OPERATIVE REVIEW

on

LAPAROSCOPIC CHOLECYSTECTOMY

Submitted by:

Jess Garry Adante

LAPAROSCOPIC

CHOLECYSTECTOMY
 TABLE OF CONTENTS

Introduction…………………………………………………1

Anatomy and Physiology………………………………….2

Pathophysiology……………………………………………3

Surgical Discussion………………………………………..

Instrumentation…………………………………………….

Nursing Responsibility…………………………………….

 Pre-operative


 Intra-operative


 Post-operative


References………………………………………………..
 INTRODUCTION

Laparoscopic Cholecystectomy has dramatically changed the approach to the

management of cholecystisis. It has become the new standard for therapy of

symptomatic gallstones. Approximately 700,000 patients in theUnited States require

surgery each year for removal of the gallbladder, and 80% to 90% of them are

candidates for laparoscopic cholecystectomy (Bornman and beckingham, 2001). If the

common bile duct is thought to be obstructed by a gallstone, an ECRP with

sphincterotomy may be performed to explore the duct before laparoscopy.

The advantage of the laparoscopic procedure is that the patient does not

experience the paralytic ileus that occurs with open abdominal surgery and has less

postoperative abdominal pain. The patient is often discharged from the hospital on the

day of surgery within a day or two and ca resume full activity and employment within a

week of the surgery.

The laparoscopic approach may prove difficult or impossible if the patient is

obese or if there are excessive adhesions (related to a previous surgery, recurrent

attacks of cholecystisis, and so on), ductal or vascular anomalies exist, unexpected

pathology is encountered, acute inflammation distorts normal tissue planes, or there is

excessive bleeding or surgical injury. In any of those instances, the procedure must be

promptly converted to open laparotomy.

 ANATOMY AND PHYSIOLOGY
ANATOMY

The gallbladder, a pear-shaped, hollow, saclike organ, 7.5 to 10 cm (3 to 4 in) long, lies

in a shallow depression on the inferior surface of the liver, to which it is attached by

loose connective tissue. The capacity of the gallbladder is 30 to 50 ml of bile. Its wall is

composed largely of smooth muscle. The gallbladder is connected to the common bile

duct by the cystic duct.

PHYSIOLOGY

The gallbladder functions as a storage depot for bile. Between meals, when sphincter of

Oddi is closed, bile produced by the hepatocytes enters the gallbladder. During storage,

a large portion of the water in the bile is absorbed through the walls of the gallbladder,

so that gallbladder bile is five to ten times more concentrated than that originally

secreted by the liver. When food enters duodenum, the gallbladder contracts and the

sphincter of Oddi (located at the junction where the common bile duct enters

duodenum) relaxes. Relaxation of the sphincter of Oddi allows the bile to enter the

intestine. This response is mediated by the secretion of the hormone cholecystokinin-

pancreozymin (CCK-PZ) from the intestinal walls. Bile is composed of water and

electrolytes (sodium, potassium, calcium, chloride, and bicarbonate) and significant

amounts of lecithin, fatty acids, cholesterol, bilirubin, and bile salts. The bile salts,

together with cholesterol, assist in emulsification of fats in the distal ileum. Then they

are reabsorbed into the portal blood for return to the liver and again excreted into the

bile. This pathway from hepatocytes to bile to intestine and back to the hepatocytes is
called the enterohepatic circulation. Because of the enterohepatic circulation, only a

small fraction of the bile salts that enter the intestine are excreted in the feces. This

decreases the need for active synthesis of bile salts by the liver cells.

If the flow of bile is impeded (ie, with gallstones in the bile ducts), bilirubin, a

pigment derived from the breakdown of red blood cells, does not enter the intestine. As

result, bilirubin levels in the blood increase. This results, in turn, in increased renal

excretion of urobilinogen, which results from conversion of bilirubin in the small

intestine, and decreased excretion in the stool. These changes produce many of the

signs and symptoms seen in gallbladder disorders.

 PATHOPHYSIOLOGY

Bile is primarily composed of water plus conjugated bilrubin, organic and

inorganic ions, small amounts of proteins, and three lipids: bile salts, lecithin, and

cholesterol. When the balance of these three lipids remains intact, cholesterol is held in

solution. If the balance is upset cholesterol can begin to precipitate. Cholesterol

gallstone formation is enhanced by the production of a mucin glycoprotein, which traps

cholesterol particles. Twenty percent of biliary cholesterol comes from new synthesis,

but the association with serum cholesterol levels remains unclear. Excess secretion is

associated with aging, obesity, and the effects of certain drugs and hormones.

Supersaturation of the bile with the cholesterol also impairs gallbladder motility and

contributes to stasis. The gallbladder has the ability to absorb excess water and

concentrate bile, which further complicates the picture of supersaturation and stasis.

Cholesterol stones are soft, yellowish, green, and radiolucent. They range in

size from 1mm to 2.5cm. The stones most commonly occur in multiples but solitary. The

process of stone formation is slow. Stones are theorized to grow steadily for 2 to 3

years and then stabilize in size. Eighty-five percent are less than 2cm in diameter. Most

are found in the gallbladder, but 15% to 60% of persons older than age 60 who undergo

surgery for gallstones are also found to have stones in the common bile duct.

Black stones result from an increase in conjugated bilirubin and calcium with a

corresponding decrease in bile salts. Impaired gallbladder motility may also be a factor.

Black stones are very small, hard and usually numerous. Brown stones develop in the

intrahepatic and extrahepatic ducts and are usually preceded by bacterial infection.
 Although most persons with gallstones are asymptomatic, cholecystisis can

develop at any time, usually from the stone obstructing the cystic duct or from edema

and spasm initiated by the presence or passage of the stone. In acute cholecystisis the

gallbladder is enlarged, tense, and inflamed. A secondary bacterial infection can occur

within several days and cause most of the serious consequences of the disease.

Biliary colic is the classic clinical manifestation of symptomatic gallstones in 70%

to 80% of persons. It is caused by spasm of the gallbladder or transient obstruction but

is not associated with inflammation of the mucosa. Biliary colic causes sudden-onset

sharp pain that occur anywhere in the upper abdomen or epigastrium. The pain steadily

increases in intensity, may last for minutes or up to 6 hours, and may localize to the

right upper quadrant (RUQ) or radiate to the back. It may awaken the patient at night or

occur after heavy meal. Vomiting and diaphoresis may also occur.

Acute cholecystisis begins with stone-related obstruction in more than 90% of

cases but then progresses to mucosal inflammation and damage. The patient

experiences acute pain that localizes in the RUQ, often accompanied by chills and

fever. About 75% of patients experience vomiting. Palpation of the abdomen causes a

severe increase in pain and temporary inspiratory arrest (Murphy’s sign). The episode

of cholecystisis usually subsides within 1 to 4 days. Symptoms are typically milder and

more subtle in older adults, who may develop bacteremia before they seek help.

Stones are found in the common bile duct in approximately 15% of patients.

When gallstones pass into the common bile duct, they may obstruct the flow of bile and

cause jaundice and pruritus. Cholangitis is a serious potential complication resulting in

pain, fever, chills, and rigors from bacteremia. The development of acute pancreatitis if

the stone obstructs the sphincter of Oddi is also a concern.

Diagnosis of gallstones is fairly straightforward when the classic symptoms are

milder and mimic other common GI conditions. Patients with irritable bowel syndrome or

peptic ulcer disease may also have gallstones, and the exact cause of the patient’s

symptoms needs to be determined so that the correct xlinical problem can be treated.

Cholecystisis may become chronic after several acute attacks. Chronic

cholecystisis is usually the result of stone injury to the gallbladder wall that causes

scaring, thickening, and possibly ulceration. Bacterial infection may also be present.

Patients with chronic disease often do not seek help until jaundice or other

complications develop.
 SURGICAL DISCUSSION
Operating Room Design

Laparoscopic cholecystectomy is performed in a fully equipped operating room

under sterile conditions using general anesthesia. Instruments for conversion to a open

technique should be readily available. The surgeon operates from the left side of the

table. He or she uses both hands. The first assistant stands o the patient’s left side and

is responsible for retraction of the gallbladder with instruments passed through the

subcostal cannula. Finally, the camera operator stands below the surgeon. Video

monitor on each side of he operating table make it easy for all involved to view the

operation and provide the best help.

Patient Position

The patient is placed on the operating table in the spine position. A nasogastric

tube is placed to decompress the stomach, and a urinary catheter is used to

decompress the bladder. Compression stocking and or sequential compression devices

should be placed on lower extremities for deep venous thrombosis prophylaxis. This is

especially important because the patient will be in the Trendelenburg position, which

produces venous stasis and pooling. The entire abdomen is prepped and draped for a

formal laparotomy. Special care should be taken in cleaning the umbilicus as it is the

most common site for wound infection following laparoscopic surgery.

Establishing Pneumoperitoneum

Standard method involves the use of Veress needle. Make a 10 to 12 mm skn

incision in the infraumbilical skin fold, either vertically or in a curvilinear path. Tent the

periumbilical abdominal wall upwards with the left hand and with the assistant’s help.
Towel clips placed on either side of the umbilicus can also be us to provide traction on

the abdominal wall. Then pass the needle slowly through the incision and down to the

linea alba. Hold the needle in the right hand between the thumb and index finger by its

hub so as not to restrict its opening-loaded mechanism. Direct the needle towards the

pelvis and with pressure exerted from the wrist advance it through the fascia into the

abdominal cavity. The surgeon will feel it as “pop”. Once position of the needle within

the abdominal cavity is confirmed, the abdomen is filed with gas (usually 3-4 L of CO2).

Pneumoperitoneum will be evident by distention and loss of dullness over the liver on

percussion.

Insertion of Trocars

After the pneumoperitoneum has been established, cannulas are placed. Veress

needle is removed and replaced by a 10 mm trocar and cannula. Hold the trocar and

cannula unit in the right hand and advance it slowly with a twisting motion. Pressure

should be exerted from the wrist, to prevent sudden uncontrolled penetration of the

abdominal wall. Place the video laparoscope through the umbilical cannnula and

explore the abdomen. Three additional cannulas are then placed. These are placed

under visual control using the video laparoscope to observe placement from within. A 10

mm cannula is placed in an upper midline site, on quarter the distance between the

xiphoid and umbilicus. Correct placement of the subxiphoid, or working port is

important. Dissection is most easily accomplished when the laparoscope and working

port are oriented at close to 90 degree angle.

Next, place a 5 mm cannula at least two fingerbreaths below the costal margin

in the midclavicular line. Then place the second 5 mm cannula at least two
fingerbreaths below the costal margin in the anterior axillary’s line. Place the trocars

through small skin incision just large enough to allow passage of the cannulas.

Cholecystectomy

After exploration, operation can begin. The patient is now placed in a 20 to 30

degree reverse. Trendelenburg position and rotated slightly to the left. These

maneuvers shift the stomach, omentum, intestines, and colon out of the right upper

quadrant and help expose the neck of the gallbladder and cystic ducts.

The first assistant grasps the fundus of the gallbladder with an atraumatic clamp

placed through the lateral most 5 mm cannula and lifts the gallbladder up and pushes it

towards the diaphragm. A second grasper is then placed through the midclavicular

cannula. The instrument is used to grasp the neck of the gallbladder retracting it

laterally exposing the cystic ducts. With this to graspers, the gallbladder is retracted up

and away from the hepatoduodenal ligament thus exposing the critical anatomy.

Using an angled dissector passed through the subxiphoid cannula, the surgeon

begins blunt dissection in the triangle of Calot. Dissection should be taking place in the

vicinity of the cystic duct-gallbladder junction. Ligate proximal duct with two clips and

divide it with scissors, leaving two clips on the proximal duct. Dissect the gallbladder

from the underlying liver bed using electrocautery or laser dissection. Dissection begins

at the neck of the gallbladder and proceeds superiorly along the liver. The gallbladder is

then removed from the live and it is ready for extraction. Using Kelly clamps in grasping

and securing the gallbladder. Make a small incision in the neck of the gallbladder,

aspirate the bile, and remove stone individually.

 After the gallbladder is removed, pneumoperitoneum is released through the

cannulas, which are then withdrawn. The fascial opening at the umbilicus is closed with

three non absorbable interrupted stitches and the skin incisions are closed with

subcuticular sutures or skin tapes.

 INSTRUMENTATION
Major tray (open)

Biliary tract tray (available)

Choledoscopy tray (available)

Laparoscopy Cholecystectomy tray (endoscopic instruments)

Verres needle

Hasson trocar (available)

Trocars (2) 10 or 11-mm (radiolucent cannula sheaths preferred)

Trocars (2) 5mm

Reducer caps

Dissector clamps (2)

Grasping clamps (4) (2 traumatic, locking), (2 autromatic)

Cholangiography clamp (with nipple for guide wire), several types available

Maryland clamp (almost right angle)

Right-angle hook (L-shaped)

J-hook tip suction electrosurgical dissectors

Spatula tip

Babcock clamp, 10mm (autromatic)

Babcock clamp, 5mm

Allis clamp

Scissors (3) (hook, straight, micro)

Metzenbaum double-action shears

Clip applier

Laparoscopes (2) (0º, and 30º or 40º) and camera

Extrudable retractors (2) (fan, curved)

Stone basket or 3-prong grasper

Stone-crushing forceps

Suction, irrigation, electrosurgical devices

 NURSING RESPONSIBILITY
Preoperative Care

The laparoscopic procedure is commonly done on an ambulatory care basis in a

same-day surgery suite. The surgeon explains the procedure; the nurse answers

question s and reinforce the physician’s instructions. There is no special preoperative

preparation for the client. However, the physician typically orders the usual preoperative

laboratory tests and requires the client to be on NPO status before surgery.

Intraoperative Care

Postoperative Care

Removing the gallbladder with the laparoscopic technique reduces risk of wound

complications. Some clients have a problem with “free air pain” from carbon dioxide

retention in the abdomen. Teach about importance of early ambulation to promote

absorption of the carbon dioxide. Far less opioid analgesia is necessary after the

procedure.

The client is usually discharge fro the hospital or surgery center within 1 day.

Following laparoscopic surgery, the client can return to usual activities and including

work. Most clients are able to resume usual activities within 1 – 3 weeks.