A PERIOPERATIVE EXPERIENCE: THE LAPCHOL

A Perioperative Experience: The Laparoscopic Cholecystectomy Michael S. Renfrew School of Nursing Passaic County Community College / Sussex Campus

A PERIOPERATIVE EXPERIENCE: THE LAPCHOL Abstract Human beings, have, since the very genesis of our existence had a small gland tucked on the

underside of our livers. This small gland, the gallbladder, while providing a function in digestion by concentrating and secreting bile, can fail to operate properly or become laden with gallstones, and may even eventually require removal. Prior to the days of surgery, an inflamed and then possibly ruptured gallbladder, was just another unknown reason for extreme pain, and in some cases even death. As the processes and procedures of surgery was invented and have evolved, patients were able to have their gallbladders removed via an incision and surgery. Today, with the medical advancements in anesthetics, minimally invasive techniques, and operating room sterility, the task of gallbladder removal often means a morning of surgery, then an evening back at ones home. The laparoscopic Cholecystectomy, hereinafter LAPCHOL, has now replaced open cholecystectomy as the first-choice of treatment for gallstones and inflammation of the gallbladder.

A PERIOPERATIVE EXPERIENCE: THE LAPCHOL A Perioperative Experience: The Laparoscopic Cholecystectomy

The LAPCHOL is, in its most simplistic form, the removal of a patients gallbladder, using minimally invasive, or laparoscopic techniques. Primary identifiers of the LAPCHOL procedure are found in the absence of the necessity for a large abdominal incision, parting of the abdominal muscle fascia, and the entry of a surgeons hands into the patient. The LAPCHOL necessitates only a few small incisions in the patients abdomen, with the insertion of operating ports, through which, the necessary surgical implements can be inserted into the patients abdomen and then manipulated. A characteristic of the LAPCOL that is in complete contrast with an incisional procedure, is the inflation of the patients abdomen with carbon dioxide gas. The gas inflation of the abdomen creates a working space within the abdomen that facilitates the movement of surgical tools and a small camera, which provides the surgeon a clear view of the procedure. In performing the LAPCHOL, the surgeon locates the patients liver, and retracts it superiorly. The gallbladder, now exposed, is retracted laterally to expose the underlying peritoneal tissues and structures, including the cystic duct and common hepatic duct. The cystic duct and the cystic artery are identified, separated from the peritoneal tissues, and clipped shut using clips made of an inert metal such as titanium. The gallbladder is then dissected away from the connective tissues to the liver, and removed. At all times, the surgeon takes care to prevent the spillage of any gallbladder contents into the abdomen, and carefully verifies that there is no internal hemorrhage from the cystic artery or the surface of the liver. The goal of the surgery, is the removal of a gallbladder, while placing the patient at minimal risk for internal infection, internal or external hemorrhage, and an ultimate removal of pain experienced by the patient.

A PERIOPERATIVE EXPERIENCE: THE LAPCHOL As with all surgical procedures, infection and the prevention of infection are of serious consideration with regard to the patient receiving a LAPCHOL. Perioperative measures to reduce the chances of infection start at pre-admission testing, in searching the patients history

for indicators that the patient may be prone to infection. Additionally, as part of a pre-admission screening, blood values would be used to additionally provide information regarding a patients susceptibility to infection. Infection prevention continues as the patient enters the surgical facility, street clothes are removed and the patient is placed into a clean hospital gown and onto a clean hospital stretcher. As the patient is transported into the surgical suite, infection prevention is addressed again, by covering the patients hair, the hair and feet of all staff are also covered, and the operating room is maintained at a cool temperature to slow the growth of any bacteria. Prior to any incision into the skin of the patient, a thorough surgical cleaning of the site is performed; sterile surgical drapes cover the patient, and only the area to be used during the procedure is exposed. In further prevention of infection, all members of the surgical team maintain strict sterile technique, and any compromise of sterility is addressed immediately. As the surgeon begins the operation, antibiotics begin being administered to the patient via an IV. IV antibiotics are the most effective, and also the most effective method of being administered. Surgically, the surgeon maintains extreme discipline to ensure the gallbladder is removed sans any spillage of its contents into the abdomen. At the conclusion of surgery, the patients incisional wounds are closed and dressed to prevent infection. For the conduction of the LAPCHOL in this Perioperative experience, the patient was anesthetized using two primary drugs. The first drug used, was Diprivan, a milky white liquid easy recognized for its appearance. Diprivan (propofol) is well liked as a drug for use prior to administration of general anesthesia due to its rapid onset and recovery, reliable mechanism of

A PERIOPERATIVE EXPERIENCE: THE LAPCHOL action, simple dosage profile of 1-2.5 mg/kg, and its relative safety when compared to other similar drugs. The main disadvantage to Diprivan is a rare, but serious side effect called propofol infusion syndrome. Nursing responsibilities for working with patients under sedation of Diprivan would include continual monitoring of vital signs for hypotension and apnea. For the complete surgical anesthesia, the inhaled gas called Sevoflurane was used. Sevoflurane is one of the fastest onset and offset drugs used for general anesthesia, and because it irritates the mucosa less than most other inhaled anesthetics, it is the preferred agent for mask induction. In performing the anesthesia for this procedure, the patient appeared to drift asleep quickly, and remain in a smooth period of surgical anesthesia, and ultimately made a rapid and uneventful awakening. During the procedure, it was interesting and educational to observe the circulating nurse in the performance of her role and responsibilities. Overall, the circulating nurse is the primary person responsible for the patient, the safety of the patient, and the overall execution of the operative phase of the Perioperative process. In this Perioperative experience, the circulating nurse facilitated arrival and positioning of the patient, ensured the surgical items and team were

assembled, monitored the sterile field, and added items to the sterile field. The circulating nurse performed as and advocate, a manager, and a team member. Upon the safe departure of the patient, to return home safely with his spouse and his friend, it was fulfilling to have learned about the LAPCHOL procedure and how it was performed with such precision and delicate instrument manipulation. The importance of, and the many levels and steps of infection prevention education also had an observable aspect that I now had a better understanding of. Seeing the administration, maintenance, and removal of surgical anesthesia, as well, learning about the necessary drugs, will benefit me as I move forward in

A PERIOPERATIVE EXPERIENCE: THE LAPCHOL nursing and hopefully a Perioperative nursing role. And finally, in observing the circulating nurse in performance of her roles and responsibilities, I was able to gain a better understanding of the overall operation involved in operations.

A PERIOPERATIVE EXPERIENCE: THE LAPCHOL References

Dale DC, Federman DD, Antman K, et al. ACP Medicine. 3rd edition. Hamilton ON: American College of Physicans; 2007 Glick, David B, (2012). Overview of complications occurring in the postanesthesia care unit. Wolters Kluwer Health Up To Date, September 2012, doi: [ecapp1103p.utd.com-184.6.216.127-AD053B63B6-14] or http://www.uptodate.com/contents/overview-of-complications-occurring-in-the-postanesthesia-care-unit Smeltzer SC, Bare BG, Hinkle JL, et al. Textbook of Medical Surgical Nursing. 12th edition. Philadelphia, Baltimore, New York: Lippincott & Williams: 2010