or write up-cystectomy

8/3/2019 Or Write Up-cystectomy

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Patients Profile

Case No.:23832

Name: C.B

Age: 28

Address: Poblacion Bontoc, Mountain Province

Gender: Male

Pre-op diagnosis: Multiple Cholelitiasis

Post-op diagnosis: Multiple Cholelitiasis

Operation Performed: Open Cholecystectomy


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Anatomy and Physiology:

Gallbladder is a muscular organ that serves as a reservoir for

bile, present in most vertebrates. In humans, it is a pear-

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. Structurally, the gallbladder consists of

an outer peritoneal coat (tunica serosa); a middle coat of

fibrous tissue and unstriped muscle (tunica muscularis); and an

inner mucous membrane coat (tunica mucosa). The gallbladder lies

in a shallow depression on the interior surface of the liver, to

which it is attached by loose connective tissue. Its wall is

composed largely of smooth muscle. The gallbladder is connected

to the common bile duct by the cystic duct.


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The function of the gallbladder is to store bile, secreted by

the liver and transmitted from that organ via the cystic and

hepatic ducts, until it is needed in the digestive process. The

gallbladder, when functioning normally, releases bile through

the biliary ducts into the duodenum to aid digestion by

promoting peristalsis and absorption, preventing putrefaction,

and emulsifying fat. During storage, a large portion of the

water in bile is absorbed through the walls of the gallbladder,

so that bile in the gallbladder is five to 10 times more

concentrated than that originally secreted by the liver. When

food enters the duodenum, the gallbladder contracts and the

sphincter of oddi relaxes. Relaxation of this sphincter allows

the bile to enter the intestine. This response is mediated by

secretion of the hormone cholecystokin-pancreozymin (CCK-PZ)

from the intestinal wall.


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Pathophysiology:

A.Narrative form:

Cholesterol, a normal constituent of bile, is insoluble in

water. Its solubility depends on bile acids and lecithin

(phospholipids) in bile. In gallstone- prone patients, there is

decreased bile acid synthesis and increased cholesterol

synthesis in the live, resulting in bile supersaturated with

cholesterol, which precipitates out of the bile to form stones.

The cholesterol- saturated bile predisposes to the formation of

gallstones and acts as an irritant that produces inflammatory

changes in the gallbladder.

Two to three times more women than men develop cholesterol

stones and gallbladder disease; affected women are usually older

than 40 years of age, multiparous, and obese patient. Stone

formation is more frequent in people who use oral

contraceptives, estrogens, or clofibrate; these medications are

known to increase biliary cholesterol saturation. The incidence

of stone formation increases with age as a result of increased

hepatic secretion of cholesterol and decreased bile acid

synthesis.


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B.Schematic form:Predisposing Factors:

Advanced Age

Gender

Ileal

Resection/Disease

Race

Genetics

Precipitating Factors:

Obesity/ Overweight

Pregnancy/

Contraception

Frequent Starvation,

total

parenteral nutrition

Clofibrate Use

Diet/

Weight loss

Decreased

level of Bile

Acids

Increased levels

of fat in

The blood stream

Synthesis of

cholesterol

In the liver

Excretion of

cholesterol

to the bile

Ratio of bile salts &

lecithin with

cholesterol is no

longer within the

area of solubility

Cholesterol concentration >

Solubility capacity of the

bile

No formation of mixed

miccelles


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Lithogenic bile/ supersaturated

bile (creamy)

Mucoprecipitates of organic &

inorganic calcium salts become

nucleation sites

Nucleation and production of

cholesterol monohydrate crystals

Large cholesterol stones

Extrusion of stones from

gallbladder

Impaction at cystic and bile duct

Distention of

billiary and

fundus of

gallbladder

Forceful

contraction

of

gallbladder

Spasms of

smooth muscle

in the duct

PAIN

Bile not excreted to duodenum

Backflow of the bile and goes to

the circulation

Levels of

bilirubin/

bile

pigments in

the

circulation

Conversion

of bilirubin

to

urobilinogen

in the

intestines

Excretion of

urobinilogen

in the stool

Grayish

stool

Fat not emulsified

No absorption

of fat in the

intestines

y Nausea andVomiting

y Fullnessy Indigestiony Vit. ADEK

Increased

renal

excretion

Dark urine


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Preparation of the patient:

A.Skin preparation:

Begin at the intended sight of incision, either right subcostal,

right paramedian, or midline, extending from the axilla to the

pubic symphysis and down to the table on the sides.Skin isprepared with appropriate antiseptic solution (povidone iodine

solution) at least 1/2-1 hour before surgery and just before

surgery.

B.Draping:4 folded towels and a laparotomy sheet, sterile sheets are used

to cover all of the body except the operation site and adhesive

drapes are stuck on the operation site.

Position of patient during induction of anesthesia:

Lateral position: patient

begins in supine position. Rolled onto side- operative side up.

Bottom leg flexed; top leg straight. Bottom arm on armboard, top

arm on special arm support or pillow. Head supported in

alignment with body.


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Position of the patient during the surgery:

Supine position:a position of the body:

lying down with the face up, as opposed to the prone position,

which is face down, sometimes with the hands behind the head or

neck. When used in surgical procedures, it allows access to the

peritoneal, thoracic and pericardial regions; as well as the

head, neck and extremities. Using terms defined in the

anatomical position, the dorsal side is down, and the ventral

side is up.

C.AnesthesiaSubarachnoid block or Spinal anesthesia is an

extensive nerve block that is produced into the

subarachnoid space at the lumbar level, usually between L4

and L5. It produces anesthesia of the lower extremities,

perineum, and lower abdomen. For lumbar puncture procedure,

the patient usually lies on the side in a knee- chest

position. Sterile technique is used as a spinal puncture is

made and medication is injected through the needle. As soon

as the injection has been made, the patient is positioned

on her back. The spread of anesthetic agent and the level

of anesthesia depend on the amount of fluid injected, the

speed with which it is injected, the positioning of the


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patient affecter the injection, and the specific gravity of

the agent.

Discussion of the Procedure:

The incision is right subcostal. The abdominal cavity is entered

in the usual manner. The gallbladder is grasped. The cystic

duct, cystic artery, and common bile duct are exposed. The

surgeon must be aware of anomalies of these structures. The

cystic artery is clamped using two right angle clamps and

ligated with a suture passed on a long instrument or by clips,

as is the cystic duct. The gallbladder is mobilized by incising

the overlying peritoneum and after local dissection is removed.

The underlying liver bed may be reperitonealized. A drain may be

employed exiting a stab wound and secured to the skin with a

stitch. The wound is closed layer by layer. The skin is closed

with interrupted stitches.


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INSTRUMENTATION

Retractors:

Army navy retractor

- Held at one to shallow or superficial incisions.Richardson retractor

- Used to pull layers of tissue aside in deep abdominal orchest incision.

Deaver

- Used to retract deep abdominal or chest incisions.


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Doyen:

- Used by surgeons to either actively separate the edges of asurgical incision or wound, or can hold back underlying

organs and tissues, so that body parts under the incision

may be accessed.

Forceps:

Tissue forceps

- An instrument with one or more fine teeth at the tip ofeach blade for controlling tissues during surgery,

especially during suturing.

Thumb forceps

- The forceps used for grasping soft tissue; used especiallyduring suturing.


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Scissors:

Mayo (curved)

- designed for cutting body tissues near the surface of the

wound.

- used for cutting heavy fascia and sutures.

Mayo (straight)

- Used to cut suture and supplies.Metzenbaum

- Is more delicate than Mayo scissors which is used to cutdelicate tissues.


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Clamps:

Towel clip

- Used to hold towels and drapes in place.Allis

- Give surgeons the freedom to access internal organs andstructures with minimal damage to the overlying tissues.

These forceps can grasp, hold, move or lock a tissue into a

specific position so the surgeon can concentrate on the

area requiring the surgical procedure. The locking and non-

locking options give surgeons more options and flexibility.

Right-angle or Mixter

- provides a straight surface to cut along when dividing tissue

that has been occluded.

- used to clamp hard-to-reach vessels and to place sutures

behind or around a vessel.


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Straight clamp:

- They may be used for occluding blood vessels, manipulating[tissues], or for assorted other purposes.

Curvedclamp:

- They may be used for occluding blood vessels, manipulating[tissues], or for assorted other purposes.

Needle holder

- Locks the needle in place, allowing the user to maneuverthe needle through various tissues.


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Miscellaneous:

Knife or blade holder (#3)

- Used to cut superficial tissue.


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Others:

The dissection is started from gall bladder downwards.

Anterior and posterior peritoneal leaves are stripped off

gently. Cystic duct is gradually exposed by stripping fibrous

bands and lymphatics. A lymph node is usually a land mark for

cystic artery. Cystic artery is similarly exposed and

skeletonised. It is critical that no structure is divided until

the cystic duct and cystic artery are unequivocally identified.

The fundus of gall bladder is then pushed in lateral and

cephalad direction. This maneuver exposes the entire gall

bladder, cystic duct and porta hepatis.


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