แนวทางการผ่าตัดถุงน ้ำดีอย่างปลอดภัย( Safe Cholecystectomy Guideline)

Document No : CPG-02-BUD-020

Department : Bangkok Hospital Udon

Document Type : Clinical Practice Guideline ( CPG )

Category : (02) หมวดกิจกรรมบริกำรทำงคลินิก

Subject : แนวทำงกำรผ่ำตัดถุงน้ำดีอย่ำงปลอดภัย(

Revision : 00

Effective Date : 07 Oct 2022

และ มีกำรบำดเจ็บและบอบช้ำของเนื้อเยื่อบริเวณที่ทำ ผ่ำตัด ทำให้ต้องใช้เวลำในกำรรักษำแผลผ่ำตัดนำนขึ้น 3. ปัญหำกำรเกิดกำรบำดเจ็บของอวัยวะข้ำงเคียงที่ไม่ใช่ถุงน้ำดีและท่อทำงเดินน้ำดีนอกตับ

เพื่อให้ผู้ป่วยมีควำมปลอดภัยจำกกำรผ่ำตัด และ ไม่มีภำวะแทรกซ้อน 2.3 เพื่อให้ผู้ป่วยมีระยะเวลำพักฟื้นในรพ.หลังผ่ำตัดตำมที่ประเมินไว้ตั้งแต่ก่อนผ่ำตัด

Safe Cholecystectomy Guideline)

Symptomatic Cholecystitis Include both acute and chronic Cholecystitis

Acute Cholecystitis

Acute upper abdominal pain with tenderness under the right costal margin accompanied by fever, laboratory markers of inflammation and scintigraphic or sonologic evidence

Complicated Cholecystitis Refers to emphysematous Cholecystitis, Cholecystitis with perforation and secondary peritonitis, pericholecystic abscess formation and generalized peritonitis

Early Cholecystectomy Cholecystectomy performed within 72 hrs of admission

Delayed Cholecystectomy Initial conservative treatment with antimicrobials followed by cholecystectomy

8-12 weeks later

Standard Open Cholecystectomy

Mini-incision/Mini laparotomy

Cholecystectomy

Laparoscopic Cholecystectomy

Difficult cholecystectomy

Transverse subcostal skin incision greater than 6 cm in length to provide comfortable exposure of the gallbladder

Transverse subcostal skin incision less than or equal to 6 cm in length

Use of 5-10 mm subxiphoid and 5 mm lateral trocars for cholecystectomy

Operative time more than 2 hrs , there are prior abdominal operation that can make adhesion in upper quadrant area of abdomen , Patient receive anticoagulant or antiplatelet medication , Patient who has underlying disease such as Liver cirrhosis , Portal Hypertension , Hepatitis , Pancreatitis , Obstructive jaundice , Patient who has bleeding tendency condition.

Clinical Practice Guideline for diagnosis and treatment Cholecystitis in Bangkok hospital Udon

6.1 Ultrasound is the most helpful diagnosis test for acute and chronic calculous Cholecystitis

6.2 Routine cholecystectomy is not recommended for asymptomatic gallstone, cholecystectomy may be considered in a selected group of patients

6.3 Recommended surgical approached for acute cholecystitis are open cholecystectomy or laparoscopic cholecystectomy and Laparoscopic cholecystectomy is the recommended surgical approach in the management of chronic cholecystitis

6.4 Patient with acute Cholecystitis should undergo cholecystectomy within 72 hrs

6.5 Empiric antibiotic therapy is recommended for patients with acute or chronic Cholecystitis

6.5.1 Following antibiotics are recommended for therapy in uncomplicated acute or chronic Cholecystitis :

-Cefazolin 1 gm IV every 8 hrs

-Cefuroxime 1.5 grams IV every 8 hrs

-Cefoxitin 2 grams IV every 8 hrs ( If at risk for anaerobic infection )

6.5.2 For patients with allergy to beta-lactam antibiotic :

-Fluoroquinolone 400 mg IV every 12 hrs +/- Metronidazole 500 mg IV every 6 hrs

6.5.3 Following antibiotics are recommended for therapy in complicated acute cholecystitis

- Cefoxitin 2 grams IV every 8 hrs

- Ertapenem 1 gram IV every 24 hrs

- Ampicillin-Sulbactam 1.5-3 grams IV every 6 hrs ( add Gentamicin 240 mg IV every 24 hrs if with risk for Enterococcus infection )

6.5.4 For patients with allergy to beta-lactam antibiotic :

- Fluoroquinolone 400 mg IV every 12 hrs + Metronidazole 500 mg IV every 6 hrs The duration of therapy may be maintained for 5-7 days for complicated cases

6.6 Patient with acute and chronic Cholecystitis should undergo pre op Lab investigation with Complete blood count, BUN, Cr, Liver function test and Imaging study to make sure that there are no CBD stone, no obstructive jaundice, no clinical active hepatitis or others abdominal inflammation or infection before to do cholecystectomy

6.7 If there are evidence of CBD obstruction, obstructive jaundice, Cholangitis, Pancreatitis the patient should undergo to receive empirical antibiotic treatment until clinical subside down +/- Biliary drainage before to do cholecystectomy (can do in 1 setting time)

6.8 In Condition of Laparoscopic cholecystectomy operation BUD policy recommend to do Laparoscopic cholecystectomy with 2 surgeons and the main surgeon must be expert in the operation more than another one and main surgeon must have no serious complication in 3 years ago

6.9 In all cases that have to do the second operation, attending physician and staff must report directly to PCU surgery director or chief of medical staff organization or hospital director to approve before to do second operation

6.10 Implement Standard CPG Safe Cholecystectomy in Bangkok hospital Udon for all staff PCT Surgery

6.11Monitor, Evaluation and Improvement

รวมถึงปัจจัยสภำพแวดล้อมที่ส่งเสริมกำรดำเนินของโรคและให้ คำแนะนำในกำรปฏิบัติตัวแก่ผู้ป่วยและญำติอย่ำงเหมำะสมโดยทีมสหสำขำวิชำชีพ

12.2 Hassler KR, Collins JT, Philip K, et al. Laparoscopic Cholecystectomy. [Updated 2021 Apr 21].

In: StatPearls [Internet]. Treasure Island (FL): StatPerals Publishing; 2021 Jan.

12.3 Cholecystectomy: Surgical Removal of the Gallbladder. American College of Surgeons. Surgical patient education. www.facs.org/patienteducation