1. Laparoscopic Cholecystectomy Ri 毛贊智 Ri 黃彥筑 ／ VS 林珍榮

2. Brief history 67 y/o male Multiple gallbladder polyps(0.8cm) noted for 3~4 years GB stone was also noted No RUQ pain, nausea or vomiting

3. Past history DM: (-) HTN: (+) for 17 years, under regular medical control Elevated renal function for 3~4 years BPH with medical treatment Appendectomy 10 years ago Allergic to sulfa-drug

4. Physical examination BH: 163 cm BW: 77 kg BT: 36.8 PR: 80 RR: 20 BP: 160/80 Breathing sound: clear Heart sound: normal Abdomen: normal, no RUQ pain

5. Lab examination BUN: 36.3 Cre: 5.2 Na: 145 K: 4.3 Cl: 107 T-bil: 0.4 WBC: 9.64 RBC: 4.25*10 6 Hb: 13.4 PT: 11.1/11.7 PTT: 32.4/35.1

6. Operation method Laparoscopic cholecystectomy

7. Drug used ASA class III Induction Fentanyl 100μg Atracurium 25mg Midazolam 5mg Pentothal 250mg Robinul 0.2mg Maintain Isoflurane

8. Operation course Quite smooth BP: 100~120 HR: 60~70 SpO 2 : 99~100% ET CO2 : 33~35 Use 1 hr 15 min

9. Post OP follow up No PONV Pain score: 2 Demerol 50 mg q6h Acetaminophen 1# qid No sore throat No headache

10. Laparoscopic Cholecystectomy(LC) Indication: Symptomatic gallstones Other biliary tract disease Difficult technical challenges Acute cholecystitis Obesity Previous intra-abdominal surgery Pregnancy

11. LC-surgical technique Reverse Trendelenburg position Intraperitoneal CO2 insufflation

12. LC-surgical technique

13. Benefit of LC Shorter hospital stays More rapid return to normal activities Small, limited incisions Less pain Less postoperative ileus

14. LC vs OC Treatment of Acute Cholecystitis Conversion rate: 15% Operationg time: 88 vs 77 mins Complication: 14% vs 23% Hospital stay: 3.3 vs 8.1 days Laparoscopic cholecystectomy vs Open cholecystectomy in the treatment of acute cholecystitis(ARCH SURG volume 133)

15. Anesthetic management Anesthetic technique Regional anesthesia Thoracic epidural anesthesia(T 2 ) Advantage: Awake Protective airway reflex Shorter recovery Disadvantage: Diaphragm irritation Significant nausea and vomiting Referred pain : neck and shoulder

16. Anesthetic management Anesthetic technique General anesthesia Cuffed endotracheal tube placement Controlled ventilation Urinary catheter and nasogastric tube

17. Anesthetic management Anesthetic agents Oxygen Nitrous oxide Volatile anesthetic agent Relaxants Opioids: Oddi sphincter spasm

18. Anesthetic management Use of nitrous oxide Controversial Bowel distention Postoperative nausea

19. Anesthetic management Monitoring PET co2 Increased minute ventilation by 12~16% Paco2 must less than 41 mmHg Invasive hemodynamic monitoring ASA class III~IV Especially at p ’ t with cardiopulmonary disease

20. Anesthetic management Post operative pain relief Wound infiltration with local anesthesia and NSAID - for peripheral pain Opioids - for central pain Ondansetron – for nausea and vomiting

21. Take a rest ……