Laparoscopic Cholecystectomy Periprocedural Care
- Author: Danny A Sherwinter, MD; Chief Editor: Kurt E Roberts, MD more...
Numerous studies have found no significant differences in the rate of surgical site infection (SSI) when perioperative antibiotics were compared with placebo in patients undergoing elective cholecystectomy.[55, 56, 57]
A systemic review by Sanabria et al assessed the use of antibiotic prophylaxis in laparoscopic cholecystectomy. The review concluded that the available evidence was not sufficient either to support or to rule out the use of antibiotic prophylaxis to reduce SSIs. However, larger, randomized, clinical trials are needed.
Although it is the author’s practice to use antibiotics followed by surgery for patients with acute cholecystitis, this approach has not been studied in a randomized, controlled fashion. Published studies comparing different lengths of antibiotic courses in patients with acute cholecystitis who undergo cholecystectomy have shown no benefit to a longer course of antibiotics.
Laparoscopic cholecystectomy is sometimes done in conjunction with other intra-abdominal surgery, but such pairing should be considered only when surgical exposure is adequate, the patient’s condition is satisfactory, and operating time is not unduly prolonged. Procedures that can be combined with laparoscopic cholecystectomy include the following:
Hernia repair (ventral, inguinal, umbilical, or diaphragmatic)
Breast lump excision
Common bile duct (CBD) exploration
Modified highly selective vagotomy
Gynecologic procedures, such as hysterectomy
Hydatid cyst excision
Lymph node biopsy
The duration of hospital stay for a patient who undergoes a combined procedure is similar to that for a patient who undergoes a single procedure. Thus, the patient has the benefit of receiving surgical therapy for two coexisting conditions concurrently while experiencing substantially less perioperative morbidity than would have been expected with two discrete procedures. Combined procedures also appear to be cost-effective both for patients and for hospital services.[60, 61]
Equipment typically required for laparoscopic cholecystectomy includes the following:
Light source with two video monitors (for the surgeon and the assistant)
Laparoscope, 0° or 30°
Standard gas insufflation equipment
Trocars, 5 mm (2)
Subxiphoid trocar, 11 mm (this can be replaced with another 5-mm trocar if a 5-mm laparoscopic clip applier is available)
Maryland dissector and L-hook cautery
Laparoscopic suction irrigator
Laparoscopic clip applier
Endoscopic ligature loop (eg, Endoloop; Ethicon Endo-Surgery, Blue Ash, OH)
Cotton swab affixed to a 5-mm shaft (eg, Endo Peanut; Covidien, Mansfield, MA)
Endoscopic retrieval pouch (eg, Endo Catch; Covidien, Mansfield, MA)
The authors do not routinely use a Foley catheter for laparoscopic cholecystectomy.
Because pneumoperitoneum is necessary for laparoscopic cholecystectomy, general anesthesia with intubation is routinely required. Case reports of epidural anesthesia and a pilot study comparing spinal anesthesia with general anesthesia in young, thin, healthy patients showed no significant differences in outcome. Further studies involving acute cholecystitis and an older patient population are needed.
For this procedure, the patient should be in the supine position. Peripheral intravenous lines are inserted, and electrocardiography, pulse oximetry, and blood pressure monitors are placed. The patient is intubated and general anesthesia initiated.
The patient’s arms are abducted or tucked comfortably at the sides. The two laparoscopic towers are situated on either side of the patient’s trunk, toward the head. The surgeon stands on the patient’s left, and the assistant stands on the right. An additional assistant, if present, can hold the laparoscope, but this is not essential.
Monitoring and Follow-up
The postoperative course is generally uncomplicated. If the cholecystectomy was done as an elective procedure, patients can be discharged the same day and usually should regain their normal level of physical activity within 1 week. Patients should expect some degree of postoperative discomfort around the port sites but should nonetheless be alert for any signs or symptoms (eg, fever, uncontrolled vomiting, or extreme pain) that could be manifestations of complications.
All patients who have undergone laparoscopic cholecystectomy should have a follow-up visit within 1-2 weeks postoperatively. After that initial postoperative check, they should be seen on an individual, as-needed basis.
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