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2024, Number 1

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Cir Gen 2024; 46 (1)

Fast Postoperative Recovery Strategy. Safe cholecystectomy

Noyola Villalobos, Héctor Faustino1; Ortiz Higareda, Vanessa2; Chapa Azuela, Oscar3,4; Martínez Mier, Gustavo5; Martínez Abundis, Ricardo6; Rodríguez Montalvo, Carlos Alberto7; Roldan García, Jorge Alberto4; Bandín Musa, Alfonso Ricardo8; Domínguez Rosado, Ismael9; López Gavito, Elena10; Jiménez Chavarría, Enrique11; Gómez Ramírez, José Óscar12; López Espinosa, Guillermo13

Language: English/Spanish [Versi?n en espa?ol]
References: 109
Page: 11-25
PDF size: 689.66 Kb.


ABSTRACT

In México, cholecystectomy is the most common surgical procedure in general surgery. The main objective of enhanced recovery programs in surgery is to provide efficient treatment based on the best scientific evidencie. The purpose of this document is to optimize the outcome of patients undergoing cholecystectomy in our country, based on a series of recommendations issued by experts from different institutions, and based on the best scientific evidence available to date. It is aimed for surgeons working in public institutions and those in the private sector and seeks to promote strategies for improved surgical recovery and, above all, for a safe cholecystectomy, with the goal to offer our patients the best possible surgical outcome.



INTRODUCTION

Gallbladder lithiasis is a frequent condition in our environment and the leading cause of cholecystitis and biliary colic. In Mexico, cholecystectomy is the most frequently performed surgical procedure in general surgery.1 In spite of the technological advances and the different modifications in the conventional technique for performing cholecystectomy, the procedure continues to be performed in our country both by conventional open and laparoscopic routes. The main objective of enhanced recovery programs in surgery is to provide efficient treatment based on the best scientific evidence to shorten the postoperative recovery time of patients, reduce the incidence of complications inherent to hospitalization and surgical treatment, and, consequently, reduce hospital costs. One of the initiatives of the Mexican Association of General Surgery (AMCG) A.C. is to issue a series of recommendations that support national surgeons to have better surgical results, with the sole objective of increasing the quality of care of the Mexican population.2,3 The above applies to the different modalities of the procedure and in any type of institution in the country; these are general recommendations applicable to all cases.



MATERIAL AND METHODS

This work aimed to reach a consensus of experts to issue recommendations during the preoperative, intraoperative, and postoperative periods to improve the surgical outcomes of patients who underwent cholecystectomy. All these recommendations are based on the best available scientific evidence and are oriented to general surgeons nationwide. For the purposes of these guidelines, a consensus was reached using the Delphi panel methodology, with the participation of two types of experts: firstly, surgeons with training in hepatopancreatobiliary surgery and/or transplant and/or oncologic surgery and with particular interest in this area; and secondly, general surgeons with extensive experience in cholecystectomy, who have performed more than 50 cholecystectomies per year during the last 10 years.4,5 A total of 32 questions were developed, then submitted to the panel for consideration and answered based on the best available evidence. The answers were stated as statements and submitted electronically to an anonymous vote for electronic approval to ascertain the level of agreement with the statements. After three rounds, a consensus percentage of greater than 80% was reached in 28 statements; in one case, the agreement was 77%, and in three cases, there was no consensus. All the experts approved the final document. None of the authors declared a conflict of interest.

The recommendations are based on the level of evidence available, according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) classification: grade A, level 1 evidence corresponding to randomized clinical trials; grade B, corresponding to level 2 or 3 evidence, are cohort or case-control studies; grade C, recommendations based on studies with level 4 evidence, that is, case series or cohort studies of poor quality; and grade D, which are recommendations based on level 5 evidence, corresponding to expert opinion. The quality of the evidence for each recommendation was classified as high, moderate, low, or very low. The grade of each recommendation was assigned as strong (recommended) or weak (suggested).2,6



RESULTS



RECOMMENDATIONS



PREOPERATIVE



1. IN WHICH CASES IS CHOLECYSTECTOMY RECOMMENDED FOR ASYMPTOMATIC CHOLELITHIASIS?

At present, cholecystectomy is not recommended when incidental lithiasis is found.7-9 Although there are circumstances in which the risk/benefit of prophylactic cholecystectomy can be evaluated, such as patients on transplant protocol, patients on the protocol for bariatric surgery, and regions with a high risk of gallbladder cancer, there is no consensus to date to recommend cholecystectomy in asymptomatic patients routinely.10-13

Percentage of agreement: 61.5%. Level of evidence: 2, grade: B, recommendation: strong.



2. IS GALLBLADDER DYSKINESIA AN INDICATION OF CHOLECYSTECTOMY?

The diagnosis of biliary dyskinesia within the functional disorders of the gallbladder and biliary sphincter is based on the definition of Rome IV guidelines.14 Although gallbladder dyskinesia is associated with concomitant gastrointestinal disorders, cholecystectomy can provide relief of symptoms secondary to functional gallbladder disorder in most adult patients (> 90%). Therefore, cholecystectomy is considered the standard treatment for biliary dyskinesia, as up to 90% of patients have symptomatic relief.15-18

Although gallbladder dyskinesia is associated with concomitant gastrointestinal disorders, cholecystectomy can provide relief of symptoms secondary to functional gallbladder disorder in most adult patients (> 90%). Therefore, cholecystectomy is considered the standard treatment for biliary dyskinesia, as up to 90% of patients have symptomatic relief.15,16,19

Percentage of agreement: 92.3%. Level of evidence: 2, grade: B, recommendation: strong.



3. IS THE PRESENCE OF GALLBLADDER POLYPS AN INDICATION OF CHOLECYSTECTOMY?

In patients with vesicular polyps, treatment should be individualized, considering the size, number, and ultrasonographic characteristics of the polyps and the patient's symptomatology.20

In patients with gallbladder polyps larger than 10 mm, cholecystectomy is recommended due to the described risk of malignant transformation; in polyps smaller than 10 mm with concomitant biliary pathology (lithiasis) or biliary symptoms, surgical treatment is also recommended.20,21

In patients with asymptomatic polyps smaller than 10 mm, follow-up imaging (abdominal ultrasound) is recommended every six months; if growth is demonstrated or symptoms develop during follow-up, cholecystectomy is recommended.20-24

Percentage of agreement: 92.3%. Level of evidence: 2, grade: B, recommendation: strong.



4. WHAT ARE THE MINIMUM PREOPERATIVE STUDIES (LABORATORY AND IMAGING) RECOMMENDED FOR ELECTIVE AND/OR EMERGENCY CHOLECYSTECTOMY, AND WHAT ARE THESE STUDIES' VALIDITY?

In the case of elective surgery, it is recommended that complete blood count, blood chemistry, liver function tests (including bilirubin and liver enzymes), and coagulation tests be performed as part of the pre-surgical protocol in all patients. Among the imaging studies, liver and biliary tract ultrasound is suggested.3 In patients over 50 years of age, chest X-ray and electrocardiogram are also suggested.25-27

The validity of these studies ranges from one to three months if the patient remains clinically stable.

In patients with acute cholecystitis who are considered for emergency cholecystectomy, pancreatic function tests (serum amylase and lipase) are also suggested.

Percentage of agreement: 92.3%. Level of evidence: 5, grade: D, recommendation: strong.



5. WHAT ARE THE RECOMMENDED ASSESSMENTS PRIOR TO ELECTIVE CHOLECYSTECTOMY SCHEDULING?

According to the American Society of Anesthesiologists (ASA) classification, anesthesiology evaluation is recommended prior to surgery for ASA I patients under 40 years of age.

Preoperative evaluation by an internist is recommended for ASA I patients over 40 and ASA II and older patients (regardless of age).

Depending on the patient's comorbidities, in the case of patients with known conditions (heart disease, lung disease, kidney disease, rheumatologic pathologies, and others), assessment by the corresponding specialty should be considered, especially in cases of decompensation of the underlying pathology.28,29

Percentage of agreement: 92.3%. Level of evidence: 2, grade: B, recommendation: strong.



6. IN WHICH CASES IS IT RECOMMENDED TO HAVE BLOOD PRODUCTS FOR TRANSFUSION?

It is recommended that blood products be available only to patients with known coagulation disorder or thrombocytopenia.3,30

Percentage of agreement: 85%. Level of evidence: 2, grade: B, recommendation: strong.



7. WHAT IS THE IDEAL TIME FOR SCHEDULING ELECTIVE AND EMERGENCY CHOLECYSTECTOMIES?

According to the 2018 Tokyo Guidelines, urgent cholecystectomy is recommended within 24 hours in cases of severe acute cholecystitis. In cases of moderate acute cholecystitis, early cholecystectomy is suggested between 24 and 72 hours. In mild acute cholecystitis, early cholecystectomy is suggested within the first seven days of the onset of the symptoms to reduce the risk of complications.31-33

Surgical resolution is suggested in patients with chronic cholecystitis within 30 days34,35 (Table 1).

Percentage of agreement: 85%. Level of evidence: 2, grade: B, recommendation: strong.



8. IS IT RECOMMENDED TO PERFORM CHOLECYSTECTOMIES DURING THE NIGHT SHIFT?

Elective cholecystectomy at night is not recommended. In cases of acute cholecystitis, urgent cholecystectomy can be performed if the hospital has all the resources (medical and infrastructure) to offer a safe procedure.36-39

Percentage of agreement: 85%. Level of evidence: 2, grade: B, recommendation: strong.



9. IS ANTIMICROBIAL PROPHYLAXIS RECOMMENDED? IN WHICH CASES?

Antimicrobial prophylaxis is recommended in all cases, with one dose before the incision.40-44

Percentage of agreement: 92.3%. Level of evidence: 1, grade: A, recommendation: strong.



10. IS ANTITHROMBOEMBOLIC PROPHYLAXIS RECOMMENDED?

Antithromboembolic prophylaxis is only recommended in patients at high thromboembolic risk, with a score on the Caprini scale greater than or equal to 5 points.45-47

Percentage of agreement: 92.3%. Level of evidence: 2, grade: B, recommendation: strong.



11. WHAT PREHABILITATION MANEUVERS ARE RECOMMENDED FOR ELECTIVE CHOLECYSTECTOMY?

In general, in all patients scheduled for elective cholecystectomy, control of comorbidities should be optimized (adequate glycemic and blood pressure control), and smoking should be suspended.

Among the main perioperative risks associated with smoking are an increased risk of myocardial infarction, arrhythmia, and stroke. The risk of postoperative pneumopathy doubles; there is an alteration of skin healing, increased postoperative pain and postoperative consumption of opioids, and risk of withdrawal syndrome.3,48-51

Percentage of agreement: 92.3%. Level of evidence: 2, grade B, recommendation: strong.

Transoperative



12. WHAT IS THE RECOMMENDED ANESTHETIC TECHNIQUE FOR ELECTIVE AND/OR EMERGENCY CHOLECYSTECTOMY?

General anesthesia is considered the technique of choice for cholecystectomy. It is less uncomfortable for the patient with the changes in position required for the procedure because it facilitates mechanical respiratory support and relaxation of the abdominal wall during surgery. Although regional anesthesia has proven to be equally effective in the patient's recovery process, hemodynamic stability, and lower risk of respiratory problems, the consensus recommendation is to opt for general anesthesia.3,9,51,52

Percentage of agreement: 100%. Level of evidence: 1, grade: A, recommendation: strong.



13. IS INFILTRATION WITH LOCAL ANESTHETICS RECOMMENDED?

Infiltration of laparoscopy ports with local anesthetics is recommended.53-55

Percentage of agreement: 100%. Level of evidence: 1, grade: A, recommendation: strong.



14. WHICH SURGICAL APPROACH (OPEN OR LAPAROSCOPIC) IS RECOMMENDED FOR ELECTIVE AND/OR URGENT CHOLECYSTECTOMY?

In all cases, as long as the resources and experience are available, the laparoscopic approach is recommended; among the most frequent contraindications for a laparoscopic approach are anatomical alterations or adhesions from previous abdominal procedures and the inability to tolerate pneumoperitoneum; however, depending on each case, the feasibility of this approach should be evaluated as long as all the resources are available to perform the procedure safely.1,3,9,25,26,31,33,56-58

Percentage of agreement: 100%. Level of evidence: 2, grade: B, recommendation: strong



15. IN THE CASE OF LAPAROSCOPIC CHOLECYSTECTOMY, HOW MANY ACCESS PORTS SHOULD BE USED?

Laparoscopic cholecystectomy with four ports is considered the gold standard since it allows for better exposure to the surgical field and facilitates obtaining a critical safety view, decreasing the risk of biliary tract disruption. Although techniques with three, two, or only one port have been described, studies report that the fewer the ports, the less postoperative pain, greater technical difficulty, longer surgical time, and greater risk of bleeding have also been reported. These techniques with less than four ports require a longer learning curve, and in some cases, they will not be feasible and will require "conversion" to conventional laparoscopy (four ports) by placing additional trocars, and in the long-term follow-up they are associated with a higher risk of incisional hernia (mainly in single port). On the other hand, there are no significant differences in terms of hospital stay, analgesic requirement, conversion rate to open procedure, or immune response to surgical stress compared to the four-port technique.

Therefore, although these techniques may have comparable results in selected patients and with experienced surgeons, the consensus recommendation is four-port laparoscopic cholecystectomy.59,60

Percentage of agreement: 100%. Level of evidence: 2, grade: B, recommendation: strong.



16. IN THE CASE OF LAPAROSCOPIC CHOLECYSTECTOMY, WHAT IS THE RECOMMENDED ENTRY TECHNIQUE FOR PNEUMOPERITONEUM INSUFFLATION?

In general, there is no completely safe entry technique; closed techniques have been described, such as the use of the Veress needle, or open techniques, such as the Hasson technique; however, to date, there is no consensus as to the ideal technique for access to the abdominal cavity and for pneumoperitoneum insufflation. Each surgeon should perform the technique with which he/she was trained and with which he/she is familiar, to reduce the risk of complications.61-63

Percentage of agreement: 54%. Level of evidence: 2, grade: B, recommendation: weak.



17. IN WHICH CASES IS THE CONVERSION FROM A LAPAROSCOPIC TO AN OPEN APPROACH RECOMMENDED?

Conversion should be considered as a strategy to perform a safe procedure and for the resolution of transoperative complications; within the indications for conversion should be considered those derived from systemic complications (as in the case of patients who cannot tolerate pneumoperitoneum), complications attributable to local inflammation (multiple adhesions, fibrosis that makes it difficult to correctly identify the anatomy or inflammatory processes that are difficult to dissect) or transoperative complications (such as bleeding that is difficult to control, intestinal perforation or any that cannot be resolved by laparoscopy).56,64,65

Before conversion, when obtaining a critical view of safety is impossible, it is suggested to consider salvage procedures, such as subtotal cholecystectomy (fenestrated or reconstituted).64,66-70

Conversion should also be considered in cases of technical failure of the equipment when there is a need to explore the biliary tract, when there is no adequate equipment to perform it laparoscopically, and when the surgeon is uncomfortable with the approach or exposure in laparoscopy.64-66,71-73

Percentage of agreement: 100%. Level of evidence: 2, grade: B, grade of recommendation: strong.



18. IN WHICH CASES IS IT RECOMMENDED TO PERFORM THE "CRITICAL SAFETY OVERVIEW"?

Always. Strasberg's critical view of safety has three dissection goals, which are maintained as the first recommendation for the culture of safe cholecystectomy. These goals consist of 1) complete dissection (anterior and posterior) of the hepatocystic triangle freeing fatty and fibrous tissue to observe and identify, in a complete manner, the cystic artery and cystic duct, 2) exposure of the lower third of the gallbladder bed, and 3) observe two and only two tubular structures entering the gallbladder corresponding to the cystic artery and cystic duct.66

By obtaining this safety-critical view, within this dissection space, up to 95% of the vascular variations and more than 80% of the anatomical variants of the extrahepatic bile duct can be identified.

If this critical safety view is not possible, it is recommended a salvage procedure, such as subtotal cholecystectomy and drainage, derivative cholecystostomy, or conversion to open surgery be considered 1,56,66,69,70,74-80 (Figure 1).

Percentage of agreement: 100%. Level of evidence: 1, grade: A, grade of recommendation: strong.



19. IN WHICH CASES IS TRANSOPERATIVE CHOLANGIOGRAPHY INDICATED?

The use of transoperative cholangiography is recommended in those patients with uncertainty of the biliary anatomy and in those with suspected choledocholithiasis (dilatation of the cystic duct and main bile duct, obstructive jaundice, or alteration in liver function tests). In cases of suspected bile duct disruption, transoperative cholangiography allows for the characterization of the extent of the disruption.56,70,77-79

Percentage of agreement: 100%. Level of evidence: 2, grade: B, grade of recommendation: strong.



20. IN WHICH CASE IS A SALVAGE PROCEDURE (SUBTOTAL CHOLECYSTECTOMY/CHOLECYSTOSTOMY/CONVERSION) INDICATED?

Depending on the surgeon's experience, whenever a critical safety view is not possible, a rescue procedure, such as subtotal cholecystectomy and drainage, derivative cholecystostomy, or conversion to open surgery, is recommended.

These salvage procedures should be considered when it is impossible to identify the structures of the hepatocystic triangle in acute or chronic inflammatory processes that are difficult to dissect and in unstable septic patients.

In patients with high surgical risk and severe cholecystitis, derivative cholecystostomy (percutaneous or surgical) can be considered as an alternative procedure for resolution of the septic process, with scheduling of interval cholecystectomy.1,56,65,66,69,70,74,75

Percentage of agreement: 100%. Level of evidence: 1, grade: A, grade of recommendation: strong.



21. WHAT OTHER SAFETY STRATEGIES ARE RECOMMENDED FOR CHOLECYSTECTOMY?

Among the strategies to achieve a correct identification of the structures and to achieve a safe cholecystectomy, the following are recommended:

  • 1. Strategies for anatomical orientation: B-SAFE, Rouviere's sulcus, R4U, and asking for a second trans-operative opinion in difficult cases (ask for help from a more experienced colleague).
  • 2. Intraoperative imaging techniques: conventional transoperative cholangiography, infrared fluorescent cholangiography (indocyanine green), and intraoperative ultrasound.
  • 3. Conversion: In cases in which tactile discrimination allows resolving doubts regarding the anatomy, a conversion to an open procedure can be chosen.
  • 4. Fundus first: fundocystic or antegrade cholecystectomy has been associated with a higher risk of vasculobiliary lesions, mainly of the right hepatic artery. It is, therefore, no longer recommended except in exceptional cases.
  • 5. Finally, in cases in which a safe procedure is not possible, the procedure can be aborted, and deferred cholecystectomy can be performed at another level of care with more experience and resources (Table 2).78,80-87

Percentage of agreement: 85%. Level of evidence: 2, grade: B, grade of recommendation: strong.



22. IN WHICH CASES IS THE PLACEMENT OF DRAINS RECOMMENDED?

In general, drains are not routinely recommended in uncomplicated cholecystectomy; however, they are recommended in patients in whom a salvage procedure has been performed, those with septic processes (necrotic/emphysematous cholecystitis/pyocholecystitis), or when there is suspicion of biliary leakage.

Depending on the center's availability, in those cases in which it is decided to leave drainage, this should ideally be a closed and soft drainage, or in its absence, open and soft drainage. The placement of rigid drains is not recommended.88-90

Percentage of agreement: 100%. Level of evidence: 1, grade: A, grade of recommendation: strong.



POSTOPERATIVE



23. WHAT ARE THE RECOMMENDATIONS FOR OPTIMAL POSTOPERATIVE ANALGESIA?

In the transoperative period, infiltration of the laparoscopic access ports with local anesthetics is suggested. Postoperatively, most patients can be managed with paracetamol plus nonsteroidal anti-inflammatory analgesic with a schedule. On an individual basis, a stepwise approach is recommended, reserving opioid analgesia for selected cases.53-55,91-93

Percentage of agreement: 100%. Level of evidence: 1, grade: A, grade of recommendation: strong.



24. WHAT WOULD BE THE IDEAL POSTOPERATIVE RECOMMENDATIONS FOR AN IMPROVED RECOVERY?

After anesthetic recovery and in the absence of nausea or vomiting, the following measures for an improved recovery are recommended: initiation of the oral route, early ambulation, and bathing. Bandaging is not recommended for laparoscopic surgery.

Hospital discharge can be performed the same day at the surgeon's discretion, as long as the following discharge criteria are met: pain control with oral analgesics according to the analog pain rating scale (VAS) of less than 4, adequate tolerance to the oral route, ambulation, ability to urinate, hemodynamic stability, full mental recovery, surgeon's approval, and absence of nausea and vomiting.3,48-51

Percentage of agreement: 85%. Level of evidence: 2, grade: B, recommendation: strong.



25. IN WHICH CASES IS THE HISTOPATHOLOGICAL STUDY OF THE GALLBLADDER RECOMMENDED

Histopathological studies are currently recommended in all cholecystectomy surgical specimens. If neoplasia is documented similarly, the patient should be referred to surgical oncology for complete staging and, if required, complete oncologic treatment.94

Percentage of agreement: 100%. Level of evidence: 2, grade: B, recommendation: strong.



26. WHAT IS THE RECOMMENDED POSTOPERATIVE FOLLOW-UP AFTER HOSPITAL DISCHARGE?

In general, an evaluation 7-10 days after discharge is recommended to know the postoperative evolution, to rule out complications, to review the histopathological study, and, if necessary, to remove the stitches. According to the evolution and at the surgeon's discretion, an assessment at 30 days for discharge is suggested.25

Percentage of agreement: 61%. Level of evidence: 5, grade: D, recommendation: weak.



27. HOW MANY DAYS OF INCAPACITY FOR WORK ARE RECOMMENDED AFTER ELECTIVE AND/OR EMERGENCY CHOLECYSTECTOMY?

Depending on whether the procedure was open or laparoscopic and whether there were any complications, 10 to 28 days are suggested. The type of work the patient performs should also be considered.25

Percentage of agreement: 77%. Level of evidence: 5, grade: D, recommendation: weak.



SPECIAL CONSIDERATIONS



28. IN WHICH CASES IS CHOLECYSTECTOMY INDICATED DURING PREGNANCY?

Cholecystectomy during pregnancy is indicated exclusively in patients with acute cholecystitis.

Although laparoscopic cholecystectomy is considered safe and effective during all trimesters of pregnancy, in the third trimester, its feasibility should be carefully evaluated given the presence of the pregnant uterus..95-99

Percentage of agreement: 92.3%. Level of evidence: 3, grade: B, recommendation: strong.



29. IN CASES WHERE CHOLECYSTECTOMY IS REQUIRED DURING PREGNANCY, WHAT IS THE RECOMMENDED APPROACH?

Laparoscopic cholecystectomy is considered safe and effective during all trimesters of pregnancy; therefore, laparoscopic cholecystectomy is recommended in the first and second trimesters of pregnancy; however, in the third trimester, its feasibility should be assessed, and an open approach should be considered due to the presence of the pregnant uterus.95-99

Percentage of agreement: 100%. Level of evidence: 3, grade: B, recommendation: strong.



30. IN PATIENTS WITH ACUTE PANCREATITIS OF BILIARY ORIGIN, WHEN IS CHOLECYSTECTOMY RECOMMENDED?

In patients with acute pancreatitis of biliary origin, the performance of cholecystectomy will depend on the severity of the pancreatitis, the presence or absence of local complications, and the patient's general condition.

In patients with mild acute pancreatitis, according to the Atlanta criteria (without local or systemic complications), cholecystectomy is suggested during the same hospitalization to reduce the risk of recurrence.100-103

In moderately severe acute pancreatitis, the timing of cholecystectomy will depend on the presence of local complications; when there are no local complications, cholecystectomy can be performed once the systemic inflammatory response is controlled and there is no evidence of pancreatic necrosis. If local complications develop, it is recommended that cholecystectomy be deferred until the need for surgical resolution of the complications is determined.104-105

In severe acute pancreatitis, without local complications, surgery can be performed in the same hospitalization once the organic failures are resolved, and the patient's clinical conditions allow it. However, if pancreatic necrosis or other local complications develop, it is recommended to defer cholecystectomy until the need for surgical resolution of the complications is determined (Table 3).

Percentage of agreement: 85%. Level of evidence: 1, grade: A, grade of recommendation: strong.



31. WHICH PATIENTS SHOULD BE REFERRED TO AS A THIRD LEVEL OF CARE FOR CHOLECYSTECTOMY?

Cholecystectomy is considered a procedure that can be safely performed at a second level of care; however, in some cases, referral to a third level is recommended when the cholecystectomy has preoperative risk factors for being a problematic cholecystectomy, and the resources (medical and infrastructure) are not available to resolve it, in patients with icteric syndrome of unstudied etiology or with suspected gallbladder cancer.

Referral is also suggested in patients with underlying pathologies that merit third-level management.3,25,28,29,32,56

Percentage of agreement: 92.3%. Level of evidence: 5, grade: D, recommendation: weak.



32. WHAT SPECIAL CONSIDERATIONS SHOULD THE INFORMED CONSENT FOR CHOLECYSTECTOMY HAVE?

It should be as detailed as possible and include minor and major risks associated with the patient's characteristics, those attributable to anatomical variants, inflammatory alterations, and technical failures of the equipment. It is suggested to specify bleeding risk, risk of biliary tract disruption or involvement of other organs, the possibility of conversion (in the case of laparoscopy), and even the possibility of not concluding the procedure due to technical difficulties and of performing a rescue procedure and/or subsequent referral to a center with hepatopancreatic biliary surgery or a third level of care.106-109 (Figure 2).

Percentage of agreement: 92.3%. Level of evidence: 5, grade: D, recommendation: strong.



CONCLUSIONS

This document seeks to optimize the outcome of patients undergoing cholecystectomy in our country based on a series of recommendations issued by experts from different institutions and based on the best scientific evidence available at this time. It is aimed both at surgeons working in public institutions and those in the private sector. It seeks to disseminate strategies for improved surgical recovery and, above all, for a safe cholecystectomy, seeking to offer our patients the best possible surgical outcome.


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AFFILIATIONS

1 Director of the Regional Military Hospital Mazatlan, SEDENA, Mazatlan, Sinaloa.

2 Gastro Surgery Service, Hospital de Especialidades "Dr. Bernardo Sepúlveda Gutiérrez", UMAE Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City.

3 Chief of General Surgery Service, Hospital General de México "Dr. Eduardo Liceaga", Secretaría de Salud, Mexico City.

4 Pancreas Clinic, Hospital General de México "Dr. Eduardo Liceaga", Secretaría de Salud, Mexico City.

5 Transplant and Hepatobiliary Surgery; Research Department. Unidad Médica de Alta Especialidad Hospital de Especialidades No. 14 "Adolfo Ruiz Cortines", Instituto Mexicano del Seguro Social, Veracruz, Mexico.

6 General Surgery Service, Hospital General Regional No. 46 "Lázaro Cárdenas", Instituto Mexicano del Seguro Social, Guadalajara, Jalisco, Mexico.

7 Director of the Liver Disease Center, Hospital Angeles Valle Oriente, Monterrey, Nuevo Leon, Mexico.

8 Chief of Transplant Division, Hospital Central Sur de Alta Especialidad, PEMEX, Mexico City, Mexico.

9 Hepatopancreatobiliary Surgery Service, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Secretaría de Salud, Mexico City.

10 Sharp Hospital, Mazatlan, Sinaloa.

11 Director of the Acapulco Military Hospital, SEDENA, State of Mexico.

12 Clinic of HPB Surgery, Robotic HPB Surgery, Hospital Central Militar, SEDENA, Mexico City.

13 Project Coordinator and General Surgeon, Hospital General Tijuana, Secretaría de Salud, Tijuana, Baja California.



Funding: no sponsorship was received to carry out this study or for the publication of this article.

Disclosure: the authors declare that they have no conflicts of interest.



CORRESPONDENCE

Vanessa Ortiz-Higareda, MD. E-mail: higared@hotmail.com




Received: 05/01/2024. Accepted: 05/01/2024.

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