What is laparoscopic cholecystectomy?

The surgery to remove the gallbladder is called a cholecystectomy (chol-ecys-tec-to-my). The gallbladder is removed through a 5 to 8 inch long
incision, or cut, in your abdomen. The cut is made just below your ribs on the
right side and goes to just below your waist. This is called open
cholecystectomy.
A less invasive way to remove the gallbladder is called laparoscopic
cholecystectomy. This surgery uses a laparoscope (an instrument used to see
the inside of your body) to remove the gallbladder. It is performed through
several small incisions rather than through one large incision.
What is a laparoscope and how is it used to remove the gallbladder?
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A laparoscope is a small, thin tube that is put into your body through a tiny
cut made just below your navel. Your surgeon can then see your gallbladder
on a television screen and do the surgery with tools inserted in three other
small cuts made in the right upper part of your abdomen. Your gallbladder is
then taken out through one of the incisions.
Are there any benefits of laparoscopic cholecystectomy compared
with open cholecystectomy?
With laparoscopic cholecystectomy, you may return to work sooner, have
less pain after surgery, and have a shorter hospital stay and a shorter
recovery time. Surgery to remove the gallbladder with a laparoscope does
not require that the muscles of your abdomen be cut, as they are in open
surgery. The incision is much smaller, which makes recovery go quicker.
With laparoscopic cholecystectomy, you probably will only have to stay in the
hospital overnight. With open cholecystectomy, you would have to stay in
the hospital for about five days. Because the incisions are smaller with
laparoscopic cholecystectomy, there isn't as much pain after this operation
as after open cholecystectomy.

The Four Fs: using derogatory labels for patients

A gall bladder full of gall stones. The typical patient with this is a middleaged overweight woman with many children.
Last year, I spent a day shadowing a doctor in the Emergency Room. As we
would see a patient, he would take the time to explain his thought process to
me, like why he might suspect a certain diagnosis over another, or how he
knew to perform a particular physical exam maneuver based on the patients
symptoms. It was an incredible learning experience.
One of our patients, an overweight woman in her mid-forties, was having
stomach pains after she ate. After asking the patient basic questions about
the pain she was experiencing, he asked her how many children she had (she
had five kids). Then the doctor turned to me and said, You know why Im
asking that, right? Can you tell me the Four Fs?
Heres where I froze. The Four Fs refers to risk factors for gall stones
(which could explain her stomach pain) Female, Fertile, Fat, and Forty. High
levels of estrogen (from being a woman and having many children) and high
lipids in the blood (from being overweight and older) are both correlated with
a higher incidence of gall bladder disease. But the Four Fs are not the nicest
descriptors to recite to the patient. I chose to answer the doctors question
quite literally, responding, Yes, I can.
I think he quickly realized his faux pas, because then the patient herself
asked, What are the Four Fs?, and he chose to ignore her. I just felt so bad
for the patient, because she didnt get her question answered, and probably
Googled it later, and then saw that her doctor thinks she is fat. Its quite a
derogatory term, and not really a medical word at all. Yet this Four Fs
mnemonic is so widely used, it even shows up in our text books. How awful.
Clearly the discomfort the doctor showed with saying the Four Fs in front of

the patient signals that there is something problematic with calling our
patients fat behind their backs.
Whereas it is true that no operation has been more profoundly affected by
the advent of laparoscopy than cholecystectomy has, it is equally true that
no procedure has been more instrumental in ushering in the laparoscopic
age than laparoscopic cholecystectomy has. Laparoscopic cholecystectomy
has rapidly become the procedure of choice for routine gallbladder removal
and is currently the most commonly performed major abdominal procedure
in Western countries.[1]
A National Institutes of Health consensus statement in 1992 stated that
laparoscopic cholecystectomy provides a safe and effective treatment for
most patients with symptomatic gallstones and has become the treatment of
choice for many patients.[2] This procedure has more or less ended attempts
at noninvasive management of gallstones.
The initial driving force behind the rapid development of laparoscopic
cholecystectomy was patient demand. Prospective randomized trials were
late and largely irrelevant because advantages were clear. Hence,
laparoscopic cholecystectomy was introduced and gained acceptance not
through organized and carefully conceived clinical trials but through
acclamation.
Laparoscopic cholecystectomy decreases postoperative pain, decreases the
need for postoperative analgesia, shortens the hospital stay from 1 week to
less than 24 hours, and returns the patient to full activity within 1 week
(compared with 1 month after open cholecystectomy).[3, 4] Laparoscopic
cholecystectomy also provides improved cosmesis and improved patient
satisfaction as compared with open cholecystectomy.
Although direct operating room and recovery room costs are higher for
laparoscopic cholecystectomy, the shortened length of hospital stay leads to
a net savings. More rapid return to normal activity may lead to indirect cost
savings.[5] Not all such studies have demonstrated a cost savings, however. In
fact, with the higher rate of cholecystectomy in the laparoscopic era, the
costs in the United States of treating gallstone disease may actually have
increased.

Trials have shown that laparoscopic cholecystectomy patients in outpatient

settings and those in inpatient settings recover equally well, indicating that a
greater proportion of patients should be offered the outpatient modality.[6]
Laparoscopic cholecystectomy has received nearly universal acceptance and
is currently considered the criterion standard for the treatment of
symptomatic cholelithiasis.[7, 6] Many centers have special short-stay units
or 23-hour admissions for postoperative observation following this
procedure.[6]
Santiago Horgan, MD

Director, Minimally Invasive Surgery

POST-OPERATIVE INSTRUCTIONS

Laparoscopic Cholecystectomy

The following is a list of instructions to help you do well with getting better from your surgery.

Please read over this material carefully. While instructions may vary from patient to patient, the

material should provide you with a general idea of things to do to help you get well after your

surgery.

Activity

You will likely feel tired for at least 1 week after your surgery. Take your pain medicine as

needed in order to stay active, but rest as needed for recovery. Take short walks 2-3 times a day.

This will help reduce the risk of blood clots following surgery. You may use the stairs as needed

as long as you are not dizzy or weak. Make sure someone is around the first few times you use

the stairs or exercise.

Driving

Do not drive until you have been seen for your first post-operative clinic office visit. Unless

otherwise instructed by us, you may drive after your first visit and when you can react safely in

an emergency situation. You must not be taking pain medicines stronger than regular Tylenol

(acetaminophen) at the time you are driving, nor should you have a great deal of pain, as this will

affect your ability to react quickly. Also: do not take Tylenol #3 and Tylenol at the same time

as Tylenol is in both of them. If you are trying to take yourself off Tylenol #3 by switching to

Tylenol, allow 6 hours between doses.

Lifting/Coughing

Practice 10 deep breaths every hour and 2 coughs every hour, (for at least 12 hours a day), while

awake for the first week after surgery to reduce the risk of lung problems or pneumonia. Do not

lift heavy objects (more than 8 pounds) for the first 4 weeks. Also avoid pushing, pulling or

abdominal pressure for these first 4 weeks. When coughing, be sure to place a pillow over the

incision and gently press inward to reduce the pressure (from coughing) on your incision.

Medications

Use your pain medicine as prescribed. Pain medications may cause nausea on an empty stomach

so it is recommended you take with food. You may switch to plain Tylenol, as directed by your

surgeon after surgery. If you are feeling constipated and have not had a bowel movement by the

4th day after surgery, you may take 1 ounce of Milk of Magnesia in the morning. .

PH268 (03/2008) Incisions

Your incisions have been closed with dissolvable suture on the inside and a special skin glue

over the incision. The skin glue will dissolve so do not attempt to remove it from your skin.

You may shower the day after surgery and allow clean, soapy water to run over your incision but

do not expose your incisions to soaking in water (i.e. hot tub, bathtub or swimming pools) for the

first 6 weeks after surgery. Do not put any ointment or creams over the incisions for the first 6

weeks after surgery or while the incision is open, draining or scabbed.

Diet

You may return to normal food after you go home from your surgery. You may wish to avoid

fatty or heavy foods for the first few days, since some of these foods may cause diarrhea or

nausea temporarily following surgery.

Follow Up

You should follow up in the clinic 1 week after your surgery and 3 months after your surgery.

You may be seen sooner if indicated the surgical team. Please call

Dr Horgans office at (619) 471-0701 to schedule your follow up visits.

PRECAUTIONSWhen Should I call the Physician?

Diarrhea: Occasional loose bowel movements are not uncommon. However, constant watery

diarrhea, especially with fever, can indicate an infection of the bowels.

Fever with or without cough: This could be a sign of lung, wound or stomach infection.

Elevated heart rate: If your heart rate is more than 100 beats per minute, this could be a sign of

infection.

Sudden shortness of breath and/or chest pain: This could be related to a heart problem, such as a

heart attack, or could be related to a blood clot to the lung (pulmonary embolus) or a lung

infection.

Leg swelling and pain: Blood clot formation in the leg, particularly if it is on one side, could

cause swelling with pain in the calf.

Passing out: This could be a sign of low blood pressure, which could be caused by blood loss,

low blood sugar or other causes.

Sudden new stomach pain: This could be a sign of leakage around your stomach or an infection

in your stomach.

Wound drainage: gold colored drainage is normal, call however if your incisional drainage is

green, brown, has a foul odor, or becomes red and irritated.

For urgent matters, you may call (858) 657-7000 and ask to have the physician on call for

the silver team paged. Please remove call block from your phone and refrain from using

your phone so that the physician may return your call promptly.

UTI
Fall 2011
Because each facility has its own challenges and risk factors that can
contribute to the occurrence of urinary
tract infections (UTIs), there is no universal checklist that will prevent all UTIs
in all settings. Therefore, the
following are examples of practices you may choose to adapt within your
facility to promote urinary health.
Promote healthy hydration practices:
Fluid rounds offering a variety of liquids throughout the day or roving
hydration carts
Happy Hours to promote increased fluid intake in a relaxed setting
Tea Time to increase fluid intake in a more formal setting
Educate all residents, staff, and family members about the benefits of
hydration and urinary health
Creative seasonal offerings such as lemonade or popsicles during warm
weather months
Involve other healthcare disciplines (e.g. therapists) in offering hydration
during resident visits
Leave filled, fresh water pitchers at residents bedsides and make sure that
they are able to easily reach
pitchers and glasses
Note the residents preferences for type and temperature of fluids, and
individualize the hydration plan to
encourage compliance
Have a taste test and have let the residents guess the flavor of the juice,
drink, tea, coffee, shake, or other
liquid they are drinking
Promote healthy behaviors:
Adequate fluid intake
Promote complete bladder emptying in a relaxed environment
Ensure that daily personal hygiene is performed to prevent excess skin
contact with urine or feces
Use appropriate incontinence products that are designed for the residents
absorbency needs
Teach staff to use a direct, positive approach when administering fluids such
as Here is some cool,

refreshing water for you, Mrs. Jones rather than Do you want something to
drink, Mrs. Jones?
Promote practices to avoid a catheter-associated UTI (CAUTI):
Avoid unnecessary urinary catheterization
Educate and train staff to consider other alternatives to indwelling
catheterization
If a urinary catheter is required, monitor and observe practices for proper
insertion, care, and maintenance
of a closed-drainage system
Provide written guidance and education for use of urinary catheters and
reminders for removal when no
longer indicated
Educate staff in the proper technique for obtaining urine samples if
laboratory analysis is indicated
Ensure compliance to proper hand hygiene practices and general infection
prevention practices
UTI Prevention Strategies: Ideas for
Customization for your Facilitys Needs