I. OBJECTIVES:

After the completion of the study, the students will be able to:

- Learn more about the said disease

- be familiarize with the surgical procedure

- perform appropriate nursing care during peri-operative phase

- familiarize with the instruments used during the surgery

II. INTRODUCTION:

Cholecystectomy is the surgical removal of the gallbladder, a small

pear-shaped sac that is located directly beneath the liver in the upper right

side of the abdomen. The gallbladder's main function is to store bile, which is

produced by the liver, and to

release it as needed for

digestion. The gallbladder's

function is important, but it

is not an essential organ.

According to Steven P. Shikiar M.D., Cholecystectomy is perhaps the

most common procedure performed by a general surgeon possibly second

only to herniorrhaphy. Today the standard treatment for symptomatic

gallstones is Laparoscopic Cholecystectomy, which is the performance of

Cholecystectomy through small (1/4” - ½”) incisions, aided by a special

camera called a Laparoscope, which is designed to be introduced into the

abdomen. The major advantage of this procedure as compared to the

open procedure is in short post-operative recovery and rapid return to full

function. 

At that time advanced biliary disease, hepatic disease, inadequacies in

surgical management, and anaesthetic complications were common causes

of death. Fifty years later McSherry reported mortality ranging from 0.3% for

elective open cholecystectomy to 8.0% for elderly patients with acute

cholecystitis. Comorbidity and age had become the major mortality

predictors, with cardiovascular disease, cerebrovascular disease, and

pulmonary embolism in decreasing frequency accounting for the great

majority of postcholecystectomy deaths. Morbidity for open cholecystectomy

varies between 5% and 15% and is also heavily influenced by patterns of

comorbidity and by the presence of gall stone complications such as

cholecystitis and choledocholithiasis. Wound infection rates are generally less

than 5% for elective cases, rising to 10-15% for urgent, acute cases.

Cholecystitis is associated with very low mortality. However,

cholecystectomy in the presence of acute cholecystitis doubles perioperative

mortality and increases morbidity, particularly from bleeding, sepsis, and

duct injury. The same reasoning applies to gall stone pancreatitis, except

that the pancreatitis should be allowed to settle and the serum amylase

activity to return to normal before cholecystectomy. Morbidity specific to

cholecystectomy centres on injuries to the biliary tract.

Two procedures are utilized to surgically remove the gallbladder: open

cholecystectomy and laparoscopic cholecystectomy. The laparoscopic

method is utilized more frequently, but some patients, particularly if they are

obese, have a bleeding disorder, are pregnant and near the due date, or

have extensive scarring from previous abdominal surgeries are not

candidates. The choice of procedure is made on an individual basis.

Open Cholecystectomy

The surgery is performed under general anesthesia, which renders the

patient unconscious. After the anesthesia is administered, the abdomen is

cleaned with an antiseptic solution to reduce the risk for infection. The

surgeon makes a 4- to 6-inch incision in the right upper portion of the

abdomen. The liver is lifted out of the way and the gallbladder is carefully

removed. The incision is closed and sutured.

The disadvantages of this procedure are longer hospitalization and recovery

period, significant postoperative pain, and a large scar. However, the surgery

is safe and carries a low risk for complications. Open cholecystectomy is

used when laparoscopy is unsuitable for the patient.

Laparoscopic Cholecystectomy

Laparoscopic cholecystectomy is the method of choice, provided the

patient meets the criteria. The surgery is performed using general

anesthesia and the abdomen is cleaned with an antiseptic solution. Instead

of making one large incision, the surgeon makes four tiny cuts in the

abdomen. One incision is made right under the navel (umbilicus) and a

laparoscope is inserted. The laparoscope is a miniature telescope attached to

a camera, and through its lens the surgeon can see the interior of the

abdomen.

Instruments are inserted through the other incisions to perform the surgery.

The gallbladder is cut free and pulled through one of the incisions. Before

removing it, the surgeon sometimes shrinks the gallbladder by suctioning

out the bile. Incisions are sutured or stapled closed at the end of the surgery.

The procedure usually takes 30 to 60 minutes.

III. INDICATIONS:

Most often the stones cause no symptoms and their presence goes

unrecognized.  The most common symptom complex is biliary colic

(gallbladder disease), characterized by abdominal pain localized to the right

upper abdomen, which often follows large or excessively fatty meals. 

Symptoms of biliary colic may include pain radiating to the right shoulder,

nausea, and excessive flatulence and/or belching.  The surgical removal of

the gallbladder can provide relief of these symptoms.  

Gallstones may also cause other concerns including cholecystitis (infection of

the gallbladder), gallstone pancreatitis (inflammation of the pancreas),

jaundice, or cholangitis (infection of the ducts connecting the gallbladder

with the liver and small intestine).  Medical evidence exists to suggest that

long-standing gallstone disease may eventually lead to cancer of the

gallbladder, a very aggressive and often deadly tumor.  Other indications for

cholecystectomy include prophylactic removal of the gallbladder in patients

with cholelithiasis (gallstones of varying shapes and sizes form from the solid

components of bile) who are scheduled to undergo organ transplantation, or

in patients with a calcified (porcelain) gallbladder, thought to be associated

with gallbladder cancer.  Rarer indications include trauma, biliary dyskinesis

(gallbladder is not functioning normally), and symptomatic gallbladder

polyps.

One of the foremost aims of the procedure is to return the client to its

optimal level of functioning and for him to do his activities of daily living

normally as he lived before he experienced the disease.

IV. ANATOMY AND PHYSIOLOGY OF THE ORGAN:

Gallbladder

Gallbladder is a muscular organ that serves as a reservoir for bile. It is

a pera-shaped membranous sac on the undersurface of the right lobe of the

liver just below the lower ribs. It is generally about 7.5 cm (about 3 in) long

and 2.5 cm (1 in) in diameter at its thickest part; it has a capacity varying

from 1 to 1.5 fluid ounces. The body (corpus) and neck (collum) of the

gallbladder extend backward, upward, and to the left. The wide end (fundus)

points downward and forward, sometimes extending slightly beyond the

edge of the liver. The gallbladder consists of an outer peritoneal coat (tunica

serosa); a middle coat of fibrous and unstriped muscle (tunica muscularis);

and an inner mucous membrane coat (tunica serosa).

Bile secretion by the liver is stimulated by secretin, which is released

from the duodenum. Cholecystokinin stimulates the gallbladder to contract

and release bile into the duodenum. Parasympathetic stimulation through

the vagus nerver also stimulates the bile secretion and release.

Most bile salts are reabsorbed in the ileum, and the blood carries them

back to the liver, where they are once again secreted into the bile. The loss

of bile salts in the feces is reduced by this recycling process.

The liver can remover sugar forms the blood and stores it in the form

of glycogen. It can also store fat, vitamins, copper, and iron, this storage

functions is usually short term.

Foods are not always ingested in the proportion needed by the tissues.

If this is the case, the liver can convert some nutrients into others. For

example, if a person eats a meal that is very high in protein, a large amount

of amino acids and only a small amount of lipids and carbohydrates are

delivered to the liver. The liver can break down the amino acids and cycle

may of them through metabolic pathways to produce ATP and to synthesize

lipids and glucose.

The liver also transforms some nutrients into more readily usable

substances. Ingested fats, for example, can be combined with choline and

phosphorous in the liver to produce phospholipids, which are essential

components of cell membranes.

Many ingested substances are harmful to the cells of the body. In

addition, the body itself produces many by-products of metabolism that, if

accumulated, are toxic. The liver is an important line of defense against

many of those harmful substances. It detoxifies them by altering their

structure, making their excretion easier. For example, the liver removes

ammonia, which is a toxic by-product of amino acid metabolism, from the

circulation and converts it to urea, which is then secreted into the circulation

and eliminated by the kidneys in the urine. Other substances are removed

from the circulation and excreted by the liver into the bile.

The liver can also produce its own unique new compounds. Many of the blood proteins, such as

albumins, fibrinogen, globulins, and clotting factors, are synthesized in the liver and released into the

circulation.

V. POSITIONING, ANESTHESIA AND SKIN PREPARATION:

Positioning

Place the patient supine.

Wrap the arms up on the chest using the patient's operating gown.

Get access from above nipples to mid-thigh and from one posterior

axillary fold to the other.

Anesthesia

Open Cholecystectomy

The surgery is performed under general anesthesia, which renders the

patient unconscious. After the anesthesia is administered, the

abdomen is cleaned with an antiseptic solution to reduce the risk for

infection.

Laparoscopic Cholecystectomy

Laparoscopic cholecystectomy is the method of choice, provided the

patient meets the criteria. The surgery is performed using general

anesthesia and the abdomen is cleaned with an antiseptic solution.

Skin Preparation

Clean the skin:

From the nipples to the pubis.

From the posterior axillary fold on the right side to the anterior axillary

fold on the left.

Use two swabs on sticks with aqueous povidone iodine, followed by

one to dry off.

Dry the skin completely or adhesive drape edges will not stick down.

VI. INSTRUMENTS WITH ILLUSTRATION:

1) #4 knife handle with a # 10 blade

2) hemostats;Kellys

3) Bovie pencil (electrocautery),

4) Richardson retractors

5) Balfour Retractor

6) Carmalt clamps (heavy duty clamps) and Schmidt clamps for silk ties

7) Curved dissecting scissors

8) Needle holders of different lengths and structure.

VII. DISCUSION OF THE PROCEDURE:

Open cholecystectomy

Anaesthesia

Commonly:

o General anesthesia.

Simplified steps:

Step I Incision.

Types of Incision:

Upper Right SubCostal Incision.

Kocher's Incision.

Modified Kocher's Incision.

Transverse Incision.

Step II: Exposure of the gallbladder:

Retraction of the liver

The dome of the gallbladder is initially scored with electrocautery, and

a tonsil clamp is used to establish a plane in the thickened gallbladder

in proximity to the gallbladder wall itself. The cautery is then used to

incise the peritoneal surface of the entire dome.

Step III: Removal of the Gallbladder:

The fundus of the gallbladder is removed from the liver bed with blunt

and sharp dissection. Care should be taken in mobilizing the

infundibulum of the gallbladder to be certain that it is not adherent to

the common bile duct. The cystic artery and its extension are usually

encountered on the medial surface of the gallbladder. The cystic

artery can be temporarily controlled with a clip on the surface of the

gallbladder prior to its formal ligation. The gallbladder is then

completely mobilized from the liver bed until it is attached only by the

cystic duct.

Laparoscopic cholecystectomy

General anesthesia is utilized, so the patient is asleep throughout the

procedure.

An incision that is approximately half an inch is made around the

umbilicus ( belly button), three other quarter to half inch incisions are

made for a total of four incisions. Four narrow tubes called

laparoscopic ports are placed through the tiny incisions for the

laparoscopic camera and instruments.

A laparoscope (which is a long thin round instrument with a video lens

at its tip) is inserted through the belly button port and connected to a

special camera. The laparoscope provides the surgeon with a

magnified view of the patient's internal organs on a television screen.

Long specially designed instruments are inserted through the other

three ports that allow your surgeon to delicately separate the

gallbladder from its attachments to the liver and the bile duct and then

remove it through one of the ports from the abdomen.

Your surgeon may occasionally perform an X-ray, called a

cholangiogram, to exam for stones in the bile duct.

After the gallbladder is removed from the abdomen then the small

incisions are closed

VIII. NURSING DIAGNOSIS:

PRE-OP:

Deficient Knowledge

Anxiety

Fear

INTRA-OP:

Risk for infection

Risk for fluid volume deficit

Risk for aspiration

POST-OP:

Acute pain

Impaired breathing pattern

Activity intolerance

Disturbed body image

IX. NURSING RESPONSIBILITIES WITH RATIONALE:

PRE-OP:

Because gallbladder surgery is performed under general

anesthesia, instruct the patient to empty the stomach. This

precaution is taken to avoid vomiting during and after surgery.

Nothing may be taken by mouth after midnight, and smoking is

prohibited.

Advise patient to discontinue Blood "thinning" medication,

including aspirin, NSAIDs for 1week before the operation to avoid

excessive bleeding during the procedure.

On admission to the hospital, secured an informed consent form

acknowledging that the patient understands the procedure, the

risks, and that they will be receiving anesthesia and possibly

other medications must be signed.

Remove the accessories of the patient to practice aseptic

technique and to avoid loses of jewellery.

Advice the patient to remove the dentures to avoid the

possibility of aspiration.

Enemas may be ordered to clean out the bowel. If nausea or

vomiting is present, a suction tube to empty the stomach may be

used, and for laparoscopic procedures, a urinary drainage

catheter will also be used to decrease the risk of accidental

puncture of the stomach or bladder with insertion of the trocar (a

sharp-pointed instrument).

Change the clothes to OR gown (without underwear) and deliver

the patient to the OR room.

INTRA-OP:

Monitoring the vital signs of the patient is one of the

responsibilities of the nurse during the surgery.

Assisting the anesthesia care provider during induction of

general anesthesia

Ensuring adequate oxygenation and hydration

POST-OP:

Assess the patient's vital signs, oxygen saturation level, level of

consciousness, circulation, pain, IV site, fluid rate, and hydration

status, as well as the status of the surgical site and dressing and

all related monitoring equipment

Place the patient in the low fowler’s position. IV fluids may be

given and nasogastric suction may be given to relieve abdominal

distention. Water and other fluids are given in about 24hours,

and soft diet is started when bowel sounds returned.

provides skin care like cleaning the incision part and providing

clean dressing following a strict aseptic technique

Instruct patient how to relieve the pain by proper positioning.

X. DISCHARGE PLANING/TEACHING:

Encourage the patient to:

Avoid fatty or greasy foods

Gradually resumes his/her ADL over a three day period, while

avoiding heavy lifting for about 10 days.

Early ambulation/mobilization to promote circulation and

reduces risks associated with immobility.

Have optimum nutrition, including vitamins and increase

protein intake to aid in skin/tissue healing and to maintain

general good health.

Take prescribed medications at right time and dosage to help

in fast recovery.

Have enough sleep and rest.

Report back to the physician if there are any signs of

complications such as fever, inflammation, redness on the

incision site.

HOLY ANGEL UNIVERSITY

COLLEGE OF NURSING

ANGELES CITY

CHOLECYSTECTOM

Y

SUBMITTED BY:

DELA CRUZ, JENNELYN

GONZALES, MC NEIL

PUNZALAN, ELTON KYLE

TIAMZON, CARLA JANE

N – 310 / GROUP 4

SUBMITTED TO:

MS. NIÑA JOYCE YALUNG RN, MAN

DECEMBER 18, 2009