Perioperative management - Cholecystectomy, open

Note:  Today, laparoscopic cholecystectomy is regarded as the gold standard! Open procedures therefore require special indications.

General indications

• Symptomatic cholecystolithiasis
• Choledocholithiasis with/without biliary pancreatitis
• Cholecystitis
• Empyema or gangrene of the gallbladder
• Cystic duct obstruction
• Benign and malignant tumor of the gallbladder
• Mirizzi syndrome
• Chronic salmonella carrier

Specific indications

• Extensive previous upper quadrant surgery
• Unclear anatomy
• Abscesses and larger empyemas
• Patients with conditions unable to tolerate pneumoperitoneum
• Choledocholithiasis not amenable to endoscopic treatment
• Confirmed malignancy

In vital indications, severe comorbidity does not constitute grounds enough to forgo surgery.

• Patient history and clinical examination
• Lab panel: Red blood count, CRP, transaminases, bilirubin, amylase, lipase; in case of suspected malignancy possibly also tumor marker CA 19-9; before surgery possibly coagulation panel, electrolytes, creatinine
• Ultrasound study
• CT, MRCP, endoscopic ultrasound, ERCP; choledochoscopy reserved for special cases, suspected malignancy and unclear findings, particularly when working up bile duct pathology
• Gastroscopy when the clinical picture is ambivalent and the complaints might also arise from the stomach

• In acute cholecystitis and choledocholithiasis: Perioperative antibiotic regimen
• In elective cholecystectomy: Discontinue metformin; switch from phenprocoumon to low-molecular weight heparin
• Otherwise: Perioperative single-shot antibiotic prophylaxis

General: Thrombosis, embolism, pneumonia, keloid formation, incisional hernias, injuries to cutaneous nerves, drug intolerance, wound infection, secondary hemorrhage, hematoma, seroma

Specific: Injury to abdominal organs, e.g., colon, small intestine, stomach, liver

Injury to and transection of the extrahepatic bile ducts with at times massive consequences

Possible lifelong changes in dietary and bowel habits

Biliary fistula

Pancreatitis

Note: Biliary duct injuries are complications resulting in significant morbidity and mortality.

General anesthesia

• Supine, with legs adducted
• Marked lordosis with upper body slightly elevated
• Arms may be abducted or adducted; it is recommended to adduct the left arm because this is where the C-arm may have to be positioned (if needed)

• Surgeon on right and assistant on left side of patient (in open cholecystectomy a second assistant often proves helpful)
• Scrub nurse and instrument table at the patient’s feet
• If needed, C-arm with monitor on left side of patient

• Standard laparotomy set with long, wide and slim liver retractors
• Electrocautery, bipolar scissors are quite helpful
• Abdominal retractor

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 medical management: Any gastric tube should be removed at the end of the procedure; lab panel with these parameters on postoperative day 1 or 2: Red blood count, CRP, transaminases, bilirubin, amylase, and lipase. In case of abnormalities additional diagnostic studies, e.g., ultrasound, MRI, CT or ERCP. Monitoring the amount and quality of the drained fluid. Drains are usually removed on day 2 or 3 after surgery. In case of abnormalities additional diagnostic studies, see above. If the skin was closed with non-absorbable sutures, these are removed 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. This link will take you to the International Guideline Library.

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

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: 2-4 weeks

The cause of any abnormal change in the course must be diagnosed immediately and by all means possible!