Laparoscopic Cholecystectomy
Patient phenotype
Most commonly female, 30s–50s, BMI often elevated, occasional cardiopulmonary disease. Typical American: GERD, obesity, sometimes diabetes. Outpatient unless conversion or comorbidity.
Procedure
Removal of the gallbladder via 4 abdominal trocars. Reverse Trendelenburg with left-lateral tilt to displace bowel. CO₂ insufflation to ~12–15 mmHg.
Anesthetic plan
GETA with cuffed ETT, NMB to facilitate insufflation + still field. Multimodal analgesia (acetaminophen, ketorolac if no contraindication, port-site lidocaine). Expect 60–90 min surgical time.
Setup
- ·Standard ASA monitors + temp
- ·18g PIV (no need for second unless high-risk)
- ·OG tube (decompress stomach to protect from trocar entry + improve view)
- ·BAIR hugger upper body
Biggest concerns by phase
Aspiration risk in obese / GERD patient
Many gallbladder patients have hiatal hernia or GERD. Consider RSI or modified RSI especially in BMI > 35 or symptomatic reflux. Pretreat with H2 blocker + nonparticulate antacid (sodium citrate) if true reflux history.
Hemodynamic effect of pneumoperitoneum
Insufflation to 15 mmHg drops venous return, raises SVR + PVR. CO often falls 10–30%. Vulnerable patients (CAD, pulmonary HTN, hypovolemia) need preload optimization + judicious vasopressor titration. Reverse Trendelenburg compounds the venous return drop.
Hypercarbia from CO₂ absorption
Increase minute ventilation 20–40% during insufflation to maintain ETCO₂ < 50. PaCO₂ runs ~5 mmHg higher than ETCO₂ — confirm with ABG if metabolic concern. Hypercarbia + sympathetic stim raises BP/HR.
Shoulder pain referral + diaphragmatic irritation
CO₂ trapped under diaphragm refers via phrenic to shoulder — common postop complaint. Surgical evacuation of gas + multimodal analgesia (NSAID, acetaminophen) help. Reposition supine before extubation to release.
PONV — high baseline risk in this population
Female + non-smoker + lap chole = Apfel score commonly 3–4. Multimodal antiemetic prophylaxis: dex 4–8 mg at induction + ondansetron 4 mg at end + consider scopolamine patch + droperidol 0.625 mg. Avoid N₂O if possible.
Bile duct injury or unrecognized bowel perforation
If postop pain is severe, fever rises, or HR/BP trend wrong — surgical reassessment now. CRNA's job in PACU: notice pain disproportionate to the case, don't just chase opioids.
Mock-defense scenarios
Practice answering these out loud. The probes show what an examiner is listening for.
Your patient is a 52-year-old female, BMI 38, symptomatic gallstones, GERD on omeprazole. She vomited 30 minutes before arriving. The surgeon is asking to start. Walk me through your induction plan.
What an examiner probes for
- ▹Recognizes RSI indication + airway difficulty risk
- ▹Names specific premedication (H2 blocker, nonparticulate antacid)
- ▹Plans cricoid + back-up airway device
- ▹Justifies drug choices (sux vs. roc + sugammadex)
Five minutes after insufflation, BP drops from 130/80 to 85/45, HR rises from 70 to 110. ETCO₂ is 48. What's happening and what do you do?
What an examiner probes for
- ▹Differentiates pneumo-related preload drop from CO₂ embolism, MI, anaphylaxis, or surgical bleeding
- ▹First moves: ask surgeon to pause/desufflate, check vitals, fluid bolus, vasopressor
- ▹Recognizes ETCO₂ trend matters — sudden drop = embolism, sustained rise = absorption + ventilation issue
Sources
- Miller's Anesthesia 9e Ch 71
- ASA Practice Advisory: Pneumoperitoneum
- Stoelting/Hines Ch 19
Anatomy reference
Sourced reference images. 4 matches for "liver gallbladder biliary".
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