Cholecystectomy

 Definition
 Indications
 Clinical Manifestation
 Diagnostic Finding (Laboratory Procedure)
 Pathophysiology
 Pharmacologic Therapy
 Nursing Management

DEFINITION:

Definition

A cholecystectomy is the surgical removal of the gallbladder. The two basic types of this
procedure are open cholecystectomy and the laparoscopic approach. It is estimated that the
laparoscopic procedure is currently used for approximately 80% of cases.

definition

Cholecystectomy (ko-lay-sis-TEK-tuh-me) is a surgical procedure to remove your gallbladder —

a pear-shaped organ that sits just below your liver on the upper right side of your abdomen. Your
gallbladder collects and stores bile — a digestive fluid produced in your liver.

Cholecystectomy may be necessary if you experience pain from gallstones that block the flow of
bile. Cholecystectomy is a common surgery, and it carries only a small risk of complications. In
most cases, you can go home the same day of your cholecystectomy.

Cholecystectomy is most commonly performed using a tiny video camera to see inside your
abdomen and special surgical tools to remove the gallbladder. Doctors call this laparoscopic
cholecystectomy.

Why is it Done?

Cholecystectomy is used to treat gallstones and the complications they cause. Your doctor may
recommend cholecystectomy if you have:

 Gallstones in the gallbladder (cholelithiasis)

 Gallstones in the bile duct (choledocholithiasis)
 Gallbladder inflammation (cholecystitis)
 Pancreas inflammation (pancreatitis)

Risks

Cholecystectomy carries a small risk of complications including:

  Bile leak
 Bleeding
 Blood clots
 Death
 Heart problems
 Infection
 Injury to nearby structures, such as the bile duct, liver and small intestine
 Pancreatitis
 Pneumonia

Your risk of complications depends on your overall health and the reason for your
cholecystectomy. Emergency cholecystectomy carries a higher risk of complications than does a
planned cholecystectomy.

How do you prepare

To prepare for cholecystectomy, your surgeon may ask you to:

 Drink a solution to clean out your intestines. In the days before your procedure you
may be given a prescription solution that flushes stool out of your intestines.
 Eat nothing the night before your surgery. You may drink a sip of water with your
medications, but avoid eating and drinking at least four hours before your surgery.
 Stop taking certain medications and supplements. Tell your doctor about all the
medications and supplements you take. Continue taking most medications as prescribed.
Your doctor may ask you to stop taking certain medications and supplements because
they may increase your risk of bleeding.
 Shower using a special soap. Your doctor may give you a special antibacterial soap to
use before your surgery.

Prepare for your recovery

Plan ahead for your recovery after surgery. For instance:

 Plan for a hospital stay. Most people go home the same day of their cholecystectomy,
but complications can occur that require one or more nights in the hospital. If the surgeon
needs to make a long incision in your abdomen to remove your gallbladder, you may
need to stay in the hospital longer. It's not always possible to know ahead of time what
procedure will be used. Plan ahead in case you need to stay in the hospital by bringing
personal items, such as your toothbrush, comfortable clothing and books or magazines to
pass the time.
 Find someone to drive you home and stay with you. Ask a friend or family member to
drive you home and stay close the first night after surgery.

What can you expect

During your cholecystectomy
Cholecystectomy is performed using general anesthesia, so you won't be aware during the
procedure. Anesthesia drugs are given through a vein in your arm. Once the drugs take affect,
your health care team will insert a tube down your throat to help you breathe. Your surgeon then
performs the cholecystectomy using either a laparoscopic or open procedure.

Minimally invasive (laparoscopic) cholecystectomy

During laparoscopic cholecystectomy, the surgeon makes four small incisions in your abdomen.
A tube with a tiny video camera is inserted into your abdomen through one of the incisions. Your
surgeon watches the picture on a monitor in the operating room as special surgical tools are
inserted through the other incisions in your abdomen and your gallbladder is removed.

Next you'll undergo cholangiography, a special X-ray to check your bile duct for abnormalities.
If your surgeon finds gallstones or other problems in your bile duct, those may be remedied.
Then your incisions are sutured, and you're taken to a recovery area. Laparoscopic
cholecystectomy takes one or two hours.

Laparoscopic cholecystectomy isn't appropriate for everyone. In some cases your surgeon may
begin with a laparoscopic approach and find it necessary to make a larger incision because of
scar tissue from previous operations or complications.

Traditional (open) cholecystectomy

During open cholecystectomy your surgeon makes a 6-inch (about 15 cm) incision in your
abdomen below your ribs on your right side. The muscle and tissue are pulled back to reveal
your liver and gallbladder. Your surgeon then removes the gallbladder. The incision is sutured,
and you're taken to a recovery area. Open cholecystectomy takes one or two hours.

After cholecystectomy
You'll be taken to a recovery area as the anesthesia drugs wear off. Then you'll be taken to a
hospital room to continue recovery. Recovery varies depending on your procedure:

 Laparoscopic cholecystectomy. People are often allowed to go home the same day as
their surgery, though sometimes a one-night stay in the hospital is needed. In general, you
can expect to go home once you're able to eat and drink without pain and are able to walk
unaided. It takes about a week to fully recover.
 Open cholecystectomy. Expect to spend two or three days in the hospital recovering.
Once at home, it may take four to six weeks to fully recover.

Results

Cholecystectomy can relieve the pain and discomfort of gallstones. Conservative treatments,
such as dietary modifications, usually can't stop gallstones from recurring. Cholecystectomy is
the only way to prevent gallstones.
Some people experience mild diarrhea after cholecystectomy, though this usually goes away
with time. Most people won't experience digestive problems after cholecystectomy. Your
gallbladder isn't essential to healthy digestion.

How quickly you can return to normal activities after cholecystectomy depends on which
procedure your surgeon uses and your overall health. People undergoing laparoscopic
cholecystectomy may be able to go back to work in a matter of days. Those undergoing open
cholecystectomy may need a week or more to recover enough to return to work.

PURPOSE

Purpose

A cholecystectomy is performed to treat cholelithiasis and cholecystitis. In cholelithiasis,

gallstones of varying shapes and sizes form from the solid components of bile. The presence of
these stones, often referred to as gallbladder disease, may produce symptoms of excruciating
right upper abdominal pain radiating to the right shoulder. The gallbladder may become the site
of acute infection and inflammation, resulting in symptoms of upper right abdominal pain,
nausea, and vomiting. This condition is referred to as cholecystitis. The surgical removal of the
gallbladder can provide relief of these symptoms. Cholecystectomy is used to treat both acute
and chronic cholecystitis when there are significant pain symptoms. The typical composition of
gallstones is predominately cholesterol, or a compound called calcium bilirubinate.

Cholelithiasis

Most patients with cholelithiasis have no significant physical symptoms. Approximately 80% of
gallstones do not cause significant discomfort. Patients who develop biliary colic generally do
have some symptoms. When gallstones obstruct the cystic duct, intermittent, extreme, cramping
pain typically develops in the right upper quadrant of the abdomen. This pain generally occurs at
night and can last from a few minutes to several hours. An acute attack of cholecystitis is often
associated with the consumption of a large, high-fat meal.

The medical management of gallstones depends to a great degree on the presentation of the
patient. Patients with no symptoms generally do not require any medical treatment. The best
treatment for patients with symptoms is usually surgery. Laparoscopic cholecystectomy is
typically preferred over the open surgical approach because of the decreased recovery period.
Patients who are not good candidates for either type of surgery can obtain some symptom relief
with drugs, especially oral bile salts.
Cholecystitis

Cholecystitis is an inflammation of the gallbladder, both acute and chronic, that results after the
development of gallstones in some individuals. The most common symptoms and physical
findings associated with cholecystitis include:

 pain and tenderness in the upper right quadrant of the abdomen

 nausea
 vomiting

 fever
 jaundice
 history of pain after eating large, high-fat meals

DEMOGRAPHICS:

Demographics

Overall, cholelithasis is found in about 20,000,000 Americans. An overwhelming majority of

these individuals do not ever develop symptoms. Overall, about 500,000 to 600,000 (2–3%) are
treated with cholecystectomies every year. Typically, the incidence of cholelithasis increases
with age. The greatest incidence occurs in individuals between the ages of 40 and 60 years. The
following groups are at an increased risk for developing choleliathiasis:

 pregnant women
 female sex
 family history of gallstones
 obesity
 certain types of intestinal disease
 age greater than 40 years
 oral contraceptive use
 diabetes mellitus
 estrogen replacement therapy
 rapid weight loss

Overall, patients with cholelathiasis have about a 20% chance of developing biliary colic (the
extremely painful complication that usually requires surgery) over a 20-year period.

Acute cholecystitis develops most commonly in women between the ages of 40 and 60 years.
Some ethnic groups such as Native Americans have a dramatically higher incidence of
cholecystitis.
INDICATIONS:
Cholecystectomy is indicated in the presence of gallbladder trauma, gallbladder cancer, acute cholecystitis, and other
complications of gallstones. More controversial are the indications for elective cholecystectomy. To properly
determine the indications for elective cholecystectomy, the risk of the operation (taking into account the age and
comorbid factors of the individual patient) must be weighed against the risk of complications and death without
operation (taking into account the symptomatic status of the individual and the functional status of the gallbladder).
Cholecystectomy (or some other form of gallstone therapy) is indicated in most patients with symptomatic
cholelithiasis--especially those with non-functioning gallbladders. Cholecystectomy is not indicated in most patients
with asymptomatic stones.

Agreed indication and contra indications:

Indications as to which patients should undergo cholecystectomy remain, at least in part, a matter of
controversy. In 1987, a panel of nine Israeli physicians from different specialties established a list of
indications for the performance of cholecystectomy based on the literature available at the time. The
panel agreed that cholecystectomy was appropriate for 59 indications and that it was inappropriate
for 58. The major indications for surgery were biliary colic and acute cholecystitis. Patients who were
asymptomatic or had vague symptoms were not recommended to undergo surgery unless they had
stones in the common bile duct and were less than 71 years of age. Patients with pancreatitis were
recommended for surgery if they had stones in the common bile duct and did not have a history of
alcohol abuse. Performing a cholecystectomy at the same time as abdominal surgery was being
performed for other reasons was indicated only if the patient was symptomatic from his gall-stones.

CLINICAL MANIFESTATION:

Laparoscopic cholecystectomy has become the preferred treatment for patients with symptomatic
gallstones. During this procedure, perforation of the gallbladder with spillage of stones into the peritoneal
cavity is not uncommon. Finding and removing all of the spilled gallstones can be laborious and is often
avoided. Left in the peritoneal cavity, however, the stones may lead to intraperitoneal abscess formation,
which may require a second procedure. We report here on a patient with an intraperitoneal abscess
located between the right liver lobe and the anterior abdominal wall, which contained a large gallstone (4
cm3), found 3 months after an undetected stone spillage during laparoscopic cholecystectomy. Healing
was achieved after conventional laparotomy, removal of the gallstone, and surgical drainage of the
abscess cavity. The review of the literature emphasizes the clinical manifestations of this rare
laparoscopic complication.

Diagnostic Finding:

Diagnosis/Preparation

The initial diagnosis of acute cholecystitis is based on the following symptoms:

  constant, dull upper right quadrant abdominal pain
 fever
 chills
 nausea
 vomiting
 pain aggravated by moving or coughing

Most patients have elevated leukocyte (white blood cells) levels. Leukocyte levels are
determined using laboratory analysis of blood samples. Traditional x rays are not particularly
useful in diagnosing cholecystitis. Ultrasonography of the gallbladder usually provides evidence
of gallstones, if they are present. Ultrasonography can also help identify inflammation of the
gallbladder. Nuclear imaging may also be used. This type of imaging cannot identify gallstones,
but it can provide evidence of obstruction of the cystic and common bile ducts.

Cholelithiasis is initially diagnosed based on the following signs and symptoms:

 history of biliary colic or jaundice

 nausea
 vomiting
 sudden onset of extreme pain in the upper right quadrant of the abdomen
 fever
 chills

Laboratory blood analysis often finds evidence of elevated bilirubin, alkaline phosphatase, or
aminotransferase levels. Ultrasonography, computed tomography (CT) scanning, and
radionuclide imaging are able to detect the impaired functioning of bile flow and of the bile
ducts.

As with any surgical procedure, the patient will be required to sign a consent form after the
procedure is explained thoroughly. Food and fluids will be prohibited after midnight before the
procedure. Enemas may be ordered to clean out the bowel. If nausea or vomiting are 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).

PROCEDURE:

Cholecystectomy is performed in the operating room under general anesthesia. Laparoscopic

cholecystectomy, the most commonly performed method of gallbladder removal, has been modified by
more recent surgical innovations that involve the use of voice-controlled, robotic arm-like extensions
manipulated by the surgeon (robotic or telerobotic laparoscopy). Single-port access surgery is another
laparoscopic procedure that requires only one incision at the naval; it is performed more frequently in
recent years. In all laparoscopic cholecystectomies, a small incision is made near the navel (umbilicus)
and a thin, flexible laparoscope with a tiny camera attached is inserted, allowing the surgeon to view the
gallbladder and surrounding organs. Carbon dioxide is used to inflate the abdominal cavity for better
viewing (insufflation), unless the individual is elderly or has an underlying condition that might lead to
complications from the gas. Except for single-port access surgery, several smaller laparoscopic incisions
are made on the abdomen to allow for insertion of surgical instruments. The artery to the gallbladder and
the cystic duct (tubular canal carrying bile from the gallbladder) are tied off and cut. The gallbladder is
freed from its surrounding tissue and removed. The incisions are closed with sutures.

Open cholecystectomy is major surgery that is performed in 5% of cases (NDDIC). Most often, open
cholecystectomy is performed because of complications such as perforation, infection, or adhesions from
previous surgery, and sometimes after such complications are encountered during laparoscopy. Patients
with suspect cancer, very large stones, end stage liver disease, or bleeding disorders may also require
open cholecystectomy. First, a 5- to 8-inch right or midline incision is made in the abdomen, and the
abdominal cavity is opened to expose the gallbladder. The artery to the gallbladder and the cystic duct
leading from it are tied off and cut, and the gallbladder is removed. Before the abdomen is closed, drains
may be placed under the liver and in the bile duct. The drains, which are kept in place from 4 to 10 days,
are removed after x-ray studies show there are no more stones.

In percutaneous cholecystostomy, used in individuals with fragile health, high frequency sound waves and
a computer (ultrasound) are used to guide a puncture for access and insertion of a catheter that drains
the gallbladder. When the individual's health stabilizes, a laparoscopic or open surgical procedure may
later be used to remove the gallbladder.

Recovery from a laparoscopic cholecystectomy typically is rapid. The individual usually leaves the
hospital the next day. Soreness is minimal, and return to work is often within 1 to 2 weeks. Open
cholecystectomies usually necessitate a longer hospital stay, often up to 7 days. Once the pain has
diminished and the individual is tolerating a regular diet, he or she is discharged to home. The individual
undergoing percutaneous cholecystostomy likely has other health issues that may delay discharge from
the hospital and/or recovery.

Aftercare

Postoperative care for the patient who has had an open cholecystectomy, as with those who
have had any major surgery, involves monitoring of blood pressure, pulse, respiration, and
temperature. Breathing tends to be shallow because of the effect of anesthesia, and the patient's
reluctance to breathe deeply due to the pain caused by the proximity of the incision to the
muscles used for respiration. The patient is shown how to support the operative site when
breathing deeply and coughing and is given pain medication as necessary. Fluid intake and
output is measured, and the operative site is observed for color and amount of wound drainage.
Fluids are given intravenously for 24–48 hours, until the patient's diet is gradually advanced as
bowel activity resumes. The patient is generally encouraged to walk eight hours after surgery and
discharged from the hospital within three to five days, with return to work approximately four to
six weeks after the procedure.

Care received immediately after laparoscopic cholecystectomy is similar to that of any patient
undergoing surgery with general anesthesia. A unique postoperative pain may be experienced in
the right shoulder related to pressure from carbon dioxide used in the laparoscopic tubes. This
pain may be relieved by lying down on the left side with right knee and thigh drawn up to the
chest. Walking will also help increase the body's reabsorption of the gas. The patient is usually
discharged the day after surgery and allowed to shower on the second postoperative day. The
patient is advised to gradually resume normal activities over a three-day period, while avoiding
heavy lifting for about 10 days.

Normal Results

Normal results

The prognosis for cholecystitis and cholelithaisis patients who receive cholecystectomy is
generally good. Overall, cholecystectomy relieves symptoms in about 95% of cases