NMS. Casos Clínicos

176 Part II ♦ Specific Disorders (WBC) of 12,000–15,000/mm 3 , who have uncomplicated cholelithiasis. Alkaline phospha- tase and transaminase levels may also be elevated. The patient’s blood studies are normal, with the exception of mild elevation of her alkaline phosphatase. Q: What would be your next step? A: Once symptomatic cholelithiasis is established, the patient should be offered a cholecystec- tomy for treatment.

Digging Deep

Patients have the right to participate in their own treatment plans and can decide if the symptoms and risks of the disease outweigh the risks of the intervention.

Q: Should the patient receive antibiotics? A: Most patients with uncomplicated, symptomatic cholelithiasis do not need antibiotics at presentation. A cholecystectomy is considered to be a clean-contaminated case, and a single, preoperative dose of a first-generation cephalosporin is recommended. Antibiotics may be appropriate for longer-term use in patients who have a high risk of developing septic complications following cholecystectomy. This typically includes patients older than 70 years of age, patients with acute cholecystitis, and patients with a history of obstruc- tive jaundice, common duct stones, or jaundice. Patients who have undergone preoperative ERCP also warrant treatment with preoperative antibiotics.

The patient decides to proceed with a cholecystectomy.

Q: What type of cholecystectomy would you recommend? A: The commonly accepted standard procedure is laparoscopic cholecystectomy . Open cho- lecystectomy is usually done when laparoscopic cholecystectomy cannot be tolerated phys- iologically or due to difficult anatomy. Q: What are the basic steps in a cholecystectomy? A: Entry to the abdomen occurs through an incision or through trocars for the laparoscopic procedure. After exploration of the abdomen, the surgeon removes the gallbladder from the fundus to the junction of the cystic and common duct (retrograde cholecystectomy) or starts with the cystic duct and artery. The important parts of the procedure include identi- fying and ligating the cystic duct without injury to the common duct, and ligating the cystic artery without injury to the hepatic artery, particularly the right hepatic artery. An operative cholangiogram to visualize the biliary tree and rule out other diseases such as common duct stones is also important if there is any doubt about the anatomy (Fig. 7-3). Q: What are the major potential complications of a cholecystectomy? A: Injury to the common duct is a serious complication that can result in chronic bili- ary strictures, infection, and even cirrhosis and is more common during laparoscopic SAMPLE