CHOLECYSTECTOMY

CHOLECYSTECTOMY

BY: HOPE ALBURO

surgical removal of the surgical removal of the gallbladder, an organ gallbladder, an organ located just under the located just under the liver on the upper liver on the upper right quadrant of the right quadrant of the abdomenabdomen

A Gallbladder is….A Gallbladder is….

•small pear-shaped small pear-shaped organ which lies on organ which lies on the underside of the the underside of the liverliver

• is connected by is connected by ducts (or tubes) with ducts (or tubes) with the liver and with the liver and with the upper portion of the upper portion of the small intestine the small intestine (duodenum). (duodenum).

•a branch of the bile duct which a branch of the bile duct which runs into the first part of the runs into the first part of the intestines that stores some of the intestines that stores some of the bilebile

•contracts and forces bile out into contracts and forces bile out into the duct leading into the intestinethe duct leading into the intestine

•when removed, this function is when removed, this function is taken over by the liver and its taken over by the liver and its ductsducts

The Reasons…..The Reasons…..

•gallbladder contains gallstones (cholelithiasis)

•is inflamed

•infected (cholecystitis)

•is cancerous

Types of Types of CholecystectomyCholecystectomy

OPENOPEN

•4- to 6-inch incision in 4- to 6-inch incision in the right upper portion the right upper portion of the abdomen of the abdomen

•liver is lifted out of the liver is lifted out of the way and the gallbladder way and the gallbladder is carefully removed is carefully removed

Laparoscopic Laparoscopic MethodMethod

• instead of making one large instead of making one large incision, the surgeon makes four incision, the surgeon makes four

•one incision is made right under one incision is made right under the navel (umbilicus) and a the navel (umbilicus) and a laparoscope is insertedlaparoscope is inserted

• the laparoscope is a miniature the laparoscope is a miniature telescope attached to a camera, telescope attached to a camera, and through its lens the surgeon and through its lens the surgeon can see the interior of the can see the interior of the abdomenabdomen

• Instruments are inserted through Instruments are inserted through the other incisions the other incisions

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

• Before removing it, the surgeon Before removing it, the surgeon sometimes shrinks the gallbladder sometimes shrinks the gallbladder by suctioning out the bile.by suctioning out the bile.

• Incisions are sutured or stapled Incisions are sutured or stapled closed closed

• takes 30 to 60 minutestakes 30 to 60 minutes

Nursing ResponsibilitiesNursing Responsibilities

Before…Before…

• Obtain informed consent. The role of the Obtain informed consent. The role of the nurse is to witness the signing of the nurse is to witness the signing of the informed consent. It is the nurse’s informed consent. It is the nurse’s responsibility to reinforce what is learned responsibility to reinforce what is learned by the patientby the patient

• Reinforced to client and family the surgical Reinforced to client and family the surgical procedure to be done, how long it will take, procedure to be done, how long it will take, possible complications and preventive possible complications and preventive measuresmeasures

• Health teachings done regarding proper Health teachings done regarding proper hygiene necessary for pre-operative hygiene necessary for pre-operative preparations like taking a bath and preparations like taking a bath and cleansing of perineal areacleansing of perineal area

• Instruct that walking and limited movement Instruct that walking and limited movement are generally encouraged postoperatively, are generally encouraged postoperatively, but strenuous activity should be avoided.but strenuous activity should be avoided.

• Inform the patient of signs and symptoms Inform the patient of signs and symptoms that needs to be reported to the physician that needs to be reported to the physician immediatelyimmediately– fever and/or chills fever and/or chills – redness, swelling, or bleeding or other redness, swelling, or bleeding or other

drainage from the incision site(s) drainage from the incision site(s) – increased pain around the incision site(s) increased pain around the incision site(s) – abdominal pain, cramping, or swelling abdominal pain, cramping, or swelling – pain behind the breastbonepain behind the breastbone

• NPO post midnight to allow time for NPO post midnight to allow time for stomach to empty and decrease stomach to empty and decrease aspirationaspiration

• Pre op medication to be givenPre op medication to be given• Operative records completeOperative records complete

During…During…

• Assist patient to OR theaterAssist patient to OR theater• Remove prosthesis, jewelries, nail polish etc. Remove prosthesis, jewelries, nail polish etc. • Valuables takenValuables taken• Assist patient in transferring to OR tableAssist patient in transferring to OR table• Attachment of life- supportive devices and Attachment of life- supportive devices and

indwelling catheterindwelling catheter• Induction of anesthesiaInduction of anesthesia

– assist patient in c-shape positionassist patient in c-shape position– skin preparation on posterior surface using skin preparation on posterior surface using

betadine paintbetadine paint– assist in the induction of anesthesiaassist in the induction of anesthesia

• Patient prepared for initial Patient prepared for initial intraoperative cholangiogramintraoperative cholangiogram

• Skin preparation done on operative site Skin preparation done on operative site • Medical and surgical handwashing done Medical and surgical handwashing done

by nurseby nurse• Gowning and gloving by nurseGowning and gloving by nurse• Setting up of complete pack and Setting up of complete pack and

instrument setinstrument set• Initial counting of instruments, needles, Initial counting of instruments, needles,

ATR, operating sponges, visceral packsATR, operating sponges, visceral packs

Skin PreparationSkin Preparation

• Gowning and gloving of physiciansGowning and gloving of physicians• Offering of draw sheets, towels, towel clips, Offering of draw sheets, towels, towel clips,

lap sheetlap sheet• Offering of scalpel needed for initial cuttingOffering of scalpel needed for initial cutting

– physician makes an oblique right physician makes an oblique right subcortal incision, carried down to subcortal incision, carried down to peritoneumperitoneum

• Offering of cautery cord and spongesOffering of cautery cord and sponges• Offering of US Army navy retractors, tissue Offering of US Army navy retractors, tissue

forcep without teeth and spongesforcep without teeth and sponges– physician performs intraoperative physician performs intraoperative

assessment of surgical siteassessment of surgical site

• Richardson retractors, OS and visceral packsRichardson retractors, OS and visceral packs– physician continuously visualizes interior physician continuously visualizes interior

portionportion• Offering of series of Kelly curve forcepOffering of series of Kelly curve forcep

– clipped on adjacent organs as well as to clipped on adjacent organs as well as to reduce bleedingreduce bleeding

• Offering of Scalpel and metzenbaumOffering of Scalpel and metzenbaum• physician performs Kocher maneuver physician performs Kocher maneuver

( release of lateral and posterior attachments ( release of lateral and posterior attachments of second portion of duodenumof second portion of duodenum

• physician palpates common bile duct, physician palpates common bile duct, pancreas and duodenumpancreas and duodenum

• PNSS prepared for flushing and suction PNSS prepared for flushing and suction cord to clear sitecord to clear site– site of removal identified and skeletonized site of removal identified and skeletonized

by physicianby physician• Set of stick ties ,traction sutures and OS Set of stick ties ,traction sutures and OS

preparedprepared

• traction sutures placed laterally and traction sutures placed laterally and medially medially

• stick ties tied to ducts thus checking for stick ties tied to ducts thus checking for patencypatency

• Metzenbaum offered Metzenbaum offered

• physician continuously cuts attachment physician continuously cuts attachment site of gallbladdersite of gallbladder

• cystic ducts and arteries are ligatedcystic ducts and arteries are ligated

– Offering of bowl of PNSSOffering of bowl of PNSS

• irrigation done proximally and irrigation done proximally and distally to flush out excess clots and distally to flush out excess clots and stones present in common bile ductsstones present in common bile ducts– Suctioning cord offered for Suctioning cord offered for

suctioningsuctioning– Deaver with wooden handle Deaver with wooden handle

preparedprepared• physician continuously visualizes site in physician continuously visualizes site in

preparation for insertion of t-tubepreparation for insertion of t-tube• t-tube inserted with limbs cut short to drain and t-tube inserted with limbs cut short to drain and

stent the ducts intraoperativelystent the ducts intraoperatively

– More stick ties and Kelly curve offeredMore stick ties and Kelly curve offered

• choledochotomy is closed around t-tubecholedochotomy is closed around t-tube– Radiopaque contrast material dye is prepared Radiopaque contrast material dye is prepared

introduced in a French 5 catheterintroduced in a French 5 catheter– Follow up counting of instruments,needles, ATR, Follow up counting of instruments,needles, ATR,

operating sponge, visceral packs operating sponge, visceral packs – Patient is prepared for another cholangiography to Patient is prepared for another cholangiography to

confirm presence of stones and leaksconfirm presence of stones and leaks– A bowl of PNSS, long tissue forcep without teeth A bowl of PNSS, long tissue forcep without teeth

offeredoffered

• physician continuously views removal sitephysician continuously views removal site• Offering of kelly curvesOffering of kelly curves• physician clamps organs attached to gallbladder physician clamps organs attached to gallbladder

ready for surgical removalready for surgical removal

•Cautery and suction cord preparedCautery and suction cord prepared•series of cauterization and suctioning is series of cauterization and suctioning is

done for clottingdone for clotting•hemostasis donehemostasis done

• Offering of operating sponges and sponge sticks to Offering of operating sponges and sponge sticks to clear siteclear site

• Metzenbaum and Pott’s sciccors are offeredMetzenbaum and Pott’s sciccors are offered– removal of gallbladder and stones doneremoval of gallbladder and stones done– specimen outspecimen out

• Suture prepared for repair of detachment siteSuture prepared for repair of detachment site• Scalpel prepared Scalpel prepared • phyisician makes a separate insicion below the phyisician makes a separate insicion below the

main surgical site for insertion of Jackson Pratt main surgical site for insertion of Jackson Pratt DrainDrain

– Counting of instrument, needles, ATR, Counting of instrument, needles, ATR, operating sponges, visceral packsoperating sponges, visceral packs

• Necessary sutures and mayo scissors are Necessary sutures and mayo scissors are prepared for layer by layer closure prepared for layer by layer closure – closure of peritoneum and rectus sheath – closure of peritoneum and rectus sheath –

continuous interlockingcontinuous interlocking– closure of anterior rectus sheath and closure of anterior rectus sheath and

fascia – continuous interlockingfascia – continuous interlocking– closure of subcutaneous layer and muscleclosure of subcutaneous layer and muscle– skin closed subcuticularlyskin closed subcuticularly

• Final counting of instruments, needles, Final counting of instruments, needles, ATR, operating sponges, visceral packsATR, operating sponges, visceral packs

•Final counting of instruments, Final counting of instruments, needles, ATR, operating needles, ATR, operating sponges, visceral packssponges, visceral packs

•Final cleansing of surgical siteFinal cleansing of surgical site•Application of dry sterile Application of dry sterile dressingdressing

After…After…•Removal of attached Removal of attached

assistive and operative assistive and operative devicesdevices

•Patient is undraped Patient is undraped •Aftercare to be done in the Aftercare to be done in the

OR theaterOR theater•Patient transferred to post Patient transferred to post

anesthetic care unitanesthetic care unit

•Patient for NPOPatient for NPO•Monitor vital signs for 15 min. Monitor vital signs for 15 min.

for 2 hours then 30 min. for 2 for 2 hours then 30 min. for 2 hrs ; q hourly thereafterhrs ; q hourly thereafter

•Monitor pain score q hourlyMonitor pain score q hourly•Administer post-op medicationsAdminister post-op medications•Monitor intake and output q Monitor intake and output q

hourlyhourly•Refer accordinglyRefer accordingly

THANK YOU AND GOD BLESS!