Investigations
Blood count reported a white cell count of 10.0 x109/L, C-reactive protein 1 mg/dL, haemoglobin 132 g/L, platelet count 304 x109/L, amylase 30 U/L, bilirubin 7 U/L, alkaline phosphatase (ALP) 53 U/L, alanine aminotransferase (AST) 28 U/L, with a normal kidney function. An abdominal ultrasound reported multiple gallstones with sludge in a thin walled gallbladder without biliary tree dilatation.
Our surgical team conducted an extensive preoperative assessment which included discussion with a regional genetic service as well as surgical colleagues in other tertiary centers. The first decision was whether to commit to surgical intervention or not. The decision making process required clear communication with the patient of the risks and benefits of intervention versus a watch and wait approach. Both patient and surgeon felt that it would be safer to intervene in a controlled elective setting rather than risk intervention should the patient develops gallstone related complications such as acute cholecystitis or gallstone pancreatitis. The benefits of intervention in a controlled elective manner seemed to be the most favourable approach. With regards to the timing of surgery, it was felt that it would be prudent to offer surgery at the earliest opportunity rather than delay and risk an emergency presentation.
Regarding the surgical technique and associated risks, a decision needed to be made about a laparoscopic versus open surgical approach. Due to the potential for post-operative wound herniation, both short and long-term, it was felt that a standard laparoscopic approach was preferable to open surgery. Following discussion with various members from the vascular surgery team the risk of tissue friability was highlighted particularly with respect to using automatic closure or clipping devices. It was felt that these devices may exert shear forces along which could divide rather than secure tissues e.g. cystic duct. A decision was made to use haemolocks rather than mechanical clippers since the former could be placed in a more controlled manner with less force. Alternative methods to hand, if needed, such as ligatures were also made available.
Review of computed tomography (CT) images at a vascular multidisciplinary team (MDT) showed no visible aneurysms close to the proposed operation site reducing the risk of aneurysm rupture during the operation. Arrangements were made for a vascular surgeon to be on standby during the operation in the event of any vascular rupture (e.g. splenic artery aneurysm rupture). The patient’s medications were discussed with a cardiology team and ticagrelor was stopped. Vascular cover was arranged. A HDU bed was booked in advance to observe for any acute post-operative complication. The predicted operative mortality was 4.8%, ASA grade was 3 and Body Mass Index (BMI) 24.5. The risks of general anaesthesia (e.g. airway disruption from endotracheal intubation) were also considered and arrangements made to ensure a consultant led pre-assessment visit as well as senior anaesthetic presence during surgery.
The patient was subsequently fully informed of any possible complications, particularly the increased risks of bleeding and bile leak from a failure to secure the cystic duct and a small but not insignificant risk of mortality.