• Surgical removal of the gallbladder, open or laparoscopic, for treatment of symptomatic cholelithiasis (stones in the biliary tract resulting in mechanical obstruction), cholecystitis (inflammation of gallbladder secondary to obstruction of cystic duct), or gallbladder cancer.
• Open cholecystectomy
  • Resection from the liver and isolation of the cystic duct and artery are performed.
  • Chosen for patients with significant inflammation, intraabdominal adhesions, coagulopathies, known gallbladder cancer, or the inability to tolerate laparoscopic procedures.
  • Laparoscopic approach may be converted to an open approach if technically difficult.
• Laparoscopic cholecystectomy
  • Four trochars are inserted to pass instruments; one in the umbilicus and three in the right upper quadrant (RUQ).
  • A pneumoperitoneum is created to aid with visualization; insufflation is done with carbon dioxide (CO₂) at pressures of 10–15 mm Hg.
  • Following resection from the liver and isolation of the cystic duct and artery, the gallbladder is detached via cauterization, clipping, or stapling.
  • The gallbladder is placed in a bag and removed through the trocar site in the abdominal wall.
• Cholangiograms (injection of contrast dye via a catheter in the cystic duct) can be performed intraoperatively to detect gallstones in the cystic duct (choledocholithiasis). An absence of spread/filling on radiography indicates that a stone is present. Some surgeons use ultrasound in place of cholangiograms.
• Common bile duct exploration is performed via a small incision (choledochotomy). A fiberoptic scope (choledoscope) is passed through the incision to aid in visualization.

Supine; reverse Trendelenburg with right side up to displace bowel (laparoscopic and open procedures)

• Laparoscopy: 5–7 mm incisions for the insertion of trocars. Supraumbilical, epigastric, midclavicular, and anterior axillary ports are most frequently placed.
• Open: Right subcostal approach or upper midline (less common) 5–7 inches.

20–60 minutes; intraoperative cholangiogram may add 10–20 minutes.

• Open cholecystectomy: <250 mL
• Laparoscopic: Minimal EBL

• Some ambulatory centers discharge the same day after careful observation.
• Complicated cases may require 1 day hospitalization or longer.

• Laparoscopic equipment
• Possible fluoroscopy for cholangiogram

Incidence

• In the US, ~500,000 cholecystectomies are performed each year.
• 10% of the US adult population has cholelithiasis; 20% over the age of 40 years, and 30% over the age of 70 years. (1) [A].
• Urgent laparoscopic conversion rate: <15%
• Elective laparoscopic conversion rate: <5%

Prevalence

• Mostly adults, increases with age
• Female to male ratio 4:1 during reproductive years; ratio narrows as age increases (1) [A].
• Risk factors: Obesity, diabetes mellitus, estrogen, pregnancy, hemolytic diseases, and cirrhosis.
• "Fat, Female, Fertile, forty" is a pneumonic used to describe patients prone to cholelithiasis.

• Hemorrhage, bile leak, perforation of gallbladder, common bile duct injury, retained bile duct stones.
• Open cholecystectomy morbidity rate is 3.3 times more than that for laparoscopic cholecystectomy (2) [A]. This may be a function of the selection criteria of patients needing an open procedure.

• Standardized mortality ratio (SMR) within 90 days for open cholecystectomy is 3.89.
• SMR within 90 days for laparoscopic cholecystectomy is 0.73 (2) [A].

History

• Duration of symptoms
• Oral intake, quantity and quality of urine
• Last menstrual cycle in women of child-bearing age

Signs/Physical Exam

• Tachycardia, hypotension, and jaundice
• Guarding or rebound with acute cholecystitis; otherwise, normal abdominal exam with mild tenderness.
• Fluid status: Capillary refill, mucus membranes, urine output, lethargy, and orthostatic BPs.

Labs/Studies

• White count to rule out infection
• Cirrhotic patients: Consider coagulation profile, albumin, and hemoglobin.
• Abdominal ultrasound is the test of choice for diagnosis of cholelithiasis: 90–95% sensitive (1) [A].

• Patients at risk for gastric aspiration: Give H₂ blockers, antacids, promotility, or proton pump inhibitors.
• Nasogastric tube may be considered.
• Fluid resuscitation as appropriate prior to induction.
• Transfusion of fresh frozen plasma or other blood products as appropriate in cirrhotics.
• If pain medication needed, meperidine may cause less Sphincter of Oddi spasm than other opiates.

• Surgeons consent for the potential to convert to an open procedure.
• Open procedures may benefit from an epidural for postoperative pain management.

• Indicated for acute cholecystitis and/or cholangitis; should cover gram-negative aerobes (Escherichia coli, Klebsiella) as well as anaerobes (Bacteroides species)
• Third-generation cephalosporins (ceftriaxone) with good anaerobic coverage or a second-generation cephalosporin (cefuroxime or cefotetan) combined with metronidazole is a typical regimen.
• Cephalosporin allergy: Aminoglycoside and metronidazole.

• Laparoscopic technique: General endotracheal anesthesia with a cuffed tube allows for positive pressure ventilation, muscle relaxation, protection against aspiration, and minimizes hypercarbia from absorbed CO₂. These same requirements preclude the use of laryngeal mask airway (LMA); GETA can also generate greater positive pressure (reduced compliance requires higher peak inspiratory pressures) that LMA use cannot. As a sole anesthetic technique, an epidural/spinal is not ideal because it requires a high block/level. If performed, consider supplementing with nitrous oxide and keeping insufflation pressures <10 mm Hg.
• Open technique: Epidural anesthesia may be utilized for open procedures in conjunction with GETA.

• Standard ASA monitors
• Invasive hemodynamic monitoring may be needed for ASAIII–IV patients.
• Foley catheter is a surgical preference.

Rapid sequence induction if not NPO; also consider other risks for aspiration (nausea, vomiting, narcotic use, gastroesophageal reflux).

• Orogastric/nasogastric tube placement allows for suctioning of gastric and biliary juices and decompressing the stomach to facilitate laparoscopic visualization.
• Balanced anesthetic with volatile or total intravenous anesthetic.
• Muscle relaxation facilitates resection for laparoscopic and open procedures.
• Vagal episodes can occur when a pneumoperitoneum is instituted; it typically resolves immediately with desufflation.
• Opioids may cause Sphincter of Oddi spasm; theoretically, meperidine has a reduced incidence.
• Reverse Trendelenburg affects the cardiopulmonary system
  • Cardiac: Preload to the right atrium is reduced due to gravity; this effect can be exacerbated in patients who are volume depleted.
  • Pulmonary: Parameters are usually improved due to increased compliance and functional residual capacity.
• Laparoscopic-induced pneumoperitoneum in the reverse Trendelenburg position affects the cardiopulmonary systems:
  • Cardiac: Preload to the right atrium is further decreased; pneumoperitoneum pressures are often equal to or greater than right atrial filling pressures.
  • Pulmonary: Reverse Trendelenburg position initially improves pulmonary mechanics, but pneumoperitoneum reduces pulmonary compliance and functional residual capacity; may need to adjust ventilator settings. Use of CO₂ for insufflation can increase PaCO₂ unless the tidal volume or respiratory rate is increased.

• Give prophylactic antiemetics prior to extubation.
• Bile is an emetic and caustic; suction the gastric tube prior to extubation.
• Patient should be awake and capable of protecting their airway.