Cholecystectomy - Revision history

Chris.Rishel at 06:20, 5 April 2022

2022-04-05T06:20:55Z

Svdg at 00:12, 4 August 2021

2021-08-04T00:12:18Z

← Older revision		Revision as of 17:12, 3 August 2021
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	{{Infobox surgical case reference		{{Infobox surgical case reference
	\| anesthesia_type = General		\| anesthesia_type = General
	\| airway = ~~Endotracheal tube~~		\| airway = ETT
	\| lines_access = Peripheral IV		\| lines_access = Peripheral IV
	\| monitors = ~~Standard ASA<br />~~		\| monitors = No procedure-specific monitoring requirements
	5-~~lead EKG~~		\| considerations_preoperative = PONV prophylaxis
	\| considerations_preoperative = ~~NG Tube~~		\| considerations_intraoperative = General considerations for laparoscopic surgery
	\| considerations_intraoperative = ~~Rapid sequence intubation~~		\| considerations_postoperative = PONV, consider TAP block
	\| considerations_postoperative = PONV
	}}Cholecystectomy is performed to treat symptomatic cholelithiasis and its complications (e.g., cholecystitis, pancreatitis, cholangitis), and other gallbladder conditions (e.g., polyps, porcelain gallbladder). This is one of the most common procedures performed in hospitals in the United States. Of the more than 20 million people in the US with gallstones, about 30% will eventually require cholecystectomy to relieve symptoms or treat complications. Cholecystectomy is most commonly performed laparoscopically, though there are specific indications for open surgery. The rate of conversion to an open operation is 2-3% for elective surgery and ~10% for acute cholecystitis<ref>{{Cite book\|last=Jaffe\|first=Richard A\|url=http://public.ebookcentral.proquest.com/choice/publicfullrecord.aspx?p=3418805\|title=Anesthesiologist's manual of surgical procedures\|last2=Schmiesing\|first2=Clifford A\|last3=Golianu\|first3=Brenda\|date=2014\|isbn=978-1-4963-0594-7\|language=English\|oclc=888551588}}</ref>.		}}Cholecystectomy is performed to treat symptomatic cholelithiasis and its complications (e.g., cholecystitis, pancreatitis, cholangitis), and other gallbladder conditions (e.g., polyps, porcelain gallbladder). This is one of the most common procedures performed in hospitals in the United States. Of the more than 20 million people in the US with gallstones, about 30% will eventually require cholecystectomy to relieve symptoms or treat complications. Cholecystectomy is most commonly performed laparoscopically, though there are specific indications for open surgery. The rate of conversion to an open operation is 2-3% for elective surgery and ~10% for acute cholecystitis<ref>{{Cite book\|last=Jaffe\|first=Richard A\|url=http://public.ebookcentral.proquest.com/choice/publicfullrecord.aspx?p=3418805\|title=Anesthesiologist's manual of surgical procedures\|last2=Schmiesing\|first2=Clifford A\|last3=Golianu\|first3=Brenda\|date=2014\|isbn=978-1-4963-0594-7\|language=English\|oclc=888551588}}</ref>.
	==Preoperative management==		==Preoperative management==
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	* Open<ref>{{Cite journal\|last=Savas\|first=Jeannie F.\|last2=Litwack\|first2=Robert\|last3=Davis\|first3=Kevin\|last4=Miller\|first4=Thomas A.\|date=2004-11\|title=Regional anesthesia as an alternative to general anesthesia for abdominal surgery in patients with severe pulmonary impairment\|url=https://pubmed.ncbi.nlm.nih.gov/15546579\|journal=American Journal of Surgery\|volume=188\|issue=5\|pages=603–605\|doi=10.1016/j.amjsurg.2004.07.016\|issn=0002-9610\|pmid=15546579}}</ref> and laparoscopic<ref>{{Cite journal\|last=Sinha\|first=Rajeev\|last2=Gurwara\|first2=A. K.\|last3=Gupta\|first3=S. C.\|date=2009-06\|title=Laparoscopic cholecystectomy under spinal anesthesia: a study of 3492 patients\|url=https://pubmed.ncbi.nlm.nih.gov/19522659\|journal=Journal of Laparoendoscopic & Advanced Surgical Techniques. Part A\|volume=19\|issue=3\|pages=323–327\|doi=10.1089/lap.2008.0393\|issn=1092-6429\|pmid=19522659}}</ref><ref>{{Cite journal\|last=Bessa\|first=Samer S.\|last2=Katri\|first2=Khaled M.\|last3=Abdel-Salam\|first3=Wael N.\|last4=El-Kayal\|first4=El-Saed A.\|last5=Tawfik\|first5=Tarek A.\|date=2012-07\|title=Spinal versus general anesthesia for day-case laparoscopic cholecystectomy: a prospective randomized study\|url=https://pubmed.ncbi.nlm.nih.gov/22686181\|journal=Journal of Laparoendoscopic & Advanced Surgical Techniques. Part A\|volume=22\|issue=6\|pages=550–555\|doi=10.1089/lap.2012.0110\|issn=1557-9034\|pmid=22686181}}</ref><ref>{{Cite journal\|last=Agrawal\|first=Malti\|last2=Verma\|first2=A. P.\|last3=Kang\|first3=L. S.\|date=2013-01\|title=Thoracic epidural anesthesia for laparoscopic cholecystectomy using either bupivacaine or a mixture of bupivacaine and clonidine: A comparative clinical study\|url=https://pubmed.ncbi.nlm.nih.gov/25885719\|journal=Anesthesia, Essays and Researches\|volume=7\|issue=1\|pages=44–48\|doi=10.4103/0259-1162.113988\|issn=0259-1162\|pmc=4173493\|pmid=25885719}}</ref><ref>{{Cite journal\|last=Das\|first=Writuparna\|last2=Bhattacharya\|first2=Susmita\|last3=Ghosh\|first3=Sarmila\|last4=Saha\|first4=Swarnamukul\|last5=Mallik\|first5=Suchismita\|last6=Pal\|first6=Saswati\|date=2015-04\|title=Comparison between general anesthesia and spinal anesthesia in attenuation of stress response in laparoscopic cholecystectomy: A randomized prospective trial\|url=https://pubmed.ncbi.nlm.nih.gov/25829908\|journal=Saudi Journal of Anaesthesia\|volume=9\|issue=2\|pages=184–188\|doi=10.4103/1658-354X.152881\|issn=1658-354X\|pmc=4374225\|pmid=25829908}}</ref> cholecystectomy can be performed under neuraxial anesthesia with a sensory level of T4-T6.		* Open<ref>{{Cite journal\|last=Savas\|first=Jeannie F.\|last2=Litwack\|first2=Robert\|last3=Davis\|first3=Kevin\|last4=Miller\|first4=Thomas A.\|date=2004-11\|title=Regional anesthesia as an alternative to general anesthesia for abdominal surgery in patients with severe pulmonary impairment\|url=https://pubmed.ncbi.nlm.nih.gov/15546579\|journal=American Journal of Surgery\|volume=188\|issue=5\|pages=603–605\|doi=10.1016/j.amjsurg.2004.07.016\|issn=0002-9610\|pmid=15546579}}</ref> and laparoscopic<ref>{{Cite journal\|last=Sinha\|first=Rajeev\|last2=Gurwara\|first2=A. K.\|last3=Gupta\|first3=S. C.\|date=2009-06\|title=Laparoscopic cholecystectomy under spinal anesthesia: a study of 3492 patients\|url=https://pubmed.ncbi.nlm.nih.gov/19522659\|journal=Journal of Laparoendoscopic & Advanced Surgical Techniques. Part A\|volume=19\|issue=3\|pages=323–327\|doi=10.1089/lap.2008.0393\|issn=1092-6429\|pmid=19522659}}</ref><ref>{{Cite journal\|last=Bessa\|first=Samer S.\|last2=Katri\|first2=Khaled M.\|last3=Abdel-Salam\|first3=Wael N.\|last4=El-Kayal\|first4=El-Saed A.\|last5=Tawfik\|first5=Tarek A.\|date=2012-07\|title=Spinal versus general anesthesia for day-case laparoscopic cholecystectomy: a prospective randomized study\|url=https://pubmed.ncbi.nlm.nih.gov/22686181\|journal=Journal of Laparoendoscopic & Advanced Surgical Techniques. Part A\|volume=22\|issue=6\|pages=550–555\|doi=10.1089/lap.2012.0110\|issn=1557-9034\|pmid=22686181}}</ref><ref>{{Cite journal\|last=Agrawal\|first=Malti\|last2=Verma\|first2=A. P.\|last3=Kang\|first3=L. S.\|date=2013-01\|title=Thoracic epidural anesthesia for laparoscopic cholecystectomy using either bupivacaine or a mixture of bupivacaine and clonidine: A comparative clinical study\|url=https://pubmed.ncbi.nlm.nih.gov/25885719\|journal=Anesthesia, Essays and Researches\|volume=7\|issue=1\|pages=44–48\|doi=10.4103/0259-1162.113988\|issn=0259-1162\|pmc=4173493\|pmid=25885719}}</ref><ref>{{Cite journal\|last=Das\|first=Writuparna\|last2=Bhattacharya\|first2=Susmita\|last3=Ghosh\|first3=Sarmila\|last4=Saha\|first4=Swarnamukul\|last5=Mallik\|first5=Suchismita\|last6=Pal\|first6=Saswati\|date=2015-04\|title=Comparison between general anesthesia and spinal anesthesia in attenuation of stress response in laparoscopic cholecystectomy: A randomized prospective trial\|url=https://pubmed.ncbi.nlm.nih.gov/25829908\|journal=Saudi Journal of Anaesthesia\|volume=9\|issue=2\|pages=184–188\|doi=10.4103/1658-354X.152881\|issn=1658-354X\|pmc=4374225\|pmid=25829908}}</ref> cholecystectomy can be performed under neuraxial anesthesia with a sensory level of T4-T6.
	* Transversus abdominis plane (TAP) block likely provides improved analgesia compared to local wound infiltration<ref>{{Cite journal\|last=Grape\|first=Sina\|last2=Kirkham\|first2=Kyle Robert\|last3=Akiki\|first3=Liliane\|last4=Albrecht\|first4=Eric\|date=2021-07-06\|title=Transversus abdominis plane block versus local anesthetic wound infiltration for optimal analgesia after laparoscopic cholecystectomy: A systematic review and meta-analysis with trial sequential analysis\|url=https://pubmed.ncbi.nlm.nih.gov/34243030\|journal=Journal of Clinical Anesthesia\|volume=75\|pages=110450\|doi=10.1016/j.jclinane.2021.110450\|issn=1873-4529\|pmid=34243030}}</ref>.		* Transversus abdominis plane (TAP) block likely provides improved analgesia compared to local wound infiltration<ref name=":0">{{Cite journal\|last=Grape\|first=Sina\|last2=Kirkham\|first2=Kyle Robert\|last3=Akiki\|first3=Liliane\|last4=Albrecht\|first4=Eric\|date=2021-07-06\|title=Transversus abdominis plane block versus local anesthetic wound infiltration for optimal analgesia after laparoscopic cholecystectomy: A systematic review and meta-analysis with trial sequential analysis\|url=https://pubmed.ncbi.nlm.nih.gov/34243030\|journal=Journal of Clinical Anesthesia\|volume=75\|pages=110450\|doi=10.1016/j.jclinane.2021.110450\|issn=1873-4529\|pmid=34243030}}</ref>.

	==Intraoperative management==		==Intraoperative management==
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	* Supine (USA) or lithotomy (Europe).		* Supine (USA) or lithotomy (Europe).
	* Reverse Trendelenburg (head up), often steep. Roll ("airplane") to left.		* Reverse Trendelenburg (head up), often steep. Roll ("airplane") to patient's left.
	** Ensure patient secured and well padded.		** Ensure patient secured and well padded.
	* Both arms or left arm only tucked (primary surgeon on left).		* Both arms or left arm only tucked (primary surgeon on left).
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	===Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. -->===		===Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. -->===

	* General considerations for laparoscopic surgery		* General considerations for laparoscopic surgery.

	===Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. -->===		===Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. -->===

	* PONV prophylaxis, otherwise no procedure-specific considerations		* PONV prophylaxis, otherwise no procedure-specific considerations.

	==Postoperative management==		==Postoperative management==
	===Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. -->===		===Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. -->===

			* PACU, often same-day discharge

	===Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. -->===		===Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. -->===

	* NSAIDs and acetaminophen for ~~mild pain~~		* NSAIDs and acetaminophen often adequate for laparoscopic cases
	* ~~Opioids for breakthrough pain~~. ~~Consider PCA for open cases~~		* Transversus abdominis plane (TAP) block likely provides improved analgesia compared to local wound infiltration<ref name=":0" />.

	===Potential complications<!-- List and/or describe any potential postoperative complications for this case. -->===		===Potential complications<!-- List and/or describe any potential postoperative complications for this case. -->===

	* ~~PONV~~		* General complications of laparoscopic surgery
	* Subcutaneous emphysema (from insufflation)
	* Bowel injury

	==Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). -->==		==Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). -->==
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	!Laparoscopic Cholecystectomy		!Laparoscopic Cholecystectomy
	\|-		\|-
	\|~~Unique considerations~~		\|
	\|		\|
	\|		\|

Svdg: Some changes in progress. Reference is required for the lifetime surgery incidence here from before. Is gastric tube not standard equipment in ORs? Reverse Trendelenberg we should use explanation (head up) as default as lots of resources confuse the two, will add this to style guide

2021-07-26T02:00:25Z

Some changes in progress. Reference is required for the lifetime surgery incidence here from before. Is gastric tube not standard equipment in ORs? Reverse Trendelenberg we should use explanation (head up) as default as lots of resources confuse the two, will add this to style guide

← Older revision		Revision as of 19:00, 25 July 2021
Line 11:		Line 11:
	==Preoperative management==		==Preoperative management==
	===Patient evaluation===		===Patient evaluation===
	~~{\| class="wikitable"~~		Most patients are healthy presenting for elective surgery, though others with acute cholecystitis may be critically unwell (e.g., patients with critical illness who develop acalculous cholecystitis).
	\|+
	~~!System~~
	~~!Considerations~~
	\|-
	~~\|Respiratory~~
	\|
	* Acute abdominal pain can cause respiratory impairment (~~respiratory splinting~~) ~~resulting in atelectasis~~
	\|-
	~~\|Cardiovascular~~
	\|
	* Sepsis can result in hypotension, tachycardia
	\|-
	~~\|Renal~~
	\|
	*
	\|-
	~~\|Gastrointestinal~~
	\|
	\|-
	~~\|Hematologic~~
	\|
	* Sepsis can result in leukocytosis/leucopenia
	\|-
	~~\|Endocrine~~
	\|
	\|-
	~~\|Other~~
	\|
	\|}

	=== Labs and studies ===		=== Labs and studies ===

	* ~~CBC~~		* No procedure-specific considerations for otherwise healthy patients.
	* Chemistry Panel

	*		*
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	===Operating room setup<!-- List any special, non-standard equipment, medications, fluids, or other preparations that should be made prior to surgery. If none, this section may be removed. -->===		===Operating room setup<!-- List any special, non-standard equipment, medications, fluids, or other preparations that should be made prior to surgery. If none, this section may be removed. -->===

	* ~~NG tube~~		* No procedure-specific equipment required.

	*		*
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	=== Patient preparation and premedication ===		=== Patient preparation and premedication ===

	* ~~Midazolam~~		* Laparoscopy and cholecystectomy specifically are minor risk factors for PONV<ref>{{Cite journal\|last=Apfel\|first=C. C.\|last2=Heidrich\|first2=F. M.\|last3=Jukar-Rao\|first3=S.\|last4=Jalota\|first4=L.\|last5=Hornuss\|first5=C.\|last6=Whelan\|first6=R. P.\|last7=Zhang\|first7=K.\|last8=Cakmakkaya\|first8=O. S.\|date=2012-11\|title=Evidence-based analysis of risk factors for postoperative nausea and vomiting\|url=https://pubmed.ncbi.nlm.nih.gov/23035051\|journal=British Journal of Anaesthesia\|volume=109\|issue=5\|pages=742–753\|doi=10.1093/bja/aes276\|issn=1471-6771\|pmid=23035051}}</ref>, consider the need for pre-operative prophylaxis (e.g., scopolamine, aprepitant)
			* Anxiolysis as indicated by patient characteristics and local practices.

	===Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. -->===		===Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. -->===

	* ~~Consider~~ epidural for ~~open approach~~		* Open<ref>{{Cite journal\|last=Savas\|first=Jeannie F.\|last2=Litwack\|first2=Robert\|last3=Davis\|first3=Kevin\|last4=Miller\|first4=Thomas A.\|date=2004-11\|title=Regional anesthesia as an alternative to general anesthesia for abdominal surgery in patients with severe pulmonary impairment\|url=https://pubmed.ncbi.nlm.nih.gov/15546579\|journal=American Journal of Surgery\|volume=188\|issue=5\|pages=603–605\|doi=10.1016/j.amjsurg.2004.07.016\|issn=0002-9610\|pmid=15546579}}</ref> and laparoscopic<ref>{{Cite journal\|last=Sinha\|first=Rajeev\|last2=Gurwara\|first2=A. K.\|last3=Gupta\|first3=S. C.\|date=2009-06\|title=Laparoscopic cholecystectomy under spinal anesthesia: a study of 3492 patients\|url=https://pubmed.ncbi.nlm.nih.gov/19522659\|journal=Journal of Laparoendoscopic & Advanced Surgical Techniques. Part A\|volume=19\|issue=3\|pages=323–327\|doi=10.1089/lap.2008.0393\|issn=1092-6429\|pmid=19522659}}</ref><ref>{{Cite journal\|last=Bessa\|first=Samer S.\|last2=Katri\|first2=Khaled M.\|last3=Abdel-Salam\|first3=Wael N.\|last4=El-Kayal\|first4=El-Saed A.\|last5=Tawfik\|first5=Tarek A.\|date=2012-07\|title=Spinal versus general anesthesia for day-case laparoscopic cholecystectomy: a prospective randomized study\|url=https://pubmed.ncbi.nlm.nih.gov/22686181\|journal=Journal of Laparoendoscopic & Advanced Surgical Techniques. Part A\|volume=22\|issue=6\|pages=550–555\|doi=10.1089/lap.2012.0110\|issn=1557-9034\|pmid=22686181}}</ref><ref>{{Cite journal\|last=Agrawal\|first=Malti\|last2=Verma\|first2=A. P.\|last3=Kang\|first3=L. S.\|date=2013-01\|title=Thoracic epidural anesthesia for laparoscopic cholecystectomy using either bupivacaine or a mixture of bupivacaine and clonidine: A comparative clinical study\|url=https://pubmed.ncbi.nlm.nih.gov/25885719\|journal=Anesthesia, Essays and Researches\|volume=7\|issue=1\|pages=44–48\|doi=10.4103/0259-1162.113988\|issn=0259-1162\|pmc=4173493\|pmid=25885719}}</ref><ref>{{Cite journal\|last=Das\|first=Writuparna\|last2=Bhattacharya\|first2=Susmita\|last3=Ghosh\|first3=Sarmila\|last4=Saha\|first4=Swarnamukul\|last5=Mallik\|first5=Suchismita\|last6=Pal\|first6=Saswati\|date=2015-04\|title=Comparison between general anesthesia and spinal anesthesia in attenuation of stress response in laparoscopic cholecystectomy: A randomized prospective trial\|url=https://pubmed.ncbi.nlm.nih.gov/25829908\|journal=Saudi Journal of Anaesthesia\|volume=9\|issue=2\|pages=184–188\|doi=10.4103/1658-354X.152881\|issn=1658-354X\|pmc=4374225\|pmid=25829908}}</ref> cholecystectomy can be performed under neuraxial anesthesia with a sensory level of T4-T6.
			* Transversus abdominis plane (TAP) block likely provides improved analgesia compared to local wound infiltration<ref>{{Cite journal\|last=Grape\|first=Sina\|last2=Kirkham\|first2=Kyle Robert\|last3=Akiki\|first3=Liliane\|last4=Albrecht\|first4=Eric\|date=2021-07-06\|title=Transversus abdominis plane block versus local anesthetic wound infiltration for optimal analgesia after laparoscopic cholecystectomy: A systematic review and meta-analysis with trial sequential analysis\|url=https://pubmed.ncbi.nlm.nih.gov/34243030\|journal=Journal of Clinical Anesthesia\|volume=75\|pages=110450\|doi=10.1016/j.jclinane.2021.110450\|issn=1873-4529\|pmid=34243030}}</ref>.

	==Intraoperative management==		==Intraoperative management==
	===Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. -->===		===Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. -->===

	* ~~Standard ASA monitors~~		* No procedure-specific considerations for otherwise healthy patients.
	* 5-~~lead EKG~~
	* Urinary catheter
	* NG tube
	* 1-2 peripheral IVs (16-18 gauge)
	* In unstable patients ~~or if open cholecystectomy, consider arterial line and central access~~

	===Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. -->===		===Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. -->===

	* ~~Standard~~ induction		* Rapid-sequence induction and intubation (RSII) may be required for unfasted patients undergoing emergency surgery.
	* ~~In unstable patients~~, ~~consider etomidate~~ (~~BP control~~) and ~~rapid sequence intubation (RSI)~~		* Endotracheal intubation is most common for laparoscopic surgery, though supraglottic airways (preferrably with an inbuilt drain channel) can be used<ref>{{Cite journal\|last=Belena\|first=J. M.\|last2=Nunez\|first2=M.\|last3=Vidal\|first3=A.\|last4=Gasco\|first4=C.\|last5=Gilsanz\|first5=C.\|last6=Alcojor\|first6=A.\|last7=Anta\|first7=D.\|last8=Lopez\|first8=A. E.\|date=2016\|title=Use of second generation supra-glottic airway devices during laparoscopic cholecystectomy: a prospective, randomized comparison of LMA Proseal™, LMA SupremeTM and igel™\|url=https://pubmed.ncbi.nlm.nih.gov/29873467\|journal=Acta Anaesthesiologica Belgica\|volume=67\|issue=3\|pages=121–128\|issn=0001-5164\|pmid=29873467}}</ref>.
			* Orogastric or nasogastric tube should be inserted and suction applied shortly after induction and before trocar insertion.

	===Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. -->===		===Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. -->===

	* Supine, ~~Trendelenburg~~		* Supine (USA) or lithotomy (Europe).
	* ~~Secure~~ and ~~tuck~~ arms		* Reverse Trendelenburg (head up), often steep. Roll ("airplane") to left.
			** Ensure patient secured and well padded.
			* Both arms or left arm only tucked (primary surgeon on left).

	===Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. -->===		===Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. -->===

	* ~~Intraoperative insufflation may cause~~		* General considerations for laparoscopic surgery
	** Resp: atelectasis, decrease FRC, increase PIPs, and increase CO2. May also cause endobronchial intubation
	** GI: gastric content regurgitation
	** Cardiac: decreased cardiac output

	===Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. -->===		===Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. -->===

	* PONV prophylaxis		* PONV prophylaxis, otherwise no procedure-specific considerations

	==Postoperative management==		==Postoperative management==

Svdg at 00:55, 26 July 2021

2021-07-26T00:55:54Z

← Older revision		Revision as of 17:55, 25 July 2021
Line 8:		Line 8:
	\| considerations_intraoperative = Rapid sequence intubation		\| considerations_intraoperative = Rapid sequence intubation
	\| considerations_postoperative = PONV		\| considerations_postoperative = PONV
	}}~~A cholecystectomy~~ is ~~generally~~ performed to treat symptomatic cholelithiasis and other gallbladder conditions. This is one of the most common procedures performed in hospitals in the United States. Of the more than 20 million people in the US with gallstones, about 30% will eventually require cholecystectomy to relieve symptoms or treat complications. ~~A cholecystectomy can be~~ performed laparoscopically ~~or as an~~ open ~~procedure. Surgical practice has largely transitioned to the laparoscopic approach~~. The rate of conversion to an open operation is 2-3% for elective ~~gallbladder~~ surgery and ~10% for acute cholecystitis<ref>{{Cite book\|last=Jaffe\|first=Richard A\|url=http://public.ebookcentral.proquest.com/choice/publicfullrecord.aspx?p=3418805\|title=Anesthesiologist's manual of surgical procedures\|last2=Schmiesing\|first2=Clifford A\|last3=Golianu\|first3=Brenda\|date=2014\|isbn=978-1-4963-0594-7\|language=English\|oclc=888551588}}</ref>.		}}Cholecystectomy is performed to treat symptomatic cholelithiasis and its complications (e.g., cholecystitis, pancreatitis, cholangitis), and other gallbladder conditions (e.g., polyps, porcelain gallbladder). This is one of the most common procedures performed in hospitals in the United States. Of the more than 20 million people in the US with gallstones, about 30% will eventually require cholecystectomy to relieve symptoms or treat complications. Cholecystectomy is most commonly performed laparoscopically, though there are specific indications for open surgery. The rate of conversion to an open operation is 2-3% for elective surgery and ~10% for acute cholecystitis<ref>{{Cite book\|last=Jaffe\|first=Richard A\|url=http://public.ebookcentral.proquest.com/choice/publicfullrecord.aspx?p=3418805\|title=Anesthesiologist's manual of surgical procedures\|last2=Schmiesing\|first2=Clifford A\|last3=Golianu\|first3=Brenda\|date=2014\|isbn=978-1-4963-0594-7\|language=English\|oclc=888551588}}</ref>.
	==Preoperative management==		==Preoperative management==
	===Patient evaluation===		===Patient evaluation===

Nkamdar: Added to the procedure risk summary table regarding elevated perioperative cardiac risk with open procedures compared to laparoscopic. I added a 2018 citation with this edit.

2021-04-05T17:51:00Z

Added to the procedure risk summary table regarding elevated perioperative cardiac risk with open procedures compared to laparoscopic. I added a 2018 citation with this edit.

← Older revision		Revision as of 10:51, 5 April 2021
Line 115:		Line 115:
	{\| class="wikitable"		{\| class="wikitable"
	\|+		\|+
			''*PACE: Perioperative Adverse Cardiac Event''
	!		!
	!Open Cholecystectomy		!Open Cholecystectomy
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	\|-		\|-
	\|Morbidity		\|Morbidity
	\|		\|Elevated PACE vs laparoscopic<ref>{{Cite journal\|last=Liu\|first=Jason B.\|last2=Liu\|first2=Yaoming\|last3=Cohen\|first3=Mark E.\|last4=Ko\|first4=Clifford Y.\|last5=Sweitzer\|first5=Bobbie J.\|date=2018-02-01\|title=Defining the Intrinsic Cardiac Risks of Operations to Improve Preoperative Cardiac Risk Assessments\|url=https://pubs.asahq.org/anesthesiology/article/128/2/283/17742/Defining-the-Intrinsic-Cardiac-Risks-of-Operations\|journal=Anesthesiology\|language=en\|volume=128\|issue=2\|pages=283–292\|doi=10.1097/ALN.0000000000002024\|issn=0003-3022}}</ref>
	\|		\|
	\|-		\|-

Tony.Wang: Intraop/postop management changes

2021-03-11T06:05:32Z

Intraop/postop management changes

← Older revision		Revision as of 23:05, 10 March 2021
Line 5:		Line 5:
	\| monitors = Standard ASA<br />		\| monitors = Standard ASA<br />
	5-lead EKG		5-lead EKG
	\| considerations_preoperative =		\| considerations_preoperative = NG Tube
	\| considerations_intraoperative =		\| considerations_intraoperative = Rapid sequence intubation
	\| considerations_postoperative =		\| considerations_postoperative = PONV
	}}A cholecystectomy is generally performed to treat symptomatic cholelithiasis and other gallbladder conditions. This is one of the most common procedures performed in hospitals in the United States. Of the more than 20 million people in the US with gallstones, about 30% will eventually require cholecystectomy to relieve symptoms or treat complications. A cholecystectomy can be performed laparoscopically or as an open procedure. Surgical practice has largely transitioned to the laparoscopic approach. The rate of conversion to an open operation is 2-3% for elective gallbladder surgery and ~10% for acute cholecystitis<ref>{{Cite book\|last=Jaffe\|first=Richard A\|url=http://public.ebookcentral.proquest.com/choice/publicfullrecord.aspx?p=3418805\|title=Anesthesiologist's manual of surgical procedures\|last2=Schmiesing\|first2=Clifford A\|last3=Golianu\|first3=Brenda\|date=2014\|isbn=978-1-4963-0594-7\|language=English\|oclc=888551588}}</ref>.		}}A cholecystectomy is generally performed to treat symptomatic cholelithiasis and other gallbladder conditions. This is one of the most common procedures performed in hospitals in the United States. Of the more than 20 million people in the US with gallstones, about 30% will eventually require cholecystectomy to relieve symptoms or treat complications. A cholecystectomy can be performed laparoscopically or as an open procedure. Surgical practice has largely transitioned to the laparoscopic approach. The rate of conversion to an open operation is 2-3% for elective gallbladder surgery and ~10% for acute cholecystitis<ref>{{Cite book\|last=Jaffe\|first=Richard A\|url=http://public.ebookcentral.proquest.com/choice/publicfullrecord.aspx?p=3418805\|title=Anesthesiologist's manual of surgical procedures\|last2=Schmiesing\|first2=Clifford A\|last3=Golianu\|first3=Brenda\|date=2014\|isbn=978-1-4963-0594-7\|language=English\|oclc=888551588}}</ref>.
	==Preoperative management==		==Preoperative management==
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	* Standard ASA monitors		* Standard ASA monitors
	* 5-lead EKG		* 5-lead EKG
	* 1-2 peripheral IVs		* Urinary catheter
	* In unstable patients, consider arterial line and central access		* NG tube
			* 1-2 peripheral IVs (16-18 gauge)
			* In unstable patients or if open cholecystectomy, consider arterial line and central access

	===Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. -->===		===Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. -->===
Line 80:		Line 82:
	===Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. -->===		===Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. -->===

	* Supine		* Supine, Trendelenburg
	* Secure and tuck arms		* Secure and tuck arms

Line 86:		Line 88:

	* Intraoperative insufflation may cause		* Intraoperative insufflation may cause
	** Resp: atelectasis, decrease FRC, increase PIPs, and increase CO2		** Resp: atelectasis, decrease FRC, increase PIPs, and increase CO2. May also cause endobronchial intubation
	** GI: gastric content regurgitation		** GI: gastric content regurgitation
	** Cardiac: decreased cardiac output		** Cardiac: decreased cardiac output
Line 98:		Line 100:

	===Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. -->===		===Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. -->===

			* NSAIDs and acetaminophen for mild pain
			* Opioids for breakthrough pain. Consider PCA for open cases

	===Potential complications<!-- List and/or describe any potential postoperative complications for this case. -->===		===Potential complications<!-- List and/or describe any potential postoperative complications for this case. -->===

			* PONV
			* Subcutaneous emphysema (from insufflation)
			* Bowel injury

	==Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). -->==		==Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). -->==

Tony.Wang: more preop changes

2021-03-11T05:48:12Z

more preop changes

← Older revision		Revision as of 22:48, 10 March 2021
Line 50:		Line 50:

	===Operating room setup<!-- List any special, non-standard equipment, medications, fluids, or other preparations that should be made prior to surgery. If none, this section may be removed. -->===		===Operating room setup<!-- List any special, non-standard equipment, medications, fluids, or other preparations that should be made prior to surgery. If none, this section may be removed. -->===

			* NG tube

	*		*
Line 56:		Line 58:

	=== Patient preparation and premedication ===		=== Patient preparation and premedication ===

			* Midazolam

	===Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. -->===		===Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. -->===

Tony.Wang: Preop and intraop management changes

2021-03-11T05:39:46Z

Preop and intraop management changes

← Older revision		Revision as of 22:39, 10 March 2021
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	\|Cardiovascular		\|Cardiovascular
	\|		\|
			* Sepsis can result in hypotension, tachycardia
	\|-		\|-
	\|Renal		\|Renal
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	\|Hematologic		\|Hematologic
	\|		\|
	* Sepsis can result in ~~tachycardia, tachypnea, hyperthermia, and~~ leukocytosis/leucopenia		* Sepsis can result in leukocytosis/leucopenia
	\|-		\|-
	\|Endocrine		\|Endocrine
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	=== Labs and studies ===		=== Labs and studies ===

			* CBC
			* Chemistry Panel

	*		*

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	==Intraoperative management==		==Intraoperative management==
	===Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. -->===		===Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. -->===

			* Standard ASA monitors
			* 5-lead EKG
			* 1-2 peripheral IVs
			* In unstable patients, consider arterial line and central access

	===Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. -->===		===Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. -->===

			* Standard induction
			* In unstable patients, consider etomidate (BP control) and rapid sequence intubation (RSI)

	===Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. -->===		===Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. -->===

			* Supine
			* Secure and tuck arms

	===Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. -->===		===Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. -->===

	* Intraoperative insufflation may cause atelectasis, decrease FRC, increase PIPs, and increase CO2		* Intraoperative insufflation may cause
			** Resp: atelectasis, decrease FRC, increase PIPs, and increase CO2
			** GI: gastric content regurgitation
			** Cardiac: decreased cardiac output

	===Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. -->===		===Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. -->===

			* PONV prophylaxis

	==Postoperative management==		==Postoperative management==

Chris.Rishel at 01:57, 22 February 2021

2021-02-22T01:57:12Z

← Older revision		Revision as of 18:57, 21 February 2021
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	<references />		<references />

	[[Category:Surgical ~~case reference~~]]		[[Category:Surgical procedures]]
	[[Category:General surgery]]		[[Category:General surgery]]
	[[Category:Biliary tract surgery]]		[[Category:Biliary tract surgery]]

Chris.Rishel at 15:49, 20 February 2021

2021-02-20T15:49:37Z

← Older revision		Revision as of 08:49, 20 February 2021
Line 122:		Line 122:

	[[Category:Surgical case reference]]		[[Category:Surgical case reference]]
			[[Category:General surgery]]
			[[Category:Biliary tract surgery]]