Cholecystectomy

What is a cholecystectomy and why is it necessary?

Cholecystectomy is the surgical removal of the gallbladder, which is located in the abdomen beneath the right
side of the liver. Gallbladder problems are usually the result of gallstones. These stones may block the flow of
bile from your gallbladder, causing the organ to swell. Other causes include cholecystitis (inflammation of the
gallbladder) and cholangitis (inflammation of the bile duct).

Details of the procedure

What do I need to do before surgery?

Please contact your insurance company to verify the coverage and determine whether a referral is required.
You will be asked to pre-register with the appropriate hospital and provide demographic and insurance
information. This must be completed at least five to ten days before the surgery date. Your surgeon will give
you specific instructions on how to prepare for the procedure.

What happens on the day of surgery?

You will report to a pre-operative nursing unit, where you will change into a hospital gown. A nurse will review
your chart and confirm that all the paperwork is in order. You will be taken to a pre-operative nursing unit
where the anesthesiologist will start an IV. Before any medications are administered, your surgeon will verify
your name and the type of procedure you are having. You will then be taken to the operating room. After the
appropriate form of anesthesia is administered, surgery will be performed.

What type of anesthesia will be used?

You will have a pre-operative interview with an anesthesiologist, who will ask you questions regarding your
medical history. Gallbladder removal is performed under general anesthesia, which will keep you asleep during
surgery.

What happens during surgery, and how is it performed?

If your surgery is performed laparoscopically, your surgeon will make three to four small incisions and insert
tube-like instruments through them. The abdomen will be filled with gas to help the surgeon view the
abdominal cavity. A camera will be inserted through one of the tubes to display images on a monitor located in
the operating room. Other instruments will be placed through the additional tubes. In this manner, your
surgeon will be able to work inside your abdomen without having to make a larger incision.

Your surgeon will perform the gall bladder removal with the laparoscopic method unless other factors require
open surgery. If the performed with the open method, a larger incision will be made in the abdomen.

Once inside, your surgeon will separate and remove the gall bladder.

What happens after the surgery?

Once the surgery is completed, you will be taken to a post-operative or recovery unit where a nurse will
monitor your recovery. It is important to keep your bandages clean and dry. Your physician may
prescribe medication for pain, nausea and vomiting which are not uncommon with this procedure. You will be
scheduled for a follow-up appointment within two weeks after your surgery.

How long will I be in the hospital?

Although some patients may stay overnight, most go home the same day.

What are the risks associated with gallbladder removal?

As with any surgery, there are risks such as bleeding, infection, or an adverse reaction to anesthesia. Other
risks include bile duct or bowel injury. Your surgeon will inform you of the risks prior to surgery.

What should I watch out for?

Be sure to call your doctor if any of the following symptoms appear:

Will there be scar(s)?

When can I expect to return to work and/or resume normal activities?

This varies among patients. There are no restrictions after laparoscopic gallbladder removal. You will be
encouraged to return to normal activities such as showering, driving, walking up stairs, light lifting, and work as
soon as you feel comfortable. Some patients can return to work in a few days, while others prefer to wait
longer. You should not engage in heavy lifting or straining for six to eight weeks after open surgery. If you are
taking narcotic medications for pain, you should not drive.

Cholecystectomy is performed most frequently through laparoscopic incisions using laser. However, traditional open
cholecystectomy is the treatment of choice for many patients with multiple/large gallstones either because of acute
symptomatology or to prevent recurrence of stones.

CARE SETTING

This procedure is usually done on a short-stay basis; however, in the presence of suspected complications, e.g.,
empyema, gangrene, or perforation, an inpatient stay on a surgical unit is indicated.

RELATED CONCERNS

Cholecystitis with cholelithiasis

Pancreatitis

Peritonitis

Psychosocial aspects of care

Surgical intervention

Patient Assessment Database/Diagnostic Studies

Refer to CP: Cholecystitis with Cholelithiasis.

TEACHING/LEARNING

Discharge plan

DRG projected mean length of inpatient stay: 1 (laparoscopic)–4.3 days

May require assistance with wound care/supplies, homemaker tasks

Refer to section at end of plan for postdischarge considerations.

NURSING PRIORITIES

1. Promote respiratory function.

2. Prevent complications.

3. Provide information about disease, procedure(s), prognosis, and treatment needs.

DISCHARGE GOALS

1. Ventilation/oxygenation adequate for individual needs.

2. Complications prevented/minimized.

3. Disease process, surgical procedure, prognosis, and therapeutic regimen understood.

4. Plan in place to meet needs after discharge.

A cholecystectomy is the surgical removal of the gallbladder, typically to relieve pain, treat severe infections and stop
recurring gall stones. A surgeon can do the procedure laparoscopically through small incisions in the abdomen or
through a larger incision under the rib cage. Open gallbladder surgeries require a two- to six-day hospital stay,
according to Medline Plus. Laparoscopic procedures may allow patients to go home the same day as the procedure. By
making nursing diagnoses before and after gallbladder removal, a nurse can develop a care plan for the patient.

Pre-Operative Teaching
1. Some patients find it easier to relax if they know what to expect during and after the surgery. For such a
person, a possible nursing diagnosis is "deficient knowledge related to surgical procedure as manifested by
patient stating he is concerned about recovery." Take the time to answer questions and provide information
about pain control after the procedure. If the patient is going home the same day as the surgery, educate
caretakers about possible post-operative risks.
Post-Operative Concerns
2. Every surgery carries risks such as excessive bleeding, infection at the site of the incision, blood clots due to
lack of leg movement and pneumonia related to anesthesia and lack of movement. Additional risks of a
 cholecystectomy include injury or blockage of the bile duct, bile leakage and kidney problems. The surgeon
may order tests to determine liver functioning and may request monitoring of the patient's urine output.
Risk Diagnoses
3. Possible priority diagnoses for risk factors include "risk for impaired liver functioning related to gallbladder
removal surgery." Be alert for signs of jaundice, including yellowing of the skin and eyes. Report any changes
to the doctor immediately. A "risk for infection" diagnosis would require monitoring of vital signs and
temperature as well as regular evaluation of the incisions. Patients who have difficulty breathing after
anesthesia may be diagnosed with "risk for aspiration." Assess the patient's gag reflex and ability to swallow,
and monitor lung sounds through a stethoscope.
Pain Management
4. Pain is very subjective, and nurses must rely solely on the patient's verbal and nonverbal cues to determine
the level of discomfort. The patient may state that she has pain, or she may grimace or wince when moving. A
possible diagnosis may be "acute pain related to gallbladder removal surgery as manifested by the patient
verbalizing pain." Interventions include instructing the patient to place a pillow against her abdomen when
coughing or moving, monitoring the effectiveness of pain medication and encouraging distractions such as
television or music.
Emotional Impact
5. Cholecystectomy can leave scarring, which means patients may suffer from or be at risk for situational low
self-esteem or disturbed body image. Open procedures may leave a more pronounced scar than a laparoscopic
procedure. Tell the patient what to expect in the scar healing process.The scar will heal during a period of four
to six weeks and will become less pronounced in the following year, according to the American College of
Surgeons.

Read more: Nursing Diagnosis for Cholecystectomy | eHow.com http://www.ehow.com/about_5513908_nursing-

Cholecystitis is inflammation of the gallbladder, usually resulting from a gallstone blocking the cystic duct.

• Gallbladder inflammation usually results from a gallstone blocking the flow of bile.
• Typically, people have abdominal pain that lasts more than 6 hours, fever, and nausea.
• Ultrasonography can usually detect signs of gallbladder inflammation.
• The gallbladder is removed, often using a laparoscope.
Cholecystitis is the most common problem resulting from gallbladder stones. It occurs when a stone blocks the cystic
duct, which carries bile from the gallbladder.

Cholecystitis is classified as acute or chronic.

Acute Cholecystitis: Acute cholecystitis begins suddenly, resulting in severe, steady pain in the upper abdomen. At
least 95% of people with acute cholecystitis have gallstones. The inflammation almost always begins without infection,
although infection may follow later. Inflammation may cause the gallbladder to fill with fluid and its walls to thicken.

Rarely, a form of acute cholecystitis without gallstones (acalculous cholecystitis) occurs. Acalculous cholecystitis is
more serious than other types of cholecystitis. It tends to occur after the following:

• Major surgery
• Critical illnesses such as serious injuries, major burns, and bodywide infections (sepsis)
• Intravenous feedings for a long time
• Fasting for a prolonged time
• A deficiency in the immune system
It can occur in young children, perhaps developing from a viral or another infection.

Chronic Cholecystitis: Chronic cholecystitis is gallbladder inflammation that has lasted a long time. It almost always
results from gallstones. It is characterized by repeated attacks of pain (biliary colic). In chronic cholecystitis, the
gallbladder is damaged by repeated attacks of acute inflammation, usually due to gallstones, and may become thick-
walled, scarred, and small. The gallbladder usually contains sludge (microscopic particles of materials similar to those
in gallstones), or gallstones that either block its opening into the cystic duct or reside in the cystic duct itself.

Symptoms
A gallbladder attack, whether in acute or chronic cholecystitis, begins as pain. The pain of cholecystitis is similar to
that caused by gallstones (biliary colic) but is more severe and lasts longer—more than 6 hours and often more than
12 hours. The pain peaks after 15 to 60 minutes and remains constant. It usually occurs in the upper right part of the
abdomen. The pain may become excruciating. Most people feel a sharp pain when a doctor presses on the upper right
part of the abdomen. Breathing deeply may worsen the pain. The pain often extends to the lower part of the right
shoulder blade or to the back. Nausea and vomiting are common.

Within a few hours, the abdominal muscles on the right side may become rigid. Fever occurs in about one third of
people with acute cholecystitis. The fever tends to rise gradually to above 100.4° F (38° C) and may be accompanied
by chills. Fever rarely occurs in people with chronic cholecystitis.
In older people, the first or only symptoms of cholecystitis may be rather general. For example, older people may lose
their appetite, feel tired or weak, or vomit. They may not develop a fever.

Typically, an attack subsides in 2 to 3 days and completely resolves in a week. If the acute episode persists, it may
signal a serious complication. A high fever, chills, a marked increase in the white blood cell count, and cessation of the
normal rhythmic contractions of the intestine (ileus—see Gastrointestinal Emergencies: Appendicitis) suggest pockets
of pus (abscesses) in the abdomen near the gallbladder from gangrene (which develops when tissue dies) or a
perforated gallbladder.

If people develop jaundice (see Manifestations of Liver Disease: Jaundice) or pass dark urine and light-colored stools,
the common bile duct is probably blocked by a stone, causing a backup of bile in the liver (cholestasis). Inflammation
of the pancreas (pancreatitis) can develop. It is caused by a stone blocking the ampulla of Vater, near the exit of the
pancreatic duct.

Acalculous cholecystitis typically causes sudden, excruciating pain in the upper abdomen in people with no previous
symptoms or other evidence of a gallbladder disorder. The inflammation is often very severe and can lead to gangrene
or rupture of the gallbladder. In people with other severe problems (including people in the intensive care unit for
another reason), acalculous cholecystitis may be overlooked at first. The only symptoms may be a swollen (distended),
tender abdomen or a fever with no known cause. If untreated, acalculous cholecystitis results in death for 65% of
people.

Diagnosis
Doctors diagnose cholecystitis based mainly on symptoms and results of imaging tests. Ultrasonography is the best
way to detect gallstones in the gallbladder. Ultrasonography can also detect fluid around the gallbladder or thickening
of its wall, which are typical of acute cholecystitis. Often, when the ultrasound probe is moved across the upper
abdomen above the gallbladder, people report tenderness.

Cholescintigraphy, another imaging test, is useful when acute cholecystitis is difficult to diagnose. For this test, a
radioactive substance (radionuclide) is injected intravenously. A gamma camera detects the radioactivity given off,
and a computer is used to produce an image. Thus, movement of the radionuclide from the liver through the biliary
tract can be followed. Images of the liver, bile ducts, gallbladder, and upper part of the small intestine are taken. If the
radionuclide does not fill the gallbladder, the cystic duct is probably blocked by a gallstone.

Liver blood tests are often normal unless the person has an obstructed bile duct. Other blood tests can detect some
complications such as a high level of a pancreatic enzyme (lipase or amylase) in pancreatitis. A high white blood cell
count suggests inflammation, an abscess, gangrene, or a perforated gallbladder.

Treatment
People with acute or chronic cholecystitis need to be hospitalized. They are not allowed to eat or drink and are given
fluids and electrolytes intravenously. A doctor may pass a tube through the nose and into the stomach, so that
suctioning can be used to keep the stomach empty and reduce fluid accumulating in the intestine if the intestine is not
contracting normally. Usually, antibiotics are given intravenously, and pain relievers are given.

If acute cholecystitis is confirmed and the risk of surgery is small, the gallbladder is usually removed within 24 to 48
hours after symptoms start. If necessary, surgery can be delayed for 6 weeks or more while the attack subsides. Delay
is often necessary for people with a disorder that makes surgery too risky (such as a heart, lung, or kidney disorder). If
a complication such as an abscess, gangrene, or perforated gallbladder is suspected, immediate surgery is necessary.

In chronic cholecystitis, the gallbladder is usually removed after the acute episode subsides.

In acalculous cholecystitis, immediate surgery is necessary to remove the diseased gallbladder.

Surgical removal of the gallbladder (cholecystectomy) is usually done using a flexible viewing tube called a
laparoscope. After small incisions are made in the abdomen, the laparoscope and other tubes are inserted, and
surgical tools are passed through the incisions and used to remove the gallbladder.

Pain After Surgery: A few people have new or recurring episodes of pain that feel like gallbladder attacks even
though the gallbladder (and the stones) have been removed. The cause is not known, but it may be malfunction of the
sphincter of Oddi, the muscles that control the release of bile and pancreatic secretions through the opening of the
bile and pancreatic ducts into the small intestine. Pain may occur because pressure in the ducts is increased by
sphincter spasms, which hinders the flow of bile and pancreatic secretions. Pain also may result from small gallstones
that remain in the ducts after the gallbladder is removed. More commonly, the cause is another problem, such as
irritable bowel syndrome or even peptic ulcer disease.

Endoscopic retrograde cholangiopancreatography (ERCP) may be necessary to determine if the cause of pain is
increased pressure. For this procedure, a flexible viewing tube (endoscope) is inserted through the mouth and into the
intestine, and a device to measure pressure is inserted through the tube. If pressure is increased, surgical instruments
are inserted into the tube and used to cut and thus widen the sphincter of Oddi. This procedure (called endoscopic
sphincterotomy) can relieve symptoms in people who have an abnormality of the sphincter.

Cholecystectomy

(Gallbladder Removal, Open Cholecystectomy, Laparoscopic Cholecystectomy)

Procedure Overview
What is a cholecystectomy?

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.

Types of cholecystectomies:

Click Image to Enlarge

The gallbladder may be removed in one of two ways:

• open method: 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.

• laparoscopic method: This procedure uses several 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.

A laparoscopic cholecystectomy is considered less invasive and generally requires a shorter recovery time than an
open cholecystectomy. Occasionally, the gallbladder may appear severely diseased upon laparoscopic examination or
other complications may be apparent, and the surgeon may have to perform an open surgical procedure to remove
the gallbladder safely.

Reasons for the Procedure

A cholecystectomy may be performed if the gallbladder contains gallstones (cholelithiasis), is inflamed or infected
(cholecystitis), or is cancerous.

Gallbladder inflammation or infection may cause pain which may be described as follows:

• is generally located on the right side of the upper abdomen

• may be constant or may become more severe after a heavy meal

• at times, may feel more like fullness than pain

• may be experienced in the back and in the tip of the right shoulder blade

Other symptoms of gallbladder inflammation or infection include, but are not limited to, nausea, vomiting, fever, and
chills.

The symptoms of gallbladder problems may resemble other medical conditions or problems. In addition, each
individual may experience symptoms differently. Always consult your physician for a diagnosis.

There may be other reasons for your physician to recommend a cholecystectomy.

Risks of the Procedure

As with any surgical procedure, complications may occur. Some possible complications of cholecystectomy may
include, but are not limited to, the following:

• bleeding

• infection

• injury to the bile duct - the tube that carries bile from the gallbladder to the small intestine

During laparoscopic cholecystectomy, insertion of the instruments into the abdomen may injure the intestines or blood
vessels.

If you are pregnant or suspect that you may be pregnant, you should notify your physician.
There may be other risks depending on your specific medical condition. Be sure to discuss any concerns with your
physician prior to the procedure.

Before the Procedure

• Your physician will explain the procedure to you and offer you the opportunity to ask any questions that you
might have about the procedure.

• You will be asked to sign a consent form that gives your permission to do the test. Read the form carefully and
ask questions if something is not clear.

• In addition to a complete medical history, your physician may perform a physical examination to ensure you
are in good health before undergoing the procedure. You may undergo blood or other diagnostic tests.

• You will be asked to fast for eight hours before the procedure, generally after midnight.

• If you are pregnant or suspect that you may be pregnant, you should notify your physician.

• Notify your physician if you are sensitive to or are allergic to any medications, latex, tape, and anesthetic
agents (local and general).

• Notify your physician of all medications (prescribed and over-the-counter) and herbal supplements that you
are taking.

• Notify your physician if you have a history of bleeding disorders or if you are taking any anticoagulant (blood-
thinning) medications, aspirin, or other medications that affect blood clotting. It may be necessary for you to
stop these medications prior to the procedure.

• If your procedure is to be done on an outpatient basis, you will need to have someone drive you home
afterwards because of the sedation given prior to and during the procedure.

• The area around the surgical site may be shaved.

• Based upon your medical condition, your physician may request other specific preparation.

During the Procedure

Click Image to Enlarge

A cholecystectomy may be performed on an outpatient basis or as part of your stay in a hospital. Procedures may vary
depending on your condition and your physician's practices.

A cholecystectomy is generally performed while you are asleep under general anesthesia.

Generally, a cholecystectomy follows this process:

1. You will be asked to remove any jewelry or other objects that may interfere with the procedure.

2. You will be asked to remove clothing and be given a gown to wear.

3. An intravenous (IV) line will be inserted in your arm or hand.

4. You will be positioned on the operating table on your back.

5. The anesthesiologist will continuously monitor your heart rate, blood pressure, breathing, and blood oxygen
level during the surgery.

6. The skin over the surgical site will be cleansed with an antiseptic solution.

open method cholecystectomy:

7. An incision (open method) will be made. The incision may slant under the ribs on the right side of the
abdomen, or it may be an up-and-down incision in the upper part of the abdomen.

8. The gallbladder is removed.

9. In some cases, one or more drains may be inserted through the incision to allow drainage of fluids or pus.
laparoscopic method cholecystectomy:

7. Three to four small incisions will be made in the abdomen. Carbon dioxide gas will be introduced into the
abdomen to inflate the abdominal cavity so that the gallbladder and surrounding organs can be more easily
visualized.

8. The laparoscope will be inserted through one of the incisions and instruments will be inserted through the
other incisions to remove the gallbladder.

9. When the procedure is completed, the laparoscope will be removed.

procedure completion, both methods:

10. The gallbladder will be sent to the lab for examination.

11. The skin incision(s) will be closed with stitches or surgical staples.

12. A sterile bandage/dressing or adhesive strips will be applied.

After the Procedure

In the hospital:

After the procedure, you will be taken to the recovery room for observation. Your recovery process will vary depending
upon the type of procedure performed and the type of anesthesia that is given. Once your blood pressure, pulse, and
breathing are stable and you are alert, you will be taken to your hospital room. As a laparoscopic cholecystectomy
procedure may be performed on an outpatient basis, you may be discharged home from the recovery room.

You may receive pain medication as needed, either by a nurse or by administering it yourself through a device
connected to your intravenous line.

You may have a thin plastic tube inserted through your nose into your stomach to remove air that you swallow. The
tube will be removed when your bowels resume normal function. You will not be able to eat or drink until the tube is
removed.

You may have one or more drains in the incision if an open procedure was done. The drains will be removed in a day or
so. You might be discharged with the drain still in your abdomen covered with a dressing. Follow your physician’s
instructions for taking care of it.

You will be encouraged to get out of bed within a few hours after a laparoscopic procedure or by the next day after an
open procedure.

Depending on your situation, you may be given liquids to drink a few hours after surgery. Your diet may be gradually
advanced to more solid foods as tolerated.

Arrangements will be made for a follow-up visit with your physician, usually two to three weeks after the procedure.

At home:

Once you are home, it is important to keep the incision clean and dry. Your physician will give you specific bathing
instructions. If stitches or surgical staples are used, they will be removed during a follow-up office visit. If adhesive
strips are used, they should be kept dry and generally will fall off within a few days.

The incision and the abdominal muscles may ache, especially after long periods of standing. Take a pain reliever for
soreness as recommended by your physician. Aspirin or certain other pain medications may increase the chance of
bleeding. Be sure to take only recommended medications.

Walking and limited movement are generally encouraged, but strenuous activity should be avoided. Your physician will
instruct you about when you can return to work and resume normal activities.

Notify your physician to report any of the following:

• fever and/or chills

• redness, swelling, or bleeding or other drainage from the incision site(s)

• increased pain around the incision site(s)

• abdominal pain, cramping, or swelling

• pain behind the breastbone

Following a cholecystectomy, your physician may give you additional or alternate instructions, depending on your
particular situation.

Online Resources
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