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Laparoscopic Cholecystectomy

Laparoscopic Cholecystectomy. Ri 毛贊智 Ri 黃彥筑. ／VS 林珍榮. Brief history. 67 y/o male Multiple gallbladder polyps(0.8cm) noted for 3~4 years GB stone was also noted No RUQ pain, nausea or vomiting. Past history. DM: (-)

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Laparoscopic Cholecystectomy

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  1. LaparoscopicCholecystectomy Ri 毛贊智 Ri 黃彥筑 ／VS 林珍榮

  2. Brief history • 67 y/o male • Multiple gallbladder polyps(0.8cm) noted for 3~4 years • GB stone was also noted • No RUQ pain, nausea or vomiting

  3. Past history • DM: (-) • HTN: (+) for 17 years, under regular medical control • Elevated renal function for 3~4 years • BPH with medical treatment • Appendectomy 10 years ago • Allergic to sulfa-drug

  4. Physical examination • BH: 163 cm BW: 77 kg • BT: 36.8 PR: 80 • RR: 20 BP: 160/80 • Breathing sound: clear • Heart sound: normal • Abdomen: normal, no RUQ pain

  5. Lab examination • BUN: 36.3 Cre: 5.2 • Na: 145 K: 4.3 Cl: 107 • T-bil: 0.4 • WBC: 9.64 • RBC: 4.25*106 Hb: 13.4 • PT: 11.1/11.7 PTT: 32.4/35.1

  6. Operation method • Laparoscopic cholecystectomy

  7. Drug used • ASA class III • Induction • Fentanyl 100μg • Atracurium 25mg • Midazolam 5mg • Pentothal 250mg • Robinul 0.2mg • Maintain • Isoflurane

  8. Operation course • Quite smooth • BP: 100~120 • HR: 60~70 • SpO2: 99~100% • ETCO2: 33~35 • Use 1 hr 15 min

  9. Post OP follow up • No PONV • Pain score: 2 • Demerol 50 mg q6h • Acetaminophen 1# qid • No sore throat • No headache

  10. Laparoscopic Cholecystectomy(LC) • Indication: • Symptomatic gallstones • Other biliary tract disease • Difficult technical challenges • Acute cholecystitis • Obesity • Previous intra-abdominal surgery • Pregnancy

  11. LC-surgical technique • Reverse Trendelenburg position • Intraperitoneal CO2 insufflation

  12. LC-surgical technique

  13. Benefit of LC • Shorter hospital stays • More rapid return to normal activities • Small, limited incisions • Less pain • Less postoperative ileus

  14. LC vs OC • Treatment of Acute Cholecystitis • Conversion rate: 15% • Operationg time: 88 vs 77 mins • Complication: 14% vs 23% • Hospital stay: 3.3 vs 8.1 days Laparoscopic cholecystectomy vs Open cholecystectomy in the treatment of acute cholecystitis(ARCH SURG volume 133)

  15. Anesthetic management • Anesthetic technique • Regional anesthesia • Thoracic epidural anesthesia(T2) • Advantage: • Awake • Protective airway reflex • Shorter recovery • Disadvantage: • Diaphragm irritation • Significant nausea and vomiting • Referred pain : neck and shoulder

  16. Anesthetic management • Anesthetic technique • General anesthesia • Cuffed endotracheal tube placement • Controlled ventilation • Urinary catheter and nasogastric tube

  17. Anesthetic management • Anesthetic agents • Oxygen • Nitrous oxide • Volatile anesthetic agent • Relaxants • Opioids: Oddi sphincter spasm

  18. Anesthetic management • Use of nitrous oxide • Controversial • Bowel distention • Postoperative nausea

  19. Anesthetic management • Monitoring • PETco2 • Increased minute ventilation by 12~16% • Paco2 must less than 41 mmHg • Invasive hemodynamic monitoring • ASA class III~IV • Especially at p’t with cardiopulmonary disease

  20. Anesthetic management • Post operative pain relief • Wound infiltration with local anesthesia and NSAID - for peripheral pain • Opioids - for central pain • Ondansetron – for nausea and vomiting

  21. Take a rest……

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