Cholecystectomy

1. (Gallbladder Removal, Open Cholecystectomy, Laparoscopic Cholecystectomy) cholecystectomy

2. What is Cholecystectomy ? A cholecystectomy is the surgical removal of the gallbladder, an organ located just under the liver on the upper right quadrant of the abdomen. The gallbladder stores and concentrates bile, a substance produced by the liver and used to break down fat for digestion.

3. Why is it done? Cholecystectomy is used to treat gallstones and the complications they cause. Your doctor may recommend cholecystectomy if you have: Gallstones in the gallbladder (cholelithiasis) Gallstones in the bile duct (choledocholithiasis) Gallbladder inflammation (cholecystitis) Pancreas inflammation (pancreatitis)

4. Why is it done? Several  conditions may lead to surgery to remove the gallbladder. Conditions that may require open rather than laparoscopic surgery include: Severe inflammation of the bile duct or gallbladder. Inflammation of the abdominal lining (peritonitis). High pressure in blood vessels in the liver (portal hypertension). This is caused by cirrhosis of the liver. Being in the third trimester of pregnancy. A major bleeding disorder or use of medicines to prevent blood clotting (blood thinners or anticoagulants). Scar tissue from many previous abdominal surgeries. Abnormal anatomy in the abdomen.

5. 2 Types of Cholecystectomy Open cholecystectomy and laparoscopic cholecystectomy

6. Open Cholecystectomy In this method, a two- to three-inch incision is made in the upper right-hand side of the abdomen. The surgeon locates the gallbladder and removes it through the incision.

7. Laparoscopic Cholecystectomy This procedure uses at least three to four small incisions and three or more laparoscopes—small thin tubes with video cameras attached—to visualize the inside of the abdomen during the operation. The surgeon performs the surgery while looking at a TV monitor. The gallbladder is removed through one of the incisions.

8. Cholecystectomy and the Procedure

9. Anesthesia Most open cholecystectomies are performed under general anesthesia. Less common alternatives include regional (epidural or spinal) and, rarely, local anesthesia.

10. Equipment and Instrumentation Equipment for open cholecystectomy includes instruments common to a major instrument tray. This includes the following: Kelly clamps, Kocker forceps, needle holders, scissors, clips, suctions, knife/knife handles, forceps, retractors, right angle clamps, Kitner dissectors, and electrosurgical devices should be assembled. Balfour retractors, Bookwalter retractors, or other self-retaining retractors can be used, based on the surgeon's preference. Sutures or clips can be used to control the cystic duct and artery, based on the surgeon's preference and the size of structures (see Technique section below). Long instruments may be needed, depending on the body habitus of the patient. A headlight worn by the operating surgeon or assistant is often valuable in open cholecystectomy to improve visualization.

11. Positioning Patients are positioned supine with arms extended. Placing a folded blanket or bump underneath the patient's right back or inverting the table may be beneficial.

12. Technique In general, open cholecystectomy can be performed using 2 different methods: the retrograde and anterograde techniques .

13. Retrograde Video 1 The more traditional retrograde ("top down") technique starts with dissection at the gallbladder fundus and proceeds toward the portal triad and triangle of Calot. This strategy facilitates sure identification of the cystic duct and artery, as they remain the only 2 attachments to the gallbladder.

14. Anterograde Video 2 With increased experience and expertise in the laparoscopic technique, surgeons often feel more comfortable with the anterograde technique. In this technique, dissection begins at the triangle of Calot with dissection and ligation of the cystic artery and duct. This is followed by dissection of the gallbladder from the liver bed, starting usually from the infundibulum up. Dissection from the fundus down can also be used.

15. Preparation Place the patient under general anesthesia, supine, with arms extended. Place a Foley catheter and sequential compression devices before the operation begins, and, if indicated, administer preoperative anticoagulation. If indicated, administer preoperative antibiotics within 60 minutes of skin incision. The surgeon stands on the patient's left with the assistant opposite. The operating room and table should be oriented so that cholangiography can be performed, if necessary.

16. Incision A right subcostal (Kocher) incision is the most often used incision and allows excellent exposure of the gallbladder bed and cystic duct. Alternatively, an upper midline incision can be used when other concomitant operations are planned and a wider exposure is needed. Typically, the midline incision remains above the umbilicus, still allowing for adequate exposure of the gallbladder with appropriate retraction. A right paramedian incision is another option but is not often used in current times. Start the subcostal incision approximately 1 cm to the left of the linea alba, about 2 fingerbreadths below the costal margin (approximately 4 cm). Extend the incision laterally for 10-15 cm, depending on the patient's body habitus. Incise the anterior rectus sheath along the length of the incision, and divide the rectus and lateral muscle (external oblique, internal oblique, and transversus abdominis) using electrocautery. Then, incise the posterior rectus sheath and peritoneum and enter the abdomen.

17. Inspection To the extent possible, perform a thorough manual and visual inspection to evaluate for concomitant pathology or anatomical abnormalities. Place a retracting device (eg, Balfour retractor, Bookwalter retractor, wound protractor retractor) as needed for adequate exposure. The videos on the next slide show anatomy and exposure for open cholecystectomy.

18. Inspection Video 3 Exposure for open cholecystectomy.

19. Video 4 Anatomy, exposure, and beginning of dissection for retrograde technique of open cholecystectomy.

20. Video 5 Palpate and inspect the liver and admit air into the subphrenic space to inferiorly displace the liver and better expose the inferior surface. If additional downward displacement is needed, laparotomy pads can be placed above and lateral to the liver to aid exposure (see video on the right). Retract the duodenum inferiorly to expose the porta hepatis.

21. Palpate the gallbladder for stones or masses. The porta hepatis can be assessed by inserting the left index finger into the foramen of Winslow and using the thumb to palpate anteriorly on the porta hepatis/common bile duct for stones or tumors.

22. Dissection Grasp the dome of the gallbladder with a Kelly clamp and elevate it superiorly. Adhesions to the undersurface of the gallbladder from the transverse colon or duodenum are typically encountered; these can be lysed with sharp dissection or judicious use of electrocautery. Dissection of the gallbladder can be performed in 2 ways. Traditionally, dissection in open cholecystectomy is performed using a "top down" or retrograde technique, in which the fundus is mobilized toward the porta hepatitis. This technique differs from the anterograde technique, in which the dissection begins at the porta hepatis and extends up to the fundus (as is done in laparoscopic cholecystectomy).

23. Retrograde approach In the retrograde approach, incise the visceral peritoneum overlying of the gallbladder fundus approximately 1 cm from its attachment to the liver. Grasp the fundus of the gallbladder using a Kelly clamp. Using a right angle clamp or suction device, develop the plane on both the lateral and medial side of the gallbladder and carry the incision along the gallbladder parallel to the liver. This dissection ensures complete mobilization of the gallbladder from the liver bed before dissecting within the triangle of Calot. See videos on the next slide.

24. Retrograde approach video 6   Beginning of dissection for retrograde technique of open cholecystectomy.

25. video7 Dissecting gallbladder off liver bed in retrograde technique.

26. Retrograde approach Video 8 The dissection plane is typically avascular, with only small cholecystic veins that need to be divided. Occasionally, more prominent veins may be encountered requiring ligation, especially in the presence of portal hypertension or gallbladder distention. If significant bleeding occurs, the dissection has likely been too deep entering the liver parenchyma.

27. Anterograde approach In the anterograde approach, attention is initially directed to the porta hepatis. Grasp the fundus of the gallbladder and elevate it superiorly while the neck of the gallbladder is mobilized away from the liver laterally to expose the triangle of Calot. Dissect the cystic artery and cystic duct with careful attention to the potential for anatomical variations. Once the cystic duct and cystic artery are completely dissected and identified entering directly into the gallbladder (the so-called  critical view popularized by Strasberg   ), the structures can be divided if cholangiography is not being performed. Before division of the cystic duct, "milk" the duct from proximal to distal to deliver stones that reside in the cystic duct into the gallbladder lumen. Following divisions of the cystic artery and duct, dissect the gallbladder away from the liver bed as described in the retrograde technique.

28. Division of cystic duct and artery When the cystic duct and artery are correctly identified and completely dissected, they are ligated. Various techniques for ligation have been described, including using suture, staplers, and clips. See videos on the next slide.

29. Video 9 Ligation of cystic duct and artery in retrograde technique of open cholecystectomy.

30. video10   Completion of retrograde technique of open cholecystectomy showing ligated cystic artery and cystic duct.

31. Nonabsorbable sutures are acceptable for use on the cystic duct stump; however, they are not recommended for biliary-enteric anastomosis or choledochotomy suture lines, as they can be lithogenic and incite a chronic inflammatory reaction. Absorbable sutures, such as polyglactin 910 (Vicryl, Ethicon, Sommerville, NJ) or polydioxanone (PDS, Ethicon) are traditionally used for ligation of the cystic duct. Metallic (titanium) clips or locking (Weck) clips can also be used. If the cystic duct is large and inflamed, mechanical staplers may be used, as well. The cystic artery can be ligated with ties (absorbable or nonabsorbable), suture ligature, or clips. Mechanical staplers are rarely necessary for ligation of the cystic artery.

32. Nursing Care Plans and Nursing Management

33. NURSING DIAGNOSIS: Breathing Pattern, ineffective May be related to Pain Muscular impairment Decreased energy/fatigue Possibly evidenced by Tachypnea; respiratory depth changes, reduced vital capacity Holding breath; reluctance to cough Desired Outcomes Establish effective breathing pattern. Experience no signs of respiratory compromise/complications.

34. Nursing Management  Observe respiratory rate/depth. Rationale: Shallow breathing, splinting with respirations, holding breath may result in hypoventilation/atelectasis .  Auscultate breath sounds. Rationale:  Areas of decreased/absent breath sounds suggest atelectasis, whereas adventitious sounds (wheezes, rhonchi) reflect congestion .  Assist patient to turn, cough, and deep breathe periodically. Rationale:  Promotes ventilation of all lung segments and mobilization and expectoration of secretions .  Show patient how to splint incision. Instruct in effective breathing techniques. Rationale: Facilitates lung expansion. Splinting provides incisional support/decreases muscle tension to promote cooperation with therapeutic regimen .  Elevate head of bed, maintain low-Fowler’s position. Rationale: Maximizes expansion of lungs to prevent/resolve atelectasis .  Support abdomen when coughing, ambulating. Rationale: Facilitates more effective coughing, deep breathing, and activity.

35. NURSING DIAGNOSIS: Impaired Skin Integrity May be related to Chemical substance (bile), stasis of secretions Altered nutritional state (obesity)/metabolic state Invasion of body structure (T-tube) Possibly evidenced by Disruption of skin/subcutaneous tissues Desired Outcomes Achieve timely wound healing without complications. Demonstrate behaviors to promote healing/prevent skin breakdown.

36. Nursing management  Observe the color and character of the drainage . Rationale:  Initially, drainage may contain blood and bloodstained fluid,normally changing to greenish brown (bile color) after the first several hours.  Change dressings as often as necessary. Clean the skin with soap and water. Use sterile petroleum jelly gauze, zinc oxide, or karaya powder around the incision. Rationale: Keeps the skin around the incision clean and provides a barrier to protect skin from excoriation .  Apply Montgomery straps. Rationale:  Facilitates frequent dressing changes and minimizes skin trauma .  Use a disposable ostomy bag over a stab wound drain. Rationale:  Ostomy appliance may be used to collect heavy drainage for more accurate measurement of output and protection of the skin .  Place patient in low- or semi-Fowler’s position. Rationale: Facilitates drainage of bile.

37. Nursing management  Monitor puncture sites (3–5) if endoscopic procedure is done. Rationale: These areas may bleed, or staples and Steri-Strips may loosen at puncture wound sites .  Check the T-tube and incisional drains; make sure they are free flowing. Rationale: T-tube may remain in common bile duct for 7–10 days to remove retained stones. Incision site drains are used to remove any accumulated fluid and bile. Correct positioning prevents backup of the bile in the operative area .  Maintain T-tube in closed collection system. Rationale: Prevents skin irritation and facilitates measurement of output. Reduces risk of contamination .  Anchor drainage tube, allowing sufficient tubing to permit free turning and avoid kinks and twists. Rationale: Avoids dislodging tube and/or occlusion of the lumen .  Observe for hiccups, abdominal distension, or signs of peritonitis, pancreatitis. Rationale:Dislodgment of the T-tube can result in diaphragmatic irritation or more serious complications if bile drains into abdomen or pancreatic duct is obstructed.

38. Nursing management  Observe skin, sclerae, urine for change in color. Rationale: Developing jaundice may indicate obstruction of bile flow . Note color and consistency of stools. Rationale: Clay-colored stools result when bile is not present in the intestines . Investigate reports of increased/unrelenting RUQ pain; development of fever, tachycardia; leakage of bile drainage around tube/from wound. Rationale: Signs suggestive of abscess or fistula formation, requiring medical intervention . Administer antibiotics as indicated. Rationale: Necessary for treatment of abscess/infection . Clamp the T-tube per schedule. Rationale: Tests the patency of the common bile duct before tube is removed.

39. NURSING DIAGNOSIS: Risk for Deficient Fluid Volume Risk factors may include Losses from NG aspiration, vomiting Medically restricted intake Altered coagulation, e.g., reduced prothrombin, prolonged coagulation time Possibly evidenced by [Not applicable; presence of signs and symptoms establishes an  actual  diagnosis.] Desired Outcomes Display adequate fluid balance as evidenced by stable vital signs, moist mucous membranes, good skin turgor/capillary refill, and individually appropriate urinary output.

40. Nursing management  Monitor I&O, including drainage from NG tube, T-tube, and wound. Weigh patient periodically. Rationale:  Provides information about replacement needs and organ function. Initially, 200–500 mL of bile drainage may be expected via the T-tube, decreasing as more bile enters the intestine. Continuing large amounts of bile drainage may be an indication of unresolved obstruction or, occasionally, a biliary fistula .  Monitor vital signs. Assess mucous membranes, skin turgor, peripheral pulses, and capillary refill. Rationale: Indicators of adequacy of circulating volume/perfusion .  Observe for signs of bleeding, e.g., hematemesis, melena, petechiae, ecchymosis. Rationale:  Prothrombin is reduced and coagulation time prolonged when bile flow is obstructed, increasing risk of bleeding/hemorrhage .  Use small-gauge needles for injections, and apply firm pressure for longer than usual after venipuncture. Rationale: Reduces trauma, risk of bleeding/hematoma.

41. Nursing management  Have patient use cotton/sponge swabs and mouthwash instead of a toothbrush. Rationale: Avoids trauma and bleeding of the gums . Monitor laboratory studies, e.g., Hb/Hct, electrolytes, prothrombin level/clotting time. Rationale:  Provides information about circulating volume, electrolyte balance, and adequacy of clotting factors . Administer IV fluids, blood products, as indicated;Electrolytes; Vitamin K. Rationale:  Maintains adequate circulating volume and aids in replacement of clotting factors.Corrects imbalances resulting from excessive gastric/wound losses.Provides replacement of factors necessary for clotting process.

42. References: Visser BC, Parks RW, Garden OJ. Open cholecystectomy in the laparoendoscopic era.  Am J Surg . Jan 2008;195(1):108-14 . McAneny D. Open cholecystectomy.  Surg Clin North Am . Dec 2008;88(6):1273-94, ix.  Fong Y, Jarnagin W, Blumgart LH. Gallbladder cancer: comparison of patients presenting initially for definitive operation with those presenting after prior noncurative intervention.  Ann Surg . Oct 2000;232(4):557-69.  de Goede B, Klitsie PJ, Hagen SM, van Kempen BJ, Spronk S, Metselaar HJ, et al. Meta-analysis of laparoscopic versus open cholecystectomy for patients with liver cirrhosis and symptomatic cholecystolithiasis.  Br J Surg . Jan 2013;100(2):209-16.  Matt Vera in Nursing Care Plans July 14, 2013

43. Requirement on R.L.E. (rotation 10-wmmc O.R. Prepared by: Salinas, sarah jane g. Bsn 4-d (wmsu)