Perioperative management - Cholecystectomy, laparoscopic

Symptomatic cholecystolithiasis or gallbladder sludge with characteristic biliary pain.

Asymptomatic cholecystolithiasis with evidence of gallstones > 3 cm, gallbladder polyps > 1 cm, or porcelain gallbladder (significantly increased risk of gallbladder carcinoma).

Biliary colic in the first trimester of pregnancy should be treated with early elective surgery due to a high risk of recurrence during the course of pregnancy.

Acute cholecystitis: According to guidelines, early laparoscopic surgery should be performed within 24 hours of hospital admission. Alternatively, if symptoms have persisted for more than 5 days, in cases of ongoing anticoagulation therapy, or in patients with complex comorbidities requiring further evaluation, surgery should be performed in the asymptomatic interval 6 weeks after the acute inflammation.

After successful bile duct clearance in patients with additional cholecystolithiasis, surgery should be performed within 72 hours whenever possible.

After acute biliary pancreatitis with resolving cholestasis/pancreatitis and without the need for ERCP, early elective surgery is recommended to prevent a high risk of recurrent pancreatitis.

• Tumors of the gallbladder and bile ducts
• significant intra-abdominal adhesions
• biliodigestive fistulas
• pregnancy in the last trimester
• Mirizzi syndrome (rare form of obstructive jaundice) from the advanced stages with fistula formation

Relative contraindications

• Acute pancreatitis
• Portal hypertension

• History: Colicky pain (> 15 minutes) in the right upper abdomen/epigastrium, jaundice, and fever are key symptoms of gallbladder and bile duct diseases.
• Clinical examination: Typical symptoms of acute cholecystitis include right upper abdominal pain, Murphy's sign (localized pain over the gallbladder with direct pressure), elevated inflammatory markers, and fever.
• Laboratory: Complete blood count, CRP, transaminases, bilirubin, amylase, lipase, in case of suspected malignancy possibly tumor marker CA 19-9, preoperative coagulation, electrolytes, creatinine if necessary.
• Abdominal ultrasound examination: Detection of stones, wall thickening, or triple-layering of the gallbladder wall, as well as sonographic-palpatory Murphy's sign in acute cholecystitis.
• If there are no indications of choledocholithiasis (clinical, laboratory, and ultrasound), further imaging can be omitted.
• An ERCP (endoscopic retrograde cholangiography) should only be performed with therapeutic intent. In case of doubt, precede with endosonography or MRCP.
• Endosonography has the highest sensitivity for detecting stones in the common bile duct.
• CT, MRCP/MRI in case of unclear ultrasound findings or suspicion of a tumor.
• Choledochoscopy only for specific questions, suspicion of malignancy, or unclear findings, especially for clarifying bile duct pathologies.
• Gastroscopy if the clinical picture is not clear and the symptoms could also originate from the stomach.

• In acute cholecystitis or choledocholithiasis: Perioperative antibiotic therapy
• Otherwise, optional perioperative single-shot antibiotic prophylaxis

• Conversion to open cholecystectomy
• Bile duct injury
• Gallbladder perforation
• Intra-abdominal stone loss
• Vascular injury (hepatic artery, portal vein)
• Injury to adjacent organs: duodenum, small intestine, colon, liver
• Peritonitis
• Abscess
• Subsequent intervention

Intubation anesthesia in capnoperitoneum

• Supine position
• left arm positioned
• legs spread

The surgeon stands between the spread legs, the first assistant on the left side (camera guidance), the second assistant (optional) towards the head of the first assistant (liver retractor). The scrub nurse stands over the patient's left leg. The laparoscopy tower is on the right side, the monitor in good view of the surgeon.

• laparoscopic basic tray

additionally:

• trocars
• 45° (or 30°) camera
• grasping forceps
• dissector
• electro hook
• suction device
• if necessary, liver retractor
• scissors
• titanium or laparo-clips
• retrieval bag
• re-order

Postoperative analgesia: Nonsteroidal anti-inflammatory drugs usually suffice; if necessary, they can be enhanced by opioid analgesics.

Follow this link to PROSPECT (Procedures Specific Postoperative Pain Management).

This link will take you to the International Guideline Library.

Postoperative care: At end of procedure remove any gastric tube; lab panel with transaminases and bilirubin on postop. day 1; remove any drains on postop. day 2 or 3; unless absorbable sutures were used, remove stitches on day 10 - 12 after surgery.

Deep venous thrombosis prophylaxis: Unless contraindicated, the moderate risk of thromboembolism (surgical operating time > 30 min) calls for prophylactic physical measures and low-molecular-weight heparin, possibly adapted to weight or dispositional risk, until full ambulation is reached.

Note: Renal function, HIT II (history, platelet check)

This link will take you to the International Guideline Library.

Ambulation: Immediate mobilization

Physical therapy: Possibly prophylactic respiratory therapy for pneumonia

Diet: Unrestricted

Bowel movement: Laxatives may have to be started on postoperative day 2

Work disability: 5-12 days