CHOLECYSTECTOMY (LAPAROSCOPIC)

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A laparoscopic cholecystectomy is a surgical procedure used to remove the gallbladder. The gallbladder is a small organ located under your liver that stores and concentrates bile, a digestive enzyme produced by the liver.

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It is performed to treat gallstones and diseases of the gallbladder.

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A laparoscopic cholecystectomy is performed under general anesthesia. The surgeon makes several small incisions in the abdomen. A port (trocar) is inserted into one of the incisions, and carbon dioxide gas inflates the abdomen. This helps to increase the visibility of the gallbladder and surrounding organs.

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A laparoscope, a long, thin tube with a high-intensity light and a high-resolution camera at the front, is inserted through another port. The camera displays images on a video monitor, allowing the surgeon to see inside the abdomen and guide the surgical instruments.

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The surgeon then uses specialized tools to separate the gallbladder from its attachments (the cystic duct and artery) and then removes it from the body through one of the ports.

 

After the gallbladder has been removed, the surgeon will deflate the abdomen and remove the ports. The incisions are then closed with sutures or staples and covered with dressings.

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                                     Anesthetic Implications for Laparoscopic Cholecystectomy

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Anesthesia type: General with ETT

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Airway: Endotracheal tube

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Preoperative:

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• Patients with acute cholecystitis may present with severe abdominal pain causing diaphragmatic splinting and basal lung atelectasis

• Assess for the possibility of a "full stomach"

• An orogastric tube should be inserted to decompress the stomach

• Make sure the patient is securely strapped

• Opioids may cause Sphincter of Oddi spasms 

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Intraoperative:

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• Carbon dioxide is used to insufflate the abdomen to help visualization

• Intraadbominal CO2 insufflation causes atelectasis, decreased pulmonary compliance and decreased functional residual capacity (FRC)

• CO2 insufflation is associated with increased PIP, increased PaCo2 and decreased PaO2

• Intraabdominal pressure greater than 15 mmHg may be associated with decreased venous return, increased systemic vascular resistance, and decreased cardiac output

• Risk of bradycardia with pneumoperitoneum 

• An intraoperative cholangiogram may be performed (requires fluoroscopy)

• Position: reversed T-burg with left-sided tilt (decreases venous return, increases lung volumes)

• EBL minimal

• Duration 0.5-2 hours. Intraoperative cholangiogram may add 10-20 minutes

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Postoperative:

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• Pain management

• PONV prophylaxis

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Complications:

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• Bleeding

• Injury to bowel

• Infection

• Major vascular injury

• Pneumoperitoneum

• Pneumothorax

• Pneumomediastinum

• Hypercarbia/hypoxemia

• Endobronchial intubation

• Subcutaneous emphysema

• PONV

• Shoulder pain from insufflation

• Pancreatitis

• Atelectasis 

• Venous embolism

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Sources:

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Macksey, L. F. (2011). Surgical procedures and anesthetic implications: A handbook for nurse anesthesia practice. 

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Jaffe, R. A. (2020). Anesthesiologist's Manual of Surgical Procedures (6th ed.). 

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Singh-Radcliff, N. (2013). 5-Minute Anesthesia Consult.

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