CHOLECYSTECTOMY

CHOLECYSTECTOMY
Is the surgical removal of the gallbladder
It is a common treatment of symptomatic gallstones
and other gallbladder conditions.
The surgery can lead to Postcholecystectomy
syndrome.

TYPES OF CHOLECYSTECTOMY
1. Laparoscopic cholecystectomy
- has now replaced open cholecystectomy as the firstchoice of treatment for gallstones and inflammation of
the gallbladder unless there are contraindications to the
laparoscopic approach. This is because open surgery
leaves the patient more prone to infection.
- Sometimes, a laparoscopic cholecystectomy will be
converted to an open cholecystectomy for technical
reasons or safety.

2. Open cholecystectomy
- an older and more invasive proceure

- occasionally performed in certain circumstances, such as

failure of laparoscopic surgery, severe systemic illness
causing intolerance of pneumoperitoneum, or as part of a
liver transplant.
- In open cholecystecomy, a surgical incision of
approximately 10 to 15 cm is typically made below the edge
of the right ribcage. The liver is retracted superiorly, and a
top-down approach is taken (from the fundus towards the
neck) to remove the gallbladder from the liver, typically
using electrocautery.

Indications
Conditions*
Biliary pain

When to perform surgery

First open operative day

Biliary dyskinesia

First open operative day

Calcified gallbladder

First open operative day

Acute cholecystitis

Urgent (within 72 hours)

Choledocholithiasis

After the common bile duct is cleared

Gallstone pancreatitis

Before discharge but after pancreatitis resolves

INSTRUMENTS
A scalpel is used to make a small incision at the umbilicus. Using
either a Veress needle or Hasson technique, the abdominal cavity is
entered. The surgeon inflates the abdominal cavity with carbon
dioxide to create a working space. The camera is placed through the
umbilical port and the abdominal cavity is inspected. Additional
ports are opened inferior to the ribs at the epigastric, midclavicular,
and anterior axillary positions. The gallbladder fundus is identified,
grasped, and retracted superiorly. With a second grasper, the
gallbladder infundibulum is retracted laterally to expose and open
Calot's Triangle (cystic artery, cystic duct, and common hepatic
duct). The triangle is gently dissected to clear the peritoneal
covering and obtain a view of the underlying structures. The cystic
duct and the cystic artery are identified, clipped with tiny titanium
clips and cut. Then the gallbladder is dissected away from the liver

 This type of surgery requires meticulous surgical skill, but in

straightforward cases, it can be done in about an hour. Recently,
this procedure is performed through a single incision in the
patient's umbilicus. This advanced technique is called
Laparoendoscopic Single Site Surgery or "LESS" or Single
Incision Laparoscopic Surgery or "SILS". In this procedure,
instead of making 3-4 four small different cuts (incisions), a
single cut (incision) is made through the navel (umbilicus).
Through this cut, specialized rotaculating instruments (straight
instruments which can be bent once inside the abdomen) are
inserted to do the operation. The advantage of LESS / SILS
operation is that the number of cuts are further reduced to one
and this cut is also not visible after the operation is done as it is
hidden inside the navel.

SPECIAL INSTRUMENTS
Spatula
Electrode
w/Suctio
n

L Hook
Electrode
w/Suctio
n
High
Volume
Suction
Irrigation
System

Needle for
Injection
and
Irrigation

Metzenbau
m Scissors,
Straight

Metzenbau
m Scissors,
Curved

Hook
Scissors

Micro
Scissors,
Curved

Maryland
Dissector

Mixter
Forceps,
Diamond
Serrations
Dolphin
forceps
w/spoon

Standard
Grasping
Forceps

Wave
Grasper

Mixter
Forceps

Maxi
(Fundus)
Grasper

Claw
Forceps

NURSING RESPONSIBILITIES

PRE-OPERATIVE CARE
Patients can have significant co-morbidity associated with
gallstones, for example obesity or hypercholesterolaemia. They
might have experienced complications associated with gallstone
surgery, such as acute cholecystitis, cholangitis or pancreatitis.
These co-morbidities can have significant influence on the
conduct and risks of anaesthesia and should be discussed
before surgery.
Blood "thinning" medication, including aspirin, must be
discontinued several days before the operation to avoid
excessive bleeding during the procedure

 Because gallbladder surgery is performed under general

anesthesia, the stomach must be completely empty. This
precaution is taken to avoid vomiting during and after surgery.
Nothing may be taken by mouth after midnight, and smoking is
prohibited.
Preoperative tests are usually ordered and completed a few
days before the surgery. Depending on the patient's health,
these may include blood tests, a chest x-ray, an EKG, and a
urinalysis.
On admission to the hospital, 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.

POST-OPERATIVE CARE
Take short walks 2-3 times a day 1 week postop. This will help
reduce the risk of blood clots following surgery. You may use the
stairs as needed as long as you are not dizzy or weak.
Do not drive until you have been seen for your first postoperative clinic office visit.
Practice 10 deep breaths every hour and 2 coughs every hour,
(for at least 12 hours a day), while awake for the first week after
surgery to reduce the risk of lung problems or pneumonia.

 Do not lift heavy objects (more than 8 pounds) for the first 4
weeks. Also avoid pushing, pulling or abdominal pressure for
these first 4 weeks. When coughing, be sure to place a pillow
over the incision and gently press inward to reduce the pressure
(from coughing) on your incision.
Use your pain medicine as prescribed.
You may shower the day after surgery and allow clean, soapy
water to run over your incision but do not expose your incisions
to soaking in water

 You may return to normal food after you go home from your
surgery. You may wish to avoid fatty or heavy foods for the first
few days,
You should follow up in the clinic 1 week after your surgery and
3 months after your surgery. You may be seen sooner if
indicated the surgical team.

Contact your healthcare provider if:

You have a fever over 101F (38C) or chills.
You have pain or nausea that is not relieved by medicine.
You have redness and swelling around your incisions, or blood
or pus is leaking from your incisions.

 You are constipated or have diarrhea.

Your skin or eyes are yellow, or your
pale.

bowel movements are

You cannot stop vomiting.

Your bowel movements are black or bloody.
You have pain in your abdomen and it is swollen or hard.
You cough up blood.