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Laparoscopic cholecystectomy

Laparoscopic cholecystectomy
Procedure Laparoscopic removal of gall bladder
Time 1–2 h
Pain ++/++++
Position Supine, 15–20 degree head up, table tilted towards surgeon
Blood loss Not significant
Practical technique GA, ETT, IPPV
Preoperative
  • Patients typically ‘fair, fat, female, forty’.
  • The procedure is potentially painful.
Perioperative
  • The stomach may need deflating, hence insert a larger bore nasogastric tube—remove it at end of surgery.
  • 16 gauge IV access—blood loss may become significant.
  • Combination of pneumoperitoneum and obesity may make ventilation difficult.
  • Head up/sideways tilt.
  • Surgical time is very variable and operator dependent.
  • Ask the surgeon to infiltrate port sites with local anaesthetic at the end.
  • Conversion to open procedure 1–7%. This is usually due to difficulty identifying the cystic duct, suspected common bile duct injury, uncontrolled bleeding from the cystic artery, stones present in the common bile duct, or acute inflammatory changes.
Postoperative
  • High incidence of PONV.
  • Pain can be severe and may require opioids.
Special considerations
  • This can be a very stimulating and painful procedure, particularly during diathermy around the liver.
  • Analgesic requirements can be reduced by asking the surgeon to spray local anaesthetic onto the gall bladder bed before starting dissection (20 ml bupivacaine 0.25%).
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