Cholelithiasis (Gallstones)

Find out where the stone is - LFTs with a fractionated bilirubin plus the RUQ ultrasound or HIDA report separate simple colic from an obstructed duct or an inflamed gallbladder. That decides whether this is an outpatient lap chole or an urgent case in a sick patient.

Full stomach - vomiting, obstruction and pain-driven gastric stasis are the rule in acute cholecystitis and gallstone ileus. RSI, then decompress the stomach after the airway is secured.

Volume and potassium - protracted vomiting means dehydration and hypokalemia. Get a BMP and resuscitate preop rather than chasing hypotension after induction.

Sepsis - cholangitis, acalculous cholecystitis and emphysematous cholecystitis carry a high risk of perforation and necrosis. Check lactate, WBC and hemodynamics; if the patient is septic, treat it as a source-control emergency with antibiotics in before incision.

Insufflation physiology - CO2 pneumoperitoneum runs at 10–15 mmHg against a normal intra-abdominal pressure under 5 mmHg. Expect sympathetic stimulation with catecholamine release, a rise in MAP and SVR, and a fall in venous return and cardiac output at higher pressures. Ask for the belly to be let down if the numbers deteriorate.

Vagal response at insufflation - peritoneal stretch on initial insufflation can produce abrupt bradycardia and hypotension. Have glycopyrrolate or atropine drawn and tell the surgeon to stop insufflating.

Ventilation - absorbed CO2 raises PaCO2. Increase minute ventilation and follow ETCO2, and remember the arterial-to-ETCO2 gradient widens in lung disease.

Plan for conversion - laparoscopic cholecystectomy is the single most common procedure causing bile duct injury. A difficult dissection can become an open subcostal case with more blood loss and a much larger analgesic requirement.

Regional adjunct - bilateral erector spinae plane or transversus abdominis plane blocks reduce postoperative pain after abdominal surgery and fit an opioid-sparing multimodal plan.

ERCP - the scope goes to the second part of the duodenum with the patient semi-prone, off-site, on a shared airway. Screen with STOP-BANG; a high score plus deep sedation prone in a remote location argues for a secured airway.

Pregnancy - symptomatic cholelithiasis with choledocholithiasis is managed laparoscopically in pregnancy. Add left uterine displacement, tighter ETCO2 control, and fetal monitoring per your obstetric service.

Gallstones are hardened deposits of cholesterol, bilirubin and bile that form in the gallbladder. They are common — roughly 6% of men and 9% of women in the US — and most are asymptomatic, found incidentally. Symptoms begin when a stone obstructs. Biliary colic is right upper quadrant or epigastric pain after a large, fatty meal that makes the gallbladder contract against a stone in the cystic or common bile duct, classically radiating to the right scapula or mid-back with nausea and vomiting. The complications are what bring the patient to you: acute cholecystitis from cystic duct occlusion, choledocholithiasis (common bile duct stones in 1–15% of patients with gallstones) with obstructive jaundice, gallstone pancreatitis, and rarely gallstone ileus, a mechanical bowel obstruction.