① Cholecystectomy Case Study

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Cholecystectomy Case Study



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If the patient tolerates liquids, the IV is removed, and the patient is offered a regular diet. Analgesics are administered orally as prescribed as soon as the patient can take liquids. Once the patient is comfortable, he is helped to walk because early ambulation speeds recovery. The patient is usually fully awake and walking within 3 or 4 hr of arrival on the unit. If he experiences shoulder pain, a heating pad may be applied.

The surgeon, however, usually removes the carbon dioxide at the end of the procedure to prevent this problem. The nurse evaluates the patient's readiness for discharge, which usually can occur if the patient is afebrile, walking, eating, and voiding, and has stable vital signs with no evidence of bleeding or bile leakage. To assess for the latter risks, the patient is observed for severe pain and tenderness in the right upper quadrant, an increase in abdominal girth, leakage of bile-colored drainage from the puncture site, a fall in blood pressure, and increased heart rate.

The patient is instructed to keep the adhesive bandages covering the puncture site clean and dry. He may remove them the next day and bathe or shower as usual. The patient most likely will require little analgesia, but a prescription is given for use as needed. He is reminded to pace activity according to energy level. While no special diet is required, the patient may wish to avoid excessive fat intake and gas-forming foods for 4 to 6 weeks. He should return to the surgeon for follow-up evaluation as directed and report any vomiting, abdominal distention, signs of infection, and new or worsening pain.

What is a cholecystectomy and how is it done? My Doctor diagnosed me with gallstones and said I have to have a cholecystectomy surgery. What is this and how is it done? Cholecystectomy is a surgery in which the gallbladder is removed. Don't be alarmed since you can live without your gallbladder. When the gallbladder is gone, bile flows directly from the liver into the small intestine. You will probably have a laparoscopic cholecystectomy, which means a surgeon will make a small slit in your abdomen, then insert a tubelike instrument which has a camera and surgical instruments attached. This is used to take out the gallbladder with the stones inside it. This procedure causes less pain than open surgery, is less likely to cause complications, and has a faster recovery time.

This surgery is performed in an operating room and you will be under general anesthesia. It usually takes 20 minutes to one hour. Related to cholecystectomy: laparoscopic cholecystectomy , gallbladder. Cholecystectomy Definition A cholecystectomy is the surgical removal of the gallbladder. The two basic types of this procedure are open cholecystectomy and the laparoscopic approach.

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 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.

Although the laparoscopic procedure requires general anesthesia for about the same length of time as the open procedure, laparoscopy generally produces less postoperative pain, and a shorter recovery period. The laparoscopic procedure would not be preferred in cases where the gallbladder is so inflamed that it could rupture, or when adhesions additional fibrous bands of tissue are present. The laparoscopic cholecystectomy involves the insertion of a long narrow cylindrical tube with a camera on the end, through an approximately 1 cm incision in the abdomen, which allows visualization of the internal organs and projection of this image onto a video monitor.

Three smaller incisions allow for insertion of other instruments to perform the surgical procedure. A laser may be used for the incision and cautery burning unwanted tissue to stop bleeding , in which case the procedure may be called laser laparoscopic cholecystectomy. In a conventional or open cholecystectomy, the gallbladder is removed through a surgical incision high in the right abdomen, just beneath the ribs. A drain may be inserted to prevent accumulation of fluid at the surgical site.

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.

Post-operative 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 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 hours, until the patient's diet is gradually advanced as bowel activity resumes. You can live a healthy life without a gallbladder; bile that would normally be stored there will simply travel straight to the small intestine. What happens during your surgery depends on the approach the surgeon uses. Regardless of the approach used, the procedure should take about one to two hours. In the recovery area, a nurse will monitor your vital signs e. If you underwent a laparoscopic or robotic-assisted cholecystectomy, you may stay in the hospital for one or two nights or be discharged from the recovery room after around six hours. If you underwent open surgery, you will be taken to a hospital room where you will stay for approximately two to four days.

Once discharged from the recovery room or hospital, you will have various post-operative instructions to follow at home. Full recovery from open gallbladder surgery takes about six weeks; recovery from a laparoscopic surgery takes about four weeks. When recovering from gallbladder surgery, be sure to contact your healthcare provider if you experience any of the following symptoms:.

To ensure that you are healing and recovering well after surgery and to monitor for complications, it's important to attend all follow-up appointments with your surgeon. These appointments are usually scheduled at two weeks and then four or six weeks after surgery. While the goal of gallbladder surgery is to alleviate symptoms of gallstones in most cases , a small subset of patients continues to have symptoms after surgery, including nausea, vomiting, bloating, jaundice, diarrhea, or abdominal pain. This phenomenon is termed post-cholecystectomy syndrome PCS , and it may occur early hours to days or later weeks to months after the gallbladder is removed. Since there are multiple potential etiologies that may cause this syndrome, your surgeon may need to perform imaging of your abdomen as well as blood tests at your follow-up appointments.

While gallbladder surgery is a common operation, it nevertheless poses risks. If you or a loved one are undergoing this surgery, be sure to adhere to your post-operative instructions, and reach out to your surgical team with any questions or concerns. Sign up for our Health Tip of the Day newsletter, and receive daily tips that will help you live your healthiest life. Laparoscopic cholecystectomy under spinal anesthesia: a study of patients. Acute calculous cholecystitis: Review of current best practices. World J Gastrointest Surg. Techniques of laparoscopic cholecystectomy: Nomenclature and selection. J Minim Access Surg. Johns Hopkins Medicine.

Robotic-assisted versus laparoscopic cholecystectomy for benign gallbladder diseases: a systematic review and meta-analysis. Surg Endosc. Soper NJ, Malladi P. Laparoscopic cholecystectomy. Ashley SW, ed. The papillary region looks abruptly narrowed, with a concave appearance of the distal border of the suprasphincteric part of the common bile duct arrow. The rate of bile duct injuries is slightly higher using laparoscopic surgery than open surgery 0. In general, a laparoscopic approach allows less complete traction of the gallbladder and cystic duct than open surgery. The main causes of ductal injury are erroneous cutting of bile ducts, inadvertently placed clips or ligatures, periductal bile leakage resulting in fibrosis and thermal injury owing to electrocautery [ 3 ].

Common sites of biliary leaks include injured ducts, the cystic duct stump and the gallbladder stump. Bile duct injury manifests as a leak, stricture or transection [ 9 ]. Strictures and transection appear as a focal narrowing or abrupt interruption of the bile duct, respectively, with or without biliary dilatation upstream Figure 5. The distinction between biliary stricture and transection is often impossible. Nevertheless, a complete lack of visualisation on source and projection images is highly suspicious for duct disruption [ 9 ]. Injuries derived from laparoscopic cholecystectomy are usually more extensive than those following an open surgical approach; they may involve major intrahepatic bile ducts and are more frequent in patients with anatomic variants [ 3 , 10 ].

A year-old male patient who underwent laparoscopic cholecystectomy 5 years previously. Because of several episodes of cholangitis since the time of surgery caused by a known clip inadvertently positioned at the common bile duct just below the hepatic confluence, the patient underwent repeated balloon dilatation procedures. Nevertheless, biloma is often indistinguishable from post-operative collections or haemorrhage, unless direct cholangiography is performed to demonstrate contrast leak [ 3 ]. A year-old male patient presenting with abdominal pain, fever and altered liver function tests in the post-operative period after laparoscopic cholecystectomy.

Thick coronal maximum intensity projection reconstruction from T 2 weighted thin source images shows a thin rim of hyperintense fluid signal contiguous with the cystic duct stump arrow. Free fluid is present in the perihepatic space, especially in the subhepatic site arrowheads. Moreover, a focal stricture of the common bile duct is appreciable just below the insertion of the cystic duct remnant, suggesting a co-existing injury curved arrow. Strictures occur in up to 0. If not involving previously injured anatomical variants, strictures usually occur because the CBD is injured during clamping or ligation of the cystic duct close to its insertion [ 10 ].

Strictures are the most common late complication of biliary surgery, developing a few months to years after cholecystectomy. On MRCP, they appear as a narrowing of the luminal signal and are usually short with smooth regular margins Figure 7. The typical locations of strictures are in the CBD, near the insertion of the cystic duct, or at the hepatic confluence [ 10 ]. Defining the site and extent of a stricture according to the Bismuth classification shown in Figure 8 is of crucial importance, particularly when bilio-digestive reconstruction is planned. MRCP tends to overestimate the length and the extent of the stricture, especially when the duct immediately distal to the stricture is collapsed but not strictured. This can lead to misinterpretation of the position of the distal end of the stenosis [ 4 ].

The use of the multislice technique, with a careful analysis of source images, helps to reduce the risk of overestimating the stricture length [ 4 ]. A year-old male patient with a history of recurrent lithiasis and cholangitis after open cholecystectomy. Several previous endoscopic cholangiopancreatograms had been performed. Coronal maximum intensity projection reconstruction from a volumetric turbo spin-echo heavily T 2 weighted sequence shows multiple moderate-to-severe strictures of variable length along the course of the common bile duct arrows and intrahepatic bile ducts arrowheads. No calculi were visible at the time of examination. Strictures were a consequence of either previous common bile duct operative injury or scarring from repeated calculi migration and cholangitis.

Bismuth classification of bile duct strictures after duct injury, according to their location and relationship to the hepatic duct bifurcation [ 9 ]. Papillary stenosis has been described as an organic variant of SOD related to a fibrotic narrowing of the sphincter in response to inflammatory processes from pancreatitis or gallstone migration through the papilla [ 11 ].

The causes of abdominal pain in these patients are thought to be impeded flow, resulting in ductal hypertension, distension and inflammation. The role of MRCP in diagnosing SOD is still undefined, as correlation with endoscopic retrograde cholangiopancreatography or biliary manometry has been poorly investigated, and differentiation between stenotic or spasmotic papilla is difficult. State-of-the-art MRCP techniques may serve as a first-line non-invasive tool with which to demonstrate biliary abnormalities in patients with possible SOD [ 11 ].

On MRCP, narrowing of the papilla ranges from a mild, progressive and smoothly marginated stricture to a lack of visualisation of the sphincteric segment Figure 9 , with no clear cause of extrinsic compression. A dynamic evaluation with repeated single thick slices is mandatory to verify whether stenosis is temporary and due to physiological contraction. According to Van Hoe et al [ 8 , 12 ], a spasmodic sphincter shows no morphological variations and appears either as a prolonged lack of visualisation of the sphincter Figure 10 or as a thin rim of signal entrapped in a asymmetrically narrowed sphincter Figure An year-old female patient presenting with a history of recurrent biliary-like intense pain after previous open cholecystectomy for calculi.

There is associated biliary tract dilation upstream. No masses were found at extended contrast-enhanced MRI of the upper abdomen. This appearance, probably representing scarring from calculi migration, was confirmed at follow-up; sphincterotomy and stent placement provided symptom relief.

Cholecystectomy Case Study technique was first described in by Cholecystectomy Case Study et al. Pelvic Pain Research Paper 2 Main extrabiliary causes of Cholecystectomy Case Study syndrome modified Cholecystectomy Case Study [ 1 Cholecystectomy Case Study. Peptide a chain of amino acids.