Surgical Consultation

Referred by Dr. Sarah Chen (Gastroenterology) for elective laparoscopic cholecystectomy evaluation. Patient has symptomatic cholelithiasis with 3 documented episodes of biliary colic in the past 4 months, most recent requiring ED visit 2 weeks ago. Ultrasound confirms multiple gallstones, largest 14 mm, with thickened gallbladder wall (5 mm). No evidence of choledocholithiasis on MRCP.

First episode of RUQ pain 4 months ago — postprandial, lasting 4 hours, resolved spontaneously. Second episode 6 weeks ago, similar character. Third episode 2 weeks ago: severe RUQ pain radiating to right scapula, associated with nausea and vomiting. Presented to ED, given analgesics, discharged with surgery referral. No fever, jaundice, or cholangitis symptoms at any point.

Appendectomy (age 18, open). Left knee arthroscopy (age 45). No prior abdominal surgery other than appendectomy.

Type 2 Diabetes Mellitus (dx 8y, on metformin 1000mg BID, HbA1c 7.4% last month)

Obesity Class I (BMI 34.2 kg/m2)

Obstructive Sleep Apnea (diagnosed 3y ago, CPAP compliant, AHI 12/h on treatment)

Hyperlipidemia (rosuvastatin 10mg, LDL 94)

HTN (lisinopril 10mg, well-controlled)

RCRI score: 1 point (ischemic heart disease — remote stent placement 2018, currently asymptomatic, stress test 2023 negative)

Functional status: METs >4 (walks 1 mile daily, climbs 2 flights without symptoms)

Echocardiogram (2024): EF 55%, mild concentric LVH, grade I diastolic dysfunction, no valvular disease, normal RV size and function

ACC/AHA perioperative risk: Elevated (RCRI 1 + vascular surgery equivalent category for intra-abdominal procedure)

Cardiology clearance: Obtained. Recommendation: continue beta-blocker through perioperative period, no additional cardiac testing indicated.

Abdomen: soft, non-distended, +BS x4 quadrants. Tenderness to deep palpation in RUQ, positive Murphy's sign (mild). No rebound or guarding. No hepatosplenomegaly. No masses. Well-healed appendectomy scar RLQ.

Vitals: BP 134/82, HR 72, RR 16, SpO2 96% RA, 98.8 F

CBC: WBC 7.2, Hgb 14.8, Plt 245 — normal

CMP: Na 139, K 4.3, Cr 1.0, TBili 0.8, AST 22, ALT 28, Alk Phos 78 — normal

Coag: INR 1.0, PTT 28 — normal

HbA1c: 7.4%

Procedure: Laparoscopic Cholecystectomy, elective

Approach: Standard 4-port technique, French position

Antibiotic prophylaxis: Cefazolin 2g IV within 60 min of incision

DVT prophylaxis: SCDs + unfractionated heparin 5000U SC pre-op

Glucose management: Check fingerstick q4h perioperatively, hold morning metformin, restart POD 1

CPAP: Bring from home, use immediately post-extubation in PACU

Estimated blood loss: <50 mL

Expected discharge: Same-day discharge or POD 1

Risks reviewed with patient and spouse: bleeding, infection, bile duct injury (~0.3-0.5%), conversion to open (~5%), bowel injury, retained stones, post-cholecystectomy syndrome. Patient verbalizes understanding. Questions answered. Consent signed and witnessed.

Symptomatic cholelithiasis, surgical candidate for elective laparoscopic cholecystectomy. ASA III (optimized comorbidities). Cardiac clearance obtained. Proceeding to OR scheduling.

1. Schedule elective LC — OR coordination calling with dates

2. Pre-op optimization: continue all home meds, bring CPAP day-of-surgery

3. NPO after midnight before surgery

4. Hold metformin day of surgery, resume POD 1

5. Post-op: diet advance, ambulate evening of surgery, discharge when tolerating PO/pain controlled