CHOLECYSTECTOMY

ALYSSA JAMILLA Q. MARTINEZ

LIRIO CLAIRE T. AZUL
GALLBLADDER

Stores and concentrates bile and contracts to force bile into the
duodenum during the digestion of fats
The cystic duct joins the hepatic duct to form the common bile duct
The sphincter of Oddi is located at the entrance to the duodenum
The presence of fatty materials in the duodenum stimulates the
liberation of cholecystokinin, which causes contraction of the
gallbladder and relaxation of the sphincter of Oddi
500- 1000 ml of bile/day
Cholecystitis

Inflammation of the gallbladder that may occur as an acuteor chronic

process

Acute cholecystitis associated with gallstones (cholelithiasis)

Chronic cholecystitis results in inefficient bile emptying and gallbladder wall

disease cause a fibrotic and contracted gallbladder

Acalculous cholecystitis occurs in the absence of gallstones and is caused

by bacterial invasion via the lymphatic or vascular system
Assessment

N/V
Indigestion
Belching
Flatulence
Epigastric Pain (radiating to the scapula 2-4 hrs after eating fatty foods
and may persist 4-6 hrs)
Pain localized in RUQ
Guarding, rigidity and rebound tenderness
Mass palpated in RUQ
Assessment

MURPHYs SIGN ( cannot take a deep breath when the examiners

fingers are passed below the hepatic margin because of pain)
Increased Temp
Tachycardia
Signs of Dehydration
Fever
BILIARY OBSTRUCTION
-Jaundice
-Dark orange and foamy urine
-Steatorrhea and clay-colored feces
- Pruritus
Risk factors:

Women are more likely to get gallstones than men

Anyone older than 60
Pregnant or multigravidas
Women taking ERT or birth control pills
Obese
People who have lost weight rapidly
People who eat high-fat diet
Interventions

NPO when N/V

Administer Antiemetics, Analgesics
Administer Antispasmodic (anticholinergics) relax smooth muscles
Chronic Cholecystitis- eat small, low-fat meals
Avoid gas-forming foods
Types of Cholecystectomy
Open Method
4- to 6-inch incision in the right
upper portion of the abdomen
liver is lifted out of the way and the
gallbladder is carefully removed
Laparoscopic Method
Laparoscopic Cholecystectomy

is considered less invasive and generally requires a

shorter recovery time than an open cholecystectomy.
Occasionally, the gallbladder may appear severely
diseased on laparoscopic examination or other
complications may be apparent, and the surgeon may
have to perform an open surgical procedure to
remove the gallbladder safely.
 instead of making one large incision, the surgeon
makes four

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

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

takes 30 to 60 minutes
NURSING RESPONSIBILITIES
Pre-op

Obtain informed consent.

Reinforced to client and family the surgical procedure

to be done, how long it will take, possible
complications and preventive measures

Health teachings done regarding proper hygiene

necessary for pre-operative preparations like taking a
bath and cleansing of perineal area
 Instructthat walking and limited movement are generally
encouraged postoperatively, but strenuous activity should be
avoided.

Inform the patient of signs and symptoms that needs to be

reported to the physician immediately
fever and/or chills
redness, swelling, or bleeding or other drainage from the incision site(s)
increased pain around the incision site(s)
abdominal pain, cramping, or swelling
pain behind the breastbone
 NPOpost midnight to allow time for
stomach to empty and decrease aspiration

Pre op medication to be given

Operative records complete

Intra

Assist patient to OR theater

Remove prosthesis, jewelries, nail polish etc.

Valuables taken

Assist patient in transferring to OR table

 Attachment of life- supportive devices and
indwelling catheter

Induction of anesthesia
assist patient in c-shape position
skin preparation on posterior surface using betadine paint
assist in the induction of anesthesia
 Patient prepared for initial intraoperative
cholangiogram (The doctor places a small tube called
a catheter into the cystic duct, which drains bile from
the gallbladder into the common bile duct.)

Skin preparation done on operative site

Medical and surgical handwashing done

 Gowning and gloving

Setting up of complete pack and instrument set

Initial
counting of instruments, needles, ATR,
operating sponges, visceral packs
Skin Preparation
 Gowning and gloving of physicians

Offering of draw sheets, towels, towel clips, lap sheet

Offering of scalpel needed for initial cutting

physician makes an oblique right subcortal incision, carried
down to peritoneum
 Offering of cautery cord and sponges

Offering
of US Army navy retractors, tissue
forcep without teeth and sponges
physician performs intraoperative assessment of
surgical site
 Richardson retractors, OS and visceral packs
physician continuously visualizes interior portion

Offering of series of Kelly curve forcep

clipped on adjacent organs as well as to reduce bleeding

Offering of Scalpel and metzenbaum

 physician performs Kocher maneuver ( release of
lateral and posterior attachments of second portion of
duodenum

physician palpates common bile duct, pancreas and

duodenum

PNSS prepared for flushing and suction cord to clear

site
site of removal identified and skeletonized by physician
Set of stick ties ,traction sutures and OS prepared
 traction sutures placed laterally and medially

stick ties tied to ducts thus checking for patency

Metzenbaum offered

physician continuously cuts attachment site of

gallbladder

cystic ducts and arteries are ligated

 Offering of bowl of PNSS

irrigation done proximally and distally to flush out excess clots and
stones present in common bile ducts
Suctioning cord offered for suctioning
Deaver with wooden handle prepared

physician continuously visualizes site in preparation for insertion of t-

tube

t-tube inserted with limbs cut short to drain and stent the ducts
intraoperatively
 More stick ties and Kelly curve offered
choledochotomy is closed around t-tube
Radiopaque contrast material dye is prepared
introduced in a French 5 catheter
Follow up counting of instruments,needles, ATR,
operating sponge, visceral packs
Patientis prepared for another cholangiography to
confirm presence of stones and leaks
A bowl of PNSS, long tissue forcep without teeth
offered
 physician continuously views removal site

Offering of kelly curves

physician clamps organs attached to gallbladder ready for

surgical removal
Cautery and suction cord prepared
seriesof cauterization and suctioning is done for
clotting
hemostasis done
 Offering of operating sponges and sponge sticks to clear site

Metzenbaum and Potts sciccors are offered

removal of gallbladder and stones done
specimen out

Suture prepared for repair of detachment site

Scalpel prepared
 phyisician makes a separate insicion below the main surgical site for
insertion of Jackson Pratt Drain
Counting of instrument, needles, ATR, operating sponges, visceral
packs

Necessary sutures and mayo scissors are prepared for layer by layer
closure
closure of peritoneum and rectus sheath continuous interlocking
closure of anterior rectus sheath and fascia continuous
interlocking
closure of subcutaneous layer and muscle
skin closed subcuticularly
 Final counting of instruments, needles, ATR, operating
sponges, visceral packs
Final counting of instruments, needles, ATR,
operating sponges, visceral packs
Final cleansing of surgical site
Application of dry sterile dressing
Post-op

Removal of attached assistive and operative

devices

Patient is undraped

Aftercare to be done in the OR theater

Patient transferred to post anesthetic care

unit
 Patient for NPO

Monitor vital signs for 15 min. for 2 hours then 30 min. for 2
hrs ; q hourly thereafter

Monitor pain score q hourly

Administer post-op medications

Monitor intake and output q hourly

Refer accordingly
Meds

Ceftriaxone
Surgical Interventions

CHOLECYSTECTOMY - removal of the gallbladder

CHOLEDOCHOLITHOTOMY incision in the common bile duct to

remove the stone
Post- op Interventions

Monitor for respiratory complications caused by pain at the incision site

Encourage coughing and deep breathing

Encourage early ambulation

Instruct the client about splinting the abdomen to prevent discomfort

during coughing

Administer Antiemetics, analgesics

Post- op Interventions

Maintain NPO status and NGT suction as prescribed

Advanced diet from clear liquids to solids when prescribed and as

tolerated by the client

Maintain and monitor drainage from the T-tube, if present

Care for the T-tube

Place the client in Semi-fowlers position

Monitor the output, amount, color, consistency and odor of the drainage
Report sudden increase in bile output to the HCP
Monitor for inflammation and protect skin from irritation
Keep the drainage system below the level of the gallbladder
Monitor for foul odor and purulent drainage report to HCP
Avoid irrigation, aspiration, or clamping of the T-tube without HCP
prescription
As prescribed clamp the tube before a meal and observe for: abdl
discomfort distention, nausea, chills and fever; unclamp the
tube if N/V occurs