|
|
BONUS
CONTENT FROM NURSING MADE INCREDIBLY EASY!
Cholecystectomy:
Take a look at two options
By Bernadette R. Thomas, RN, CNOR, BSN
About 700,000 cholecystectomies are performed
each year for patients diagnosed with gallbladder disease, making
it one of the most routine surgeries performed. The minimally
invasive laparoscopic cholecystectomy is the standard of care
for most patients needing cholecystectomy. Open surgery is an
option for patients who can’t have laparoscopic surgery.
In this article, I’ll review
gallbladder pathophysiology and your role in caring for a patient
who needs a cholecystectomy. For details on gallbladder anatomy,
see the image to the right.
Gallbladder dysfunction
Typically, cholecystitis is caused by gallstones and is called
calculous cholecystitis. Acalculous cholecystitis, or gallbladder
inflammation without gallstones, can occur in critically ill patients.
In this article, I’ll focus on calculous cholecystitis.
Gallstones are caused by changes
in the composition of bile, especially bile salts, phospholipids,
bilirubin, and cholesterol. When these solids are supersaturated
in the gallbladder, gallstones may form. The gallbladder secretes
mucus and proteins that promote cholesterol crystal formation,
which is the precursor for stone formation in supersaturated bile.
Impaired gallbladder motility, biliary stasis, and changes in
bile content can lead to stone formation. For details, see Not
the rolling stones.
The risk of gallstones increases with advancing
age, and women face a higher risk than men. Other risk factors
include white race, obesity, sedentary lifestyle, alcoholism,
pregnancy, rapid weight loss, oral contraceptive use, high-fat
diet, diseases of the ileum, terminal ileum resection, parenteral
nutrition, dyslipidemia, use of cholesterol-lowering drugs, cirrhosis,
hereditary spherocytosis, and hemolytic anemia.
Diagnosing gallbladder trouble
Signs and symptoms of cholecystitis include steady pain in the
right upper abdominal quadrant or epigastrium that may radiate
to the right scapular region or back, epigastric or right upper
abdominal quadrant tenderness, abdominal guarding, nausea, vomiting,
and fever. Abdominal pain is similar to biliary colic but is prolonged
and lasts hours or days. (Biliary colic usually resolves gradually
over 2 to 6 hours.) In about half the patients with acute cholecystitis,
pain may occur about an hour after eating a high-fat meal; other
patients may awaken from sleep with sudden pain. Another sign
of cholecystitis is a positive Murphy sign: an inspiratory pause
on right upper abdominal palpation.
To evaluate a patient for possible
cholecystitis, obtain specimens for lab tests, including a complete
blood cell (CBC) count, liver function tests, serum amylase and
lipase levels, and pregnancy test. In a patient with cholecystitis,
the CBC count typically shows elevated white blood cell count
related to inflammation; aspartate aminotransferase, alanine aminotransferase,
and alkaline phosphate levels may also be elevated in common bile
duct obstructions.
The healthcare provider will order
imaging studies, such as an ultrasound of the right upper quadrant
(the standard imaging test). This can reveal gallstones, gallbladder
wall hickening, and pericholecystic fluid.
In cases where an ultrasound won’t
yield clear images (for example, if the patient is obese), the
healthcare provider may order a hydroxyiminodiacetic acid (HIDA)
scan. This study can help confirm cholecystitis by demonstrating
abnormal gallbladder function.
A pear-shaped storage tank
A distensible, pear-shaped sac located on the underside of the
right side of the liver, the gallbladder concentrates and stores
bile, which aids in fat emulsification and helps the body absorb
lipid-soluble vitamins. When food enters the stomach, the duodenum
releases cholecystokinin, the hormone that causes the gallbladder
to contract and the sphincter of Oddi to relax, letting bile stored
in the gallbladder flow into the duodenum.
Treatment options
Most patients who need gallbladder removal are candidates for
laparoscopic cholecystectomy. Relative contraindications to laparoscopic
cholecystectomy are previous upper abdominal surgery and some
preexisting medical conditions. Laparoscopic and open cholecystectomy
are performed with the patient under general anesthesia. Absolute
contraindications to both surgical procedures are an inability
to tolerate general anesthesia and uncorrected coagulopathy.
Laparoscopic cholecystectomy has
many benefits for patients, including a shorter hospital stay,
less pain and scarring, less trauma to tissues, a shorter healing
and recovery time, and a quick return to normal activities (usually
within 3 to 5 days). Instead of making a 5- to 7-inch-long (12.5-
to 17.5-cm-long) abdominal incision, the surgeon makes just four
small stab wounds (see One big or four small?).
He inserts trocars at all incision sites to provide ports of entry.
This minimally invasive surgery requires a special arrangement
of equipment to provide maximum visualization. The surgeon insufflates
carbon dioxide into the abdominal cavity through the Verres needle
to establish pneumoperitoneum. Pneumoperitoneum facilitates visualization
of abdominal structures and instrument manipulation.
The surgeon identifies the cystic duct and artery
and looks for stones in the biliary tree with the laparoscopic
instruments. After dividing the cystic duct and artery, he dissects
the gallbladder away from the liver using a laparoscopic instrument
connected to cautery for hemostasis. After freeing the gallbladder,
he removes it through the umbilical incision. He then checks the
liver bed for bleeding and the abdomen for bile and stones. The
peritoneal cavity is decompressed of carbon dioxide and all incisions
are closed. The gallbladder and its contents are sent to pathology
for analysis.
At any time during a laparoscopic procedure, the
surgeon may convert to an open procedure if complications arise
that threaten patient safety. Possible problems requiring open
surgery include adhesions that impair the surgeon's ability to
visualize abdominal structures, an injury to the bile duct or
associated organs, gallbladder edema, and bleeding.
Open gallbladder surgery is much like the laparoscopic
version. The surgeon examines the biliary tree and cystic duct
and handles them in the same surgical manner. But in the open
procedure, the surgeon can use his hands to palpate for stones
and can directly examine the gallbladder before removal.
Because a patient who needs open surgery may have
major medical issues, the fragile tissues of the inflamed gallbladder
put him at greater risk for bleeding or bile spillage. (Bile spillage
also can occur during the laparoscopic procedure because of gallbladder
inflammation or perforation with a laparoscopic instrument.) If
bile is spilled, the surgeon irrigates the abdomen with 0.9% sodium
chloride solution to prevent peritonitis. He also may place a
drain in the subhepatic space.
After separating the gallbladder from the liver
bed and sending it to pathology, the surgeon closes the muscle
layers of the incision with durable sutures that will withstand
abdominal pressure. He may approximate the skin incision line
with sutures or staples, depending on his preference.
Before the procedure
In general, preoperative care is the same regardless of surgery
type. The patient’s preoperative medical evaluation may
include blood work, a chest X-ray, and an electrocardiogram. She
should follow her healthcare provider’s directions about
taking certain medications, such as heart medications and insulin,
before surgery. She should be N.P.O. for at least 4 hours before
surgery but can usually take medication with a sip of water.
Prepare a patient undergoing laparoscopic surgery
for postoperative shoulder and neck pain secondary to phrenic
nerve irritation from the carbon dioxide used to insufflate the
peritoneum. This minor discomfort may last a few days, but may
be relieved by changing position.
For patients having an open cholecystectomy, review
the importance of incentive spirometry, deep breathing, and coughing
after surgery to reduce the risk of atelectasis and pneumonia.
Also review the importance of early and aggressive ambulation
to help reduce the risk of venous thromboembolism (VTE).
On the day of surgery, verify patient identification
and review the patient’s medical history and physical, surgical
history (including a personal or family history of anesthesia
problems), lab results, limitations for positioning the patient
on the OR table, and allergies. Perform medication reconciliation,
confirm her N.P.O. status, confirm evidence of the informed consent
process, and discuss postoperative care and pain management, including
how to use a patient-controlled analgesia (PCA) pump, if applicable.
Prophylactic antibiotics will be administered within 1 hour prior
to the surgical incision and a nasogastric tube will be inserted
for gastric decompression once the patient is under general anesthesia.
After the procedure
Most patients who’ve had laparoscopic cholecystectomy are
discharged after 4 to 8 hours of observation. She should be hemodynamically
stable, alert and oriented, tolerating oral fluids, and she should
have voided. Her pain and nausea should be controlled; her surgical
dressings, clean, dry and intact. A patient who’s had open
surgery will remain in the hospital for 2 to 3 days.
Postoperative care for patients is the same for
both types of surgery. Regularly assess your patient’s level
of consciousness and vital signs and monitor her closely for signs
and symptoms of bleeding. Use a valid and reliable pain intensity
rating scale to assess her pain and provide optimal pain management.
If she has a PCA pump, review how to use it.
Check dressings for drainage and incision sites
for signs of infection. Persistent pain unrelieved by analgesics,
persistent fever over 101° F (38° C), chills, abdominal
distension, anorexia, persistent nausea and vomiting, and jaundice
may indicate bile duct injury and should be reported immediately
to the surgeon.
Place a patient who’s had an open cholecystectomy
in low Fowler’s position. When she’s alert, encourage
her to use the incentive spirometer. Show her how to splint her
incision when necessary.
After laparoscopic surgery, position the patient
in a left side-lying Sims position to move retained pockets of
carbon dioxide away from the diaphragm and decrease discomfort.
Encourage early and aggressive ambulation after
surgery to help prevent VTE. Evaluate the patient’s hemoglobin
and hematocrit levels and notify the healthcare provider if they’re
abnormal. Follow the American College of Chest Physicians evidence-based
clinical practice guidelines for VTE prophylaxis, depending on
level of thromboembolism risk.
The patient should start with clear liquids and
gradually advance her diet as tolerated. She should eat a high-fiber
diet and drink plenty of fluids unless contraindicated. If she
has cramping in the right upper abdominal quadrant, advise her
to reduce her fat intake.
Explain that feces will pass through the colon
faster after cholecystectomy. She may need a bile acid binder
(such as cholestyramine or colestipol) if she develops chronic
diarrhea.
Before discharge, teach your patient to call her
healthcare provider if she has excessive or abnormal bleeding,
a fever greater than 101° F, jaundice, abdominal distension
or pain, persistent cough, or shortness of breath. Teach her about
her prescribed pain medications and how to monitor wound healing.
Also teach her to monitor her bowel habits, especially if she’s
been prescribed a bile acid binder. Tell her that bile acid binders
can cause constipation and heartburn and can interact with other
drugs, including beta-blockers, thiazide diuretics, and warfarin.
She should take medications at least 1 hour before or 4 to 6 hours
after taking the bile acid binder and should call her healthcare
provider immediately if she has any noticeable physical changes.
Staying well
By understanding the types of cholecystectomy, you can help your
patient before, during, and after gallbladder removal.
Not
the rolling stones
Gallstones can be of three types:
- Yellow-green stones are
the most common type of gallstone; they’re formed
from cholesterol supersaturation in bile and are soft.
- Black stones, formed from
high concentrations of calcium bilirubinate, carbonate,
and phosphate, are small and brittle and usually caused
by hemolytic disorders such as hereditary spherocytosis
or sickle-cell disease.
- Brown stones are formed
from calcium bilirubinate and bacterial cell bodies. These
soft, mushy stones usually are secondary to a bacterial
infection that causes bile stasis.
|
One
big or four small?
When performing a laparoscopic cholecystectomy, the surgeon
makes four half-inch-long (1.25-cm-long) incisions as shown
below:
- one at the umbilicus for
placement of the Verres needle for insufflation of carbon
dioxide gas into the abdomen. This site is primarily used
for the camera and laparoscope. The laparoscope magnifies
the visual field and projects it onto video screens positioned
at the head of the OR table. (An emerging technique is
to perform single-port laparoscopic cholecystectomy through
an umbilical incision.)
- one at the midline epigastric
region for the dissecting laparoscopic instrument.
- two at the upper right
quadrant for gallbladder retraction—one at the midclavicular
line and one at the anterior axillary line.
For an open cholecystectomy,
the surgeon makes a single large incision (called a Kocher
incision) at the right subcostal space. This incision may
extend over to the xiphoid process to expose the gallbladder
better for the surgeon. |
References
Ahrendt S, Pitt H. Biliary tract. In Townsend C, et al. (eds),
Sabiston Textbook of Surgery: The Biological Basis of Modern
Surgical Practice, 17th edition. W.B. Saunders Co., 2004.
Hirsh J, Guyatt G, Albers GW, Harrington R, Schuenemann HJ. Antithrombotic
and thrombolytic therapy, 8th edition. ACCP guidelines. Chest,
2008;133(6 Suppl):1S-968S.
Kelley WE Jr. Single port laparoscopic surgery. http://www.laparoscopytoday.com/2008/09/single-port-lap.html.
Oddsdottir M, Hunter J. Gallbladder and the extrahepatic biliary
system. In Brunicardi F, et al. (eds), Schwartz's Principles
of Surgery, 8th edition. McGraw-Hill Co., Inc., 2005.
Petty R. Surgery of the liver, biliary tract, pancreas, and spleen.
In Rothrock J, et al. (eds), Alexander's Care of the Patient
in Surgery, 12th edition. Mosby, Inc., 2003.
Sands J. Gallbladder and exocrine pancreatic problems. In Phipps
W, et al. (eds), Medical-Surgical Nursing: Health and Illness
Perspectives, 7th edition. Mosby, Inc., 2003.
Source: Nursing2009. February
2009.
|