Acute Cholecystitis - Forum

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Noro

Acute Cholecystitis - Ärzteforum

Post#1 »

A 50 YO woman, Aortic Valve Replacement X2, on coumadin. 6 weeks post acute
cholecystitis, almost asymptomatic now, came in for Lap Chole after switching
the coumadin to LMW heparin, prophylaxis antibiotics given pre-op.
Findings were of markedly thickened wall gallbladder, covered by omental
adhesions, stomach and duodenum densely adhered to the GB, and aspiration
yielded bile-less pus. Dissection of the adhesions was oozy, and separating
the stomach was extremely difficult.
How would you continue?
-persist?
-convert?
-abort?
Considering the high risk for bleeding and infection with the prosthetic valve
and the anticoagulation, we left a drain near the puncture site of the GB (no
obvious leak), and decided to wait a few more weeks for better conditions.


User avatar
Surgeon

Re: Acute Cholecystitis - Ärzteforum

Post#2 »

I would persist, but I realize that is unusual. I was stunned when I heard
Barry McKernan suggest this at one of those "advanced laparoscopic surgery"
courses years ago, but it has made me a better laparoscopic surgeon. I have
been very careful whenever I am "persisting" and I may have also been very
lucky, but I haven't had occasion to regret it yet. I do about 120 lap
choles a year, and probably "persist" on about ten of them.

Hans

Re: Acute Cholecystitis - Ärzteforum

Post#3 »

Well that seems like a tough situation to me having all that pus in a
gallbladder in a patient with a prosthetic heart valve. I would have
converted to an open cholecystectomy simply to reach a "safe" situation.
I feel "uneasy" waiting weeks(?) for an improvement of the conditions.
Despite my laparoscopic experience I would not have risked another hour
(?) of operation time (or facing problems "closing" an acutely inflamed
cystic duct). Performing an open cholecystectomy still has its value
despite the increasing feasibility reports of laparoscopic approaches
with acute cholecystitis.

User avatar
Doctor Green

Re: Acute Cholecystitis - Ärzteforum

Post#4 »

I am sure that surgeon will soon tell you to convert to
open operation. That is probably the "correct" answer. However, provided
that you can continue to make progress safely, continue with lap, and
ignore the clock. Once you can only make progress by compromising safety
you have to make a decision whether to convert or not. If you decide not
to do so, you may well be able to do a cholecystostomy laparoscopically
with help from outside, evacuating the stones, and leaving a drain into
the GB. Most cholecystostomies will need no further treatment if all
stones are removed.
I do about 130 lap choles per year, and conversion
rates are now down to 3% max. That is unimportant, but demonstrates that
perseverance is justified, provided you NEVER compromise with safety. We
have now done two fistulas laparoscopically, and both of these were very
slow (two to three hours). We have also done two of these cardiac
patients on Warfarin changed to subcut heparin - bleeding was not a
problem. Of course these patients may have pacemakers, in which case I
do not allow electrocautery to be set up (in case I am tempted to use
it!) and just use harmonic scalpel.

User avatar
Old surgeon

Re: Acute Cholecystitis - Ärzteforum

Post#5 »

I would have taken care of the problem at this setting. I see no value in
waiting
till a later date, unless you are going to presume things will settle down and
an easier dissection can occur. This I doubt. If the stomach and duodenum are
plastered to the area, they will still be plastered there in 4-6 weeks, and
probably
the adhesions will be more fibrous and dense.

So, knowing that I'm going to proceed...what course to take? It's a
judgement call.
If i felt things were progressing at a satisfactory rate i might continue with
laproscopy for a little bit, but with what you are describing I would just
convert
to open and finish the job. Subjecting this patient to a second operation and
anesthetic risk seems unjustifiable.

When i first began doing lap chole's almost any sign of acute inflamation and
i would quickly bail out. With more experience I am successfully able to do
some acutely inflamed ones. (about 500-600 total now) My rule for myself
is...when
i have almost ANY doubt about continuing with laproscopy I open. Another
rule is...
if i don't have things fairly well wrapped up by one hour (cystic duct
identified and
triangle in site, ready to clip etc) i'm looking for the #10 blade and the
bookwalter
retractor. Flailing around for 4 hours like i've seen other surgeons in
this town do,
then firing an endo GIA stapler across the lower portion of the gallbladder
doesn't
make a lot of sense to me (btw i've also seen two of those leak). Then they
brag
about their "i hardly ever have to open" success rate. bleh

OPENING A LAP CHOLE IS NOT A FAILURE.

User avatar
Alalo

Re: Acute Cholecystitis - Ärzteforum

Post#6 »

I think you did the patient a disservice. My policy is to continue with
the laparoscopic procedure as long as I am making SAFE PROGRESS. If you
aren't getting anywhere or you can't see what you are doing, it is time to
change plans; either convert, or, if you think the patient is too sick to
tolerate further operation, try one of the following options: At the very
least, you should have put a cholecystostomy tube into the gallbladder. If
you were able to separate the viscera from the liver and gallbladder, you
could have cut away half the wall of the gallbladder and destroyed the
retained mucosa with electrocautery.

What you did was to leave the patient with an undrained abscess.

User avatar
Resident

Re: Acute Cholecystitis - Ärzteforum

Post#7 »

I don't get a lot of patients with pacemakers, but have never considered a
pacemaker a contraindication to the use of electrocautery. We don't have an
alternative, except laser which I haven't used since residency. Pardon my
ignorance, but am I committing a grave error?

bonjorno

Re: Acute Cholecystitis - Ärzteforum

Post#8 »

> -persist?

Yes, as others have said, as long as progress is made safely. In my opinion, it is
better to complete the procedure laparoscopically for the patients benefit.

> -convert?

Only when no progress is being made, laparoscopic techniques are inadequate, and
patient safety is compromised by continuing.

> -abort?

I would abort if the patient's life was being held in the balance by continuing.
This goes for any technique, open or laparoscopic.

> Considering the high risk for bleeding and infection with the prosthetic valve
> and the anticoagulation, we left a drain near the puncture site of the GB (no
> obvious leak), and decided to wait a few more weeks for better conditions.

You were there, and this must be the appropriate management. In similar situations
in the future, if you can drain the spot, think about inserting a cholecystostomy
tube, rather than just a drain. This can buy you a lot of time, and may even solve
the problem of future attacks, if the stones can be evacuated. If the drain hole
sealed, and the cystic duct was obstructed in your case, the cholecystitis could
have continued and worsened. This would not be the case with a cholecystostomy.

bonjorno

Re: Acute Cholecystitis - Ärzteforum

Post#9 »

Since we are talking about laparoscopic cholecystectomies, and intraop bleeding
control, is anyone routinely using the argon beam coagulator during these cases?
It is a cautery.

Scalpel

Re: Acute Cholecystitis - Ärzteforum

Post#10 »

Resident wrote:I don't get a lot of patients with pacemakers, but have never considered a
pacemaker a contraindication to the use of electrocautery. We don't have an
alternative, except laser which I haven't used since residency. Pardon my
ignorance, but am I committing a grave error?


Not really, but as in any surgical endeavor, you should make sure that you
can handle the complications should they arise. In the case of pacemakers,
particularly those with unipolar leads, the cautery can inhibit the
pacemaker output. If the pacemaker battery is near the end of its life,
the pacemaker can be permanently inhibited or forced into a different mode.
You should therefore make sure you have access to the requisite programmer
for the patient's pacemaker, and I would recommend that you also have a
defibrillator pack that contains an external transcutaneous pacemaker in
the OR just in case. Of course, you should never use monopolar cautery
near a pacemaker lead, since the radio frequency cautery energy can induce
a current in the pacemaker lead sufficient to cause ventricular
fibrillation. Bipolar cautery is safer, but even this can induce enough
current in the lead to affect pacemaker operation.

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