Week 15 Handout Flipped Classrooms: Cholecystectomy

Question 1

What is Cholecystectomy?

Answer 1

Surgical removal of the gallbladder.

“Chole” = bile or “gall”, “Cyst” = fluid filled sac, “Ectomy” = surgical removal.

Question 2

What are the indications for gallbladder removal?

Answer 2

Acute cholecystitis, cholelithiasis (symptomatic gallstones), gallbladder cancer or trauma.

Often diagnosed by ERCP; clip the cystic duct & artery.

Question 3

What are the patient populations and risk factors for gallbladder issues?

Answer 3

Female gender, advanced age, obesity, multiple pregnancies.

Question 4

What are the surgical techniques for cholecystectomy?

Answer 4

1. Laparoscopic (most common) - less invasive, shorter post op recovery.
2. Open Approach - used for expected difficulty.
3. Robot-Assisted - more precise but expensive.

Laparoscopic cases convert to open ~5%.

Question 5

What are the preoperative considerations for cholecystectomy?

Answer 5

Thorough airway assessment, consider PFTs in COPD patients, antibiotics within 60 minutes pre-incision.

High incidence of PONV; use dexamethasone, scopolamine patch, ondansetron.

Question 6

What are common complications of cholecystectomy?

Answer 6

Bile leak, sub-hepatic abscess, common bile duct injury.

CRNA must be prepared for hemorrhage, pneumothorax, atelectasis.

Question 7

What is the patient positioning for cholecystectomy?

Answer 7

Trocar placement: Trendelenburg + left tilt. Main procedure: Trendelenburg and Reverse Trendelenburg.

Ensure MAP is adequate.

Question 8

What are the fluid management guidelines during cholecystectomy?

Answer 8

Use warmed IV fluids, fluids: LR or NS at 8–12 mL/kg/hr.

Use 3:1 rule for replacing blood loss.

Question 9

What are the insufflation techniques for cholecystectomy?

Answer 9

Initial access at umbilicus using Hassan trocar or Veress needle. Insufflation pressure: 15 mmHg.

High pressures may lead to decreased venous return.

Question 10

What are critical intraoperative events to consider?

Answer 10

Induction: high aspiration risk. Trocar placement: risk of hemorrhage. CO₂ insufflation: monitor for PONV.

Adjust pressure if instability occurs.

Question 11

What are the alternate anesthesia approaches for cholecystectomy?

Answer 11

Standard: General anesthesia with ETT. Alternative: LMA ProSeal/Supreme or regional (T6–T8 epidural).

Question 12

What are the key takeaways for cholecystectomy?

Answer 12

Preferred technique: Laparoscopic with general anesthesia. Positioning: Trendelenburg + L tilt.

Complications: bile leak, duct injury, hemorrhage.

Question 13

What is the Open Approach in Cholecystectomy?

Answer 13

The Open Approach is used when there is expected difficulty in removal due to factors such as inflammation, previous adhesions/operations, cirrhosis, or coagulopathy.

Question 14

What are the pros of Robot-Assisted Cholecystectomy?

Answer 14

Pros include more precision and a single small incision.

Question 15

What are the cons of Robot-Assisted Cholecystectomy?

Answer 15

Cons include being expensive, longer operative time, increased risk of hernias (7–20%), and risk of post-op visual loss (POVL).

Question 16

What is the high incidence associated with Robot-Assisted Cholecystectomy?

Answer 16

There is a high incidence of postoperative nausea and vomiting (PONV).

Question 17

Cholecystectomy Common Complications * CRNA-must be prepared for:

Answer 17

o Hemorrhage
o Pneumothorax
o Atelectasis

Question 18

What is the 4-2-1 Rule for fluid maintenance?

Answer 18

First 10 kg: 4 mL/kg/hr
Next 10 kg (11–20 kg): 2 mL/kg/hr
Each kg >20 kg: 1 mL/kg/hr

Question 19

What is the shortcut formula for calculating maintenance fluid rate in adults?

Answer 19

Maintenance fluid rate (mL/hr) = Weight (kg) + 40

Question 20

What is the 3:1 rule for replacing blood loss?

Answer 20

For every 1 mL of blood lost, replace it with 3 mL of isotonic crystalloid solution (e.g., Lactated Ringer’s or Normal Saline).

Question 21

What needle is used for closed/blind access?

Answer 21

Veress needle

Requires OG and Foley placement to empty bladder & decompress stomach.

Question 22

What is a risk associated with using a Veress needle?

Answer 22

Higher risk of bladder/bowel perforation.

Question 23

What is the standard insufflation pressure?

Answer 23

15 mmHg

Question 24

What may high insufflation pressures lead to?

Answer 24

Decreased venous return, decreased cardiac output, bradycardia.

Question 25

What should be done if instability occurs during insufflation?

Answer 25

Request reduction to 10–12 mmHg.

Question 26

Student Question: What is a cholecystectomy? A. Removal of the appendix B. An exploratory laparotomy C. Removal of the gallbladder D. A sex change operation

Answer 26

Answer: C. Removal of the gallbladder Rationale: Cholecystectomy is the removal of the gallbladder usually due to cholecystitis or symptomatic gall stones (cholelithiasis). Reference: Jaffe, A.R., Schmiesing, C.A., & Golianu, B. (2019). Anesthesiologist’s manual of surgical procedures. (6th ed., pp. 575-581). Wolters Kluwer/Lippincott Williams & Wilkins.

Question 27

Student Question: Which technique is most commonly used to perform a cholecystectomy? A. Robotic B. Open C. ERCP D. Laparoscopic

Answer 27

Answer: D. Laparoscopic Rationale: The vast majority of cholecystectomies are performed laparoscopically. Less than 10% are scheduled as open and only 5% convert from laparoscopic to open. Reference: Jaffe, A.R., Schmiesing, C.A., & Golianu, B. (2019). Anesthesiologist’s manual of surgical procedures. (6th ed., pp. 575-581). Wolters Kluwer/Lippincott Williams & Wilkins

Question 28

Student Question: What is an alternate anesthesia technique that could be used for a patient preparing for laparoscopic cholecystectomy that wants to remain awake for the procedure? A. Spinal Anesthesia at the L4-L5 level B. TIVA C. General Anesthesia D. Spinal Anesthesia at the T6-T8 level.

Answer 28

Answer: D. Spinal Anesthesia at the T6-T8 level. Rationale: Spinal Anesthesia has successfully been used as the primary anesthetic is laparoscopic cholecystectomy. It can be beneficial for patients that wish to remain awake for the procedure, who have severe respiratory disease, or who have a history of difficult airway. The level of a spinal needed for cholecystectomy is T6-T8. Reference: Miller, R.D., Cohen, N.H., Eriksson, L.I., Lee, A.F., Wiener-Kronish, J.P., Young, W.L. (2020). Miller’s anesthesia. (9th ed., pp. 1420 & 2625). Elsevier Inc.

Question 29

Student Question: Which of the following is not a complication associated with Cholecystectomy? A. Atelectasis B. Hemorrhage C. Bile Leak D. Traumatic Brain Injury

Answer 29

Answer: D. Traumatic Brain Injury Rationale: Atelectasis, hemorrhage, and bile leak are all complications associated with cholecystectomy. Traumatic brain injury is not a complication associated with cholecystectomy. Reference: Jaffe, A.R., Schmiesing, C.A., & Golianu, B. (2019). Anesthesiologist’s manual of surgical procedures. (6th ed., pp. 575-581) Wolters Kluwer/Lippincott Williams & Wilkins.

Question 30

Student Question: Which of the following positions would your patient not be in during a laparoscopic cholecystectomy? A. Trendelenburg B. Reverse Trendelenburg C. Tilted toward the left side D. Lithotomy

Answer 30

Answer: D, Lithotomy Rationale: The patient will be in Trendelenburg position and leaning toward the left during trocar placement and in Reverse Trendelenburg for the subsequent portions of the surgery. There is no point in the procedure that the patient will be in Lithotomy position. Reference: Jaffe, A.R., Schmiesing, C.A., & Golianu, B. (2019). Anesthesiologist’s manual of surgical procedures. (6th ed., pp. 575-581) Wolters Kluwer/Lippincott Williams & Wilkins.

Question 31

Student Question: You are taking care of a patient that came in for a laparoscopic cholecystectomy. One minute after the surgeon insufflated the abdomen to 15 mmHg, the patient’s hemodynamics start to become unstable with low blood pressure, low HR, and major ventilatory challenges. What should you do next? A. Begin chest compressions B. Administer Phenylephrine C. Ask the surgeon to lower the insufflation pressure to 10-12 mmHg and reevaluate. D. Perform recruitment maneuvers to improve ventilation.

Answer 31

Answer: C. Ask the surgeon to lower the insufflation pressure to 10-12 mmHg and reevaluate. Rationale: Higher insufflation pressure can cause vagal nerve stimulation and make ventilation difficult. If there are ventilation or hemodynamic problems shortly after insufflation, asking the surgeon to reduce the pressure from 15 mmHg to 10-12 mmHg can help fix this problem. Reference: Jaffe, A.R., Schmiesing, C.A., & Golianu, B. (2019). Anesthesiologist’s manual of surgical procedures. (6th ed., pp. 575-581) Wolters Kluwer/Lippincott Williams & Wilkins.