Acute Cholecystitis - Forum

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Scalpel

Re: Acute Cholecystitis - Ärzteforum

Post#11 »

bonjorno wrote: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.


The Argon Beam Coagulator (ABC) is the best tool I've found for controlling
recalcitrant ooozing from the liver bed. It isn't good for much more,
since you can't use it for cutting or dissection, and the disposable
cannula isn't cheap. You or your assistant also have to diligently watch
the intraabdominal pressure since it can rise rapidly. Also note that
there have been some cases of argon gas embolization reported, so it isn't
a totally innocuous device.


User avatar
Lady Surgeon

Re: Acute Cholecystitis - Ärzteforum

Post#12 »

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?



The pacemaker people tell me it is okay to cauterize in the pocket containing the
lead only but not okay to use cautery once I put the pacemaker generator in the
pocket.

All the pacemaker manufacturers have very nice educational sessions. You can
attend these free if you place pacemakers. I suspect you could get a pacemaker
rep to come give a talk about the dos and don'ts for surgery in patients with
pacers.

Critical

Re: Acute Cholecystitis - Ärzteforum

Post#13 »

Old surgeon wrote: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.


But what is the magic about one hour? Modern anaesthesia gives
as good results after three hours as one. The magic determinant for
conversion is when no progress can be made laparoscopically, or progress
can only be made by an unsafe manoeuvre. Why give the patient the
disadvantages of an open operation when an extra half hour would see you
home just as safely.

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Old surgeon

Re: Acute Cholecystitis - Ärzteforum

Post#14 »

Nothing magic about one hour mark. Just arbitrary point. If i'm flailing
and haven't
identified the cystic duct by the one hour point then *for me* things aren't
progressing satisfactorily. If i feel i'm close i'll forge ahead, its a
judgement call.
I'm not saying the operation is done at one hour...just that i've id the
cystic duct,
even more important the cystic duct/gallbladder junction. I didn't mean to
imply
that i start a clock when the operations begins...and at the one hour point
the nurse turns off the laproscopy light and hands me the knife!

Why do we talk so much about the "disadvantages" of the open procedure?
Ask all the patients who have had their common duct injured during
a laproscopic cholecystectomy if they feel it was really an "advantage"
to have it done with the scope. Safe surgery is really what we're talking
about.
Seems i've read somewhere that there is an increased incidence of duct injury
with acute cholecystitis and the scope. I approach it with trepidation and
respect.

I wonder how many surgeons have said to themselves: I wish i would have
opened sooner as a gush of bile (not from the gallbladder) comes out of a
*severely* inflamed porta.

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Sweden surgeon

Re: Acute Cholecystitis - Ärzteforum

Post#15 »

Old surgeon wrote: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.

OPENING A LAP CHOLE IS NOT A FAILURE.


The last statement is the most important thing I try to teach
the trainees - and the hardest for them to learn.

User avatar
Sweden surgeon

Re: Acute Cholecystitis - Ärzteforum

Post#16 »

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?


There is well documented risk in using diathermy in patients
with pacemakers, though the risk is less with modern varieties. If you
use diathermy, consider the electrical path. Ensure large patient plate
with good contact, and keep it away from the heart!
Much better to use alternatives if you can - surely you can use
bipolar instruments?

User avatar
A Doctor

Re: Acute Cholecystitis - Ärzteforum

Post#17 »

>after switching the coumadin to LMW heparin, prophylaxis antibiotics

I don't know about peri-op converting to LMW heparin. I will feel much
more comfortable with switching to IV heparin and monitoring the aPTT
during the peri-op period. The half life of regulat heparin is short and
is much more controllable and allows better fine-tuning. Aortic valves
are high flow valves (as opposed to mitral valves), and could stand a
short time of loss of anticoagulation during your surgery if you have
to, especially if it was a St.Jude valve.

>-convert?

Yes, I would convert to open.

>bleeding and infection with the prosthetic valve and the anticoagulation,

The valve may get infected from the biliary tract if surgery is not
performed. With good endocarditis IV antibiotic prophylaxis you should
be able to minimize the risk of infection from the surgery and abolish
the risk of postoperative prosthetic valve infection from an incompleted
surgery. The anticoagulation issue is discussed above.

we left a drain near the puncture site of the GB (no
>obvious leak),

Why drain? Can't see the reason here.

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