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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