CHOLECYSTECTOMY

I. Definition/ description/ short introduction/ type/ category/ classification

A cholecystectomy is a surgical procedure to remove your gallbladder, a pear-shaped

organ that sits just below your liver on the upper right side of your abdomen. Your gallbladder

collects and stores bile — a digestive fluid produced in your liver. A cholecystectomy is a

common surgery, and it carries only a small risk of complications. In most cases, you can go

home the same day of your cholecystectomy. (Mayo Clinic, 2021)

A cholecystectomy is most commonly performed by inserting a tiny video camera and

special surgical tools through four small incisions to see inside your abdomen and remove the

gallbladder. Doctors call this a laparoscopic cholecystectomy. In some cases, one large incision

may be used to remove the gallbladder. This is called an open cholecystectomy. (Mayo Clinic,

2021)

Gallstone-related disease was the commonest cause of hospital admissions in the

developed world at the beginning of the 21st Century. In developed nations, gallstones affect 10–

20% of adults, of whom 80% are asymptomatic. The remainder can present with anything from

biliary colic, cholecystitis, cholangitis, choledocholithiasis (i.e., common bile duct [CBD] stones)

and gallstone pancreatitis, to rarer severe variants such as Mirizzi's syndrome, gangrenous,

haemorrhagic, or emphysematous cholecystitis. (Argiriov, Y. et al. 2020)

A cholecystectomy may be used to treat some cases of: 

 Gallbladder cancer. 

 Cholelithiasis (gallstones within the gallbladder). 

  Choledocholithiasis (gallstones within the bile duct). 

 Cholecystitis (inflammation of the gallbladder). 

 Pancreatitis (inflammation of the pancreas).

A cholecystectomy can be done in a few different ways, including:

 Simple Cholecystectomy: The gallbladder and some of the surrounding tissue is

removed. This is used in cases of early-stage cancers or non-cancerous issues. The

procedure can be done open or laparoscopically:

 Open Cholecystectomy: The gallbladder is removed through a large (about 6 inch)

abdominal incision (cut). This is not the preferred method when cancer is known or

suspected. Most patients will have an extended cholecystectomy in these cases.

 Laparoscopic Cholecystectomy: Many small incisions (cuts) are made in the belly. A

laparoscope (lighted tube), placed through the incisions, is used to remove the

gallbladder. This method is not used when gallbladder cancer is known or suspected.

 Extended (Radical) Cholecystectomy: Often, an extended cholecystectomy is used for

patients with gallbladder cancer to decrease the risk of recurrence. This involves

removing the gallbladder, part of the liver, and several lymph nodes. In some cases, a

more extensive operation may be needed to remove any of the following: a larger portion

of the liver (wedge resection), an entire liver lobe (hepatic lobectomy), the common bile

duct, certain ligaments, additional lymph nodes, the pancreas, the duodenum and any

other areas where the disease is found.

II. Nursing and Medical management/ preparations for the procedure/ Nursing
considerations
Nursing management:
 Assess the vital signs frequently and inform the doctor if there is any abnormality.
 Assess abdominal pain through physical examination, nausea, and vomiting.
 Start IV fluid and pain medications as prescribed. 
 Prepare the patient for the operative room by keeping him NPO, teach the patient about
the procedure steps, and about the postoperative management. 
 Place the patient in a semi-fowlers position.
 Monitor laboratory data and report if there is any abnormality.
 Ensure a pregnancy test done if the patient is female.
 Teach the patient that they will probably experience pain to their right shoulder due to
insufflation of air during a lap-chole procedure and should increase activity (such as
walking as tolerated) to assist with reducing this pain.
Medical Management:
Management may involve controlling the signs and symptoms and the inflammation of the
gallbladder.
 Fasting. The patient may not be allowed to drink or eat at first in order to take the stress
off the inflamed gallbladder; IV fluids are prescribed to provide temporary food for the
cells.
 Supportive medical care. This may include restoration pf hemodynamic stability and
antibiotic coverage for gram-negative enteric flora.
 Gallbladder stimulation. Daily stimulation of gallbladder contraction with IV
cholecystokinin may help prevent the formation of gallbladder sludge in patients
receiving TPN.
Pharmacologic Therapy
The following medications may be useful in patients with cholecystitis:
 Antibiotic therapy. Levofloxacin and Metronidazole for prophylactic antibiotic
coverage against the most common organisms.
 Promethazine or Prochlorperazine may control nausea and prevent fluid and electrolyte
disorders.
 Oxycodone or Acetaminophen may control inflammatory signs and symptoms and
reduce pain.
Preparations for the procedure:
Before the procedure
A cholecystectomy is performed using general anesthesia, so you won't be aware during the
procedure. Anesthesia drugs are given through a vein in your arm. Once the drugs take effect,
your health care team will insert a tube down your throat to help you breathe. Your surgeon then
performs the cholecystectomy using either a laparoscopic or open procedure.
During the procedure
Depending on your situation, your surgeon will recommend one of two surgical approaches:
Minimally invasive (laparoscopic) cholecystectomy
During a laparoscopic cholecystectomy, the surgeon makes four small incisions in your
abdomen. A tube with a tiny video camera is inserted into your abdomen through one of the
incisions. Your surgeon watches a video monitor in the operating room while using surgical tools
inserted through the other incisions in your abdomen to remove your gallbladder.
Next you may undergo an imaging test, such as an X-ray or ultrasound, if your surgeon is
concerned about possible gallstones or other problems in your bile duct. Then your incisions are
sutured, and you're taken to a recovery area. A laparoscopic cholecystectomy takes one or two
hours.
A laparoscopic cholecystectomy isn't appropriate for everyone. In some cases your surgeon may
begin with a laparoscopic approach and find it necessary to make a larger incision because of
scar tissue from previous operations or complications.
Traditional (open) cholecystectomy
During an open cholecystectomy, the surgeon makes a 6-inch (15-centimeter) incision in your
abdomen below your ribs on your right side. The muscle and tissue are pulled back to reveal
your liver and gallbladder. Your surgeon then removes the gallbladder.
The incision is sutured, and you're taken to a recovery area. An open cholecystectomy takes one
or two hours.
After the procedure
You'll be taken to a recovery area as the anesthesia drugs wear off. Then you'll be taken to a
hospital room to continue recovery. Recovery varies depending on your procedure:
 Laparoscopic cholecystectomy. People are often able to go home the same day as their
surgery, though sometimes a one-night stay in the hospital is needed. In general, you can
expect to go home once you're able to eat and drink without pain and are able to walk
unaided. It takes about a week to fully recover.
 Open cholecystectomy. Expect to spend two or three days in the hospital recovering.
Once at home, it may take four to six weeks to fully recover.
Nursing Considerations:
Health Teaching and Health Promotion
 Avoid foods high in fat and maintain healthy diet.
 Avoid foods that cause gas like carbonated beverages, coffee
Discharge Planning
Once the gallbladder has been removed, most patients can be discharged on the same day.
The pain is minimal and can be managed by over the counter analgesics. The patient may
complain of severe shoulder pain due to retained CO2 from laparoscopic insufflation and should
be explained that such pain will dissipate as patient moves and gas is slowly absorbed, which can
take up to three days.
Prior to discharge, the patient should be advised on possible intolerance to greasy food, which
may cause bloating or diarrhea.  This can be temporary or, at some degree permanent, due to the
decreased speed of fat emulsification by the loss of stored bile in the gallbladder. Most patients
will have an up-regulation in bile production by the liver and will see improvement in symptoms
with time. 
Follow up time is between 3-4 weeks from operation. 
Ill. Current Trends and Issue of the procedure/ New innovations
 Initial Experience with a New Robotic Surgical System for Cholecystectomy
(Aggarwal, R. et al. 2019)
Background. Laparoscopic cholecystectomy has been the gold standard treatment for
symptomatic cholelithiasis for more than 3 decades. Robotic techniques are gaining traction in
surgery, and recently, the Senhance ™ robotic system was introduced. The system offers
advantages over other robotic systems such as improved ergonomics, haptic feedback, eye
tracking, and usability of standard laparoscopic trocars and reusable instruments. The Senhance
was evaluated to understand the feasibility, benefits, and drawbacks of its use in
cholecystectomy. 

Study Design. A prospectively maintained database of the first 20 patients undergoing

cholecystectomy with the Senhance was reviewed at a single hospital. Data including operative
time, console time, set up time, and adverse events were collected, with clinical outcome and
operative time as primary outcome measures. A cohort of 20 patients having laparoscopic
cholecystectomy performed by the same surgeon was used as a comparator group. 

Results. The 2 groups had comparable demographic data (age, sex, and body mass index). In the
Senhance group, 19 of the 20 procedures (95%) were completed robotically. The median
(interquartile range) total operating, docking, and console times were 86.5 (60.5-106.5), 11.5 (9-
13), and 30.8 (23.5-35) minutes, respectively. In the laparoscopic group, the median
(interquartile range) operating time was 31.5 (26-41) minutes. Postoperatively, only one patient
had a surgical complication, namely a wound infection treated with antibiotics. 

Conclusion. Our results suggest that Senhance-assisted cholecystectomy is safe, feasible, and
effective, but currently has longer operative times. Further prospective and randomized trials are
required to determine whether this approach can offer any other benefits over other minimally
invasive surgical techniques.

Robotic cholecystectomy using Senhance robotic platform versus laparoscopic conventional

cholecystectomy: a propensity score analysis
(Samalavicius, N. et al. 2021)
Introduction: Our study objective was to evaluate differences in intraoperative and postoperative
outcomes of robotic cholecystectomy (RC) using Senhance robotic platform vs laparoscopic
cholecystectomy (LC).

Material and methods: A retrospective case - matched analysis was performed for all patients
who underwent cholecystectomy from November 2018 to November 2019. RC cases were
matched to LC. RC was performed using Senhance robotic platform. Propensity score matching
analysis with a ratio of 1:1 (RC: LC) was performed. The groups were matched according to age,
sex, body mass index (BMI). All procedures were performed by two same experienced robotic
surgeons at Klaipeda University Hospital (O.D. and V.E.). Age, BMI, operative time, blood loss
and length of hospital stay were collected and analysed between those patient groups.

Results: A total of 40 patients underwent RC or LC. There were no statistical differences

between groups in concern of length of hospital stay, blood loss or complications. There were no
bile duct injuries in either group, no intraoperative complications, no conversions either RC to
LC or LC to open surgery. One patient in robotic group was reoperated on postoperative day 5
regarding sub-hepatic haematoma. The only statistical significance was in operative time
(p < .05) which was longer in RC group. Median docking time was 12 min (range 5-23).

Conclusions: Robotic cholecystectomy using Senhance robotic platform appears to be safe in

comparison with laparoscopic cholecystectomy. Laparoscopic cholecystectomy might be feasible
in gaining robotic surgery skills.

Intraoperative and postoperative outcomes of robot-assisted cholecystectomy: a systematic

review
(Shenoy, R. et al. 2021)
Background: Rapid adoption of robotic-assisted general surgery procedures, particularly for
cholecystectomy, continues while questions remain about its benefits and utility. The objective
of this study was to compare the clinical effectiveness of robot-assisted cholecystectomy for
benign gallbladder disease as compared with the laparoscopic approach.

Methods: A literature search was performed from January 2010 to March 2020, and a narrative
analysis was performed as studies were heterogeneous.

Results: Of 887 articles screened, 44 met the inclusion criteria (range 20–735,537 patients). Four
were randomized controlled trials, and four used propensity-matching. There were variable
comparisons between operative techniques with only 19 out of 44 studies comparing techniques
using the same number of ports. Operating room time was longer for the robot-assisted technique
in the majority of studies (range 11–55 min for 22 studies, p < 0.05; 15 studies showed no
difference; two studies showed shorter laparoscopic times), while conversion rates and
intraoperative complications were not different. No differences were detected for the length of
stay, surgical site infection, or readmissions. Across studies comparing single-port robot-assisted
to multi-port laparoscopic cholecystectomy, there was a higher rate of incisional hernia;
however, no differences were noted when comparing single-port robot-assisted to single-port
laparoscopic cholecystectomy.

Conclusions: Clinical outcomes were similar for benign, elective gallbladder disease for robot-
assisted compared with laparoscopic cholecystectomy. Overall, the rates of complications were
low. More high-quality studies are needed as the robot-assisted technique expands to more
complex gallbladder disease, where its utility may prove increasingly beneficial.

References;
https://systematicreviewsjournal.biomedcentral.com/articles/10.1186/s13643-021-01673-x
https://pubmed.ncbi.nlm.nih.gov/31771424/
https://journals.sagepub.com/doi/abs/10.1177/1553350619890736
https://www.mayoclinic.org/tests-procedures/cholecystectomy/about/pac-20384818
https://www.frontiersin.org/articles/10.3389/fsurg.2020.00042/full
https://www.oncolink.org/cancers/gastrointestinal/gallbladder-cancer/surgical-procedures-
cholecystectomy