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Angeles CityCollege of Nursing

Case Report:

Laparoscopic Cholecysectomy

Submitted by:Agravantes, DenniseCruz, Hazel IrishGarcia, Christina BeatrizSubmitted to:Maam Karen Sembrano, OR JBLBSN III-1 Group 1

I. Introduction

Gallstones are small, pebble-like substances that develop in the gallbladder. The gallbladder is a small, pear-shaped sac located below the liver in the right upper abdomen. Gallstones form when liquid stored in the gallbladder hardens into pieces of stone-like material. The liquid called bile helps the body digest fats. Bile is made in the liver, then stored in the gallbladder until the body needs it. The gallbladder contracts and pushes the bile into a tube-called the common bile duct-that carries it to the small intestine, where it helps with digestion.

Literature shows that gallstones are present in approximately 10-20% of the population. Gallstones may be present at any age but are unusual before the third decade. There is a progressive increase with age, and in patients over 50 the prevalence ranges between 25-30%. The prevalence is two to three times higher in women than in men.

Laparoscopic gallbladder surgery (cholecystectomy) removes the gallbladder and gallstones through several small cuts (incisions) in the abdomen. The surgeon inflates the abdomen with air or carbon dioxide in order to see clearly. The surgeon inserts a lighted scope attached to a video camera (laparoscope) into one incision near the belly button. The surgeon then uses a video monitor as a guide while inserting surgical instruments into the other incisions to remove the gallbladder.

In laparoscopic cholecystectomy (LC), application of clips is the standard method for controlling the cystic duct and artery. However, a lot of sources identified disadvantages of the said technique. Some of the disadvantages of the application of clips are: duct leaks due to mismatch of the clips, necrosis of the duct at the site of clipping, or slip-page of the clips off the end of the duct. Some sources also showed that in the process of application, the metallic clips can fall from the applicator, there is a significant inflammatory reaction to metallic clips.

Due to these disadvantages, researchers managed to come up with a new technique in alternative for the application of clips (standard method). The new technique which is performed by division of cystic artery by monopolar cautery and ligation of the cystic duct intracorporeally using non-absorbable suture, shows a few negative results like bleeding of three patients from cauterized cystic artery. This bleeding was controlled by diathermy in two of them and application of metal clip was necessary in the remaining patient. Cystic duct leak was also detected in only one patient, and it was managed by percutaneous drainage. These negative results still was lesser than the disadvantages from using the standard method. In conclusion, proposed modification of LC is feasible, practical, safe and economic as well. It is associated with reduced risk of postoperative morbidity. (ElGeidie, 2011)

As future nurses, this is only one of the several cases we may encounter as we go along with our career. We believe that our job could help a lot of people in one way or another. Being able to identify new trends, modifications and technological advancements of the said procedure, we may be able to share and distribute these information to several other nurses, surgeons and other part of the OR team.

II. Anatomy and Physiology of the Digestive System

The apparatus for the digestion of food consists of the alimentary canaldigestive tractand of its accessory organs, collectively known as the digestive system. The function of the digestive system include: taking in food through mastication and swallowing, breaking down the food during the process of digestion, absorbing nutrients through the walls of the intestinal tract, and eliminating wastes by use of defecation.

The digestive tract is a tube extending from the mouth to the anus and including the associated organs that secret fluid into the digestive tract. It consists of the oral cavity, pharynx, esophagus, stomach, small intestine, large intestine, and anus. The accessory glands include the salivary glands, liver, and pancreas. The digestive tract consists of nerve plexuses called the enteric nervous system. The plexuses are composed of sensory neurons connecting to the digestive tract to the central nervous system, autonomic nervous system motor neurons connecting to the CNS to the digestive tract, and enteric neurons, which are only in the enteric nerve plexus. The enteric plexus controls activities within specific, short regions of the digestive tract through local reflexes. The ENS is capable of controlling the complex movements, secretions and blood flow of the GI tract, without any outside influences. Although the ENS can control the activities of the digestive tract independent of the CNS, normally the two systems work together.

The Liver and Gall Bladder

The liver is the largest internal organ of the body and is located in the right-upper quadrant of the abdomen, tucked against the inferior surface of the surface of the diaphragm. The liver was divided into four lobes based on superficial structures. Anteriorly, the boundary between the left and right lobes is marked by the falciform ligament. Inferiorly, the left lobe is separated from the quadrate and caudate lobes by the lesser omentum. The porta hepatis on the inferor surface of the liver is where the various vessels, ducts, and nerves enter and exit the liver. The porta hepatis separates the quadrate and caudate lobes. The gallbladder is small sac on the inferior surface of the of the liver that stores bile. The gallbladder marks the division between the right and quadrate lobes. The inferior vena cava marks the division between the right and caudate lobes.

A connective tissue capsule and visceral peritoneum cover the liver, except for the bare area, which is a small area on the diaphragmatic surface that lacks a visceral peritoneum and is surrounded by the coronary ligament. At the porta hepatis, the connective tissue capsule sneds a branching network of septa into the substance of the liver to provide its main support. Vessel, nerves, and ducts follow the connective tissue branches throughout the liver.

It is now known as the external division of the liver into lobes and has nothing to do with its internal organization. Internally, the liver is divided into eight segments based on the distribution of blood vessels and ducts transporting bile.

The porta hepatis contains the hepatic artery and hepatic portal vein, which carries blood to the liver, and the left and right hepatic ducts, which conduct bile toward the duodenum. Connective tissue septa divide the liver segments into many hexagon-shaped lobules with a portal triad at each corner. The triads are so named because three structures derived from the porta hepatis: branches of the hepatic artery, hepatic portal vein, and hepatic ducts. The hepatic artery braches and the hepatic portal branches join enlarged capillaries called hepatic sinusoids. The wall of the hepatic sinusoids consists of simple squamous epithelium and hepatic phagocystic cells, Kupffer cells. The hepatic sinusoids join a central vein located in the center of the lobule. Hepatic cords radiate out from the central vein of each lobule like the spokes of a wheel, surrounding the hepatic sinusoids. The hepatic cords are composed of hepatocytes, the cells of the liver. A cleftlike lumen, the bile canaliculus, lies between the hepatocytes within each cord. The bile canaliculi join the hepatic duct branches in the portal triad.

The liver performs important digestive and excretory functions, stores and processes nutrients, synthesizes new molecules, and detoxifies harmful chemicals.

Bile Production

The liver produces and secrets about 600-1000 mL of bile each day. Bile contains no digestive enzymes, but it plays a role in digestion because it neutralizes and dilutes gastric acid and emulsifies fats. The pH of chime as it leaves the stomach is too low for the normal function of pancreatic enzymes. Bicarbonate ions in bile help neutralize the acidic chyme and brings pH up to a level at which pancreatic enzymesn functions can function. Bile alts emulsify fats, changing large lipid droplets into much smaller droplets. Bile contains excretory products, such as the bile pigment bilirubin. Bile also contains cholesterol, fats, fat-soluble hormones, and lecithin.

Storage

Hepatocytes can remove sugar from the blood and store it in the form of glycogen.They can also store fat, vitamins, copper, and iron. This storage function is usually short-term, and the amount of stored material in the hepatocytes and the cell size fluctuate during a given day.

Hepatocytes help control blood sugar levels within very narrow limits. If a large amount of sugar were to enter the general circulation after a meal, it would increase the osmolality of the blood and produce hyperglycemia. This is prevented because the blood from the intestine passes to the liver, where glucose and other substance are removed from the blood by hepatocytes, stored, and secreted back into the circulation when needed.

Bile Transport

Bile, produced by the hepatocyes, flows through the bile canaliculi to the hepatic duct branches in the portal triads. The hepatic ducts converge and empty into the right and left hepatic ducts which transport bile of the liver. The right and left hepatic ducts unite to form a single common hepatic duct. The common hepatic duct is joined by the cystic duct from the gallbladder to form the common bile duct. The gallbladder is a small sac on the inferior surface of the liver that stores and concentrates bile. The common bile duct joins the pancreatic duct at the hepatopancreatic ampulla, and enlargement where the hepatic and pancreatic ducts come together. The hepatopancreatic ampulla empties into the duodenum at the major duodenal pailla. Smooth muscle sphincters surround the common bile duct, hepatopancreatic ampulla, and pancreatic duct.

The gallbladder is asaclike structure on the inferior surface of the lvier. Three tunics form the gall bladder wall: an inner mucousa folded into rugae that allow the gallbladder to expand, a muscularis allowing the gallbladder to contract, and an outer covering of serosa. The cystic duct connects the gallbladder to the common bile duct.

Bile is continually secreted by the liver and flows through the cystic duct into the gallbladder. While the bile is in the gallbladder, water and electrolytes are absorbed, and bile salts and pigments become as much as 5-10 times more concentrated than they were when secreted by the liver. Contraction of the gallbladder moves the stored bile into the duodenum.

Secretin released from the duodenum stimulate bile secretion, primarily by increasing the water and bicarbonate inon content of bile. Cholecystokinin released from the duodenum stimulates the gallbladder to contract and sphincters of the bile duct and hepatopancreatic ampulla to relax. To a lesser degree, parasympathetic stimulation through the vagus nerves cause the gallbladder to contract. Thus, large amounts of concentrated bile move rapidlyinto the duodenum.

Bile salts also increase bile secretion through a positive feedback system. Over 90% of bile salts are reabsorbed in the ileum and carrired in the blood back to the liver, where they contribute to further bile secretion. The loss of bile salts in feces is reduced by this recycling process.

III. The Patient and His Illness

Cholesterol gallstones

Nidus for gallstone formation

Gallbladder smooth muscle hypomotility and stasis

Bile supersaturated with cholesterol

Decreased Cholesterol 7 alpha-hydroxylase

Decreased resorption of bile salts from the ileum

Increased Hepatocyte synthesis of cholesterol

Diminished secretion of bile salts

Hepatocyte Mechanisms

b. Synthesis of the Disease

Gallstones are commonly of two types: cholesterol and pigmented. Cholesterol stones are the most common. Pigmented stones, which are less common, occur later in life and are associated with cirrhosis. Cholesterol gallstones form in bile that is supersaturated with cholesterol produced by the liver. Supersaturation sets the stage for cholesterol crystal formation, or the formation of microstones. More crystals then aggregate on the microstones, which grow to form macrostones. This process usually occurs in the gall bladder, which may have decreased motility. The stones may lie silent or become lodged in the cystic or common duct, causing pail and cholecystitis. Gallstone formation may be such that the stones accumulate and fill the entire gallbladder. Impaired gallbladder motility and gallbladder stasis also may contribute to stone formation.

It is not known why the hepatocytes secrete bile that is supersaturated with cholesterol. Proposed mechanisms include: an enzymatic defect that increases the hepatocytes synthesis of cholesterol, diminished secretion of bile acids that normally promote cholesterol solubility, decreased resorption of bile alts from the ileum that decrease the bile acid pool, gallbladder smooth muscle hypomotility and stasis, genetic predisposistion, and a combination of these mechanisms. In obese individuals the mechanism appears to involve cholesterol synthesis, whereas in nonobeses individuals, it appears to involve decreased secretion of bile acids.

Pigmented stones are created by cholesterol, calcium, bilirubinate, or pigmented polymers. The formation of pigmented stones is associated with bilary tract obstruction and bacterial degration and precipitation of biliary lipids.

b.1. Definition of the Disease

Cholelithiasis is the medical term for gallstone disease. Gallstones are concretions that form in the biliary tract, usually in the gallbladder. Gallstones develop insidiously, and they may remain asymptomatic for decades. Migration of a a gallstone into the opening of the cystic duct may block the outflow of bile during gallbladder contraction. The resulting increase in gallbladder wall tension produces a characteristic type of pain (biliary colic). Cystic duct obstruction, if it persists for more than a few hours, may lead to acute gallbladder inflammation (acute cholecystitis).

Choledocholithiasisrefers to the presence of one or more gallstones in the common bile duct. Usually, this occurs when a gallstone passes from the gallbladder into the common bile duct.

A gallstone in the common bile duct may impact distally in the ampulla of Vater, the point where the common bile duct and pancreatic duct join before opening into the duodenum. Obstruction of bile flow by a stone at this critical point may lead to abdominal pain and jaundice. Stagnant bile above an obstructing bile duct stone often becomes infected, and bacteria can spread rapidly back up the ductal system into the liver to produce a life-threatening infection called ascending cholangitis. Obstruction of the pancreatic duct by a gallstone in the ampulla of Vater also can trigger activation of pancreatic digestive enzymes within the pancreas itself, leading toacute pancreatitis.

Chronically, gallstones in the gallbladder may cause progressive fibrosis and loss of function of the gallbladder, a condition known as chronic cholecystitis. Chronic cholecystitis predisposes togallbladder cancer.

Ultrasonography is the initial diagnostic procedure of choice in most cases of suspected gallbladder or biliary tract disease.

The treatment of gallstones depends upon the stage of disease. Asymptomatic gallstones may be managed expectantly. Once gallstones become symptomatic, definitive surgical intervention with excision of the gallbladder (cholecystectomy) is usually indicated. Cholecystectomy is among the most frequently performed abdominal surgical procedures (see Treatment). Complications of gallstone disease may require specialized management to relieve obstruction and infection.

b.2. Predisposing/Precipitating Factors

Predisposing Factors:

Female

Over 40 years of age

Overweight or Obese

Family History of Gallstones

Diabetes

Native Americans or Mexican-Americans

Precipitating Factors:

High fat diets

High cholesterol diets

Losing weight very quickly

Medications that contain estrogen

b.3. Signs and Symptoms

Heavy, sudden pain the right upper abdomen with radiation to the back or shoulder

Nausea and vomiting

Restlessness (due to pain)

Yellowing of skin and eyes (due to contraction of jaundice)

Discoloration of the feces which becomes kitfarvet (due to jaundice)

Dark staining of urine (due to jaundice)

IV. Clinical Intervention

1.1 Description of prescribed surgical treatment performed.

Outline or illustrate the process and support with images.

Laparoscopic cholecystectomy is a procedure in which the gallbladder is removed by laparoscopic techniques.Laparoscopic surgeryalso referred to as minimally invasive surgerydescribes the performance of surgical procedures with the assistance of a video camera and several thin instruments.

During a laparoscopic surgical procedure, small incisions of up to half an inch are made and plastic tubes called ports are placed through these incisions. The camera and the instruments are then introduced through the ports which allow access to the inside of the patient.The camera transmits an image of the organs inside the abdomen onto a television monitor. The surgeon is not able to see directly into the patient without the traditional large incision. The video camera becomes a surgeons eyes in laparoscopy surgery, since the surgeon uses the image from the video camera positioned inside the patients body to perform the procedure.

Benefits of minimally invasive or laparoscopic procedures include less post operative discomfort since the incisions are much smaller, quicker recovery times, shorter hospital stays, earlier return to full activities and much smaller scars. Furthermore, there may be less internal scarring when the procedures are performed in a minimally invasive fashion compared to standard open surgery.

PATIENT POSITIONING

The patient should be supine with the arms perpendicular

to the body or tucked to the side.

After general anesthesia, the abdomen is prepped from

nipple to pubis and sterilely draped.

The primary surgeon stands on the patients left side, while

the assistant stands on the patients right.

PROCEDURE

General anesthesia is used.

A small periumbilical incision is made, with the location

and orientation depending on the patients body habitus

and cosmetic considerations. Although most surgeons

employ a closed technique to establish pneumoperitoneum

and initial access (usually with a Veress needle), an open

technique is also appropriate.

Figure 111: Port positions:

5-mm (preferred) or 10-mm port in the periumbilical

position for a 5-mm or 10-mm laparoscopic scope.

10-mm port in the subxiphoid position with the intraabdominal portion located to the right of the falciform

ligament.

5-mm port 2 ngerbreadths below the costal margin and

close to the midclavicular line, to position the port over

the gallbladder intra-abdominally.

5-mm port laterally along the anterior axillary line for

gallbladder fundus retraction.

The laparoscope is used to explore the abdomen for adhesions and potential injuries that may have occurred during

port placement (the subxiphoid and subcostal ports are

placed under direct visualization to minimize risk of

injury).

Figure 112: A ratcheted grasper is inserted through the

lateral 5-mm port to retract the gallbladder fundus in cephalad fashion.

If the gallbladder is too distended to be grasped, it may be

rst decompressed with a needle or using the suction

device.

An atraumatic grasper is inserted through the middle

5-mm port to retract the gallbladder infundibulum laterally, exposing the anteromedial aspect of the triangle of

Calot.

The primary surgeon uses a two-handed technique and

begins the dissection.

Adhesions to the body of the gallbladder are released using

blunt or sharp dissection, as appropriate.

A hook cautery is used to carefully incise the peritoneum

overlying the triangle of Calot, continuing along the

medial aspect of the proximal gallbladder.

Figure 113: As the infundibulum is retracted superomedially, peritoneum overlying the posterolateral aspect

of the triangle of Calot is similarly incised using hook

cautery.

Figure 114: All remaining connective tissue is dissected

out of the triangle of Calot using blunt dissection and hook

cautery as needed to fully mobilize the gallbladder

infundibulum.

Figure 115: The cystic duct is dissected free.

Figure 116: The cystic artery is dissected free.

At this point, only two tubular structures (the cystic duct

and artery) remain connected to the proximal gallbladder; this represents the critical view of safety.

Figure 117: If a cholangiogram is to be performed, a clip

is applied on the cystic duct at the junction to the infundibulum. An anterolateral cystic ductotomy is made just distal

to the clip.

Figure 118: A cholangiogram catheter is inserted through

the ductotomy and secured using either clips or a cholangiogram clamp.

The whole system should be ushed with 23 mL of saline

before placement of the cholangiocatheter as well as initially upon placement in the cystic duct to remove any air

bubbles, which might produce an artifact on the cholangiogram.

Approximately 1520 mL of contrast dye diluted 1:1 with

saline is injected under uoroscopy with the table tilted

slightly to the left. The contrast is injected slowly at rst to

visualize the distal common bile duct and then at higher

pressures and volumes to visualize the entire biliary tree.

An adequate cholangiogram requires visualization of the

biliary tree proximal to the biliary bifurcation (revealing

both right and left hepatic ducts and branches) and evidence of dye passage into the duodenum.

If common bile duct stones are identi ed, they can be

managed via laparoscopic bile duct exploration or post-operative ERCP, depending on surgeon preference and

experience.

Figure 119: After the cholangiogram, the cystic duct is

double clipped proximal to the ductotomy and divided.

The cystic artery is likewise divided between the previously

placed clips.

Figure 1110: The gallbladder is then dissected out of the

gallbladder fossa using hook cautery.

Figure 1111: The gallbladder is retrieved via the umbilical

or subxiphoid port, depending on surgeon preference. A

disposable specimen bag may be used for this purpose, particularly in cases of acute cholecystitis or gallbladder perforation during dissection (to prevent stone spillage).

The ports are removed under direct vision to evaluate for

potential bleeding.

If a 10-mm trocar is used at the umbilicus, the residual

fascial defect is closed with interrupted 0 Vicryl sutures.

The fascia at the epigastric trocar site is closed in similar

fashion.

Figure 1112A: Open cholecystectomy is performed

through a 1015-cm right subcostal incision.

A Bookwalter retractor is used to retract the liver and

bowel, exposing the gallbladder.

Figure 1112B: An antegrade approach is used to dissect

the gallbladder out of the gallbladder fossa from the fundus

down toward the porta hepatis.

The triangle of Calot is exposed just as in the laparoscopic

approach.

Figure 1112C: The cystic artery is identied and ligated

Figure 1112D: The cystic duct is isolated and ligated.

1.2 Indication of prescribed surgical treatment.

General and/or specific indications; discuss risk vs. benefit.

Indications

If an attack hasn't settled after 12 hours.

If there are complications such as jaundice, pancreatitis.

If patient suffers recurrent pain or vomiting.

If patient suffers cholangitis.

Obesity

Previous Surgery

Biliary Colic

Chronic cholecystitis

Acute cholecystitis

Acalculous cholecystitis

Choledocholithiasis

Risks

The overall risk of laparoscopic gallbladder surgery is very low. The most serious possible complications include:

Infection of an incision.

Internal bleeding.

Injury to thecommon bile duct.

Injury to the small intestine by one of the instruments used during surgery.

Risks of general anesthesia.

Other uncommon complications may include:

Injury to the cystic duct, which carries bile from the gallbladder to the common bile duct.

Gallstones that remain in the abdominal cavity.

Bile that leaks into the abdominal cavity.

Injury to abdominalbloodvessels, such as the major blood vessel carrying blood from theheartto the liver (hepaticartery). This is rare.

A gallstone being pushed into the common bile duct.

The liver being cut.

Benefit

Less discomfort than regular surgery

Shorter hospital stay, with a quicker recovery time compared to regular surgery

Smaller scars than regular surgery

Call your physician if you experience:

Increasing pain and redness at an incision site

Fever higher than 101 degrees

Draining at the incision site that increases or becomes foul smelling

1.3 Required instruments, devices, supplies, equipment, and facilities.

Specific resources and/or conditions that are necessary for the success of the operation; support with images.

Trocars - a sharp-pointed surgical instrument enclosed in a cannula, used for withdrawing fluid from a cavity, as the abdominal cavity.

Laparoscope - A slender tubular endoscope that is inserted through an incision in the abdominal wall and used for viewing the abdominal or pelvic cavities.

Atraumatic graspers - To clasp firmly with or as if with the hand.

Electrocautery instrument - The medical practice or technique ofcauterizationis theburningof part of a body to remove or close off a part of it in a process calledcautery, which destroys some tissue,[1]in an attempt to mitigate damage, remove an undesired growth, or minimize other potential medical harmful possibilities such as infections, when antibiotics are not available. The practice was once widespread for treatment of wounds. Its utility before the advent of antibiotics was effective on several levels:

useful in stopping severe blood-loss and preventingexsanguination

to closeamputations

Maryland dissector - is a monopolar electrosurgical instrument for dissection and hemostasis using flexible endoscopes.

Clip applier - to occlude vessels and other tubular structures.

Laparoscopic scissors - used to cut a variety of tissue, including fibrotic or calcified tissue, sutures, and occasionally tissue containing staples.

Suction-irrigator - used as a working portensuring precise coagulation and transection of vessels and tissue with instantaneous irrigation.

Disposable specimen retrieval bag - a dual-structured pocket in which specimens are placed.

Video Monitor - to enable a surgeon to more easily conduct endoscopic procedures.

OR Light - to assist medical personnel during a surgical procedure by illuminating a local area or cavity of the patient.

OR Table - the table on which the patient lies during a surgical operation.

Verress Needle - is a spring-loaded needle used to createpneumoperitoneumforlaparoscopic surgery.

Needle holder - is asurgical instrument, similar to ahemostat, used bydoctorsandsurgeonsto hold asuturing needle for closing wounds duringsuturingand surgical procedures.

SOURCE:

http://www.mhprofessional.com/downloads/products/0071453164/minter_ch11_p089-096.pdf

http://emedicine.medscape.com/article/1582292-overview#a09

http://www.indiancontinencefoundation.org/instruments.html

1.4 Perioperative tasks and responsibilities of the Nurse.

Emphasize and outline critical tasks and responsibilities of both scrub and circulator roles pre-operatively, intra-operatively, and post-operatively.

SCRUB NURSE

Pre-operatively

Ensures that the circulating nurse has checked the equipment

Ensures that the theater has been cleaned before the trolley is set

Prepares the instruments and equipment needed in the operation

Uses sterile technique for scrubbing, gowning and gloving

Receives sterile equipment via circulating nurse using sterile technique

Performs initial sponges, instruments and needle count, checks with circulating nurse

Perform assisted gowning and gloving to the surgeon and assistant surgeon as soon as they enter the operation suite

Assemble the drapes according to use. Start with towel, towel clips, draw sheet and then lap sheet. Then, assist in draping the patient aseptically according to routine procedure

Place blade on the knife handle using needle holder, assemble suction tip and suction tube

Bring mayo stand and back table near the draped patient after draping is completed

Secure suction tube and cautery cord with towel clips or allis

Prepares sutures and needles according to use

Intra-operatively

Maintain sterility throughout the procedure

Awareness of the patients safety

Adhere to the policy regarding sponge/ instruments count/ surgical needles

Arrange the instrument on the mayo table and on the back table

Provide 2 sponges on the operative site prior to incision

Passes the 1st knife for the skin to the surgeon with blade facing downward and a hemostat to the assistant surgeon

Hand the retractor to the assistant surgeon

Watch the field/ procedure and anticipate the surgeons needs

Pass the instrument in a decisive and positive manner

Watch out for hand signals to ask for instruments and keep instrument as clean as possible by wiping instrument with moist sponge

Always remove charred tissue from the cautery tip

Notify circulating nurse if you need additional instruments as clear as possible

Keep 2 sponges on the field

Save and care for tissue specimen according to the hospital policy

Remove excess instrument from the sterile field

Adhere and maintain sterile technique and watch for any breaks

Post-operatively

Undertake count of sponges and instruments with circulating nurse

Informs the surgeon of count result

Clears away instrument and equipment

After operation: helpsto applydressing

Removes and siposes of drapes

De-gown

Prepares the patient for recovery room

Completes documentation

Hand patient over to recover room

CIRCULATING NURSE

Pre-operatively

The circulating nurse checks all equipment, such as cautery and suction machines, prior to every operation to make sure they are functioning correctly. She ensures the operating theater is clean, the lights work, the operating table is functional and all furniture in the room is ready to use. In this role, she also helps the scrub nurse prepare the operating room by placing a clean sheet and pillow on the operating table and providing a clean kick bucket and pail.

As the main coordinator in the OR, the circulating nurses assists the anesthesiologist by correctly positioning the patient to receive anesthesia. The position depends on the procedure that will be performed. If spinal anesthesia is required, for example, the patient is positioned in a quasi-fetal position. After the anesthesia is administered, the circulating nurse follows the anesthesiologist's instructions for repositioning the patient and places his arms in arm boards and restraints to prevent him from inadvertently injuring himself. To prepare for the operation, she exposes the patient's skin and, if necessary catheterizes him.

Intra-operatively

Although the circulating nurse is not scrubbed in, she remains in the theater throughout the operation, monitoring lights, connecting or adjusting equipment and replenishing sponges. She may be called upon to refocus a light, reposition a kick bucket, or replenish and record sponges and sutures. It's the circulating nurse's duty to make sure the door remains closed throughout the patient's operation to maintain his privacy and make sure he is fully covered except when nudity is unavoidable.

Post-operatively

As the operation is drawing to a conclusion, the circulating nurse assists with the final sponge and instrument count, as each must be accounted for. She signs the theater register and ensures everyone attending also signs. Other post-op duties include performing quality checks, such as ensuring all specimens are correctly labelled and signed, and assisting the surgeons and scrub nurse in making sure the patient is in the correct position and resting comfortably. She also returns all equipment to their starting positions, making sure it's clean and ready for the next procedure.

SOURCE:

http://nursingcrib.com/nursing-notes-reviewer/duties-of-scrub-nurse-2/

http://everydaylife.globalpost.com/circulating-nurse-duties-2523.html

1.5 Expected outcomes of surgical treatment performed.

Describe both physiologic and psychosocial outcomes and their impact on quality of life.

Postoperative carefor the patient who has had an open cholecystectomy, as with those who have had any major surgery, involves monitoring of blood pressure, pulse, respiration, and temperature. Breathing tends to be shallow because of the effect of anesthesia, and the patient's reluctance to breathe deeply due to the pain caused by the proximity of the incision to the muscles used for respiration. The patient is shown how to support the operative site when breathing deeply and coughing and is given pain medication as necessary. Fluid intake and output is measured, and the operative site is observed for color and amount of wound drainage. Fluids are given intravenously for 2448 hours, until the patient's diet is gradually advanced as bowel activity resumes. The patient is generally encouraged to walk eight hours after surgery and discharged from the hospital within three to five days, with return to work approximately four to six weeks after the procedure.

Care received immediately after laparoscopic cholecystectomy is similar to that of any patient undergoing surgery with general anesthesia. A unique postoperative pain may be experienced in the right shoulder related to pressure from carbon dioxide used in the laparoscopic tubes. This pain may be relieved by lying down on the left side with right knee and thigh drawn up to the chest. Walking will also help increase the body's reabsorption of the gas. The patient is usually discharged the day after surgery and allowed to shower on the second postoperative day. The patient is advised to gradually resume normal activities over a three-day period, while avoiding heavy lifting for about 10 days.

Patients will probably be able to get back to normal activities within a week's time, including driving, walking up stairs, light lifting and work. Activity is dependent on how the patient feels. Walking is encouraged. Patients can remove the dressings and shower the day after the operation. In general, recovery should be progressive, once the patient is at home.

Most patients are fully recovered and may go back to work after seven to ten days.Often, this depends on the nature of your job since patients who perform manual labor or heavy lifting may require two to four weeks of recovery.

1.6 Medical management of physiologic outcomes.

The patient may experience either constipation or diarrhea after surgery and this may be caused by anesthesia, pain medications or reaction to surgery. This is not uncommon. The patient may take any over the counter medication(s) that have worked previously to correct the situation of diarrhea or constipation. Suggestions are Milk of Magnesia, Dulcolax tablets or suppositories as directed for constipation. Also increasing fluids such as water, juices, etc. will help with elimination. Suggestions for diarrhea include Pepto-Bismol and Imodium AD as directed for diarrhea. Also drinking Gatorade and BRAT diet (bananas, rice, applesauce, toast) may help to alleviate and correct some of the side effects of diarrhea.

If there are any serious complications post-operatively, particularly damage to the bile duct, a procedure called Endoscopic Retrograde Cholangiopancreatography (ERCP) may be performed. Damage to the duct causes leakage typically manifests as fever, jaundice, and abdominal pain several days following cholecystectomy.

1.7 Nursing management of physiologic and psychosocial outcomes.

Risk for Infection

Assessment

Nursing Diagnosis

Scientific Explanation

Objectives

Interventions

Rationale

Expected Outcome

S =

O = The patient may manifest the following:

-post surgical incisions in the abdominal area

-redness on the incision site

-swelling in the incision site

-increase environmental exposure to pathogens

-immunosuppression

- increased temperature

-warm skin

Risk for Infection related to inadequate primary defense as evidenced by broken skin secondary to surgical incisions in the abdominal area

The skin provides the primary protection against infection by acting as a physical barrier. When this barriers are damage pathogens have a direct route to infiltrate the body, possibly resulting infections.

Short Term:

After 2-4 hours of nursing interventions, the patient will be able to identify interventions to prevent or reduce risk of infection

Long Term:

After 2-3 days of nursing interventions, the patient will be able to achieve timely wound healing and free from any sign of infection

>Observe for localized signs of infections around the surgical site

>Stress proper hand hygiene by all caregivers between therapies and clients

>Assess signs and symptoms of infection especially temperature

>Maintain aseptic technique when changing dressing or caring wounds

>Keep area around surgical wound clean and dry

>Note risk factors for the occurrence of infection

>Instruct patient in techniques to protect the integrity of skin, care for incision, and prevention of spread of infection

>Assists patient in administering medication regimen and note patients response

>To assess causative/contributing factors

>A first-line defense against healthcare associated infections.

>Fever may indicate presence of infection

>Regular wound caring and proper dressing promotes fast healing and drying of wounds

>Wet area can be lodge area of bacteria

>Assessing patient may serve as a baseline data and contributing factors.

>Techniques in avoiding the occurrence of infection could promote patients wellness

>To determine the effectiveness of therapy or presence of side effects

Short Term:

the patient shall have identified interventions to prevent or reduce risk of infection

Long Term:

the patient shall have achieved timely wound healing and free from any sign of infection

Pain

Assessment

Nursing Diagnosis

Scientific Explanation

Objectives

Interventions

Rationale

Expected Outcome

S =

O = The patient may manifest the following:

-restlessness

-irritability

-verbal reports of pain

-guarding behavior

-changes in blood pressure and heart rate

-self-focusing

Acute pain related to post-operative laparoscopic cholecystectomy

External and internal factor aggravates the nerve endings in the lower extremity causing production of prostaglandin, bradykinin, histamine and progesterone to react on the specific region causing pain sensation

Short term:

After 2-3 hours of nursing interventions, the patient will be able to perform comfort measures and relieve pain.

Long term:

After 2-3 days of nursing interventions, the client will be able to have more control of the pain if ever it reoccurred.

>Assess the clients pain scale and perception

>Encourage verbal report during and after the nursing interventions.

>Monitor VS and pain scale.

>Teach client diversional activities

>Advise breathing exercise

>Administer analgesics as prescribed by the physician.

>To identify the intensity, onset, duration and quality of the pain.

>Pain is highly subjective and to identify the effectiveness of interventions

>Obtain baseline VS, VS changes during onset of pain for future comparison after interventions

>To divert clients attention on pain

>To allow proper O2 supply in the body, clients tend to stop breathing during pain

>To relieve the client of pain using pharmacologic intervention

Short term:

After 2-3 hours of nursing interventions, the patient shall have performed comfort measures and relieved pain.

Long term:

After 2-3 days of nursing interventions, the client shall have more control of the pain if ever it reoccurred.

Risk for Constipation

Assessment

Nursing Diagnosis

Scientific Explanation

Objectives

Interventions

Rationale

Expected Outcome

S =

O = The patient may manifest the following:

-difficult passage of stool

-hard, dry stool

-decreased frequency of defecation

Risk for Constipation related to side effects of anesthesia post-operation.

Anesthesia paralyzes the muscles. The intestine is paralyzed during surgery along with the arms and legs. This stops the muscle contractions to push food along the intestinal tract. Until the intestines "wake up" there is no movement of feces.

Short term:

The patient will be able to verbalize risk factors and appropriate interventions to overcome the problem.

Long term:

The patient will be able to have/maintain a usual pattern of bowel functioning.

>Encourage balanced fiber and bulk in the diet (if the patient is not on NPO)

>Promote adequate fluid intake

>Encourage light activities within limits of individual ability.

>Provide privacy and routinely scheduled time for defecation.

>Ascertain frequency, color, consistency, amount of stools.

>To improve consistency of stool and facilitate passage through colon.

>To promote soft stool and stimulate bowel activity.

>To stimulate contractions of the intestines.

>So client can respond to urge of defecating.

>Provides a baseline for comparison; promotes recognition of changes.

Short term:

The patient shall have verbalized risk factors and appropriate interventions to overcome the problem.

Long term:

The patient shall have/maintain a usual pattern of bowel functioning.

Activity Intolerance

Assessment

Nursing Diagnosis

Scientific Explanation

Objectives

Interventions

Rationale

Expected Outcome

S =

O = The patient may manifest the following:

-weakness

-fatigue

-restlessness

-irritability

-verbal reports of pain

-discomfort

-pallor

-abnormal heart rate or BP response to activity

Activity intolerance related to bedrest/immobility and effects of anesthesia secondary to post-operative Laparoscopic Cholecystectomy

Effects of anesthesia post-operation may alter the patients activity due to paralysis of some organs or parts of the body. Pain could also contribute to the problem because the patient may focus more attention on the pain felt than doing activities like eating, etc.

Short term:

The patient will be able to participate willingly in necessary or desired activities.

Long term:

The patient will demonstrate a decrease in physiological signs of intolerance (pulse, respiration,and blood pressure remain within clients normal range).

>Note presence of factors contributing to fatigue.

>Note clients reports of weakness, fatigue, pain, difficulty accomplishing tasks, and insomnia.

>Ascertain ability to stand and move about.

>Plan care to carefully balance rest periods with activities.

>Provide positive atmosphere.

>Assist client with activities.

>Promote comfort measures and provide relief of pain.

>Plan for progressive increase of activity level as tolerated by client.

>Encourage client to maintain positive attitude, suggest use of relaxation techniques.

>Fatigue affects both the clients actual and perceived ability to participate in activities.

>Symptoms may be result of/or contribute to intolerance of activity.

>To determine current status and needs associated with participation in needed/desired activities.

>To reduce fatigue.

>Helps minimize frustration and rechannel energy.

>To prevent injury.

>To enhance ability to participate in activities.

>Both activity tolerance and health status may improve with progressive training.

>To enhance sense of well-being.

Short term:

The patient shall have participated willingly in necessary or desired activities.

Long term:

The patient shall have demonstrated a decrease in physiological signs of intolerance (pulse, respiration,and blood pressure remain within clients normal range).

Impaired Comfort

Assessment

Nursing Diagnosis

Scientific Explanation

Objectives

Interventions

Rationale

Expected Outcome

S =

O = The patient may manifest:

-fatigue

-restlessness

-irritability

-discomfort

-altered sleeping pattern

-verbal reports of pain

-anxiety

-activity intolerance

Impaired comfort related to pain, fatigue and restlessness secondary to post-operative Laparoscopic Cholecystectomy.

Pain due to the operation may contribute to the patients fatigue, restlessness and altered activity and sleeping pattern which results to discomfort of the patient. This may lead to the patient not showing interest on different activities and focuses attention on self and the previous surgery.

Short term:

The patient will be able to verbalize sense of comfort or contentment.

Long term:

The patient will be able to engage in behaviors or lifestyle changes to increase level of ease.

>Determine the type of discomfort the client is experiencing.

>Discuss concerns with client and active-listen to identify underlying issues.

>Determine how client is managing pain and pain components.

>Determine the clients environment.

>Review medications or treatment regimen.

>Provide age-appropriate comfort measures.

>To identify proper interventions or activities to be implemented.

>Helps determine clients specific needs and ability to change own situation.

>Lack of control may be related to other issues or emotions such as fear, anxiety and anger.

>This is an aspect that can be manipulated to enhance comfort.

>To determine possible changes or options to reduce side effects.

>To provide non-pharmacological pain management.

Short term:

The patient shall have verbalized sense of comfort or contentment.

Long term:

The patient shall have engaged in behaviors or lifestyle changes to increase level of ease.

V. Conclusion

Operating Room in the hospital setting gave me another experience that I did not learn from the other wards or even in delivery room. I was amazed on how they do the procedures without complications. They are calm and find it usual. While I was a scrub nurse in this case, I was thinking that I think I like to be an O.R. Nurse in the future. My clinical instructor was right, being an O.R. Nurse is really fun and flexible. With this report, I can still remember on how they did the procedure with the patient. I learned also that we should really keep the sterile area a sterile. There should be alertness not only at the beginning of the procedure but also before the procedure. With the instruments, you should know them all and listen carefully on what the surgeon asks for. Laparoscopic Cholecystectomy is being done depending on the situation. In this surgical procedure, there might be risk such as internal bleeding and the liver being cut. But there are also benefits that the patient can get from this surgical procedure like less discomfort, quicker recovery time and smaller scars in the abdomen. Cruz, Hazel Irish

Laparoscopic cholecystectomy has broadened my mind of the possibilities of technology in medicine, especially surgery. It was not very long ago that this particular surgery required one large incision rather than three small ones. The procedure will save time of the surgeon and also shorten the patients healing time. It also kept the sterility of the surgical area intact because the procedure was not highly evasive. The surgery itself was quick and the surgeons did not run into any complications. They were completely at ease with the level of difficulty of the laparoscopic procedure. The staff made sure to maintain the sterile area and all the tasks were done in a timely and efficient manner. It was a very good surgery to witness as a circulating scrub nurse. Garcia, Christina Beatriz

VII. References

http://www.surgeryencyclopedia.com/Ce-Fi/Cholecystectomy.html

http://www.surgery.usc.edu/divisions/tumor/PancreasDiseases/web%20pages/BILIARY%20SYSTEM/laparoscopic%20chole.html

http://www.newyorkgeneralsurgery.com/cholecystectomy-new-york.html

http://www.webmd.com/digestive-disorders/laparoscopic-gallbladder-surgery-for-gallstones

http://my.clevelandclinic.org/services/laparoscopic_surgery/hic_laparoscopic_cholecystectomy.aspx

http://www.mhprofessional.com/downloads/products/0071453164/minter_ch11_p089-096.pdfhttp://www.surgery.usc.edu/divisions/tumor/PancreasDiseases/web%20pages/BILIARY%20SYSTEM/laparoscopic%20chole.html

http://www.mhprofessional.com/downloads/products/0071453164/minter_ch11_p089-096.pdf

http://emedicine.medscape.com/article/175667-overview#a0104

http://www.healthanddisease.com/english/diseases/stomach-and-intestine/the-liver-gallbladder-and-pancreas/gallstones-(cholecystolithiasis-and-choledocholithiasis)/