Laparscopic Cholecystectomy - Anaesthesia

Last updated 01/02/19

Definition

• Anaesthesia provided for the performance of laparascopic cholecystectomy

Features

• Requires head up position (reverse Trendelenburg) and pneumoperitoneum
• Reverse Trendelenburg allows abdominal contents to fall away from field of operation
• General Anaesthesia (GA): most common technique
• Intubation and muscle relaxation
• Muscle relaxation assists port entry and visibility
• Some suggestion third generation supraglottic airways may suffice (Laryngeal Mask Airway (LMA))
• Regional anaesthesia
• Approximately 8% require conversion to GA
• Spinal anaesthetic
• Epidural
• Operative time typically 50 minutes +/- 15 minutes
• Conversion to open cholecystectomy 1-7%

Procedure

• General principles for general anaesthesia (GA) with some modifications
• Pre-operative assessment
• Premedication
• Dexamethasone 0.1mg/kg or 4mg IV STAT
• Reduces post operative nausea and vomiting (PONV) and may reduce post operative pain
• +/- Midazolam 0.03mg/kg or 2-3mg IV STAT
• IV Fluid
• Up to 40ml/kg preoperatively
• May reduce PONV
• Continue intra-operatively +/- post-op
• +/- Antibiotics: Cephazolin 2-3g IV
• Some evidence suggests no benefit
• +/- Metronidazole 500mg IV STAT
• Requested by some surgeons in context of potential conversion to laparotomy or bile leakage
• Induction
• Preoxygenation high flow rate 100% oxygen
• Pre induction BP
• Analgesic: Fentanyl 1-2mcg/kg or 50-200mcg IV STAT
• Sedative: Propofol 1.5-3mg/kg titrated to effect
• Relaxant: Rocuronium 0.6mg/kg IV STAT
• Onset 90 seconds (60-90 seconds)
• Duration 30-40 minutes
• Intubation
• Avoid excessive bag mask ventliation to reduce chance of gastric insufflation
• +/- Nasogastric Tube (NGT) insertion: 14Fr
• Assists decompression of stomach to assist surgical field of view and reduce risk of damage
• Maintanance
• Sedation
• Sevoflurane 1-4%
• MAC target 1.5 +/-
• Ventilation
• O2:air (0.5:0.5L)
• Pressure or volume control
• Pressure control (PCV) provides improved alveolar recruitment and oxygenation
• Particularly in obese patients
• Target <30cmH2O
• Volume control (VCV)
• Target Tidal Volume (TV) 8-10ml/kg
• Peak inspiratory pressures <35cmH2O
• I:E ratio 1:2 (unless obstructive airways)
• RR 12-15 breaths/minute
• EtCO2 target <35mmHg
• Will increase with CO2 pneumoperitoneum
• Reduce with increaed minute ventilation and/or deepening anaesthesia (increase Sevoflurane)
• PEEP may be used with caution
• May increase haemodynamic effects of pneumoperitoneum
• Relaxant
• Redose if interfering with surgery or ventilation
• Rocuronium 0.1-0.2mg/kg (17-33% intubation dose) lasts 15-25 minutes
• If not parralysed used PSV (Pressure Support Ventilation)
• Reverse Trendelenburg 25o +/- left lateral tilt
• Fluids: Hartmans 1L+
• Gas insulfation (pneumoperitoneum) - by surgeon
• Carbon dioxide typically used
• Intra-abdominal pressures 12-16mmHg
• EtCO2 will rise but can be reduced by increasing minute ventilation
• Monitor for cardiorespiratory effects
• Analgesia
• +/- Gabapentin 300mg PO 2hrs prior to incisions
• Or Pregabalin 50-75mg 1hr prior to surgery and 50-75mg PO BD for 7 days post-op
• +/- Port site infiltration of Local Anaesthetic (LA) at end of procedure
• Morphine 5-15mg IV titrated during case
• +/- Tramadol 50-150mg IV STAT
• Paracetamol 1g IV towards end of case
• NSAIDs once surgeon acheived haemostasis
• Ibuprofen 400mg IV over 30 minutes
• Or Parecoxib 40mg IV STAT
• Emergence
• Ondansetron 4-8mg IV STAT 15 minutes prior to completion to prevent PONV
• Droperidol 0.625-1.25mg IV STAT at end of surgery
• Extubation
• Reversal of muscle relaxant
• Neostigmine 2.5mg (or 0.05mg/kg) IV + Glycopyrrolate 400mcg (or 0.01mcg/kg) IV
• Recovery
• Oxygen 6L via Hudson mask
• Anticipate pain
• Morphine pain protocol: 3-5mg 5-10 minutely IV
• +/- Tramadol 50-150mg IV/PO
• +/- Ketamine 10-20mg IV 10 minutely
• PONV
• Antiemetic protocol
• Ondansetron 4-8mg IV 8hourly (if not already given)
• Metoclopramide 10-20mg IV 8hourly
• Ward Care
• Post operative analgesia
• Paracetamol 1g PO QID
• Ibuprofen 400mg PO TDS with food
• Targin (Oxycodone + Naloxone) 10/5mg PO BD
• Endone (Oxycodone IR) 5-10mg PO 4hourly PRN
• +/- Consider
• Morphine 5mg IV STAT 1hourly PRN (Max 15mg 24hrs)
• &/or Tramadol 50-100mg PO/IV 4hourly PRN (Max 400mg 24hrs)
• Antiemetics
• Ondansetron 4-8mg PO/IV 8hrly PRN (Max 16mg 24hrs)
• Metoclopramide 10mg PO/IV 8hourly PRN (Max 20mg 24hrs)
• Prochlorperazine (Stemetil) 12.5mg IV/IM 8hourly PRN (3rd line)
• Fluids: Hartmans up to 1-2L post operatively
• Adjust to co-morbidities, age, etc.
• Diet as indicated by surgeon
• DVT prophylaxis
• Not recommended routinely
• Base on admission length and co-morbidities
• Commence if admitted overnight if not contraindicated
• Confirm with surgeon re: potential bleeding risk
• Some patients may be suitable to be discharged home same day as procedure

Complications

• As for laparoscopy
• As for GA
• PONV: laparascopic cholecystectomy is risk factor

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References

1. Hayden P, Cowman S. Anaesthesia for laparoscopic surgery. Continuing Education in Anaesthesia Critical Care & Pain. 2011;11(5):177-180
2. Bhattarai R, Sulaimankulov R, Dangi S, Adhikari H, Lamichhane S, Das C. Anesthesia for Laparoscopic Cholecystectomy: Experience with 5000 Cases. Ann. Int. Med. Den. Res. 2016;2(6):AN20-AN26
3. Selibrant I, Ledin G, Jakobsson J. Laparoscopic cholecystectomy perioperative management: an update. Ambulatory Anaesthesia. 2015;2:53-57
4. Ahmad S. Clinical Pain Advisor. Laparascopic cholecystectomy
5. Smith J, Samara N, Ballard D, Moss J, Griffen F. Prophylactic Antibiotics for Elective Laparoscopic Cholecystectomy. Am Surg. 2018;84(4):576-580