: Open and Laparoscopic Approach
- Less than 10% of patients undergoing cholecystectomy require an open technique, with less than 5% of laparoscopic procedures requiring conversion to an open approach.
- Laparoscopic surgery has several benefits, including decreased postoperative respiratory dysfunction, pain, and analgesic requirements, leading to reduced lethargy, nausea, vomiting, and constipation.
Pathophysiology of the Gallbladder
- The gallbladder is a hollow, pear-shaped organ located on the underside of the right lobe of the liver that stores and concentrates bile.
- The cystic duct connects the gallbladder to the common hepatic duct, forming the common bile duct.
- Bile is composed of bile salts, bile pigments, cholesterol, and calcium, and aids in the intestinal absorption and breakdown of dietary fat.
- The gallbladder releases bile into the duodenum through the relaxation of the sphincter of Oddi, regulated by cholecystokinin, a hormone secreted by the duodenum.
- Normally, 500-1000 mL of bile are secreted per day.
Cholelithiasis and Cholecystitis
- Gallstones are formed from bile and can obstruct the cystic duct, leading to cholecystitis, an infection and inflammation of the gallbladder.
- Cholecystitis presents with severe right upper abdominal pain radiating to the right shoulder, and is more common in females, obese individuals, parous women, and the elderly.
- Diagnostic evaluation includes the Murphy sign, blood tests (increased plasma bilirubin, ALP, and amylase), and imaging studies (cholescintigraphy).
- Complications of cholecystitis include ileus, localized tenderness, and jaundice.
Surgical Procedures
- A cholecystectomy can be performed as an open or laparoscopic procedure.
- Open cholecystectomy involves making a right subcostal or midline incision, dissection into the peritoneal cavity, and excision of the gallbladder.
- Laparoscopic cholecystectomy involves insufflation of carbon dioxide into the peritoneum, creation of a pneumoperitoneum, and visualization of the operative field using a video laparoscope.
Anesthetic Management and Considerations
- Patients undergoing cholecystectomy may have associated disease states, including gastrointestinal disorders, cirrhosis, hemolytic disorders, choledocholithiasis, and pancreatitis.
- Respiratory function may be impaired in patients with cholecystitis, leading to atelectasis, decreased functional residual capacity, and hypoventilation.
- Preoperative evaluation should include hemodynamic status, blood pressure, heart rate, and orthostatic hypotension, with fluid resuscitation recommended for dehydrated patients.
- Preoperative testing should include chest x-ray, electrocardiogram (ECG), urinalysis (UA), blood urea nitrogen (BUN), and creatinine.
- Patients may be at risk of renal insufficiency, gastrointestinal pathology, and bile duct obstruction, necessitating further evaluation and management.
This quiz covers the surgical approaches to cholecystectomy, including open and laparoscopic techniques, as well as anesthetic management considerations for patients undergoing the procedure. Topics include pathophysiology of the gallbladder, cholelithiasis and cholecystitis, and preoperative evaluation.
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