Cholecystectomy Case Study PDF

Cholecystectomy: Open and laparoscopic approaches Key points - The open technique is utilized in less than 10% of patients having a cholecystectomy. - It is estimated that less than 5% of these procedures will require conversion to an open technique. - Many benefits are associated...

Cholecystectomy: Open and laparoscopic approaches Key points - The open technique is utilized in less than 10% of patients having a cholecystectomy. - It is estimated that less than 5% of these procedures will require conversion to an open technique. - Many benefits are associated with the laparoscopic surgical technique compared with the traditional open technique, including decreased postoperative respiratory dysfunction, decreased postoperative pain, and decreased postoperative analgesic requirements, which reduce lethargy, nausea, vomiting, and constipation. - Alterations in normal physiologic functioning occur as a result of the creation of a pneumoperitoneum during laparoscopic cholecystectomy. Case synopsis A 40-year-old man presents to the emergency room vomiting with severe upper right abdominal pain. The patient is evaluated by a general surgeon with a diagnosis of cholecystitis and prepared for emergency cholecystectomy. Preoperative evaluation and demographic data - Past medical/surgical history - Cholelithiasis - Alcohol abuse - Left knee anterior cruciate ligament repair, no anesthetic complications. - List of medications - Thiamin - Folic acid - Laboratory tests - Hemoglobin, 14.8 g/dL; hematocrit, 44%; white blood cells, 7.9/mm3; platelet count, 270/mm3 - Blood urea nitrogen (BUN), 20 mg/dL; creatinine, 1.1 mg/dL - Electrolytes: sodium, 142 mEq/L; potassium, 4.0 mEq/L; chloride, 101 mEq/L; carbon dioxide, 28 mEq/L - Coagulation: prothrombin time, 10.4 seconds; partial thromboplastin time, 41.1 seconds; international normalized ratio, 1.03 - Liver function: bilirubin, 1.0 mg/dL; aspartate aminotransferase (AST), 28 units/L; alanine aminotransferase (ALT), 30 units/mL; alkaline phosphatase (ASP), 1.9 units/mL; and albumin, 3.9 g/dL - Height/weight/vital signs - 173 cm, 85 kg; body mass index (BMI), 28.4 - Blood pressure, 168/86; heart rate, 95 beats per minute; respiratory rate, 22 breaths per minute; room air--oxygen saturation, 98%; temperature, 37.6°C - Electrocardiogram: normal sinus rhythm Pathophysiology The gallbladder is a hollow, pear-shaped organ that is located on the underside of the right lobe of the liver. Bile that is produced within the liver is stored in the gallbladder until it is released into the intestine. The cystic duct connects the gallbladder to the common hepatic duct, forming the common bile duct. The gallbladder concentrates and acts as a reservoir for bile. Bile salts, bile pigments, cholesterol, and calcium are component parts that comprise bile. The role of bile is to aid in the intestinal absorption and breakdown of dietary fat. When the gallbladder becomes full, the sphincter of Oddi will relax, allowing bile to be released into the duodenum. Cholecystokinin, a hormone secreted by the duodenum in response to acid contents, causes contraction of the gallbladder and relaxation of the sphincter of Oddi. Normally, 500 to 1000 mL of bile are secreted per day. Cholelithiasis results in hard masses formed within the gallbladder. Gallstones are formed from bile, which is composed of bile acids, bile pigments, cholesterol, and calcium. These stones can become lodged in the cystic duct, resulting in obstruction. Cholecystitis occurs as a result of infection, inflammation, and from the blockade of bile flow through the cystic duct or common bile duct. This result can cause severe right upper abdominal pain that characteristically radiates to the right shoulder. Patients with cholecystitis typically present with an acute, severe mid-gastric pain that radiates to the right abdominal quadrants. Patient factors that increase the risk for developing cholecystitis include female gender, obesity, parity, and age. A diagnostic evaluation called Murphy sign can be used to assess for the presence of cholecystitis. During an abdominal examination, the patient is asked to exhale while the practitioner places their hand over the approximate location of the gallbladder. The patient is instructed to inhale, and if the patient stops breathing, this sign may be indicative of abdominal tenderness resulting from gallbladder disease. The blood test results in patients that have cholecystitis include increased plasma bilirubin, ALP, and amylase. Ileus and localized tenderness may indicate a gallbladder perforation with associated peritonitis. If complete obstruction of the cystic duct occurs, jaundice may occur. Confirmation of cholecystitis is accomplished by cholescintigraph, a contrast study of the gallbladder that is accomplished by ultrasonography. Patients who have cholecystitis are frequently dehydrated caused by decreased oral intake, vomiting, or nasogastric tube evacuation. Unless other pathophysiologic conditions exist that preclude fluid resuscitation, it is warranted to correct volume depletion. Ileus should be treated with a nasogastric tube. Free air that is determined to be present within the abdomen causes fever, ileus, abdominal rigidity and pain, vomiting, and dehydration. It is estimated that 20% of patients who develop cholecystitis will become symptomatic and develop pain when biliary obstruction occurs. Surgical procedures A cholecystectomy can be performed as an open procedure or by a laparoscopic approach. For patients who have undergone previous abdominal surgeries, adhesions around the past surgical field can increase the complexity of the surgical procedure. Significant medical problems such as obesity, cardiac and pulmonary pathology, and coagulopathy will complicate the anesthetic management. The open technique is utilized in less than 10% of cholecystectomy procedures performed. It is estimated that less than 5% of laparoscopic cholecystectomy procedures will be converted to the open approach. Open cholecystectomy An open cholecystectomy is performed by making a right subcostal or midline incision into the abdominal wall. Dissection into the peritoneal cavity occurs, and traction is placed on the liver and the duodenum until maximum exposure of the gallbladder, cystic duct, cystic artery, and common bile duct is achieved. The gallbladder is excised from the liver bed, followed by isolation of the cystic artery and cystic duct. Alternative techniques include isolation of the cystic duct and cystic artery first, followed by retrograde removal of the gallbladder from the liver bed. Laparoscopic cholecystectomy A laparoscopic cholecystectomy is initiated through insufflation of carbon dioxide (CO2) into the patient's peritoneum in order to create a pneumoperitoneum. A Veress needle is inserted just below the umbilicus and then introduced into the peritoneal cavity. Correct needle placement is confirmed in several ways. The most common method is for the surgeon to feel and hear a distinct "pop" that occurs when the needle pierces the fascia and peritoneum. A more scientific and safe approach is accomplished by placing a drop of water on the hub of the Veress needle. Due to the negative pressure that is present in the peritoneal cavity, a drop of water will be drawn inward when placed in the hub of the Veress needle, confirming proper placement. An alternative method, the Hasson technique, involves creating a small incision through the abdominal fascia in order to place the trocars in the abdomen. Confirmation of proper location is further demonstrated by percussion of the CO2 in the abdomen during insufflation. Once correct needle placement is confirmed, it is replaced with a cannula or trocar, which allows for a video laparoscope to visualize the operative field and instruments to be inserted. Anesthetic management and considerations for cholecystectomy Preoperative period 1\. Identify the associated disease states that commonly occur in patients having a cholecystectomy. 2\. Describe the alteration in respiratory dynamics that occurs in patients who have cholecystitis. 3\. Describe the potential decreased intravascular volume status and management for patients having a cholecystectomy. 4\. Describe the benefits of using laparoscopic surgery versus open procedures. 5\. Describe the potential for renal insufficiency for patients having a cholecystectomy. 6\. Describe the potential for gastrointestinal pathology for patients having a cholecystectomy. 7\. Discuss premedication for the cholecystectomy patient. Intraoperative period 8\. Describe the anesthetic technique used for laparoscopic cholecystectomy. 9\. Which gas is utilized for insufflation during laparoscopic surgical procedures? 10\. Explain the effect of a pneumoperitoneum during laparoscopic cholecystectomy on the following body systems: cardiovascular, pulmonary, cerebral, renal, and hepatic. 11\. Discuss the effects of CO2 absorption during laparoscopic procedures. 12\. Examine the effects of steep reverse Trendelenburg positioning for laparoscopic cholecystectomy. 13\. During insufflation of CO2, the patient's heart rate abruptly decreases from 82 to 36 beats per minute. Identify the cause and treatment of this situation. 14\. What are the potential complications associated with open cholecystectomy? 15\. List the potential complications associated with laparoscopic cholecystectomy. Postoperative period 16\. Identify the key aspects of postoperative anesthetic management for a patient having an open cholecystectomy or laparoscopic cholecystectomy. Review questions 1\. Which gas is routinely used during laparoscopic surgery to create a pneumoperitoneum? 2\. Which is not a hemodynamic change associated with a pneumoperitoneum? 3\. Which respiratory effect occurs during carbon dioxide insufflation for laparoscopic surgery? 4\. Which renal effect occurs during carbon dioxide insufflation for laparoscopic surgery? 5\. Which preoperative laboratory test is not indicated for a patient having a cholecystectomy?