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Other implications of laser laparoscopic cholecystectomy

We read with interest the article by Greville and Clements (Anaesthesia 1990; 45: 944-5). Our establishment is also undertaking laser laparoscopic cholecystectomies and we would like to highlight two of the problems that we have encountered. A 65-year-old, 75 kg woman, otherwise fit and healthy, presented for routine laser laparoscopic cholecystectomy. The procedure lasted 5 hours and was complicated by bleeding from the cystic artery. The intra-operative blood loss was 3200 ml which necessitated a laparotomy to achieve haemostasis. The patient was admitted to the intensive care unit for postoperative management. She was transferred back to the general ward 24 hours later. The second patient was a 46-year-old, 85 kg man, a known smoker and also suffering from a hiatus hernia and diabetes mellitus. On examination there were no abnormal physical findings, he had good neck movements and mouth opening (Mallampati class 11). Premedication included prophylactic antacids. After pre-oxygenation, thiopentone and suxamethonium were given and cricoid pressure applied. At larnygoscopy only the tip of the epiglottis could be visualised. Tracheal intubation was unsuccessful using various manoeuvres. Cricoid pressure was maintained and the patient allowed to breathe spontaneously. Under deep halothane anaesthesia the trachea was successfully intubated, although with some difficulty. Despite these problems the laparoscopic cholecystectomy proceeded as planned. It lasted 5 hours and the patient’s trachea was extubated when he was awake. However, 30 minutes later it became obvious that he was bleeding. The systolic blood pressure was 80 mmHg, heart rate 140 beats/minute and his abdomen was significantly distended. He was resuscitated with a rapid infusion of colloid and blood, despite which it was difficult to maintain his blood pressure. An urgent laparotomy was required. The patient at this time was confused, restless and uncooperative. The options were limited, but awake fibreoptic intubation was determined to be the most suitable technique. The trachea was successfully intubated and at laparotomy the intraperitoneal blood loss was measured at 4000 ml. Haemostasis was achieved by tying off an ‘aberrant’ artery. He was transferred to the intensive care unit for postoperative management, and discharged from the unit 24 hours later. These two cases bring to attention the potentially prolonged duration of this expanding branch of surgery. There is also a risk of major haemorrhage which may be missed intra-operatively. It is obvious that anaesthetic problems such as difficult intubation should preclude selection of patients from a relatively new surgical procedure. With hindsight we should have abandoned the planned surgery and proceeded to conventional surgery. In conclusion, we would recommend that ‘experimental’ surgery be limited to ASA 1 or 2 patients without anaesthetic complications. All other patients should undergo alternative conventional surgery which is known to have a low morbidity.