POST OPERATIVE CARE AFTER LAPAROSCOPIC CHOLECYSTECTOMY

        Post operative recovery of a patients undergoing laparoscopic cholecystectomy is smooth and usually get discharge on first or second day of surgery. There are some possible complications which can be related to surgery or related to co-existing co-morbid systemic illness like diabetes. In diabetic patients, there can be fluctuation of blood sugar due to the infection. So, the management of diabetes may necessitate administration of insulin. Other systemic disorders like hypertension, hypothyroidism, coronary artery disease, bronchial asthma and chronic kidney disease has to be managed.

        Post operative fever is an indication of ongoing infection and is common with complicated cholecystitis or in patients with bile duct stones. This may necessitate to give higher antibiotics. There may be problems related to biliary pancreatitis like fluid collection around the pancreas, infection of pancreatic necrosis and other organ dysfunction.

        There are some surgery related problems that can happen after laparoscopic cholecystectomy. They are recurrence of same pain as before surgery, persisting discharge through the drainage tube, development of jaundice and wound infection.

        The reasons for recurrence of same pain as before surgery are due to the undiagnosed bile duct stone before surgery which manifest after surgery or slippage of stone into the bile duct during surgery and causes pain after operation. The pain will be colicky in nature and associated with vomiting and sometime with fever. Investigations like LFT and MRCP make the diagnosis and treatment is ERCP and stone extraction. This can come about 3 to 5% of post operative patients following laparoscopic cholecystectomy.

        Persisting discharge through the drainage tube is not uncommon problem. The reasons for this are:

1). Infected fluid coming out through the drainage tube.

2). Small bleeding in case of chronic liver disease patients

3). Ascites in case of cirrhotic patients and

4). Bilious fluid in the drainage tube can be due t

        a) Cystic duct leaks due to slippage of clips or impacted stone at lower common bile duct.

        b) Injury to accessary bile ducts due to congenital anomaly

        c) Leak from Duct of Luschka – Abnormal biliary communication between the gall bladder and gall bladder fossa which will get injured during cholecystectomy. If noticed during surgery, this has to be clipped or sutured to avoid post operative bile leak.

        d) Injury to common hepatic or common bile ducts. This can be due to abnormal course of bile ducts or dense inflammation of calot’s triangle area where the dissection and identification of structure will be difficult.

     The presence of infected fluid in the drainage tube will settle with higher antibiotics. Small bleeds are managed by giving blood products to enhance the haemostatic mechanism. Ascitic fluid discharge due to cirrhosis is managed with medicines.   

     The Leak from cystic duct and leak from the bile duct are confirmed with MRCP. The treatment protocol for the prolonged bile leak will be to perform ERCP to confirm the leak and to remove the impacted stone if any. The placement of biliary stent will stop most of the biliary leaks. The major biliary leaks may require surgical intervention.

     It is very difficult to identify the Leak from the unrecognized duct of Luschka. In case of post operative biliary leak, if MRCP does not identify any leak, then careful observation will be the protocol. If the bile leak persists for long duration the placement of biliary stent may reduce or stop the bile leak. The placement of stent in the biliary tree reduces the biliary system pressure and that leads to the closure of the leaking point.

     Leak from unrecognized bile duct injury during surgery are diagnosed by post operative MRCP and managed with post operative ERCP and placement of biliary stent. Rarely these patients may require surgery.