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Laparoscopic Cholecystectomy Periprocedural Care

  • Author: Danny A Sherwinter, MD; Chief Editor: Kurt E Roberts, MD  more...
 
Updated: Aug 05, 2015
 

Preprocedural Planning

Antibiotic prophylaxis

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.[58] 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.[59]

Combined cholecystectomy

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:

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]

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Equipment

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
  • Hasson trocar
  • 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)
  • Blunt graspers
  • Maryland dissector and L-hook cautery
  • Electrocautery equipment
  • 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.

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Patient Preparation

Anesthesia

Because pneumoperitoneum is necessary for laparoscopic cholecystectomy, general anesthesia with intubation is routinely required. Case reports of epidural anesthesia[62] and a pilot study comparing spinal anesthesia with general anesthesia in young, thin, healthy patients showed no significant differences in outcome.[63] Further studies involving acute cholecystitis and an older patient population are needed.

Positioning

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.

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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.[64]

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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Contributor Information and Disclosures
Author

Danny A Sherwinter, MD Attending Surgeon, Department of Mimially Invasive Surgery and Bariatrics, Associate Program Director, Department of Surgery, Maimonides Medical Center; Director of Minimally Invasive and Bariatric Surgery, American Society for Metabolic and Bariatric Surgery (ASMBS) Center of Excellence

Danny A Sherwinter, MD is a member of the following medical societies: American College of Surgeons, American Society for Metabolic and Bariatric Surgery, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

Harry L Adler, MD Assistant Clinical Professor of Surgery, Mount Sinai Hospital; Assistant Director and Consulting Physician, Maimonides Medical Center

Harry L Adler, MD is a member of the following medical societies: American Association for Physician Leadership, American College of Surgeons, Association for Academic Surgery

Disclosure: Nothing to disclose.

Sunny Leah Fink, MD Multi-Organ Abdominal Transplant Fellow, Department of Transplant Surgery, University of Pittsburgh Medical Center

Sunny Leah Fink, MD is a member of the following medical societies: American College of Surgeons, American Medical Student Association/Foundation

Disclosure: Nothing to disclose.

Lee S Cummings, MD Transplant Fellow, Georgetown University Hospital

Lee S Cummings, MD is a member of the following medical societies: American College of Surgeons, American Medical Association

Disclosure: Nothing to disclose.

Michele F Malit, DO Resident Physician, Department of Surgery, Maimonides Medical Center

Michele F Malit, DO is a member of the following medical societies: American College of Surgeons, American Medical Student Association/Foundation, American Osteopathic Association, American College of Osteopathic Surgeons, Student Osteopathic Medical Association

Disclosure: Nothing to disclose.

Stalin Ramakrishnan Subramanian, MD Resident Physician, Department of Medicine, Brookdale University Hospital and Medical Center

Disclosure: Nothing to disclose.

Chief Editor

Kurt E Roberts, MD Assistant Professor, Section of Surgical Gastroenterology, Department of Surgery, Director, Surgical Endoscopy, Associate Director, Surgical Skills and Simulation Center and Surgical Clerkship, Yale University School of Medicine

Kurt E Roberts, MD is a member of the following medical societies: American College of Surgeons, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons

Disclosure: Nothing to disclose.

Acknowledgements

Jerzy M Macura, MD Chief of Advanced Laparoscopic Surgery, Director of Bariatric Surgery, Maimonides Medical Center

Jerzy M Macura, MD is a member of the following medical societies: American Society for Metabolic and Bariatric Surgery, American Society of Abdominal Surgeons, and Society of American Gastrointestinal and Endoscopic Surgeons

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

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Laparoscopic cholecystectomy. Placement of fascial stay sutures.
Laparoscopic cholecystectomy. Visualization of gallbladder after placement of table in reverse Trendelenburg position.
Laparoscopic cholecystectomy. Advancement of 11-mm trocar under direct vision.
Laparoscopic cholecystectomy. Placement of two lateral 5-mm ports under direct vision.
Laparoscopic cholecystectomy. External view after port placement.
Laparoscopic cholecystectomy. Lateral grasper is used to retract fundus cephalad and retract adhesions.
Laparoscopic cholecystectomy. Medial grasper is applied to infundibulum.
Laparoscopic cholecystectomy. Medial grasper is used to retract infundibulum in caudolateral direction.
Laparoscopic cholecystectomy. Critical view, with only cystic duct and cystic artery seen entering gallbladder.
Laparoscopic cholecystectomy. Use of L-hook electrocautery to score anterior peritoneum.
Laparoscopic cholecystectomy. Division of peritoneum along medial aspect.
Laparoscopic cholecystectomy. Use of Endo Peanut to identify cystic structures.
Laparoscopic cholecystectomy. Use of Maryland dissector to dissect cystic duct.
Laparoscopic cholecystectomy. Use of Maryland dissector to dissect cystic artery.
Laparoscopic cholecystectomy. Continued dissection of critical structures.
Laparoscopic cholecystectomy. Placement of clip at lower aspect of cystic artery.
Laparoscopic cholecystectomy. Placement of superior clips on cystic artery.
Laparoscopic cholecystectomy. Transection of cystic artery with Endo Shears.
Laparoscopic cholecystectomy. Placement of clips on distal cystic duct.
Laparoscopic cholecystectomy. Placement of proximal clip on cystic duct.
Laparoscopic cholecystectomy. View of clipped cystic duct before transection.
Laparoscopic cholecystectomy. Transection of cystic duct between clips with Endo Shears.
Laparoscopic cholecystectomy. Use of hook to develop plane in areolar tissue between gallbladder and liver.
Laparoscopic cholecystectomy. Use of traction and hook to remove gallbladder from gallbladder bed.
Laparoscopic cholecystectomy. Side-to-side sweeping motion with electrocautery to remove gallbladder from gallbladder bed.
Laparoscopic cholecystectomy. Cauterization of any bleeding in gallbladder bed before complete division of gallbladder.
Laparoscopic cholecystectomy. Placement of gallbladder into endoscopic retrieval pouch.
Laparoscopic cholecystectomy. Placement of gallbladder into endoscopic retrieval pouch and removal of instrument from pouch.
Laparoscopic cholecystectomy. Irrigation and suction of gallbladder bed.
Laparoscopic cholecystectomy. Removal of ports under direct vision.
Laparoscopic cholecystectomy. Abdomen after skin closure.
Laparoscopic cholecystectomy. CT scan illustrating biloma.
Laparoscopic cholecystectomy. Postcholecystectomy ERCP showing leak of contrast.
Laparoscopic cholecystectomy. Postcholecystectomy ERCP.
Laparoscopic cholecystectomy. ERCP-guided stent placement.
Laparoscopic cholecystectomy. HIDA scan showing postcholecystectomy leak.
Anatomy of biliary tree.
 
 
 
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