Perioperative Care and Surgical Technique

Patient preparation for laparoscopic cholecystectomy does not typically include a bowel cleansing regimen, but no oral intake is restricted a minimum of 6 hours prior to induction of general anesthesia. Preoperative prophylactic antibiotics are typically administered intravenously, ideally one half hour before surgical incision. Choice of antibacterial agent is commensurate with the spectrum of biliary infectious agents.

Following induction of general anesthesia and preparation of the patient's abdomen with antibacterial agents, the procedure begins with insertion of a 10 mm diameter laparoscopic port at the umbilicus. Gas is delivered, or insufflated, through the port into the abdomen and a laparoscope with attached fiber optic video camera is introduced. Carbon dioxide is almost exclusively used to create the pneumoperitoneum, but other gases including air, helium, and nitrous oxide have been used. Intraabdominal pressures are limited to approximately 15 mm Hg because of the previously mentioned secondary hemo-dynamic and pulmonary effects created by the pneu-moperitoneum. A brief laparoscopic examination of the abdomen is performed and 3 more laparoscopic ports, typically 5 mm in diameter, are introduced through small incisions in the epigastrium and right subcostal regions.

Laparoscopic graspers allow manipulation of intraabdominal contents including the gallbladder. The dome of the gallbladder is elevated in a cephalad fashion to reveal Calot's triangle. Inflammation secondary to acute or chronic cholecystitis may lead to regional adhesions, limit exposure of Calot's triangle, and render the laparoscopic approach precarious.

Dissection begins with stripping of the peritoneal lining from the gallbladder infundibulum and cystic duct. Absolute, positive identification of the cystic duct and cystic artery are essential to performing a safe and successful laparoscopic cholecystectomy. Strong evidence exists that misidentification of the common bile duct as the cystic duct leads to most major bile duct injuries, the so-called "classic bile duct injury." Difficult identification of important anatomical landmarks requires the surgeon to maintain a low threshold to convert from the laparoscopic approach to an open cholecystectomy. Conversion to an open procedure for prevention of inadvertent injury is not considered a complication; it is considered good clinical judgment. Selective use of laparoscopic intraoperative cholangiography (IOC) can help to determine anatomical variants, diagnose chole-docholithiasis, and identify inadvertent injuries. A normal cholangiogram is followed by ligation of the cystic duct and cystic artery with clips or sutures and separation of the gallbladder from its liver attachments. The gallbladder is removed from the peritoneal cavity through one of the laparoscopic port incisions, commonly the umbilical site. Hemostasis is confirmed and the gas is removed, or desuf-flated, from the abdomen.

Duration of the procedure is dependent on regional inflammatory changes and patient anatomy. However, an elective laparoscopic cholecystectomy may be performed in < 1 hour on a routine basis. Although patients are routinely admitted for overnight observation following the procedure, outpatient laparoscopic cholecystectomies are becoming more common. A liquid diet is instituted immediately following surgery and the patients is instructed to advance to regular food as tolerated. Patients generally recover and return to normal activities in < 2 weeks after surgery.

Although the surgical technique of laparoscopic chole-cystectomy remains essentially unchanged since the early days of its development, technological refinements continue to provide improvements. Improved digital imaging provides better visualization and allows the use of smaller diameter equipment, smaller incisions, and fewer laparo-scopic ports.

Constipation Prescription

Constipation Prescription

Did you ever think feeling angry and irritable could be a symptom of constipation? A horrible fullness and pressing sharp pains against the bladders can’t help but affect your mood. Sometimes you just want everyone to leave you alone and sleep to escape the pain. It is virtually impossible to be constipated and keep a sunny disposition. Follow the steps in this guide to alleviate constipation and lead a happier healthy life.

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