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Cholecystectomy
1.
2.
A cholecystectomy is the surgical removal
of the gallbladder, an organ located just
under the liver on the upper right quadrant
of the abdomen. The gallbladder stores and
concentrates bile, a substance produced by
the liver and used to break down fat for
digestion.
3.
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)
4.
Several conditions may lead to surgery to
remove the gallbladder. Conditions that may
require open rather than laparoscopic surgery
include:
Severe inflammation of the bile duct or
gallbladder.
Inflammation of the abdominal lining
(peritonitis).
High pressure in blood vessels in the liver (portal
hypertension). This is caused by cirrhosis of the
liver.
Being in the third trimester of pregnancy.
A major bleeding disorder or use of medicines to
6. Open
Cholecystectomy
In this
method, a two- to
three-inch
incision is made
in the upper
right-hand side of
the abdomen.
The surgeon
locates the
gallbladder and
removes it
through the
incision.
7. Laparoscopic
Cholecystectomy
This
procedure uses at least
three to four small
incisions and three or
more laparoscopes—
small thin tubes with
video cameras
attached—to visualize
the inside of the
abdomen during the
operation. The surgeon
performs the surgery
while looking at a TV
monitor. The
gallbladder is removed
through one of the
incisions.
9.
Most open cholecystectomies are performed
under general anesthesia. Less common
alternatives include regional (epidural or
spinal) and, rarely, local anesthesia.
10. Equipment for open cholecystectomy includes
instruments common to a major instrument tray. This
includes the following:
Kelly clamps, Kocker forceps, needle
holders, scissors, clips, suctions, knife/knife
handles, forceps, retractors, right angle clamps, Kitner
dissectors, and electrosurgical devices should be
assembled.
Balfour retractors, Bookwalter retractors, or other selfretaining retractors can be used, based on the surgeon's
preference.
Sutures or clips can be used to control the cystic duct and
artery, based on the surgeon's preference and the size of
structures (see Technique section below). Long instruments
may be needed, depending on the body habitus of the
11. Patients
are positioned
supine with arms
extended. Placing
a folded blanket
or bump
underneath the
patient's right
back or inverting
the table may be
beneficial.
12.
In general, open cholecystectomy can be
performed using 2 different methods: the
retrograde and anterograde techniques.
13. Retrograde
The more traditional
retrograde ("top
down") technique
starts with dissection at
the gallbladder fundus
and proceeds toward
the portal triad and
triangle of Calot. This
strategy facilitates sure
identification of the
cystic duct and
artery, as they remain
the only 2 attachments
to the gallbladder.
Video 1
14. Anterograde
With increased experience
and expertise in the
laparoscopic
technique, surgeons often
feel more comfortable
with the anterograde
technique. In this
technique, dissection
begins at the triangle of
Calot with dissection and
ligation of the cystic
artery and duct. This is
followed by dissection of
the gallbladder from the
liver bed, starting usually
from the infundibulum
up. Dissection from the
fundus down can also be
used.
Video 2
15.
Place the patient under general
anesthesia, supine, with arms extended.
Place a Foley catheter and sequential
compression devices before the operation
begins, and, if indicated, administer preoperative
anticoagulation. If indicated, administer
preoperative antibiotics within 60 minutes of skin
incision.
The surgeon stands on the patient's left with the
assistant opposite. The operating room and table
should be oriented so that cholangiography can
16.
A right subcostal (Kocher) incision is the most often used incision and
allows excellent exposure of the gallbladder bed and cystic duct.
Alternatively, an upper midline incision can be used when other
concomitant operations are planned and a wider exposure is needed.
Typically, the midline incision remains above the umbilicus, still
allowing for adequate exposure of the gallbladder with appropriate
retraction. A right paramedian incision is another option but is not
often used in current times.
Start the subcostal incision approximately 1 cm to the left of the linea
alba, about 2 fingerbreadths below the costal margin (approximately 4
cm). Extend the incision laterally for 10-15 cm, depending on the
patient's body habitus.
Incise the anterior rectus sheath along the length of the incision, and
divide the rectus and lateral muscle (external oblique, internal
oblique, and transversus abdominis) using electrocautery. Then, incise
the posterior rectus sheath and peritoneum and enter the abdomen.
17.
To the extent possible, perform a thorough
manual and visual inspection to evaluate for
concomitant pathology or anatomical
abnormalities. Place a retracting device
(eg, Balfour retractor, Bookwalter
retractor, wound protractor retractor) as
needed for adequate exposure. The videos on
the next slide show anatomy and exposure for
open cholecystectomy.
20. Video 5
Palpate and inspect
the liver and admit air
into the subphrenic
space to inferiorly
displace the liver and
better expose the
inferior surface. If
additional downward
displacement is
needed, laparotomy
pads can be placed
above and lateral to
the liver to aid
exposure (see video
on the right). Retract
the duodenum
21.
Palpate the gallbladder for stones or
masses. The porta hepatis can be
assessed by inserting the left index finger
into the foramen of Winslow and using
the thumb to palpate anteriorly on the
porta hepatis/common bile duct for
stones or tumors.
22.
Grasp the dome of the gallbladder with a Kelly
clamp and elevate it superiorly. Adhesions to the
undersurface of the gallbladder from the
transverse colon or duodenum are typically
encountered; these can be lysed with sharp
dissection or judicious use of electrocautery.
Dissection of the gallbladder can be performed in
2 ways. Traditionally, dissection in open
cholecystectomy is performed using a "top down"
or retrograde technique, in which the fundus is
mobilized toward the porta hepatitis. This
technique differs from the anterograde
technique, in which the dissection begins at the
23.
In the retrograde approach, incise the visceral
peritoneum overlying of the gallbladder fundus
approximately 1 cm from its attachment to the liver.
Grasp the fundus of the gallbladder using a Kelly
clamp. Using a right angle clamp or suction
device, develop the plane on both the lateral and
medial side of the gallbladder and carry the incision
along the gallbladder parallel to the liver. This
dissection ensures complete mobilization of the
gallbladder from the liver bed before dissecting
within the triangle of Calot. See videos on the next
26. Retrograde
approach
The dissection plane is
typically
avascular, with only
small cholecystic
veins that need to be
divided.
Occasionally, more
prominent veins may
be encountered
requiring
ligation, especially in
the presence of portal
hypertension or
gallbladder distention.
If significant bleeding
occurs, the dissection
Video 8
27. In the anterograde approach, attention is initially directed to
the porta hepatis. Grasp the fundus of the gallbladder and
elevate it superiorly while the neck of the gallbladder is
mobilized away from the liver laterally to expose the
triangle of Calot. Dissect the cystic artery and cystic duct
with careful attention to the potential for anatomical
variations.
Once the cystic duct and cystic artery are completely
dissected and identified entering directly into the
gallbladder (the so-called critical view popularized by
Strasberg ), the structures can be divided if cholangiography
is not being performed. Before division of the cystic
duct, "milk" the duct from proximal to distal to deliver
stones that reside in the cystic duct into the gallbladder
lumen. Following divisions of the cystic artery and
duct, dissect the gallbladder away from the liver bed as
described in the retrograde technique.
28.
When the cystic duct and artery are correctly
identified and completely dissected, they are
ligated. Various techniques for ligation have
been described, including using
suture, staplers, and clips. See videos on the
next slide.
31.
Nonabsorbable sutures are acceptable for use on the
cystic duct stump; however, they are not recommended
for biliary-enteric anastomosis or choledochotomy
suture lines, as they can be lithogenic and incite a
chronic inflammatory reaction. Absorbable
sutures, such as polyglactin 910
(Vicryl, Ethicon, Sommerville, NJ) or polydioxanone
(PDS, Ethicon) are traditionally used for ligation of the
cystic duct. Metallic (titanium) clips or locking (Weck)
clips can also be used.
If the cystic duct is large and inflamed, mechanical
staplers may be used, as well. The cystic artery can be
ligated with ties (absorbable or nonabsorbable), suture
32.
33. May be related to
Pain
Muscular impairment
Decreased energy/fatigue
Possibly evidenced by
Tachypnea; respiratory depth changes, reduced
vital capacity
Holding breath; reluctance to cough
Desired Outcomes
Establish effective breathing pattern.
Experience no signs of respiratory
compromise/complications.
34. Observe respiratory rate/depth.
Rationale: Shallow breathing, splinting with respirations, holding breath may result in
hypoventilation/atelectasis.
Auscultate breath sounds.
Rationale: Areas of decreased/absent breath sounds suggest atelectasis, whereas adventitious sounds
(wheezes, rhonchi) reflect congestion.
Assist patient to turn, cough, and deep breathe periodically.
Rationale: Promotes ventilation of all lung segments and mobilization and expectoration of
secretions.
Show patient how to splint incision. Instruct in effective breathing techniques.
Rationale: Facilitates lung expansion. Splinting provides incisional support/decreases muscle tension
to promote cooperation with therapeutic regimen.
Elevate head of bed, maintain low-Fowler’s position.
Rationale: Maximizes expansion of lungs to prevent/resolve atelectasis.
Support abdomen when coughing, ambulating.
Rationale: Facilitates more effective coughing, deep breathing, and activity.
35. May be related to
Chemical substance (bile), stasis of secretions
Altered nutritional state (obesity)/metabolic state
Invasion of body structure (T-tube)
Possibly evidenced by
Disruption of skin/subcutaneous tissues
Desired Outcomes
Achieve timely wound healing without
complications.
Demonstrate behaviors to promote
healing/prevent skin breakdown.
36. Observe the color and character of the drainage.
Rationale: Initially, drainage may contain blood and bloodstained
fluid,normally changing to greenish brown (bile color) after the first
several hours.
Change dressings as often as necessary. Clean the skin with soap and
water. Use sterile petroleum jelly gauze, zinc oxide, or karaya powder
around the incision.
Rationale: Keeps the skin around the incision clean and provides a barrier to
protect skin from excoriation.
Apply Montgomery straps.
Rationale: Facilitates frequent dressing changes and minimizes skin trauma.
Use a disposable ostomy bag over a stab wound drain.
Rationale: Ostomy appliance may be used to collect heavy drainage for more
accurate measurement of output and protection of the skin.
Place patient in low- or semi-Fowler’s position.
Rationale: Facilitates drainage of bile.
37. Monitor puncture sites (3–5) if endoscopic procedure is done.
Rationale: These areas may bleed, or staples and Steri-Strips may loosen at puncture
wound sites.
Check the T-tube and incisional drains; make sure they are free flowing.
Rationale: T-tube may remain in common bile duct for 7–10 days to remove retained
stones. Incision site drains are used to remove any accumulated fluid and bile.
Correct positioning prevents backup of the bile in the operative area.
Maintain T-tube in closed collection system.
Rationale: Prevents skin irritation and facilitates measurement of output. Reduces risk
of contamination.
Anchor drainage tube, allowing sufficient tubing to permit free turning and avoid
kinks and twists.
Rationale: Avoids dislodging tube and/or occlusion of the lumen.
Observe for hiccups, abdominal distension, or signs of peritonitis, pancreatitis.
38. Observe skin, sclerae, urine for change in color.
Rationale: Developing jaundice may indicate obstruction of bile flow.
Note color and consistency of stools.
Rationale: Clay-colored stools result when bile is not present in the
intestines.
Investigate reports of increased/unrelenting RUQ pain;
development of fever, tachycardia; leakage of bile drainage around
tube/from wound.
Rationale: Signs suggestive of abscess or fistula formation, requiring
medical intervention.
Administer antibiotics as indicated.
Rationale: Necessary for treatment of abscess/infection.
Clamp the T-tube per schedule.
Rationale: Tests the patency of the common bile duct before tube is
39. Risk factors may include
Losses from NG aspiration, vomiting
Medically restricted intake
Altered coagulation, e.g., reduced
prothrombin, prolonged coagulation time
Possibly evidenced by
[Not applicable; presence of signs and symptoms
establishes an actual diagnosis.]
Desired Outcomes
Display adequate fluid balance as evidenced by
stable vital signs, moist mucous
membranes, good skin turgor/capillary refill, and
individually appropriate urinary output.
40. Monitor I&O, including drainage from NG tube, T-tube, and wound.
Weigh patient periodically.
Rationale: Provides information about replacement needs and organ function.
Initially, 200–500 mL of bile drainage may be expected via the Ttube, decreasing as more bile enters the intestine. Continuing large
amounts of bile drainage may be an indication of unresolved obstruction
or, occasionally, a biliary fistula.
Monitor vital signs. Assess mucous membranes, skin turgor, peripheral
pulses, and capillary refill.
Rationale: Indicators of adequacy of circulating volume/perfusion.
Observe for signs of
bleeding, e.g., hematemesis, melena, petechiae, ecchymosis.
Rationale: Prothrombin is reduced and coagulation time prolonged when bile
flow is obstructed, increasing risk of bleeding/hemorrhage.
Use small-gauge needles for injections, and apply firm pressure for longer
than usual after venipuncture.
Rationale: Reduces trauma, risk of bleeding/hematoma.
41. Have patient use cotton/sponge swabs and mouthwash
instead of a toothbrush.
Rationale: Avoids trauma and bleeding of the gums.
Monitor laboratory
studies, e.g., Hb/Hct, electrolytes, prothrombin
level/clotting time.
Rationale: Provides information about circulating
volume, electrolyte balance, and adequacy of clotting
factors.
Administer IV fluids, blood products, as
indicated;Electrolytes; Vitamin K.
Rationale: Maintains adequate circulating volume and aids in
replacement of clotting factors.Corrects imbalances
resulting from excessive gastric/wound losses.Provides
42. Visser BC, Parks RW, Garden OJ. Open
cholecystectomy in the laparoendoscopic era. Am J
Surg. Jan 2008;195(1):108-14.
McAneny D. Open cholecystectomy. Surg Clin North
Am. Dec 2008;88(6):1273-94, ix.
Fong Y, Jarnagin W, Blumgart LH. Gallbladder cancer:
comparison of patients presenting initially for
definitive operation with those presenting after prior
noncurative intervention. Ann Surg. Oct
2000;232(4):557-69.
de Goede B, Klitsie PJ, Hagen SM, van Kempen
BJ, Spronk S, Metselaar HJ, et al. Meta-analysis of
laparoscopic versus open cholecystectomy for patients
with liver cirrhosis and symptomatic
cholecystolithiasis. Br J Surg. Jan 2013;100(2):209
