ANGELES UNIVERSITY FOUNDATION

Angeles City
College of Nursing

Case Report:
Laparoscopic Cholecysectomy

Submitted by:
Agravantes, Dennise
Cruz, Hazel Irish
Garcia, Christina Beatriz
Submitted to:
Maam Karen Sembrano, OR JBL
BSN III-1 Group 1

I. Introduction
Gallstones are small, pebble-like substances that develop in the
gallbladder. The gallbladder is a small, pear-shaped sac located below the
liver in the right upper abdomen. Gallstones form when liquid stored in the
gallbladder hardens into pieces of stone-like material. The liquid called bile
helps the body digest fats. Bile is made in the liver, then stored in the
gallbladder until the body needs it. The gallbladder contracts and pushes the
bile into a tube-called the common bile duct-that carries it to the small
intestine, where it helps with digestion.
Literature shows that gallstones are present in approximately 10-20%
of the population. Gallstones may be present at any age but are unusual
before the third decade. There is a progressive increase with age, and in
patients over 50 the prevalence ranges between 25-30%. The prevalence is
two to three times higher in women than in men.
Laparoscopic gallbladder surgery (cholecystectomy) removes the
gallbladder and gallstones through several small cuts (incisions) in the
abdomen. The surgeon inflates the abdomen with air or carbon dioxide in
order to see clearly. The surgeon inserts a lighted scope attached to a video
camera (laparoscope) into one incision near the belly button. The surgeon
then uses a video monitor as a guide while inserting surgical instruments
into the other incisions to remove the gallbladder.
In laparoscopic cholecystectomy (LC), application of clips is the
standard method for controlling the cystic duct and artery. However, a lot of
sources identified disadvantages of the said technique. Some of the
disadvantages of the application of clips are: duct leaks due to mismatch of
the clips, necrosis of the duct at the site of clipping, or slip-page of the clips

off the end of the duct. Some sources also showed that in the process of
application, the metallic clips can fall from the applicator, there is a
significant inflammatory reaction to metallic clips.
Due to these disadvantages, researchers managed to come up with a
new technique in alternative for the application of clips (standard method).
The new technique which is performed by division of cystic artery by
monopolar cautery and ligation of the cystic duct intracorporeally using nonabsorbable suture, shows a few negative results like bleeding of three
patients from cauterized cystic artery. This bleeding was controlled by
diathermy in two of them and application of metal clip was necessary in the
remaining patient. Cystic duct leak was also detected in only one patient,
and it was managed by percutaneous drainage. These negative results still
was lesser than the disadvantages from using the standard method. In
conclusion, proposed modification of LC is feasible, practical, safe and
economic as well. It is associated with reduced risk of postoperative
morbidity. (ElGeidie, 2011)
As future nurses, this is only one of the several cases we may
encounter as we go along with our career. We believe that our job could help
a lot of people in one way or another. Being able to identify new trends,
modifications and technological advancements of the said procedure, we
may be able to share and distribute these information to several other
nurses, surgeons and other part of the OR team.

II. Anatomy and Physiology of the Digestive System

The apparatus for the digestion of food consists of the alimentary canal
digestive tractand of its accessory organs, collectively known as the
digestive system. The function of the digestive system include: taking in food
through mastication and swallowing, breaking down the food during the
process of digestion, absorbing nutrients through the walls of the intestinal
tract, and eliminating wastes by use of defecation.
The

digestive tract is a tube extending

from

the mouth to the anus and including

the

associated organs that secret fluid

into the digestive tract. It

consists of

the oral cavity, pharynx, esophagus,

stomach, small intestine, large
intestine, and anus. The

accessory

glands include the salivary glands,

liver, and

pancreas. The digestive tract consists

of nerve

plexuses called the

enteric nervous system. The plexuses

are composed of sensory

neurons connecting to the digestive tract to the central nervous system,

autonomic nervous system motor neurons connecting to the CNS to the
digestive tract, and enteric neurons, which are only in the enteric nerve
plexus. The enteric plexus controls activities within specific, short regions of
the digestive tract through local reflexes. The ENS is capable of controlling
the complex movements, secretions and blood flow of the GI tract, without
any outside influences. Although the ENS can control the activities of the
digestive tract independent of the CNS, normally the two systems work
together.

The Liver and Gall Bladder

The liver is the largest internal organ of the body and is located in the
right-upper quadrant of the abdomen, tucked against the inferior surface of
the surface of the diaphragm. The liver was divided into four lobes based on
superficial structures. Anteriorly, the boundary between the left and right
lobes is marked by the falciform ligament. Inferiorly, the left lobe is
separated from the quadrate and caudate lobes by the lesser omentum. The
porta hepatis on the inferor surface of the liver is where the various vessels,
ducts, and nerves enter and exit the liver. The porta hepatis separates the
quadrate and caudate lobes. The gallbladder is small sac on the inferior
surface of the of the liver that stores bile. The gallbladder marks the division
between the right and quadrate lobes. The inferior vena cava marks the
division between the right and caudate lobes.

A connective tissue
capsule and visceral
peritoneum cover the
liver, except for the bare
area, which is a small area
on the diaphragmatic
surface that lacks a
visceral peritoneum and is
surrounded by the
coronary ligament. At the
porta hepatis, the
connective tissue capsule sneds a branching network of septa into the
substance of the liver to provide its main support. Vessel, nerves, and ducts
follow the connective tissue branches throughout the liver.

It is now known as the external division of the liver into lobes and has
nothing to do with its internal organization. Internally, the liver is divided into
eight segments based on the distribution of blood vessels and ducts
transporting bile.
The porta hepatis contains the hepatic artery and hepatic portal vein,
which carries blood to the liver, and the left and right hepatic ducts, which
conduct bile toward the duodenum. Connective tissue septa divide the liver
segments into many hexagon-shaped lobules with a portal triad at each
corner. The triads are so named because three structures derived from the
porta hepatis: branches of the hepatic artery, hepatic portal vein, and
hepatic ducts. The hepatic artery braches and the hepatic portal branches
join enlarged capillaries called hepatic sinusoids. The wall of the hepatic
sinusoids consists of simple squamous epithelium and hepatic phagocystic
cells, Kupffer cells. The hepatic sinusoids join a central vein located in the
center of the lobule. Hepatic cords radiate out from the central vein of each
lobule like the spokes of a wheel, surrounding the hepatic sinusoids. The
hepatic cords are composed of hepatocytes, the cells of the liver. A cleftlike
lumen, the bile canaliculus, lies between the hepatocytes within each cord.
The bile canaliculi join the hepatic duct branches in the portal triad.
The liver performs important digestive and excretory functions, stores
and processes nutrients, synthesizes new molecules, and detoxifies harmful
chemicals.
Bile Production
The liver produces and secrets about 600-1000 mL of bile each day.
Bile contains no digestive enzymes, but it plays a role in digestion because it
neutralizes and dilutes gastric acid and emulsifies fats. The pH of chime as it
leaves the stomach is too low for the normal function of pancreatic enzymes.
Bicarbonate ions in bile help neutralize the acidic chyme and brings pH up to
a level at which pancreatic enzymesn functions can function. Bile alts

emulsify fats, changing large lipid droplets into much smaller droplets. Bile
contains excretory products, such as the bile pigment bilirubin. Bile also
contains cholesterol, fats, fat-soluble hormones, and lecithin.

Storage
Hepatocytes can remove sugar from the blood and store it in the form
of glycogen.They can also store fat, vitamins, copper, and iron. This storage
function is usually short-term, and the amount of stored material in the
hepatocytes and the cell size fluctuate during a given day.
Hepatocytes help control blood sugar levels within very narrow limits. If
a large amount of sugar were to enter the general circulation after a meal, it
would increase the osmolality of the blood and produce hyperglycemia. This
is prevented because the blood from the intestine passes to the liver, where
glucose and other substance are removed from the blood by hepatocytes,
stored, and secreted back into the circulation when needed.
Bile Transport
Bile, produced by the hepatocyes, flows through the bile canaliculi to
the hepatic duct branches in the portal triads. The hepatic ducts converge
and empty into the right and left hepatic ducts which transport bile of the
liver. The right and left hepatic ducts unite to form a single common hepatic
duct. The common hepatic duct is joined by the cystic duct from the
gallbladder to form the common bile duct. The gallbladder is a small sac on
the inferior surface of the liver that stores and concentrates bile. The
common bile duct joins the pancreatic duct at the hepatopancreatic ampulla,
and enlargement where the hepatic and pancreatic ducts come together. The

hepatopancreatic ampulla empties into the duodenum at the major duodenal

pailla. Smooth muscle sphincters surround the common bile duct,
hepatopancreatic ampulla, and pancreatic duct.
The gallbladder is asaclike structure on the inferior surface of the lvier.
Three tunics form the gall bladder wall: an inner mucousa folded into rugae
that allow the gallbladder to expand, a muscularis allowing the gallbladder to
contract, and an outer covering of serosa. The cystic duct connects the
gallbladder to the common bile duct.
Bile is continually secreted by the liver and flows through the cystic
duct into the gallbladder. While the bile is in the gallbladder, water and
electrolytes are absorbed, and bile salts and pigments become as much as 510 times more concentrated than they were when secreted by the liver.
Contraction of the gallbladder moves the stored bile into the duodenum.
Secretin released from the duodenum stimulate bile secretion,
primarily by increasing the water and bicarbonate inon content of bile.
Cholecystokinin released from the duodenum stimulates the gallbladder to
contract and sphincters of the bile duct and hepatopancreatic ampulla to
relax. To a lesser degree, parasympathetic stimulation through the vagus
nerves cause the gallbladder to contract. Thus, large amounts of
concentrated bile move rapidlyinto the duodenum.
Bile salts also increase bile secretion through a positive feedback
system. Over 90% of bile salts are reabsorbed in the ileum and carrired in
the blood back to the liver, where they contribute to further bile secretion.
The loss of bile salts in feces is reduced by this recycling process.

III. The Patient and His Illness

Hepatocyte
Mechanisms

Decreased
Cholesterol 7 alphahydroxylase

Increased
Hepatocyte
synthesis of

Diminished secretion
of bile salts

Decreased
resorption of bile
salts from the ileum

Bile supersaturated
with cholesterol

Gallbladder smooth
b. Synthesis of the Disease
muscle hypomotility
Gallstones are commonly ofand
twostasis
types: cholesterol and pigmented.
Cholesterol stones are the most common. Pigmented stones, which are less
common, occur later in life and are associated with cirrhosis. Cholesterol
gallstones form in bile that isNidus
supersaturated
with cholesterol produced by
for gallstone
the liver. Supersaturation sets theformation
stage for cholesterol crystal formation, or
the formation of microstones. More crystals then aggregate on the
microstones, which grow to form macrostones. This process usually occurs
Cholesterol
gallstones

in the gall bladder, which may have decreased motility. The stones may lie
silent or become lodged in the cystic or common duct, causing pail and
cholecystitis. Gallstone formation may be such that the stones accumulate
and fill the entire gallbladder. Impaired gallbladder motility and gallbladder
stasis also may contribute to stone formation.
It is not known why the hepatocytes secrete bile that is supersaturated
with cholesterol. Proposed mechanisms include: an enzymatic defect that
increases the hepatocytes synthesis of cholesterol, diminished secretion of
bile acids that normally promote cholesterol solubility, decreased resorption
of bile alts from the ileum that decrease the bile acid pool, gallbladder
smooth muscle hypomotility and stasis, genetic predisposistion, and a
combination of these mechanisms. In obese individuals the mechanism
appears to involve cholesterol synthesis, whereas in nonobeses individuals, it
appears to involve decreased secretion of bile acids.
Pigmented stones are created by cholesterol, calcium, bilirubinate, or
pigmented polymers. The formation of pigmented stones is associated with
bilary tract obstruction and bacterial degration and precipitation of biliary
lipids.

b.1. Definition of the Disease

Cholelithiasis is the medical term for gallstone disease. Gallstones are
concretions that form in the biliary tract, usually in the gallbladder.

Gallstones develop insidiously, and they may remain asymptomatic for

decades. Migration of a a gallstone into the opening of the cystic duct may
block the outflow of bile during gallbladder contraction. The resulting
increase in gallbladder wall tension produces a characteristic type of pain
(biliary colic). Cystic duct obstruction, if it persists for more than a few hours,
may lead to acute gallbladder inflammation (acute cholecystitis).
Choledocholithiasis refers to the presence of one or more gallstones in
the common bile duct. Usually, this occurs when a gallstone passes from the
gallbladder into the common bile duct.
A gallstone in the common bile duct may impact distally in the ampulla
of Vater, the point where the common bile duct and pancreatic duct join
before opening into the duodenum. Obstruction of bile flow by a stone at this
critical point may lead to abdominal pain and jaundice. Stagnant bile above
an obstructing bile duct stone often becomes infected, and bacteria can
spread rapidly back up the ductal system into the liver to produce a lifethreatening infection called ascending cholangitis. Obstruction of the
pancreatic duct by a gallstone in the ampulla of Vater also can trigger
activation of pancreatic digestive enzymes within the pancreas itself, leading
to acute pancreatitis.
Chronically, gallstones in the gallbladder may cause progressive
fibrosis and loss of function of the gallbladder, a condition known as chronic
cholecystitis. Chronic cholecystitis predisposes to gallbladder cancer.
Ultrasonography is the initial diagnostic procedure of choice in most
cases of suspected gallbladder or biliary tract disease.
The treatment of gallstones depends upon the stage of disease.
Asymptomatic gallstones may be managed expectantly. Once gallstones
become symptomatic, definitive surgical intervention with excision of the

gallbladder (cholecystectomy) is usually indicated. Cholecystectomy is

among the most frequently performed abdominal surgical procedures (see
Treatment). Complications of gallstone disease may require specialized
management to relieve obstruction and infection.
b.2. Predisposing/Precipitating Factors
Predisposing Factors:

Female
Over 40 years of age
Overweight or Obese
Family History of Gallstones
Diabetes
Native Americans or Mexican-Americans

Precipitating Factors:

High fat diets

High cholesterol diets
Losing weight very quickly
Medications that contain estrogen

b.3. Signs and Symptoms

Heavy, sudden pain the right upper abdomen with radiation to the
back or shoulder

Nausea and vomiting

Restlessness (due to pain)

Yellowing of skin and eyes (due to contraction of jaundice)

Discoloration of the feces which becomes kitfarvet (due to jaundice)

Dark staining of urine (due to jaundice)

IV. Clinical Intervention

1.1 Description of prescribed surgical treatment performed.
Outline or illustrate the process and support with images.
Laparoscopic cholecystectomy is a procedure in which the gallbladder is
removed by laparoscopic techniques. Laparoscopic surgery also referred to
as minimally invasive surgery describes the performance of surgical
procedures with the assistance of a video camera and several thin
instruments.
During a laparoscopic surgical procedure, small incisions of up to half an inch
are made and plastic tubes called ports are placed through these incisions.
The camera and the instruments are then introduced through the ports which
allow access to the inside of the patient. The camera transmits an image of
the organs inside the abdomen onto a television monitor. The surgeon is not
able to see directly into the patient without the traditional large incision. The
video camera becomes a surgeons eyes in laparoscopy surgery, since the
surgeon uses the image from the video camera positioned inside the
patients body to perform the procedure.
Benefits of minimally invasive or laparoscopic procedures include less post
operative discomfort since the incisions are much smaller, quicker recovery
times, shorter hospital stays, earlier return to full activities and much smaller
scars. Furthermore, there may be less internal scarring when the procedures
are performed in a minimally invasive fashion compared to standard open
surgery.
PATIENT POSITIONING
The patient should be supine with the arms perpendicular
to the body or tucked to the side.
After general anesthesia, the abdomen is prepped from
nipple to pubis and sterilely draped.
The primary surgeon stands on the patients left side, while
the assistant stands on the patients right.
PROCEDURE
General anesthesia is used.
A small periumbilical incision is made, with the location
and orientation depending on the patients body habitus

and cosmetic considerations. Although most surgeons

employ a closed technique to establish pneumoperitoneum
and initial access (usually with a Veress needle), an open
technique is also appropriate.
Figure 111: Port positions:
5-mm (preferred) or 10-mm port in the periumbilical
position for a 5-mm or 10-mm laparoscopic scope.
10-mm port in the subxiphoid position with the intraabdominal portion
located to the right of the falciform
ligament.
5-mm port 2 fi ngerbreadths below the costal margin and
close to the midclavicular line, to position the port over
the gallbladder intra-abdominally.
5-mm port laterally along the anterior axillary line for
gallbladder fundus retraction.
The laparoscope is used to explore the abdomen for adhesions and
potential injuries that may have occurred during
port placement (the subxiphoid and subcostal ports are
placed under direct visualization to minimize risk of
injury).

Figure 112: A ratcheted grasper is inserted through the

lateral 5-mm port to retract the gallbladder fundus in cephalad fashion.
If the gallbladder is too distended to be grasped, it may be
fi rst decompressed with a needle or using the suction
device.
An atraumatic grasper is inserted through the middle
5-mm port to retract the gallbladder infundibulum laterally, exposing the
anteromedial aspect of the triangle of
Calot.
The primary surgeon uses a two-handed technique and
begins the dissection.
Adhesions to the body of the gallbladder are released using
blunt or sharp dissection, as appropriate.

 A hook cautery is used to carefully incise the peritoneum

overlying the triangle of Calot, continuing along the
medial aspect of the proximal gallbladder.

Figure 113: As the infundibulum is retracted superomedially, peritoneum

overlying the posterolateral aspect
of the triangle of Calot is similarly incised using hook
cautery.

Figure 114: All remaining connective tissue is dissected

out of the triangle of Calot using blunt dissection and hook
cautery as needed to fully mobilize the gallbladder
infundibulum.

 Figure 115: The cystic duct is dissected free.

Figure 116: The cystic artery is dissected free.

At this point, only two tubular structures (the cystic duct
and artery) remain connected to the proximal gallbladder; this represents the
critical view of safety.

Figure 117: If a cholangiogram is to be performed, a clip

is applied on the cystic duct at the junction to the infundibulum. An
anterolateral cystic ductotomy is made just distal
to the clip.

 Figure 118: A cholangiogram catheter is inserted through

the ductotomy and secured using either clips or a cholangiogram clamp.
The whole system should be fl ushed with 23 mL of saline
before placement of the cholangiocatheter as well as initially upon
placement in the cystic duct to remove any air
bubbles, which might produce an artifact on the cholangiogram.
Approximately 1520 mL of contrast dye diluted 1:1 with
saline is injected under fl uoroscopy with the table tilted
slightly to the left. The contrast is injected slowly at fi rst to
visualize the distal common bile duct and then at higher
pressures and volumes to visualize the entire biliary tree.
An adequate cholangiogram requires visualization of the
biliary tree proximal to the biliary bifurcation (revealing
both right and left hepatic ducts and branches) and evidence of dye passage
into the duodenum.
If common bile duct stones are identifi ed, they can be
managed via laparoscopic bile duct exploration or post-operative ERCP,
depending on surgeon preference and
experience.

Figure 119: After the cholangiogram, the cystic duct is

double clipped proximal to the ductotomy and divided.
The cystic artery is likewise divided between the previously

placed clips.

Figure 1110: The gallbladder is then dissected out of the

gallbladder fossa using hook cautery.

Figure 1111: The gallbladder is retrieved via the umbilical

or subxiphoid port, depending on surgeon preference. A
disposable specimen bag may be used for this purpose, particularly in cases
of acute cholecystitis or gallbladder perforation during dissection (to prevent
stone spillage).
The ports are removed under direct vision to evaluate for
potential bleeding.
If a 10-mm trocar is used at the umbilicus, the residual
fascial defect is closed with interrupted 0 Vicryl sutures.
The fascia at the epigastric trocar site is closed in similar
fashion.

 Figure 1112A: Open cholecystectomy is performed

through a 1015-cm right subcostal incision.
A Bookwalter retractor is used to retract the liver and
bowel, exposing the gallbladder.
Figure 1112B: An antegrade approach is used to dissect
the gallbladder out of the gallbladder fossa from the fundus
down toward the porta hepatis.
The triangle of Calot is exposed just as in the laparoscopic
approach.
Figure 1112C: The cystic artery is identified and ligated
Figure 1112D: The cystic duct is isolated and ligated.

1.2 Indication of prescribed surgical treatment.

General and/or specific indications; discuss risk vs. benefit.
Indications
If an attack hasn't settled after 12 hours.
If there are complications such as jaundice, pancreatitis.
If patient suffers recurrent pain or vomiting.
If patient suffers cholangitis.
Obesity
Previous Surgery
Biliary Colic
Chronic cholecystitis
Acute cholecystitis
Acalculous cholecystitis
Choledocholithiasis
Risks
The overall risk of laparoscopic gallbladder surgery is very low. The most
serious possible complications include:
Infection of an incision.
Internal bleeding.
Injury to the common bile duct.
Injury to the small intestine by one of the instruments used during surgery.

Risks of general anesthesia.

Other uncommon complications may include:
Injury to the cystic duct, which carries bile from the gallbladder to the
common bile duct.
Gallstones that remain in the abdominal cavity.
Bile that leaks into the abdominal cavity.
Injury to abdominal blood vessels, such as the major blood vessel carrying
blood from the heart to the liver (hepatic artery). This is rare.
A gallstone being pushed into the common bile duct.
The liver being cut.
Benefit
Less discomfort than regular surgery
Shorter hospital stay, with a quicker recovery time compared to regular
surgery
Smaller scars than regular surgery

Call your physician if you experience:

Increasing pain and redness at an incision site
Fever higher than 101 degrees
Draining at the incision site that increases or becomes foul smelling

1.3 Required instruments, devices, supplies, equipment, and

facilities.
Specific resources and/or conditions that are necessary for the
success of the operation; support with images.
Trocars - a sharp-pointed surgical instrument enclosed in a cannula, used for
withdrawing fluid from a cavity, as the abdominal cavity.

Laparoscope - A slender tubular endoscope that is inserted through an

incision in the abdominal wall and used for viewing the abdominal or pelvic
cavities.

Atraumatic graspers - To clasp firmly with or as if with the hand.

Electrocautery instrument - The medical practice or technique

of cauterization is the burning of part of a body to remove or close off a part
of it in a process called cautery, which destroys some tissue,[1] in an attempt
to mitigate damage, remove an undesired growth, or minimize other
potential medical harmful possibilities such as infections, when antibiotics
are not available. The practice was once widespread for treatment of
wounds. Its utility before the advent of antibiotics was effective on several
levels:
useful in stopping severe blood-loss and preventing exsanguination
to close amputations

Maryland dissector - is a monopolar electrosurgical instrument for dissection

and hemostasis using flexible endoscopes.

Clip applier - to occlude vessels and other tubular structures.

Laparoscopic scissors - used to cut a variety of tissue, including fibrotic or

calcified tissue, sutures, and occasionally tissue containing staples.

Suction-irrigator - used as a working port

ensuring precise coagulation and transection of vessels and tissue with
instantaneous irrigation.

Disposable specimen retrieval bag - a dual-structured pocket in which

specimens are placed.

Video Monitor - to enable a surgeon to more easily conduct endoscopic

procedures.

OR Light - to assist medical personnel during a surgical procedure by

illuminating a local area or cavity of the patient.

OR Table - the table on which the patient lies during a surgical operation.

Verress Needle - is a spring-loaded needle used to

create pneumoperitoneum for laparoscopic surgery.

Needle holder - is a surgical instrument, similar to a hemostat, used

by doctors and surgeons to hold a suturing needle for closing wounds
during suturing and surgical procedures.

SOURCE:
http://www.mhprofessional.com/downloads/products/0071453164/minter_ch11_p089096.pdf
http://emedicine.medscape.com/article/1582292-overview#a09
http://www.indiancontinencefoundation.org/instruments.html

1.4 Perioperative tasks and responsibilities of the Nurse.

Emphasize and outline critical tasks and responsibilities of both
scrub and circulator roles pre-operatively, intra-operatively, and
post-operatively.
SCRUB NURSE
Pre-operatively
Ensures that the circulating nurse has checked the equipment
Ensures that the theater has been cleaned before the trolley is set
Prepares the instruments and equipment needed in the operation
Uses sterile technique for scrubbing, gowning and gloving

Receives sterile equipment via circulating nurse using sterile technique

Performs initial sponges, instruments and needle count, checks with
circulating nurse
Perform assisted gowning and gloving to the surgeon and assistant surgeon
as soon as they enter the operation suite
Assemble the drapes according to use. Start with towel, towel clips, draw
sheet and then lap sheet. Then, assist in draping the patient aseptically
according to routine procedure
Place blade on the knife handle using needle holder, assemble suction tip
and suction tube
Bring mayo stand and back table near the draped patient after draping is
completed
Secure suction tube and cautery cord with towel clips or allis
Prepares sutures and needles according to use
Intra-operatively
Maintain sterility throughout the procedure
Awareness of the patients safety
Adhere to the policy regarding sponge/ instruments count/ surgical needles
Arrange the instrument on the mayo table and on the back table
Provide 2 sponges on the operative site prior to incision
Passes the 1st knife for the skin to the surgeon with blade facing downward
and a hemostat to the assistant surgeon
Hand the retractor to the assistant surgeon
Watch the field/ procedure and anticipate the surgeons needs
Pass the instrument in a decisive and positive manner
Watch out for hand signals to ask for instruments and keep instrument as
clean as possible by wiping instrument with moist sponge
Always remove charred tissue from the cautery tip
Notify circulating nurse if you need additional instruments as clear as
possible
Keep 2 sponges on the field
Save and care for tissue specimen according to the hospital policy
Remove excess instrument from the sterile field
Adhere and maintain sterile technique and watch for any breaks
Post-operatively
Undertake count of sponges and instruments with circulating nurse
Informs the surgeon of count result
Clears away instrument and equipment
After operation: helps to apply dressing
Removes and siposes of drapes
De-gown
Prepares the patient for recovery room
Completes documentation

Hand patient over to recover room

CIRCULATING NURSE
Pre-operatively
The circulating nurse checks all equipment, such as cautery and suction
machines, prior to every operation to make sure they are functioning
correctly. She ensures the operating theater is clean, the lights work, the
operating table is functional and all furniture in the room is ready to use. In
this role, she also helps the scrub nurse prepare the operating room by
placing a clean sheet and pillow on the operating table and providing a clean
kick bucket and pail.
As the main coordinator in the OR, the circulating nurses assists the
anesthesiologist by correctly positioning the patient to receive anesthesia.
The position depends on the procedure that will be performed. If spinal
anesthesia is required, for example, the patient is positioned in a quasi-fetal
position. After the anesthesia is administered, the circulating nurse follows
the anesthesiologist's instructions for repositioning the patient and places his
arms in arm boards and restraints to prevent him from inadvertently injuring
himself. To prepare for the operation, she exposes the patient's skin and, if
necessary catheterizes him.
Intra-operatively
Although the circulating nurse is not scrubbed in, she remains in the theater
throughout the operation, monitoring lights, connecting or adjusting
equipment and replenishing sponges. She may be called upon to refocus a
light, reposition a kick bucket, or replenish and record sponges and sutures.
It's the circulating nurse's duty to make sure the door remains closed
throughout the patient's operation to maintain his privacy and make sure he
is fully covered except when nudity is unavoidable.
Post-operatively
As the operation is drawing to a conclusion, the circulating nurse assists with
the final sponge and instrument count, as each must be accounted for. She
signs the theater register and ensures everyone attending also signs. Other
post-op duties include performing quality checks, such as ensuring all
specimens are correctly labelled and signed, and assisting the surgeons and
scrub nurse in making sure the patient is in the correct position and resting
comfortably. She also returns all equipment to their starting positions,
making sure it's clean and ready for the next procedure.
SOURCE:
http://nursingcrib.com/nursing-notes-reviewer/duties-of-scrub-nurse-2/
http://everydaylife.globalpost.com/circulating-nurse-duties-2523.html

1.5 Expected outcomes of surgical treatment performed.

Describe both physiologic and psychosocial outcomes and their
impact on quality of life.
Postoperative 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 is 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 2448 hours, until the patient's diet is gradually advanced
as bowel activity resumes. The patient is generally encouraged to walk eight
hours after surgery and discharged from the hospital within three to five
days, with return to work approximately four to six weeks after the
procedure.
Care received immediately after laparoscopic cholecystectomy is similar to
that of any patient undergoing surgery with general anesthesia. A unique
postoperative pain may be experienced in the right shoulder related to
pressure from carbon dioxide used in the laparoscopic tubes. This pain may
be relieved by lying down on the left side with right knee and thigh drawn up
to the chest. Walking will also help increase the body's reabsorption of the
gas. The patient is usually discharged the day after surgery and allowed to
shower on the second postoperative day. The patient is advised to gradually
resume normal activities over a three-day period, while avoiding heavy lifting
for about 10 days.
Patients will probably be able to get back to normal activities within a week's
time, including driving, walking up stairs, light lifting and work. Activity is
dependent on how the patient feels. Walking is encouraged. Patients can
remove the dressings and shower the day after the operation. In general,
recovery should be progressive, once the patient is at home.
Most patients are fully recovered and may go back to work after seven to ten
days.
Often, this depends on the nature of your job since patients who perform
manual labor or heavy lifting may require two to four weeks of recovery.
1.6 Medical management of physiologic outcomes.
The patient may experience either constipation or diarrhea after
surgery and this may be caused by anesthesia, pain medications or reaction

to surgery. This is not uncommon. The patient may take any over the counter
medication(s) that have worked previously to correct the situation of diarrhea
or constipation. Suggestions are Milk of Magnesia, Dulcolax tablets or
suppositories as directed for constipation. Also increasing fluids such as
water, juices, etc. will help with elimination. Suggestions for diarrhea include
Pepto-Bismol and Imodium AD as directed for diarrhea. Also drinking
Gatorade and BRAT diet (bananas, rice, applesauce, toast) may help to
alleviate and correct some of the side effects of diarrhea.
If there are any serious complications post-operatively, particularly
damage to the bile duct, a procedure called Endoscopic Retrograde
Cholangiopancreatography (ERCP) may be performed. Damage to the duct
causes leakage typically manifests as fever, jaundice, and abdominal pain
several days following cholecystectomy.

1.7 Nursing management of physiologic and psychosocial outcomes.

Risk for Infection
Assessment
S=
O = The
patient may
manifest the
following:
-post surgical
incisions in the
abdominal
area
-redness on
the incision
site
-swelling in the
incision site
-increase
environmental
exposure to
pathogens
immunosuppre
ssion

Nursing
Diagnosis
Risk for
Infection
related to
inadequate
primary
defense as
evidenced
by broken
skin
secondary
to surgical
incisions in
the
abdominal
area

Scientific
Explanati
on
The skin
provides
the
primary
protection
against
infection
by acting
as a
physical
barrier.
When this
barriers
are
damage
pathogens
have a
direct
route to
infiltrate
the body,
possibly
resulting

Objectives
Short
Term:
After 2-4
hours of
nursing
intervention
s, the
patient will
be able to
identify
intervention
s to prevent
or reduce
risk of
infection
Long Term:
After 2-3
days of
nursing
intervention
s, the
patient will

Interventions
>Observe for
localized signs
of infections
around the
surgical site

Rationale
>To assess
causative/contributing
factors

>Stress proper
>A first-line defense
hand hygiene by against healthcare
all caregivers
associated infections.
between
therapies and
clients
>Fever may indicate
>Assess signs
presence of infection
and symptoms
of infection
especially
temperature
>Regular wound caring
and proper dressing
>Maintain
promotes fast healing
aseptic
and drying of wounds
technique when
changing
>Wet area can be

Expected
Outcome
Short Term:
the patient
shall have
identified
interventions
to prevent or
reduce risk of
infection
Long Term:
the patient
shall have
achieved
timely wound
healing and
free from any
sign of
infection

- increased
temperature
-warm skin

infections.

be able to
achieve
timely
wound
healing and
free from
any sign of
infection

dressing or
caring wounds

lodge area of bacteria

>Keep area
around surgical
wound clean
and dry

>Assessing patient
may serve as a
baseline data and
contributing factors.

>Note risk
factors for the
occurrence of
infection

>Techniques in
avoiding the
occurrence of infection
could promote
patients wellness

>Instruct
patient in
techniques to
protect the
integrity of skin,
care for incision,
and prevention
of spread of
infection
>Assists patient
in administering

>To determine the

effectiveness of
therapy or presence of
side effects

medication
regimen and
note patients
response

Pain

Assessment
S=
O = The
patient may
manifest the
following:
-restlessness
-irritability
-verbal reports
of pain
-guarding
behavior
-changes in
blood pressure

Nursing
Diagnosis
Acute pain
related to
postoperative
laparoscopi
c
cholecyste
ctomy

Scientific
Explanati
on
External
and
internal
factor
aggravate
s the
nerve
endings in
the lower
extremity
causing
production
of
prostaglan

Objectives
Short term:
After 2-3
hours of
nursing
intervention
s, the
patient will
be able to
perform
comfort
measures
and relieve
pain.

Interventions
>Assess the
clients pain
scale and
perception

>Encourage
verbal report
during and after
the nursing
interventions.
>Monitor VS
and pain scale.

Rationale
>To identify the
intensity, onset,
duration and quality of
the pain.

Expected
Outcome

>Pain is highly
subjective and to
identify the
effectiveness of
interventions

Short term:
After 2-3 hours
of nursing
interventions,
the patient
shall have
performed
comfort
measures and
relieved pain.

>Obtain baseline VS,

VS changes during

Long term:
After 2-3 days
of nursing

and heart rate

-self-focusing

din,
bradykinin
,
histamine
and
progestero
ne to
react on
the
specific
region
causing
pain
sensation

Long term:
After 2-3
days of
nursing
intervention
s, the client
will be able
to have
more control
of the pain if
ever it
reoccurred.

onset of pain for future

comparison after
interventions
>To divert clients
attention on pain
>Teach client
diversional
activities

>Advise
breathing
exercise

interventions,
the client shall
have more
control of the
pain if ever it
reoccurred.

>To allow proper O2

supply in the body,
clients tend to stop
breathing during pain
>To relieve the client
of pain using
pharmacologic
intervention

>Administer
analgesics as
prescribed by
the physician.
Risk for Constipation
Assessment

Nursing
Diagnosis

Scientific
Explanati

Objectives

Interventions

Rationale

Expected
Outcome

on
S=
Risk for
Anesthesi
Constipatio a
O = The
n related to paralyzes
patient may
side effects the
manifest the
of
muscles.
following:
anesthesia The
-difficult
postintestine
passage of
operation.
is
stool
paralyzed
-hard, dry stool
during
-decreased
surgery
frequency of
along with
defecation
the arms
and legs.
This stops
the
muscle
contractio
ns to push
food along
the
intestinal
tract. Until
the
intestines
"wake up"
there is no
movement

Short term:
The patient
will be able
to verbalize
risk factors
and
appropriate
intervention
s to
overcome
the problem.

>Encourage
balanced fiber
and bulk in the
diet (if the
patient is not on
NPO)

Long term:
The patient
will be able
to
have/maintai
n a usual
pattern of
bowel
functioning.

>Encourage
light activities
within limits of
individual ability. >So client can respond
to urge of defecating.
>Provide
privacy and
routinely
scheduled time
>Provides a baseline
for defecation.
for comparison;
promotes recognition
>Ascertain
of changes.
frequency, color,
consistency,
amount of
stools.

>Promote
adequate fluid
intake

>To improve
consistency of stool
and facilitate passage
through colon.
>To promote soft stool
and stimulate bowel
activity.
>To stimulate
contractions of the
intestines.

Short term:
The patient
shall have
verbalized risk
factors and
appropriate
interventions to
overcome the
problem.
Long term:
The patient
shall
have/maintain
a usual pattern
of bowel
functioning.

of feces.

Activity Intolerance
Assessment
S=
O = The
patient may
manifest the
following:
-weakness
-fatigue
-restlessness
-irritability
-verbal reports
of pain
-discomfort
-pallor
-abnormal
heart rate or
BP response to
activity

Nursing
Diagnosis
Activity
intolerance
related to
bedrest/im
mobility
and effects
of
anesthesia
secondary
to postoperative
Laparoscop
ic
Cholecyste
ctomy

Scientific
Explanati
on
Effects of
anesthesia
postoperation
may alter
the
patients
activity
due to
paralysis
of some
organs or
parts of
the body.
Pain could
also
contribute
to the
problem
because

Objectives

Interventions

Rationale

Short term:
The patient
will be able
to
participate
willingly in
necessary or
desired
activities.

>Note presence
of factors
contributing to
fatigue.

>Fatigue affects both

the clients actual and
perceived ability to
participate in activities.

>Note clients
reports of
weakness,
fatigue, pain,
difficulty
accomplishing
tasks, and
insomnia.

Long term:
The patient
will
demonstrate
a decrease
in
physiological
signs of
>Ascertain
intolerance
ability to stand
(pulse,
and move

>Symptoms may be
result of/or contribute
to intolerance of
activity.

>To determine current

status and needs
associated with
participation in
needed/desired
activities.
>To reduce fatigue.

Expected
Outcome
Short term:
The patient
shall have
participated
willingly in
necessary or
desired
activities.
Long term:
The patient
shall have
demonstrated a
decrease in
physiological
signs of
intolerance
(pulse,
respiration,and
blood pressure

the
patient
may focus
more
attention
on the
pain felt
than doing
activities
like
eating,
etc.

respiration,a
nd blood
pressure
remain
within
clients
normal
range).

about.

>Plan care to
carefully
balance rest
periods with
activities.
>Provide
positive
atmosphere.
>Assist client
with activities.
>Promote
comfort
measures and
provide relief of
pain.
>Plan for
progressive
increase of
activity level as
tolerated by

remain within
clients normal
range).
>Helps minimize
frustration and
rechannel energy.
>To prevent injury.
>To enhance ability to
participate in activities.

>Both activity
tolerance and health
status may improve
with progressive
training.
>To enhance sense of
well-being.

client.
>Encourage
client to
maintain
positive
attitude,
suggest use of
relaxation
techniques.
Impaired Comfort
Assessment
S=
O = The
patient may
manifest:
-fatigue
-restlessness
-irritability
-discomfort
-altered
sleeping
pattern
-verbal reports

Nursing
Diagnosis
Impaired
comfort
related to
pain,
fatigue and
restlessnes
s
secondary
to postoperative
Laparoscop
ic
Cholecyste

Scientific
Explanati
on
Pain due
to the
operation
may
contribute
to the
patients
fatigue,
restlessne
ss and
altered
activity
and

Objectives

Interventions

Short term:
The patient
will be able
to verbalize
sense of
comfort or
contentment
.

>Determine the
type of
discomfort the
client is
experiencing.

Long term:
The patient
will be able
to engage in

>Discuss
concerns with
client and
active-listen to
identify
underlying

Rationale
>To identify proper
interventions or
activities to be
implemented.
>Helps determine
clients specific needs
and ability to change
own situation.
>Lack of control may
be related to other
issues or emotions

Expected
Outcome
Short term:
The patient
shall have
verbalized
sense of
comfort or
contentment.
Long term:
The patient
shall have
engaged in
behaviors or

of pain
-anxiety
-activity
intolerance

ctomy.

sleeping
pattern
which
results to
discomfort
of the
patient.
This may
lead to the
patient
not
showing
interest on
different
activities
and
focuses
attention
on self
and the
previous
surgery.

behaviors or
lifestyle
changes to
increase
level of
ease.

issues.
>Determine
how client is
managing pain
and pain
components.

such as fear, anxiety

and anger.
>This is an aspect that
can be manipulated to
enhance comfort.
>To determine possible
changes or options to
reduce side effects.

>Determine the
clients
environment.

>Review
medications or
treatment
regimen.

>Provide ageappropriate
comfort
measures.

>To provide nonpharmacological pain

management.

lifestyle
changes to
increase level
of ease.

V. Conclusion
Operating Room in the hospital setting gave me another experience
that I did not learn from the other wards or even in delivery room. I was
amazed on how they do the procedures without complications. They are calm
and find it usual. While I was a scrub nurse in this case, I was thinking that I
think I like to be an O.R. Nurse in the future. My clinical instructor was right,
being an O.R. Nurse is really fun and flexible. With this report, I can still
remember on how they did the procedure with the patient. I learned also that
we should really keep the sterile area a sterile. There should be alertness not
only at the beginning of the procedure but also before the procedure. With
the instruments, you should know them all and listen carefully on what the
surgeon asks for. Laparoscopic Cholecystectomy is being done depending on
the situation. In this surgical procedure, there might be risk such as internal
bleeding and the liver being cut. But there are also benefits that the patient
can get from this surgical procedure like less discomfort, quicker recovery
time and smaller scars in the abdomen. Cruz, Hazel Irish
Laparoscopic cholecystectomy has broadened my mind of the
possibilities of technology in medicine, especially surgery. It was not very
long ago that this particular surgery required one large incision rather than
three small ones. The procedure will save time of the surgeon and also
shorten the patients healing time. It also kept the sterility of the surgical area
intact because the procedure was not highly evasive. The surgery itself was
quick and the surgeons did not run into any complications. They were
completely at ease with the level of difficulty of the laparoscopic procedure.
The staff made sure to maintain the sterile area and all the tasks were done
in a timely and efficient manner. It was a very good surgery to witness as a
circulating scrub nurse. Garcia, Christina Beatriz

VII. References

http://www.surgeryencyclopedia.com/Ce-Fi/Cholecystectomy.html

http://www.surgery.usc.edu/divisions/tumor/PancreasDiseases/web
%20pages/BILIARY%20SYSTEM/laparoscopic%20chole.html

http://www.newyorkgeneralsurgery.com/cholecystectomy-newyork.html

http://www.webmd.com/digestive-disorders/laparoscopic-gallbladdersurgery-for-gallstones

http://my.clevelandclinic.org/services/laparoscopic_surgery/hic_laparos
copic_cholecystectomy.aspx

http://www.mhprofessional.com/downloads/products/0071453164/mint
er_ch11_p089096.pdfhttp://www.surgery.usc.edu/divisions/tumor/PancreasDiseases/w
eb%20pages/BILIARY%20SYSTEM/laparoscopic%20chole.html

http://www.mhprofessional.com/downloads/products/0071453164/mint
er_ch11_p089-096.pdf

http://emedicine.medscape.com/article/175667-overview#a0104

http://www.healthanddisease.com/english/diseases/stomach-andintestine/the-liver-gallbladder-and-pancreas/gallstones(cholecystolithiasis-and-choledocholithiasis)/