Perioperative management - Cholecystectomy, open

Note: The laparoscopic cholecystectomy is considered the gold standard! Therefore, there must always be special reasons for an open procedure.

General Indications

• Symptomatic cholecystolithiasis
• Choledocholithiasis with or without biliary pancreatitis
• Cholecystitis
• Gallbladder empyema and gangrene
• Cystic duct obstruction
• Benign and malignant gallbladder tumors
• Mirizzi syndrome
• Chronic Salmonella carriers

Special Indications

• Extensive previous operations in the upper abdomen
• Unclear anatomical conditions
• Abscesses and larger empyemas
• Patients who, due to their condition, cannot tolerate a capnoperitoneum
• Choledocholithiasis that cannot be treated endoscopically
• Confirmed malignancy

Severe comorbidity is not a reason not to operate in the case of a vital indication.

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

• In acute cholecystitis or choledocholithiasis: perioperative antibiotic therapy
• In elective cholecystectomy: Discontinuation of Metformin, switch from phenprocoumon to low-molecular-weight heparin
• Otherwise optional perioperative single-shot antibiotic prophylaxis

General: 

Thrombosis, Embolism, Pneumonia, Keloid formation, Scar hernias, Injury to skin nerves, Intolerance to medications, Wound infection, Secondary bleeding, Hematoma formation, Seroma

Specific: 

Injury to abdominal organs such as colon and small intestine, stomach, liver
Injury or severance of the draining bile ducts with their sometimes significant consequences
Possible lifelong change in dietary and bowel habits
Bile fistulas
Pancreatitis

Note: 

Injuries to the bile ducts are complications with significant morbidity and mortality.

Intubation anesthesia

• Legs lengthwise on the table
• Hyperlordosis with slightly elevated upper body
• Arms can be variably abducted or adducted. On the left side, adduction is recommended, since the image intensifier may be used from here if necessary.

• Surgeon on the right, assistant on the left patient side ( for open cholecystectomy, a 2nd assistant is usually very helpful )
• OR nurse with instrument table at the foot end
• If necessary, image intensifier with monitor to the left of the patient

• Standard laparotomy tray with long, wide as well as narrow liver retractors
• Diathermy, a bipolar scissors is very helpful
• Abdominal retractor

postoperative analgesia:

Non-steroidal anti-inflammatory drugs are generally sufficient; if necessary, escalation with opioid-containing analgesics can occur.
Follow the link here to PROSPECT (Procedures Specific Postoperative Pain Management).
Follow the link here to the current guideline: Treatment of acute perioperative and posttraumatic pain.

medical follow-up:

• Any gastric tube is removed at the end of the operation
• Laboratory check with the following parameters on the 1st-2nd postop. day: small CBC, CRP, transaminases, bilirubin, amylase and lipase. In case of abnormalities, further diagnostics such as ultrasound, MRI, CT or ERCP.
• Monitoring of the quality and quantity of the drainage secretion. Usually removal on the 2nd or 3rd postoperative day. In case of abnormalities, further diagnostics, see above.
• If non-absorbable suture material was used, suture removal occurs on the 10th-12th postoperative day.

Thrombosis prophylaxis: 

In the absence of contraindications, due to the moderate thromboembolic risk (surgical procedure > 30min duration), low-molecular-weight heparin should be administered in prophylactic, possibly weight- or disposition risk-adapted dosage, in addition to physical measures, until full mobilization is achieved. 
To be noted: renal function, HIT II (history, platelet control)
Follow the link here to the current guideline: Prophylaxis of venous thromboembolism (VTE).

Mobilization: immediate

Physiotherapy: if necessary, breathing exercises for pneumonia prophylaxis

Diet buildup: immediate

Stool regulation: if necessary, laxatives from the 2nd day

Incapacity for work: 2-4 weeks

Note: In case of deviating course, an immediate clarification of the cause must be enforced with all means!