**3. Perioperative and diagnostic work-up of jaundiced patient**

After hospital admission, the patient should undergo routine preoperative laboratory investigations, including total blood count, liver function tests, creatinine, electrolytes, and coagulation tests, such as prothrombin time, partial thromboplastin time, and INR. Routine chest X-rays needed to exclude pleural effusions and cardiac abnormality and ECG are mandatory for those patients with or without clinical signs of cholangitis and septic complications.

If there is any suspicion of sepsis, venous lactate should be requested as well as an ABG in the case of respiratory insufficiency. In most cases, different noninvasive imaging modalities can help the diagnosis of biliary obstruction and CBD dilation, for example, MRCP, US, and CT. ABCD approach should be applied to every patient to exclude or support the life-threatening condition.

When we consider the approach to the patient with obstructive jaundice and the need for intervention, we should take into account the next three factors: existence of life-threatening biliary infection, benign or malignant origin of obstruction, and need for subsequent definitive surgical procedures.

When the patient has an AOC, age > 65 years + comorbidities and his general condition is unstable and does not improve with medical therapy [30% of all patients with AOC] or already is associated with septic shock, there is a need for emergent decompression of the CBD. In this case, [e.g., grade III AOC] a PBD under local anesthesia may be a life-saving, low-risk procedure, allowing correction of fluid, electrolytes, and coagulopathies. In this case, the PBD is a kind of "bridge therapy" before a radical surgical intervention [54, 55].

If the obstruction is benign, age ≤ 65 years, without signs of AOC or septic complications [e.g., grade I or II AOC], we can try definitive surgical procedures to resolve the problem [LCBDE or ERCP].

If the obstruction is malignant, a radical operation is possible and the patient is fit for intervention, an operation could be performed if preoperative TB (total bilirubin) < 162 μmol/L according to the literature. If preoperative TB > 162 μmol/L we can postpone definitive surgical procedures because of the risk of postoperative

### *Laparoscopic Approach in the Case of Biliary Obstruction: Choledocholithiasis DOI: http://dx.doi.org/10.5772/intechopen.106042*

complications. In this case, we could use a "bridge therapy" (e. g., ERCP, PBD, and LCBDE) to stabilize the patient's general condition [56].

If the radical operation for malignant obstruction is not possible, we can accomplish ERCP, LCBDE, or PBD, according to the general condition of the patient and life expectancy.

Surgical procedures in patients with obstructive jaundice are associated with a higher incidence of complications than those in non-jaundiced patients. The risk of infectious complications, sepsis, and septic shock is important and preventive measures should be started before any procedure.

Patients with jaundice often fasted for prolonged periods, have depleted extracellular fluid volume, and impaired ability to concentrate urine. They are usually hypovolemic with low albumin and total protein blood level. This hypovolemia with the toxic effect of bilirubin on the renal tubules may provoke a renal insufficiency.

The derangement of coagulation status also should be compensated early by the administration of vitamin K and fresh frozen plasma to restore normal prothrombin time and homeostases.

In summary, according to the literature, we can follow the following recommendations [57]:
