LAPAROSCOPY CHOLECYSTECTOMY FOR GALL BLADDER DISEASE

laparoscopy Cholecystectomy

The Condition

Cholecystectomy is the surgical removal of the gallbladder. The operation is done to remove the gallbladder due to gallstones causing pain or infection.

symptoms

Sharp pain in the upper right part of the abdomen that may go to the back, mid abdomen, or right shoulder

Low fever

Nausea and feeling bloated

Jaundice (yellowing of the skin) if stones are blocking the common bile duct

Treatment Options

Surgical procedure

laparoscopic cholecystectomy—The gallbladder is removed with instruments placed into small incisions in the abdomen. Open cholecystectomy—The gallbladder is removed through an incision on the right side under the rib cage

non-Surgical procedure

Stone retrieval by endoscopy

For Gallstones without Symptoms

Watchful waiting for all patients

Increased exercise

Benefits and Risks of the Operation

Benefits—

Gallbladder removal will relieve pain, treat infection, and, in most cases, stop gallstones from coming back.

Possible risks include—

Bile leak, bile duct injury, bleeding, infection of the abdominal cavity (peritonitis), fever, liver injury, infection, numbness, raised scars, hernia at the incision, anesthesia complications, puncture of the intestine, and death.

Risks of not having an operation—

The possibility of continued pain, worsening symptoms, infection or bursting of the gallbladder, serious illness, and possibly death.

Expectations

Before your operation—

Evaluation usually in cludes blood work,urinalysis, and an abdominal CT scan,orab dominal ultrasound. Your surgeon and anesthesia provider will review your heal this story, medications, and options for pain control. The day of your operation—You will not be allowed to eat or drink while your being value ted for an emergency appendectomy.Your recovery—If you have no complications, you usually can go home in 1or 2 days after a laparoscopic or open procedure.Call your surgeon if you are in severe pain, have stomach cramping, a high fever, odor or increased drainage from your incision, or no bowel movements for 3days.

The day of your operation—

You will not eat for 4 hours but may drink clear liquids up to 2 hours before the operation. Most often, you will take your normal medication with a sip of water. You will need someone to drive you home.

Your recovery—

If you do not have complications, you usually will go home the same day after a laparoscopic procedure or in 1 to 2 days after an open procedure.

Call your surgeon

if you have severe pain, stomach cramping, chills, a high fever (over 101°F or 38.3°C), odor or increased drainage from your incision, your skin turns yellow, no bowel movements for three days, or vomiting and the inability to keep fluids down..

The Condition,Signsand Symptoms,and Diagnostic Tests

The Condition

The Gallbladder

The gallbladder is a small pear-shaped organ under the liver. The liver makes about 3 to 5 cups of bile every day. Bile helps in digesting fats and is stored in the gallbladder. When fatty foods are eaten, the gallbladder squeezes bile out through the duct and into the small intestine.

Gallstones

Gallstones are hardened digestive fluid that can form in your gallbladder. The medical term for gallstone formation is cholelithiasis. Gallstones can leave the gallbladder and block the flow of bile to the ducts and cause pain and swelling of the gallbladder. A gallstone in the common bile duct is called choledocholithiasis.

Cholecystitis is inflammation of the gallbladder, which can happen suddenly (acute) or over a longer period of time (chronic

Gallstone Pancreatitis is caused by stones moving into and blocking the common bile duct, the pancreatic duct, or both. A cholecystectomy may be recommended

Cholecystectomy is the surgical removal of the gallbladder. Gallstones that cause biliary colic (acute pain in the abdomen caused by spasm or blockage of the cystic or bile duct) are the most common reason for a cholecystectomy

Symptoms?

The most common symptoms of cholecystitis are

Sharp pain in the right abdomen

Low fever

Nausea and bloating

Jaundice (yellowing of the skin) may occur if gallstones are in the common bile duc

Common Tests

History and Physical Exam

Your healthcare provider will ask you about your pain and any stomach problems.

Additional Tests (see Glossary)

Other tests may include

Blood tests, including complete blood count right abdomen

Liver function tests

Coagulation profile

Abdominal ultrasound is the most common study for gallbladder disease. 1-2 You may be asked not to eat for 8 hours before the test.

Hepatobiliary iminodiacetic acid scan (HIDA scan)

Endoscopic retrograde cholangiopancreatography (ERCP)

Magnetic resonance cholangiopancreatography (MRCP)

Keeping You Informed

Most adults with gallstones do not have symptoms. Eighty percent of people with gallstones go 20 years without symptoms.

Gallstones are more common in people who

Are Native American

• Have a family history of gallstones

• Are overweight

• Have sickle cell disease

• Are pregnant

• Lose weight rapidly

• Use estrogen to manage menopause

Gallbladder pain or biliary colic is usually temporary. It starts in the middle or the right the side of the abdomen and can last from 30 minutes to 24 hours. The pain may occur after eating a fatty meal

• Acute cholecystitis pain lasts longer then 6 hours, and there is abdominal tenderness and fever.

• Pain on the right side of the abdomen can also be from ulcers, liver problems, and heart pain.

• Standard treatment of acute cholecystitis is intravenous (IV) fluids, pain medication, and cholecystectomy

The Surgical and Nonsurgical Treatment

Surgical Treatment

A cholecystectomy, or removal of the the gallbladder is the recommended operation for gallbladder pain from gallstones.

Laparoscopic Cholecystectomy

Surgical Treatment This technique is the most common for simple cholecystectomy. The surgeon will make several small incisions in the abdomen. Ports (hollow tubes) are inserted into the openings. Surgical tools and a lighted camera are placed into the ports. The abdomen is inflated with carbon dioxide gas to make it easier to see the internal organs. The gallbladder is removed, and the port openings are closed with sutures, surgical clips, or glue. Your surgeon may start with a laparoscopic technique and need to change (convert) to an open laparotomy technique. The procedure takes about 1 to 2 hours.

Open Cholecystectomy

A cholecystectomy, or removal of the gallbladder, is the recommended operation for gallbladder pain from gallstones. The surgeon makes an incision approximately 6 inches long in the upper right side of the abdomen and cuts through the fat and muscle to the gallbladder. The gallbladder is removed, and any ducts are clamped off. The site is stapled or sutured closed. A small drain may be placed going from the inside to the outside of the abdomen. The drain is usually removed in the hospital. The procedure takes about 1 to 2 hours.

Nonsurgical Treatment

watchful waiting is recommended if you have gallstones but do not have symptoms. About 1 in 5 newly diagnosed patients with acute cholecystitis who do not have surgery readmit to the emergency room within about 12 weeks.

Gallstones only, without cholecystitis

Increase your exercise. Exercising 2 to 3 hours a week reduces the risk of gallstones.

Eat more fruit and vegetables, and eat less of foods high in sugars and carbohydrates like donuts, pastry, and white bread.

Cholecystitis in Children

Four of 100 gallbladder removals are done in children. Almost 70% of children with gallstones do have symptoms. Symptoms in children include abdominal pain, nausea, vomiting, jaundice, fatty food intolerance, and fever. Children also receiving continuous IV nutrition and those with long-term antibiotic use, cystic fibrosis, obesity, or a family history have a higher chance of developing gallstones. Nearly 50% of all children with sickle cell disease develop gallstones and should have a screening ultrasound. Children with cholecystitis confirmed by ultrasound, those with severe pain, or those not able to take food or fluids should be evaluated for surgery


Keeping You Informed

• Conversion rates from a laparoscopic to an open a technique is less than 1% for young healthy people

• Conversion rates from laparoscopic to open range from 1.3% to 7.4% in the presence of common bile duct stones.

• the risk of conversion increases up to 30% if you are over 50 years old, are male and have acute cholecystitis; have had past abdominal operations; or have a high fever, high bilirubin, repeated gallbladder attacks, or conditions that limit your activity

Risks of this Procedure

Risks Based on the ACS Risk Calculator

Risks Percent for Average Patient Keeping You Informed
Pneumonia: Infection in the lungs Open 1.7% Laparoscopic 0.2% You can decrease your risk by rinsing with mouthwash the morning of your operation (to decrease mouth bacteria), quitting smoking before your operation, and getting up often to walk post-operatively.
Heart complication: Heart attack or sudden stopping of the heart Open 0.7% Laparoscopic 0.1% Problems with your heart or lungs can be affected by general anesthesia. Your anesthesia provider will take your history and suggest the best option for you
Wound infection Open 7.6% Laparoscopic 1% Antibiotics are not routinely given except for high-risk patients. You should wash your abdomen with an antimicrobial soap such as dial the night before the operation
Urinary tract infection: Infection of the bladder or kidneys Open 1.5% Laparoscopic 0.5% A Foley catheter is placed during surgery to drain the urine. Let your the surgical team know if you have trouble urinating after the tube is removed—this is more common in older men or if an epidural is used for pain
Blood clot: A blood clot in the legs can travel to the lung Open 1% Laparoscopic 0.2% Longer surgery and bed rest increases the risk. Walking 5 times/day and wearing support stockings reduce the risk.
Renal (kidney) failure: Kidneys no longer function in making urine and/or cleaning the blood of toxins Open 0.9% Laparoscopic 0.1% Pre-existing renal problems, Type 1 diabetes, being over 65 years old, and other medications may increase the risk.
Return to surgery Open 3.3 % Laparoscopic 0.8% Bile leakage or a retained stone may cause a return to surgery. Your the surgical team is prepared to reduce all risks of the return to surgery.
Death Pneumonia: Infection in the lungs Open 0.8% Laparoscopic 0.1% Your surgical team will review for possible complications and be prepared to decrease all risks.
discharge to nursing or rehabilitation facility Open 5.4% Laparoscopic 0.6% Pre-existing health conditions can increase this risk.
Bile Duct Injury/Leakag 0.5% Bile Duct Injury/Leakage 1,16 Injury can happen between 1 week to 6 months after the operation from fever, pain, jaundice, or bile leakage from the incision. Further testing and surgery may be needed

Expectations: Preparing for Your Operation

Preparing for Your Operation

Home Medication

Bring a list of all of the medications and vitamins that you are taking, including blood thinners, aspirin, or NSAIDS, and inform your surgical team. Some medications can affect your recovery and response to anesthesia and may have to be adjusted before and after surgery. Most often, you will take your morning medication with a sip of water. Resources about medications can be found at.

Anesthesia

Let your anesthesia provider know if you have allergies, neurologic disease (epilepsy, stroke), heart disease, stomach problems, lung disease (asthma, emphysema), endocrine disease (diabetes, thyroid conditions), or loose teeth; if you smoke, drink alcohol, use drugs, or take any herbs or vitamins; or if you have a history of nausea and vomiting with anesthesia.

Lenght of stay

If you have a laparoscopic cholecystectomy, you will usually go home the same day. You may stay overnight if you had an open removal of the gallbladder, a laparoscopic repair with a longer anesthesia time, post-anesthesia issues such as severe nausea and vomiting or you are unable to pass urine

The Day of Your Operation

Do not eat for 4 hours or drink anything but clear liquids for at least 2 hours before the operation.

Shower and clean your abdomen and groin area with a mild antibacterial soap.

Brush your teeth and rinse your mouth out with mouthwash.

Do not shave the surgical site; your surgical team will clip the hair nearest the incision site.

What to Bring

Insurance card and identification

Advance directives (see Glossary)

List of medicines

Loose-fitting, comfortable clothes

Slip-on shoes that don’t require that you bend over

Leave jewelry and valuables at home

What You Can Expect

An identification (ID) bracelet and allergy bracelet with your name and hospital/ clinic number will be placed on your wrist. These should be checked by all health team members before they perform any procedures or give you medication. Your surgeon will mark and initial the operation site

fluide and Anesthesia

An intravenous line (IV) will be started to give you fluids and medication. For general anesthesia, you will be asleep and pain-free. A tube will be placed in your throat to help you breathe during the operation. For spinal anesthesia, a small needle with medication will be placed on your back near your spinal column

After Your Operation

You will be moved to a recovery room where your heart rate, breathing rate, oxygen saturation, blood pressure, and urine output will be closely watched. Be sure that all visitors wash their hands.

Preventing Pneumonia and Blood Clots

Movement and deep breathing after your operation can help prevent postoperative complications such as blood clots, fluid in your lungs, and pneumonia. Every hour, take 5 to 10 deep breaths and hold each breath for 3 to 5 seconds. When you have an operation, you are at risk of getting blood clots because of not moving during anesthesia. The longer and more complicated your surgery, the greater the risk. This risk is decreased by getting up and walking 5 to 6 times per day, wearing special support stockings or compression boots on your legs, and, for high-risk patients, taking a medication that thins your blood.

Questions to Ask


About My Operation:

What are the side effects and risks of anesthesia?

What type of procedure will be used to remove the gallbladder— laparoscopic or open?

Ask your surgeon how frequently they perform this procedure?

What are the risks of this procedure for myself or my child

What level of pain should I expect, and how will it be managed?

How long will it be before I can return to my normal activities (work, driving, lifting)?

Your Recovery and Discharge

Your Recovery and Discharge

Thinking Clearly

If general anesthesia is given or if you are taking narcotic pain medication, it may cause you to feel different for 2 or 3 days, have difficulty with memory, or feel more fatigued. You should not drive, drink alcohol, or make any big decisions for at least 2 days.

Nutrition

When you wake up, you will be able to drink small amounts of liquid. If you do not feel sick, you can begin eating regular foods.

Continue to drink lots of fl uids, usually about 8 to 10 glasses per day.

Eat a high-fiber diet so you don’t strain during bowel movements.

Activity

Slowly increase your activity. Be sure to get up and walk every hour or so to prevent blood clots.

ContDo not lift or participate in strenuous activity for 3 to 5 days for laparoscopic and 10 to 14 days for open procedure.

You may go home in 1 to 2 days for a laparoscopic repair. If your appendix ruptured or you have other health issues or complications, you may stay longer.

It is normal to feel tired. You may need more sleep than usual.

Work and Return to School

You may usually return to work 1 week after laparoscopic or open repair, as long as you don’t do any heavy lifting. Discuss the timing with your surgeon.

Do not lift items heavier than 10 pounds or participate in strenuous activity for at least 4 to 6 weeks.

Wound Care

Always wash your hands before and after touching near your incision site.

Do not soak in a bathtub until your stitches or Steri-Strips are removed. You may take a shower after the second postoperative day unless you are told not to.

Always wash your hands before and after touching near your incision site.

Do not soak in a bathtub until your stitches or Steri-Strips are removed. You may take a shower after the second post operative day unless you are told not to.

Follow your surgeon’s instructions on when to change your bandages.

A small amount of drainage from the incision is normal. If the drainage is thick and yellow or the site is red, you may have an infection, so call your surgeon.

If you have a drain in one of your incisions, it will be taken out when the drainage stops.

Steri-Strips will fall off in 7 to 10 days or they will be removed during your first office visit.

If you have a glue-like covering over the incision, allow the glue to fl ake off on its own.

Avoid wearing tight or rough clothing. It may rub your incisions and make it harder for them to heal.

Protect the new skin, especially from the sun. The sun can burn and cause darker scarring.

Your scar will heal in about 4 to 6 weeks and will become softer and continue to fade over the next year.

Sensation around your incision will return in a few weeks or months.

Bowel Movements

After intestinal surgery, you may have loose watery stools for several days. If watery diarrhea lasts longer than 3 days, contact your surgeon.

Pain medication (narcotics) can cause constipation. Increase the fiber in your diet with high-fiber foods if you are constipated. Your surgeon may also give you a prescription for a stool softener.

Pain

The amount of pain is different for each person. Some people need only 1 to 3 doses of pain control medication, while others need more.

Home Medications

The medicine you need after your operation is usually related to pain control.

When to Contact Your Surgeon

Contact your surgeon if you have:

Pain that will not go away

Pain that gets worse

A fever of more than 101°F or 38.3°C

Continuous vomiting

Swelling, redness, bleeding, or bad-smelling drainage from your wound site

Strong or continuous abdominal pain or swelling of your abdomen

No bowel movement 2 to 3 days after the operatio

Pain control

Everyone reacts to pain in a different way. A scale from 0 to 10 is used to measure pain. At a “0,” you do not feel any pain. A “10” is the worst pain you have ever felt. Following a laparoscopic procedure, pain is sometimes felt in the shoulder. This is due to the gas inserted into your abdomen during the procedure. Moving and walking help to decrease the gas and the right shoulder pain

Extreme pain puts extra stress on your body at a time when your body needs to focus on healing. Do not wait until your pain has reached a level “10” or is unbearable before telling you, doctor or nurse. It is much easier to control pain before it becomes severe.

Common Medicines to Control Pain

Narcotics or opioids are used for severe pain. Possible side effects of narcotics are sleepiness, lowered blood pressure, heart rate, and breathing rate; skin rash and itching; constipation; nausea; and difficulty urinating. Some examples of narcotics include morphine and codeine.

Non-Narcotic Pain Medication

Most non-opioid analgesics are classified as non-steroidal anti-inflammatory drugs (NSAIDs). They are used to treat mild pain and inflammation or can be combined with narcotics to treat severe pain. Possible side effects of NSAIDs are stomach upset, bleeding in the digestive tract, and fluid retention. These side effects usually are not seen with short-term use. Let your doctor know if you have heart, kidney, or liver problems. Examples of NSAIDs include ibuprofen, Motrin®, Aleve®, and Toradol® (given as a shot).

Pain Control without Medicine

Splinting your stomach by placing a pillow over your abdomen with firm pressure before coughing or movement can help reduce the pain.

Distraction helps you focus on other activities instead of your pain. Listening to music, playing games, or other engaging activities can help you cope with mild pain and anxiety. Splinting Your Stomach

Guided imagery helps you direct and control your emotions. Close your eyes and gently inhale and exhale. Picture yourself in the center of somewhere beautiful. Feel the beauty surrounding you and your emotions coming back to your control. You should feel calmer.