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: (-)

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

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

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

Operation method

Laparoscopic cholecystectomy

Drug used

ASA class IIIInduction Fentanyl 100μg Atracurium 25mg Midazolam 5mg Pentothal 250mg Robinul 0.2mg

Maintain Isoflurane

Operation course

Quite smoothBP: 100~120HR: 60~70SpO2: 99~100%

ETCO2: 33~35

Use 1 hr 15 min

Post OP follow up

No PONV

Pain score: 2Demerol 50 mg q6hAcetaminophen 1# qid

No sore throat

No headache

Laparoscopic Cholecystectomy(LC)

Indication:Symptomatic gallstonesOther biliary tract disease

Difficult technical challengesAcute cholecystitisObesityPrevious intra-abdominal surgeryPregnancy

LC-surgical technique

Reverse Trendelenburg position

Intraperitoneal CO2 insufflation

LC-surgical technique

Benefit of LC

Shorter hospital stays

More rapid return to normal activities

Small, limited incisions

Less pain

Less postoperative ileus

LC vs OC

Treatment of Acute CholecystitisConversion rate: 15%Operationg time: 88 vs 77 minsComplication: 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)

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

Anesthetic management

Anesthetic techniqueGeneral anesthesiaCuffed endotracheal tube placementControlled ventilationUrinary catheter and nasogastric tube

Anesthetic management

Anesthetic agentsOxygenNitrous oxideVolatile anesthetic agentRelaxants Opioids: Oddi sphincter spasm

Anesthetic management

Use of nitrous oxideControversial

Bowel distentionPostoperative nausea

Anesthetic management

MonitoringPETco2

Increased minute ventilation by 12~16%Paco2 must less than 41 mmHg

Invasive hemodynamic monitoringASA class III~IVEspecially at p’t with cardiopulmonary disease

Anesthetic management

Post operative pain reliefWound infiltration with local anesthesia and

NSAID - for peripheral painOpioids - for central painOndansetron – for nausea and vomiting

Take a rest……