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SURGICAL WEBSITES             KIDNEY SURGERY         POSTGRADUATE SURGERY LINKS 

BREAST DISEASE     Breast cancer Breast lump Breast awareness Breast calcifications  Breast cysts Breast pain Duct ectasia Fat necrosis Fibroadenoma Hyperplasia Intraductal papilloma Phyllodes tumour Sclerosing adenosis                                                                                                                                                 

LIVER ABSCESS      Anatomy of liver Physiology of liver Method of examination of liver Haematology of liver disease. Amoebic liver abscess .Pyogenic liver abscess. Percutaneous needle aspiration of liver abscess. Case study.  Result Result continued  Discussion                                                                 

CHOLECYSTECTOMY    Introduction   Historical Review  Anatomy of Gallbladder Physiology of Gallbladder Physiologic effects of pneumoperitoneum Pathology  of Gallbladder Investigations Pre- operative preparation of laparoscopic cholecystectomy Contraindications  Treatment modalities for gallstones.  Anaesthesia                                                                                                                       

INGUINAL HERNIA    HOW SURGICAL OPERATION IS DONE     THYROID EXAMINATION MANAGEMENT OF SEVERELY INJURED PATIENT      SEPSIS AND MULTIPLE ORGAN FAILURE CHEST TRAUMA     BRONCHOGENIC CARCINOMA     TETANUS AND ANAEROBIC INFECTIONS 

PRE-OPERATIVE MANAGEMENT OF PATIENT UNDERGOING LAPAROSCOPIC CHOLECYSTECTOMY

 

I. GENERAL CONSIDERATIONS:

            The preoperative evaluation of candidates for laparoscopic guided cholecystectomy differs little from that of patients undergoing traditional open cholecystectomy. A careful history and physical examination are performed to exclude the possibility of other gastrointestinal diseases that may mimic biliary colic, such as peptic ulcer disease or reflux oesophagitis. Age has been shown to affect the outcome of the surgery ⁸⁷. Physical status have been shown to be a reliable predictor of surgical risk ⁸⁸. Although it has been demonstrated repeatedly that neither age nor coomorbidity preclude safe day-care laparoscopic cholecystectomy ⁸⁹. In addition, it is important to elicit any information suggestive of choledocholithiasis, such as a history of pancreatitis or jaundice. Both calcium bilirubinate stones and periampullary duodenal diverticula are contributing factors in the development of common bile duct stones ⁹⁰. Since common bile duct stones cannot routinely be extracted with laparoscopic surgical techniques, all attempts are made to find stones in common bile duct.

          The number and size of gallstones do not affect the patient’s eligibility blood work does not suggest choledocholithiasis, additional diagnostic studies are not ordered. In patients with suspected common bile duct stones a preoperative ERCP is advised. The development of laparoscopic cholecystectomy has created a dilemma in the management of choledocholithiasis. A number of options exist, including endoscopic sphincterotomy (ES) before laparoscopic cholecystectomy in patients with suspected common bile duct (CBD) calculi, laparoscopic bile duct exploration, open CBD exploration and postoperative endoscopic sphincterotomy ⁹¹. None of these options has emerged as ideal or universally acceptable. An alternative technique, peroperative endoscopic sphincterotomy, has been developed. ⁹². If the ERCP demonstrates choledocholithiasis, endoscopic sphincterotomy and stone extraction are attempted prior to laparoscopic cholecystectomy. If common bile duct stones cannot be removed via the endoscopic approach, the patient may require an open laparotomy and common bile duct exploration. Laparoscopic exploration of common bile duct is as effective as ERCP in clearing the common bile duct of stones. There is a non-significant trend to shorter time in the operating theatre and a significantly shorter hospital stay in patients treated by laparoscopic exploration of common bile duct ⁹³. Duct clearance using either a Dormia basket or choledochotomy (and T tube placement) can be achieved with a low operative morbidity rate. Laparoscopic exploration of the CBD is an important alternative in the management of common duct calculi ⁹⁴.

            The surgeon must properly inform the patient of this option and obtain and inform consent for both laparoscopic cholecystectomy and open procedure.

            Before the patient is subjected to laparoscopic cholecystectomy following things must be considered,

i-                    Through history [including history of presenting illness, Past, Family, Drug, and Personal History]

ii-                  Through general and systemic examination.

iii-                 Relative investigations discussed in previous chapter.

iv-                Establishing the diagnosis.

v-                  Preparing the patient for surgery to the conditions like acute cholecystitis, chronic cholecystitis and empyaema of gall bladder etc.

vi-                Assessing the patient whether to laparoscopic cholecystectomy or open cholecystectomy.

vii-               Take anaesthetic/ medical opinion.

viii-             Take consent.

 

 

II PREOPERATIVE MANAGEMENT

a.       PREOPERATIVE TREATMENT OF ACUTE CHOLECYSTITIS:

The preferred treatment for acute cholecystitis is early cholecystectomy ⁹⁵. When the diagnosis of acute cholecystitis is suspected the patient should receive nothing by mouth; however, nasogastric suction usually can be reserved for patients who are vomiting or have ileus and abdominal distention. Intravenous fluids are given to correct volume depletion and any electrolyte imbalances are measured and corrected. Intramuscular narcotics are usually given for pain relief after the diagnosis is confirmed and further plans for medical or surgical therapy are made. Early laparoscopic cholecystectomy for the treatment of acute cholecystitis has no adverse effect on complication and conversion rates. Although it is technically demanding and time consuming, this procedure provides the economic advantage of a markedly reduced total hospital stay ⁹⁶.

            It is noted that early surgery for acute cholecystitis has medical advantages and is cost effective. However, conservative management with somewhat delayed elective operations is still widely used. Initial conservative treatment followed by delayed interval surgery cannot reduce the morbidity and conversion rate of laparoscopic cholecystectomy for acute cholecystitis. Early operation within 72 hours of admission has both medical and socio-economic benefits and is the preferred approach for patients managed by surgeons with adequate experience in laparoscopic cholecystectomy ⁹⁷. A conservative attitude is warranted for patients with mild cholecystitis are at high risk, and some times it is advisable to delay surgery in order to correct physiological disturbances due to the cholecystitis and oblique or complicating disease.

            In recent years non-steroid anti-inflammatory drugs (NSAIDS) have been commonly used to treat biliary pain. Sharp states that patients with mild acute cholecystitis are adequately treated with antibiotics such as ampicillin (4-6 gm/dl) or cefazolin (2-4 gm/dl). More severe cases may be treated with combinations such as penicillin, gentamicin and clindamycin to cover gram negative aerobes, enterococcus and anaerobes. The third generation cephalosporins are gaining popularity as a single agent therapy.

 

b.      PREOPERATIVE TREATMENT OF EMPYAEMA OR PERFORATION OF GALL BLADDER:

            All these conditions should be dealth as emergency. In this keep the patient nil per oral (NPO), do nasogastric aspiration, maintain hydration by giving him intravenous fluids, analgesics and antibiotics. After stabilising the patient subject him to surgery.

 

c.       PREOPERATIVE TREATMENT OF CHRONIC CHOLECYSTITIS:

The patient should be put on a low-fat diet. Give him analgesics and antiemetics. Then elective surgery should be done.

 

III. PRE-OPERATIVE IDENTIFICATION OF PATIENT WITH CHOLEDOCHOLITHIASIS:

We have come to believe in order to achieve the level of Maximum Surgical Performance with this procedure, we need to identify patients at high risk of presenting with Common Bile Duct Stones The introduction of laparoscopic cholecystectomy has resulted in increased options for the management of bile duct stones and has stimulated a fundamental reappraisal of the situation. New areas of controversy are highlighted and the need for further studies is emphasised ⁹⁸. There are several protocols to identify these patients. To better understand these protocols, surgeons must realise that the simplest methods to initially identify these patients are:

1)      History and Physical Examination,

2)      Liver Function Studies,

3)      Sonographic Findings.

 

Patients with a recent history of gallstone pancreatitis, jaundice, or presenting with such symptoms are at a high risk of having common bile duct pathology. If a patient has altered liver function studies, they are also at risk. There are only selected studies that have adequate sensitivity to identify this patient group. The most accurate studies for this are the Serum Transaminase Level (SGOT, SGPT). Elevations of these enzymes over 20% of their normal values are significant. One should remember patients with severe acute cholecystitis could generate such elevations. Also, patients with extreme elevations of these two enzymes could have hepatocyte necrosis as seen in hepatitis. The bilirubin level can also be elevated in patients with acute cholecystitis, but elevations above 2.5 or 3.0 could also indicate the patient is at risk for CBD pathology. We find the enzymes LDH and SGPT to have no real specific value in this clinical setting.

It is interesting to note that in spite of our efforts to try to identify Common Bile Duct pathology preoperatively, missed CBD Stones are found in 1.92% of all patients. Of these patients, 76% will require additional surgical intervention ERCP. Predictors of CBD stones in a patient older than 55 years is elevated bilirubin (over 30 mmol/L) and positive ultrasound findings (a dilated CBD, and a CBD stone seen on ultrasound. The identified independent clinical predictors of a CBD stone helps select a population of symptomatic gallstone bearers who benefit most from cholangiographic assessment ⁹⁹.