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.