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Laparoscopic
Cholecystectomy
Ri 毛贊智 Ri 黃彥筑/ VS 林珍榮
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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
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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
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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
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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
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Operation method
Laparoscopic cholecystectomy
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Drug used
ASA class IIIInduction Fentanyl 100μg Atracurium 25mg Midazolam 5mg Pentothal 250mg Robinul 0.2mg
Maintain Isoflurane
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Operation course
Quite smoothBP: 100~120HR: 60~70SpO2: 99~100%
ETCO2: 33~35
Use 1 hr 15 min
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Post OP follow up
No PONV
Pain score: 2Demerol 50 mg q6hAcetaminophen 1# qid
No sore throat
No headache
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Laparoscopic Cholecystectomy(LC)
Indication:Symptomatic gallstonesOther biliary tract disease
Difficult technical challengesAcute cholecystitisObesityPrevious intra-abdominal surgeryPregnancy
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LC-surgical technique
Reverse Trendelenburg position
Intraperitoneal CO2 insufflation
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LC-surgical technique
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Benefit of LC
Shorter hospital stays
More rapid return to normal activities
Small, limited incisions
Less pain
Less postoperative ileus
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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)
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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
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Anesthetic management
Anesthetic techniqueGeneral anesthesiaCuffed endotracheal tube placementControlled ventilationUrinary catheter and nasogastric tube
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Anesthetic management
Anesthetic agentsOxygenNitrous oxideVolatile anesthetic agentRelaxants Opioids: Oddi sphincter spasm
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Anesthetic management
Use of nitrous oxideControversial
Bowel distentionPostoperative nausea
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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
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Anesthetic management
Post operative pain reliefWound infiltration with local anesthesia and
NSAID - for peripheral painOpioids - for central painOndansetron – for nausea and vomiting
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Take a rest……