LAPAROSCOPIC CHOLECYSTECTOMY

PRESENTED BY

THEATRE NURSING SERVICES

NR. OLABINTAN K

NR. OYEKUNLE I.O

NR. ASHLEY-OSUZOKA C.I

NR. OZOEMENA E

NR. ORELARU F.A

NR. OMONISAYE C

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TABLE OF CONTENTS
Title Page 1
Table of Contents 2
Objectives 3
Anatomical Overview 4-7
Overview of Pathology of Cholecystitis 8
Clinical Manifestations 9
Causes of Cholecystitis 9
Incidence of Cholecystitis 10-11
Diagnostic investigations 12
Treatment 13
Surgical Preparations 14-19
Laparoscopic Surgery (Advantages & Disadvantages 20-22
Prevention of cholecystitis 23
Complication of Cholecystitis 24
Case Study 25-27
Perioperative Client Management 28
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Investigation/Results 29
Preoperative Preparation 30

Postoperative care 31-35

Nursing Care Plan 36-45

Summary & Recommendation 46

References 47

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OBJECTIVES

- To educate Nurses on causes, prevention and management of Cholecystitis

- To educate Nurses on Laparoscopic management of cholecystitis
- To enlighten Nurses on importance of minimally invasive surgeries (laparoscopic surgery)
- To broaden Nurses knowledge on available surgical options (laparoscopic surgery)
- To educate Nurses on new innovations in surgical management (minimally invasive surgeries)

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INTRODUCTION

Laparoscopic cholecystectomy, a minimally invasive surgical procedure, has revolutionized the management of gallbladder diseases
worldwide since its inception in the late 1980s. This technique, also known as keyhole or minimally invasive surgery, has become the
gold standard for the treatment of symptomatic gallstones and other gallbladder-related conditions.

The gallbladder, a small organ located beneath the liver, plays a crucial role in the digestive process by storing and releasing bile to aid
in the digestion of fats. However, when gallstones form within the gall bladder (Cholelithiasis) or when the organ becomes inflamed (a
condition known as cholecystitis), it can lead to significant discomfort and complications for the patient.

Traditional open cholecystectomy, involving a large abdominal incision, was once the primary approach for gallbladder removal.
However, the advent of laparoscopic techniques has dramatically transformed surgical management by offering patients a less invasive
alternative with numerous advantages, including reduced postoperative pain, shorter hospital stays, faster recovery times, and
improved cosmetic outcomes.

This presentation provides an overview of the laparoscopic cholecystectomy procedure, detailing its key steps, indications, patient
preparation, surgical techniques, potential complications, and pre, intra and postoperative care. Understanding the intricacies of this
minimally invasive approach is crucial for both healthcare professionals, nurses inclusive involved in its execution and patients
undergoing the procedure.

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INCIDENCE OF CHOLECYSTITIS

The global incidence of cholecystitis, which is inflammation of the gallbladder, can vary depending on factors such as population
demographics, prevalence of risk factors such as gallstones, and access to healthcare. About 15% of the world’s population has
gallstones, and about 20% of these will have complications from gallstones, which include cholecystitis. Gallstones cause 95% of all
cholecystitis cases.

Developed countries: In developed countries, more than 85% of gallstones are cholesterol stones. Approximately 20 million people in
the USA (about 15% of the population) have gallstones. The prevalence is higher in Mexican Americans than in non-Hispanic whites
and lower in non-Hispanic blacks. American Indians (specifically the Pima tribe from Arizona) have an extraordinarily high
prevalence of gallstones.

Europe: Ultrasound studies in Europe revealed a prevalence of 9% to 21% and an incidence of 0.63/100 persons/year.

Japan: Japan has seen an increased proportion of cholesterol stones and a higher gallstone prevalence (around 10%).

Southeastern Asia: The prevalence of gallstones (mostly brown pigment stones) is low.

Africa: Gallstone prevalence rates are even lower in Africa.

Southeastern Asia: The prevalence of gallstones (mostly brown pigment stones) is low.

5 YEARS INCIDENCE OF LAPAROSCOPIC CHOLECYSTECTOMY IN LUTH

2019: 7 patients had the procedure done (5 females, 2 males)

2020: 5 patients done due to the covid 19 experience (4 females, 3 males)

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2021: 15 patients done (10 females, 5 males)

2022: 14 patients done (8 females, 6 males)

2023: 13 patients done (9 females, 4 males)

Considerations for this procedure were based on patients’ demographics, duration of symptoms, indications for surgery, procedure
performed, duration of surgery, length of hospital stay and morbidity and mortality data. The age range was from 15 to 78 years with
the peak age of presentation in the fourth decade and the most common indication been biliary colic. An instance of open re-
exploration occurred because of a duodenal injury, no biliary injury during procedure and no indication for common bile duct
exploration. No long-term morbidity or mortality. It was conclusively reported that laparoscopic cholecystectomy in our environment
is safe and feasible with results comparable to other centers.

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ANATOMICAL OVERVIEW

THE GALLBLADDER

The gallbladder is a small, pear-shaped organ located beneath the liver, in the right upper quadrant of the abdomen. It measures about
7.5-10cm long and round 2.5cm wide (varies among individuals). Its main parts include the neck, body, and fundus. Its main function
is to store and concentrate bile, a digestive fluid produced by the liver. When food containing fats enters the small intestine, a hormone
called cholecystokinin is released, signaling the gallbladder to contract and release bile into the intestine to aid in digestion. It has a
capacity of about 30-50mm when full.

Location: The gallbladder is situated on the undersurface of the liver, in the right upper quadrant of the abdomen, beneath the rib cage.

Structure: It has a pear-like shape and consists of three main parts: the fundus (the rounded bottom), the body (the main portion), and
the neck (which connects to the cystic duct).

Blood Supply: It receives its blood supply primarily from the cystic artery, a branch of the hepatic artery. Venous drainage occurs
through the cystic vein, which usually drains into the portal vein.

Bile Ducts: The gallbladder is connected to the liver and the small intestine through a network of bile ducts. The cystic duct connects
the gallbladder to the common hepatic duct, forming the common bile duct. The common bile duct then joins with the pancreatic duct
to empty its contents into the duodenum (the first part of the small intestine) at the ampulla of Vater.

Function: Its main function is to store and concentrate bile produced by the liver. Bile helps in the digestion of fats by emulsifying
them, making it easier for enzymes to break them down during digestion.

Bile Composition: Bile is composed of water, electrolytes, bile salts, cholesterol, bilirubin (a breakdown product of red blood cells),
and phospholipids.

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Muscular Wall: The gallbladder has a muscular wall composed of smooth muscle tissue, which contracts to release bile into the small
intestine when needed for digestion.

Diagram 1. Gall bladder

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Diagram 2. The liver and the surrounding structures

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OVERVIEW OF PATHOLOGY OF CHOLECYSTITIS

The two most common diseases of biliary tree are; Cholelithiasis and cholecystitis.

Cholelithiasis is the stone (calculi) formation in the gall bladder. It may occur alone but usually occur simultaneously with
cholecystitis while cholecystitis is a condition characterized by inflammation of the gallbladder. This inflammation can occur acutely
or chronically and is often associated with the presence of gallstones obstructing the cystic duct, although it can also be caused by
other factors. Here's an overview of the pathology of cholecystitis

Gallstones: The most common cause of cholecystitis is the presence of gallstones, also known as cholelithiasis. Gall stones are
formed as a result of cholesterol, bile salts and calcium. It is often Gallstones can obstruct the cystic duct, preventing bile from
flowing out of the gallbladder. This obstruction leads to an accumulation of bile within the gallbladder, causing distention and
pressure buildup, which can lead to inflammationaltered so that the bile is super saturated leading to precipitation and formation of
stones.

Ischemia: In addition to gallstones, cholecystitis can also occur due to ischemia (reduced blood flow) to the gallbladder. Ischemic
cholecystitis can result from conditions such as systemic hypotension, shock, or vascular diseases affecting the blood supply to the
gallbladder.

Bacterial Infection: In some cases, cholecystitis may be associated with bacterial infection of the gallbladder. Bacteria can enter the
gallbladder either through the bloodstream or from the gastrointestinal tract, particularly in cases of prolonged obstruction or stasis of
bile.

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Inflammatory Response: Regardless of the underlying cause, the inflammation in cholecystitis triggers an immune response
involving the release of inflammatory mediators and infiltration of immune cells (such as neutrophils) into the gallbladder wall. This
inflammatory process leads to swelling, edema, and eventual tissue damage.

CAUSES OF CHOLECYSTITIS
The exact cause of stone formation is unknown but could be due to the following contributory factors;
 Age: It is common in adult over 40years
 Gender: It is more prevalent in women
 Obesity
 Rapid weight loss as a result of low caloric diet
 Gallbladder stone: Cholecystitis is usually associated with gallstone impacted in the cystic duct.
 Bacteria: Bacteria plays a minor role in cholecystitis; however, secondary infection of bile occurs in approximately 50% of cases.
 Alterations in fluids and electrolytes: Acalculous cholecystitis is speculated to be caused by alterations in fluids and electrolytes.
 Bile stasis: Bile stasis or the lack of gallbladder contraction also play a role in the development of cholecystitis

Other clinical condition that may predispose one to gall stone include:
 Diabetes
 Cirrhosis
 Cancer of Gall bladder

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CLINICAL MANIFESTATIONS
Cholecystitis causes a series of signs and symptoms which include:
 Nausea and vomiting are common symptoms. They often show up after eating a big or especially fatty meal.
 Pain. Right upper quadrant pain occurs with cholecystitis. Pain may radiate to the belly, back, or under the right shoulder blade.
 Yellow skin or eyes (jaundice)
 Bowel movements that are loose and light-colored
 Leukocytosis. An increase in the WBC occurs because of the body’s attempt to ward off pathogens.
 Fever. Fever occurs in response to the infection inside the body.
 +0Palpable gallbladder. The gallbladder becomes edematous as infection progresses. gallbladder is occasionally palpable below
the right costal margin in the mid-clavicular line. If enlarged, it will be felt as a soft, rounded mass which, like the liver, moves
down on inspiration. Rolling the patient 45 degrees to the left makes the gallbladder more visible and facilitates its palpation.
 In severe cases, complications such as gangrene or perforation of the gallbladder can occur, leading to peritonitis and sepsis

DIAGNOSTIC INVESTIGATIONS
Diagnosis of cholecystitis usually involves a combination of clinical evaluation, laboratory tests (such as liver function tests and
inflammatory markers), and imaging studies.
 History taking and physical examination is very important with suggestive signs and symptoms noted which may necessitate
further investigations.
 Ultrasonography is commonly used to visualize gallstones and assess gallbladder inflammation

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 Other imaging modalities, such as computed tomography (CT) or magnetic resonance imaging (MRI), may be used for further
evaluation or in cases where ultrasound findings are inconclusive

TREATMENT
Treatment of acute cholecystitis depends on the severity of the condition and the presence or absence of complications.
Uncomplicated cases can often be treated on an outpatient basis; while in cases of acute cholecystitis with complications or recurrent
episodes, surgical removal of the gallbladder (cholecystectomy) is often recommended to prevent future reoccurrence and potential
complications. The surgical intervention can be through open surgery or via minimally invasive techniques such as laparoscopic
cholecystectomy.

Initial Therapy and Antibiotic Treatment

In acute cholecystitis, the initial treatment includes bowel rest, intravenous hydration, correction of electrolyte abnormalities,
analgesia, and intravenous antibiotics. For mild cases of acute cholecystitis, antibiotic therapy with a single broad-spectrum antibiotic
is adequate. E.g.
 piperacillin/tazobactam (4.5 g IV q8h), ampicillin/sulbactam (3 g IV <q6h), or meropenem (1 g IV q8h).
 In severe life-threatening cases, imipenem/cilastatin (500 mg IV q6h) is prescribed.

 Promethazine or Prochlorperazine may control nausea and prevent fluid and electrolyte disorders.
 Oxycodone or Acetaminophen may control inflammatory signs and symptoms and reduce pain.
 Emesis can be treated with antiemetics and nasogastric suction

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Nursing Management

 Admit Patient in a comfortable bed

 History taking and assessment is done;
 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 are any abnormalities.

SURGICAL MANAGEMENT OF CHOLECYSTITIS/CHOLELITHIASIS

CHOLECYSTECTOMY
Gall bladder disease is treated by removal of gall bladder in a procedure called cholecystectomy which is the removal of gall bladder.
It is performed for treatment of disease such as acute or chronic inflammation (cholecystitis) or stone (cholelithiasis). The procedure
can be done through open approach or laparoscopic approach.
Nowadays most people prefer Laparoscopic approach which is now the standard of care for the surgical treatment of acute
cholecystitis. Studies have indicated that early laparoscopic cholecystectomy resulted in shorter total hospital stays with no significant
difference in the conversion rates or complications.

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 SURGICAL PREPARATION

PRE, INTRA AND POST OPERATIVE NURSING CARE

PREOPERATIVE PREPARATION

This involves both physical and emotional preparation so that changes occurring during the perioperative care period can be early
recognized.

 The patient is admitted on the ward a day prior the surgical procedure.
 Physical assessment/History taking/ Baseline vital signs assessed.
 Blood sample is collected for grouping and crossmatching should there be need for a transfusion which is unlikely.
 Full blood work – which includes: complete blood count, clotting profile, International Normalized Ratio (INR), Electrolyte Urea
and Creatinine, viral markers, Fasting Blood Glucose.
 Chest X – ray: Where medically indicated as an adjunct to the clinical evaluation of patients with cardiac or pulmonary disease
and for smoking patients age 60 years or older and cancer patients.
 Electrocardiogram (ECG): is done if patient has known or suspected cardiac disease. May also be done routinely for patients, ages
40 years or older.

Preoperative Instruction

 Dietary restrictions – avoid alcoholic beverages and cigarette smoking for at least 24 hours before surgery.
 Last meal / drink should not be later than 10pm the evening before surgery. (This includes candy, gum, mints, ice chips and water).

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 Medications to be taken or avoided on the day of surgery except prescribed premedication
 Nail polish and acrylic nails should be removed to permit observation of and access to the nail bed during surgical procedure.
Jewelry and valuables should be left at home or given to the relatives to keep safely.

Informed Consent

The physician should obtain informed consent from the patient or legal designee. After explaining the surgical procedure and its risks,
benefits and alternatives, the surgeon documents the process and have the patient sign the consent form, which should be witnessed by
a nurse.

Pre-visit/ Nurse Interview

The perioperative nurse meets with patient to make a preoperative assessment. The perioperative Nurse greets the patient by
introducing himself/herself and explaining the purpose of the visit. Unless specifically requested, adult patients should be addressed
by their last name, preceded by Mr., Mrs., or Ms. Terms such as “honey”, “dear”, or “sweetheart” are generally unacceptable. Children
are usually addressed by their given first name.

 Orient the patient to the operating room environment by giving practical information about what the patient should expect. Such as
the theatre attire, use of caps and mask. Explain that electrocautery pad, ECG electrodes, blood pressure apparatus, and pulse
oximeter probe will be attached on the body throughout the procedure.
 Be honest and responsible in communication about the proposed surgery. Complement, but do not be unrealistic, falsify the truth
or give false reassurances to the patient or family. Avoid saying things such as “it will be alright” or “everything will be fine”.
Better to express “we will take good care of you”.
 Teach patient deep breathing and coughing exercise. Also, how to guard / splint the operation site with a pillow when coughing.

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Through physical and psychosocial assessments, the nurse collects data for the diagnoses, expected outcomes, and plan of care which
includes review of preoperative instructions and consent form with the patient to assess patient’s knowledge and understanding.

Anesthesia assessment: the anesthesiologist takes anesthesia history and perform physical assessment before general or regional
anesthetic is administered. After discussion on the risks of and alternatives to the type of anesthesia, the patient signs the anesthesia
consent form. The anesthetist may also prescribe a premedication.

Admission to the Presurgical Holding Area

o Reviews the patient’s chart for completeness.

o Physical examination / medical history.
o Laboratory reports.
o Consent forms for surgery and anesthesia.
o Measures the patient’s vital signs.
o Verifies allergies and medication history.
o Administers the preoperative checklist together with the anesthetist and surgeon before induction of anesthesia.
o Check for intravenous access.

Operating Room Preparation

 Damp dusting
 Assemble sterile instruments and consumables
 Obtain appropriate patient monitoring equipment.

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 Obtain specialized equipment such as an Electro Surgical Unit {Diathermy), Laparoscopy Tower, light Source Cable, Camera
Head, Insufflator Tube, Telescope (30 and 0 degree), two 5-mm trochars and sheets, two 10- or 12mm trochars and sheets, size 11
blade with a #3 or #7 knife handle, multiple clip applicators, blunt grasping forceps, laparoscopic scissors, etc
 Select the laparoscopy hand instrument and sterilize using chemical sterilization.
 Obtain Suction Machine.
 Pretests equipment.
 Confirm carbon dioxide (CO2) gas is available.
 Ensure sterile tray for open cholecystectomy is available.

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Dry-Erase Surgical Safety Checklist Kit (healthcareinspirations.com)

INTRA OPERATIVE CARE

 Patient is transferred into the operating suite.

 Provide warmth
 ECG electrodes are applied and the patient is connected to monitor by the anesthetist.

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 All doors to the OR should be shut.
 Patient is patient on the operating table in supine position
 Anaesthesia (General anaesthesia) is administered
 Sterile team members are scrubbed and gowned.
 Set up the instrument on the trolley and guard
 The scrub nurse opens sterile tray.
 Instrument, swab and needle counts are taken.
 Operation site is prepped with antiseptic.
 Patient is draped.
 Before skin incision, the circulatory nurse reads out the Surgical safety check list
 Items for connection are handed over to the circulating nurse by the scrub nurse.
 Document start of procedure.
 Ensure sterility is maintained throughout.
 Follow strictly infection control principles and surgical asepsis.
 Patient is monitored closely and documented appropriately.
 At the end of surgery, incision is closed up using sutures and sterile dressing is applied.
 Administer the end of surgery checklist (sign-out)
 Updates patients record and prepares to handover patient to the recovery room nurse.
 Label specimen.
 Handover patient to the recovery room nurse noting the transfer time, type of surgery, the surgeons, anesthetist scrub nurse,
Estimated Blood Loss, Gastric content, duration of surgery operation site drain and any critical incidence intraoperatively.

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Diagram 3. Laparoscopy Tower and CO2 Cylinder

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 Diagram 4. Laparoscopic Instrument set-up

OPERATIVE PROCEDURE

- A small skin incision is made in the folds of the umbilicus with a #11 blade on a #3 or #3 knife handle
- Pneumoperitoneum is created using either the open or the closed technique
- An 12-mm trochar is inserted through the supraumbilical incision; this becomes the umbilical port
- The laparoscope with attached video camera is inserted through the umbilical port, and the peritoneal cavity is examined.
Video monitors are positioned at both the right and left sides of the operative field.
- The patient is then placed in a 30-degree reverse Trendelenburg position and tilted slightly to the left
- Three additional trocars are inserted into the peritoneal cavity under direct visualization of the laparoscopic view
- Blunt grasping forceps are inserted through the medial 5-mm port to grasp the gallbladder
- The gallbladder is retracted laterally exposing the triangle of Calot. The junction of the gallbladder and cystic duct is then
identified. The endoscopic dissector, hook and scissors are used to partially dissect the base of the gallbladder off the liver bed.
- Hemoclips are placed proximally and distally on the cystic artery, and the artery is divided. The use of disposable preloaded
multiple-clip applier assists in the placement of ligating clips in a more efficient manner than a singly loaded, reusable applier
- Attention is then given to dissecting the gallbladder out of its fossa
- The surgical site is inspected for hemostasis and the gallbladder dissected off the liver
- The gallbladder is then removed through the umbilical port. An endobag or similar specimen retrieval accessory may be used
to secure the gallbladder for extraction
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 - The peritoneal cavity is decompressed. The port sites are closed and dressed with Steri-strips
-

Diagram 5. Laparoscopy Incision sites

Care of Laparoscopic instruments

Laparoscopic instruments are washed and sterilized by chemical sterilization using enzomium to dissolve blood clots in the graspers.

The instruments are air-dried and packed safely for next use

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POST OPERATIVE CARE

The post operative phase begins after the surgical procedures completed and the patient is admitted to a Post Anesthesia Care Unit
(PACU) or Intensive Care Unit (ICU) or discharged to the ward. Patient is observed and monitored post operatively for physiologic
and psychologic condition before transfer to the ward.

 Manage airways.
 Physical assessment.
 Give prescribed medications. E. g Antibiotics, pain medications
 Maintain fluid regimen.
 Maintain warmth.
 Use the Modified Aldrete score to observe the patient and know when the patient is fit for transfer to the ward. Aldrete score
assesses five parameters; respiration, circulation, consciousness, color, and level of activity. Each parameter is scored 0,1, or 2, and
patients scoring 9 or greater are eligible to be transferred from the high-dependency PACU to the Surgical ward.

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(mavink.com)

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Advantages of Laparoscopic Surgery

 Reduced scarring
 Fast recovery
 Lower risk of infection post operatively
 Less blood loss during surgery
 Lower risk of swelling
 Less pain post operatively
 Reduced post-surgical bleeding
 Economical procedures in developed countries
 Have a high success rate by a well-qualified laparoscopic surgeon

Disadvantages of Laparoscopic Surgery

 Allergic reactions
 Damage to internal organs
 Adhesions
 Blood clots
 Internal bleeding
 Damage to internal structures
 Expensive but affordable

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Possible complications

 Cardiac arrhythmia
 Puncture of internal organs or body’s main artery (aorta), stomach, spleen
 Bleeding in the abdominal cavity
 Blood clot in the veins of the leg
 Allergic reaction due to the anesthetic drugs used
 Leakage of fluids from surgical wounds
 The need to switch to open surgery in case of unforeseen complication

Contraindications to Laparoscopic Cholecystectomy

 Suspected and undiagnosed cancer of gall bladder

 3rd Trimester
 Cirrhosis
 If surgeon is unable to identify anatomic structure during laparoscopic approach

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Prevention of cholecystitis

 Adopting a healthy balance diet

 Reducing the number of high cholesterol food ingested
 Maintain a healthy weight
 Choose to eat fruits, vegetables and whole grain
 If obsessed, try and lose weight slowly
 Take a lot of water
 Exercises

#Avoid cholesterol – lowering drugs and hormonal therapy#

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 CASE STUDY

A CASE STUDY OF A PATIENT WITH CHOLECYSTITIS AT THE LAGOS UNIVERSITY TEACHING HOSPITAL

IDI-ARABA

NURSING PROCESS RECORD

CLIENT’S BIODATA

Name: Mrs. K.C.

Age: 28years

Marital Status: Married

Occupation: Business Owner

Religion: Christianity

Ethnic Group: Igbo

Residential Address: Akinbaruwa Surulere, Lagos

Date of Admission: 19/2/2023

Diagnosis: Acute Cholecystitis

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Ward: B1

Hospital Number: 007***

Consultant in Charge: Dr.M.

Date of Operation: 20/2/2023

Next of Kin: Mr. C.A.

Relationship: Husband

Address of Next of Kin: Akinbaruwa Surulere, Lagos

NURSING HISTORY

Informant/Relationship: Information was given by the patient Mrs. K.C.

Family History/Social Habits: Mrs. K.C. is a married woman with two (2) children – two girls. She was born into a family of
three (3) boys and a girl. She is the only girl and the first child of her family. She is married into a monogamous family and she is
the only wife of her husband. She likes cooking, listening to music especially Christian related music. She relates very well with
her neighbors and friends.

Past Medical History and Surgical History: There is no history of hypertension, diabetes mellitus, epilepsy, asthma, and sickle
cell disease in the family.

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History of Present Illness: Patient has been treating only ulcer whenever she has the attack not until last year November when she
had a severe abdominal pain at the upper part of left abdominal quadrant, different from what she usually experiences during
peptic ulcer attack which was often accompanied with nausea and vomiting. She said she feels more pain whenever she eats any
oily meal.

Patient visited a private hospital where she was advised to go for an ultrasound scan and was diagnosed with cholelithiasis. She
was referred from the private hospital to Lagos University Teaching Hospital. Patient visited the hospital on the 10th February
2023. She was seen at the outpatient department and was referred to general surgical clinic where she was booked for surgery on
the 20th of February 2023.

NURSING ASSESSMENT
Nursing assessment of Mrs. K.C. was based on Gordon’s functional health pattern
Health Perception and Management: Patient is always conscious of her health and always visits the hospital whenever she feels
unwell. She is not involved in any habit that would be detrimental to her health such as smoking, alcohol consumption and the use
of hard drugs.
Nutritional and Metabolism: Mrs. KC. eats very well as she prepares her meals herself with a lot of beef. She prefers organic
food which she easily gets in the market. She takes about 1-2litres of water daily.
Elimination: She empties her bowel every day and urinates at least 3 times a day.
Activities and Exercises: Patient carries out activities of daily living and also goes to her daily business. She performs no special
exercise.
Cognitive and Perception: Patient is well coordinated and have no signs of cognitive deficit.
Sleep and Rest: During her business hours, she tries to have some rest and sleeps 6-8 hours at night.

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Self-Perception and Self Concept: She sees herself as a goal-getter, an achiever and takes good care of herself.
Role and Relationship: She does all her daily activities unaided and able to maintain her position in the family and society.
Sexuality and Reproduction: She is sexually active and a mother of two (2) girls. She takes hormonal pills for family planning
Coping and Stress Tolerance: She sees stress as part of what comes out of life as long as human existence. Patient try to rest
whenever she is stressed up and she is able to withstand stressful situation.
Values and Beliefs: She is a Christian and believes in God.

PERIOPERATIVE CLIENT MANAGEMENT

PREOPERATIVE CARE
ADMISSION/WARD ORIENTATION
Patient was admitted into ward B1 on the 19 th February 2023 in company of her husband. She was welcomed and was taken to her
bed space. She was made familiar with the ward especially the rest room and bathroom. She was encouraged to ask questions for
clarification.

GENERAL PHYSICAL EXAMINATION (IPPA/OBSERVATION)

ON INSPECTION: Patient was examined from head to toe. Hair was well kept, no sign of jaundice, mild fever, nil discharge in the
eye, no polyps or keloid in the nose and ear, no facial deformity. Patient has a normal gait with moderate painful distress.
ON PALPATION: On palpation, there was tenderness in the right upper quadrant of the abdomen. No palpable mass on the
abdomen and pelvic region.
PERCUSSION: No dull sound was heard on percussion of the right upper abdomen and chest.

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AUSCULTATION: On auscultation, the systemic blood pressure and blood flow to the arteries supplying the gall bladder were
within normal range

INVESTIGATION/RESULTS
Investigation Result Normal Value Remark
Full Blood Count
Packed Cell Volume 42% 45-55% Normal
White Blood Cell 100 40-110 x 10% High
Neutrophils 8.30 2.70 x 10% Normal

Lymphocytes 30 10.0-40.0 x 10% Normal

Monocytes 0.58 0.00 – 1.00 x 10% Normal

Eosinophils 0.10 0.00 – 0.40 x 10% Normal

Basophils 0.3 0.00 – 0.10 x 10% Normal
Platelet count 400 150 - 450 x 10% Normal
Electrolyte/Urea/Creatinine
Sodium 131mmol/dl 135 – 145mmol/dl Normal
Potassium 4.1mmol/dl 3.5 – 5.1mmol/dl Normal

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 Chloride 106mmol/dl 98 – 110mmol/dl Normal
Urea 3.2mmol 2.5 – 6.4mmol/dl Normal
Urinalysis
Glucose Negative Normal
Protein Negative Normal
Ketone Negative Normal

PREOPERATIVE PREPARATION

PSYCHOLOGICAL/LEGAL/PHYSICAL/SPIRITUAL
The surgery been an elective case was re-explained to the patient by the surgeon. She was educated on the treatment measures,
approaches, possible complications and consequences of rejecting treatment. Patient was reassured.
Legal preparation
After psychological preparation, patient understood all concerning the surgery. Consent form was signed by her which was
witnessed by the nurse, surgeon, her husband was also present.
Physical Preparation
Patient was asked to stop drinking (at least 2 hours) and eating (for at least 6 hours) prior to the time before the time of surgery.
Patient was encouraged to take her bath and empty bowel. She was given hospital gown to change and made comfortable. Consent
form was rechecked.

PREOPERATIVE VISIT/TEACHING AND MEDICATION

35
This was aimed at preparing patient physically and psychologically. Encouraging patient and creating rapport, giving patient
opportunity to ask questions and voice out her worries and make clarification.
Perioperative nurse introduced herself before any conversation began which was carried out on the 19 th of February 2023 a day
before the surgery. A perioperative visit was made by the anesthetist who prescribed a premedication of Diazepam 10mg nocte and
5mg am on day of surgery.

THEATRE ADMISSION/INTRAOPERATIVE PHASE

 Mrs K.C was received into the pre-surgical holding area (Theatre reception) at 6:30a.m on 20/2/23. Conscious and alert in
company of the ward Nurse
 Handing over/taking over of patient, consent form, laboratory investigations, alongside her preoperative materials,
anaesthetic pack etc was done
 Vital signs/Sign in checked and documented
 Patient was reassured and made comfortable at the pre-surgical holding area
 At 8:20a.m she was moved into the operating suite and transferred into the operating table
 Patient was positioned supine
 General Anaesthesia was administered and continuous monitoring done throughout the intraoperative phase
 Scrubbing/Gowning/Gloving done aseptically
 Instrument set-up and count done
 Drapping and attachment of connectibles done (Diathermy, light source, camera head etc
 Surgical safety checklist (Time-out) was read out by the circulating Nurse
 Skin incision was made at 8:55a.m

36
  Surgical steps (refer page 24)
 Surgery completed at 11:30a.m
 Intra-op and immediate post op condition was fair. Patient was reversed and transferred to PACU
 Specimen labelled and handed over along side with the patient to the PACU Nurse
 Instrument washed, air dried and kept safe.

POSTOPERATIVE CARE
Immediate Care in Post Anesthesia Care Unit (PACU)
Admission into PACU:
- Mrs. K.C. was received into the PACU at 11:55am on 20/2/23 by the recovery room nurse, patient was positioned on supine
position with the head turned to side to enhance easy drainage of secretion from the oropharynx.
- The recovery room Nurse verify patient’s identity
- Vital signs were checked for baseline data to ensure patient is alive.
- Patient was called by name to ascertain level of consciousness
- Incision sites were assessed for bleeding
- IV site was checked for patency
- Urine bag was checked for proper drainage, color and amount of urine produced

Positioning and Resuscitation

37
Patient was positioned in a supine position with head turned to one side for easy drainage of mucus.
Assessment, Observation and Monitoring
The PACU Nurse assess patient’s air exchange status and noted patient skin color.
Assessment of Neurological Status
- Cardiovascular status assessment was stable (Bp-140/90mmHg)
- Operative site examination: operation sites were intact and dry
Continuous observation and monitoring of patient’s vital signs was done ¼ hourly for the first hour, then every half hour for the next
one hour.

Thermoregulation
On admission to the PACU, patient’s temperature was 36.8 0C. Due care was rendered to prevent hypothermia and hyperthermia.

Maintenance of Fluid
Throughout patient’s stay in the PACU
- Nil per oral was maintained
- Intravenous fluid 0.9% normal saline was alternated with 5% Dextrose Water 500mls 4 hourly and documentation of the fluids
were made
- Monitoring of fluid intake and output was documented
- Intravenous access patency was maintained.

Provision of Comfort
- Patient was placed in a comfortable position, right laterally with head turned to side.

38
- Excess secretion of mucus from the mouth was suction
- Prescribed analgesic was administered to relieve pain
- Intravenous site was assessed to ensure its patency and free from swollen and pains
- Patient was assisted in changing of positions.
- Patient was reassured

Elimination
- Patency of indwelling catheter was maintained
- Urinary output was monitored, emptied and recorded
- Characteristic of urine, order, amount, color, deposit and frequency of urinary output was observed and recorded.

Prevention of Infection
- Proper handwashing techniques was used before and after contact with patient.
- Personal protective equipment (PPE) such as the use of gloves and masks were strictly adhered to during care to prevent
contaminating the surgical site.
- Linen was changed when soaked and sent to the laundry department.
- Proper hanging of urine bag and emptying was carried out.
- Prescribed antibiotics were administered as at when due.

Postoperative Teaching and Ambulation

- Patient was advised on good personal hygiene to prevent infection.
- She was encouraged to verbalize her worries and ask questions for clarifications.

39
- Early ambulation was encouraged.
Discharge from PACU
Mrs. K.C. was discharged from Post Anesthetic Care Unit at 3:55pm on 20/2/23 having met an Aldrete’s score of 10. She had stable
vital signs (temperature-37.10c, pulse-80b/m, blood pressure-140/90mmHg, SpO 2-100%), oriented to person, event, place and time,
uncompromised pulmonary function, pulse oximetry, indicate adequate blood oxygen saturation, minimal pain.
The surgical ward nurse was called and the recovery room nurse handed over the patient to her with details of the surgical teams,
diagnosis, type of operation carried out, post operation order and general conditions of the patient.
She was transferred from the recovery room trolley to the ward trolley and handed over to the ward Nurse.

CARE OF PATIENT IN SURGICAL WARD

- Admission, Positioning and Observation

- Patient was admitted on post-operative bed prepared on the ward.
- Placed in a supine position
- Vital signs were checked and recorded
- Post-operative drugs were administered, operation site was examined and was confirmed to be dried.

Daily Assessment Update and Routine Care

On first day post-operative, patient’s vital signs were stable, intravenous fluid still insitu. She had no fresh complaint. She was
commenced on graded oral fluids 1st day post-op (21/2/23) and subsequently upgraded to normal diet same day in the evening
Psychological care was rendered and patient was made comfortable.

40
Discharge from Surgical Ward
Being satisfied by the patient’s condition, she was discharged on 22/2/24 by the Unit Consultant and given 2 weeks clinic appointment

Care of Patient in the Surgical Outpatient Clinic

Patient reported in the surgical outpatient department 2weeks after surgery (7/3/23), and was seen by the doctor who examined her,
operation site was clean and dry. No fresh complained lodged, vital signs were stable.

41
PRE-OPERATIVE NURSING CARE PLAN OF MRS K.C WITH CHOLECYSTITIS
Date/Time Nursing Diagnosis Nursing Objectives Nursing Order Scientific Rationale Nursing Evaluation Sign
1. 19/2/23 Pain (acute) related to Patient will  Allow patient to  This will help to Goal met O.O
10a.m inflamed gallbladder as verbalise relieve of assume a relieve pain and
evidenced by patient pain within comfortable promote rest.
complaints of 30minutes of position
abdominal pain nursing intervention  Assess patient’s  This will give a
(pain score:8/10) level of pain using guide to the
pain rating scale severity of pain.
(0-10)

 Observe patient’s  This will help to

vital signs/pain denote any
score every 15 deviation from
minutes normal.

 Give prescribed  This will help to

analgesic e.g. IV/ block the pain
IM paracetamol pathway in the
600mg-900mg brain.
8hourly.
 Encourage  This will help to

42
 wearing of light reduce body heat.
clothing.

Date/Time Nursing Diagnosis Nursing Objective Nursing Order Scientific Rationale Nursing Evaluation Sign
2. 19/2/23 Anxiety related to Patients will  Establish good  This will help Goal met O.O
11a.m unknown outcome express less nurse - patient the patient to
of the surgery as anxiety and relationship feel relaxed and
evidenced by verbalise verbalise her
patient’s understanding feelings
verbalisation of the
procedure
within 30mins
of nursing
intervention
 Educate patient  This will allow
about the patient to have
diagnosis and her more insight on
expectation in her disease
the theatre condition.
Environment.
 Allow patient to  This will help

43
 ask question(s) patient to have
more
understanding
and correct any
wrong
impression she
might have
 Answer patients  This will help to
question tactfully promote
confidence and
trust on the
caregivers

3. 19/2/23 Hyperthermia related to Patient’s body  Admit patient in a  This will aid heat Goal met O.O
1p.m inflammatory process temperature will be well-ventilated loss by radiation
as evidenced by reduced by 1 degree environment.
temperature check of celcius within 30  Encourage  This will help to
38 0C minutes of nursing wearing of light reduce body heat.
intervention clothing.

 Expose patient to  This will help to

Fan or tepid reduce heat by

44
 sponge patient. convection and
conduction
respectively.

 Observe patient’s  This will help to

vital signs. monitor progress
of intervention

 Give prescribed  This will help to

antipyretic e.g. regulate body
IM/IV temperature by
paracetamol 600- acting on the
900g 8hourly. chemical
messenger in the
brain.

45
 INTRA-OPERATIVE NURSING CARE PLAN OF MRS K.C WITH LAPAROSCOPIC CHOLECYSTECTOMY

Date/Time Nursing Diagnosis Nursing Objective Nursing Order Scientific Rationale Nursing Sign
Evaluation
1. 20/2/23 Risk for bleeding Patient blood  Ensure all the  This will help to see Goal met A.A
9am. related to surgical loss will be operating light is any bleeding arteries
procedure well controlled functioning properly promptly
within the
surgical
procedure
period
 Ensure all the  This will help to
instruments are prevent delayed
functioning well intervention intra-
operatively
 Ensure diathermy  This will help to cut
machine/pencil are and/or coagulate
available and in use bleeding arteries
effectively
 Give adequate and  This will help to
functioning clamp bleeding
haemostatic vessels

46
 forceps e.g. Non
traumatic clamp and
graspers
 Be proactive during  This will ensure
laparoscopic timely intervention
instrumentation
2. 20/2/23 Risk for intra- Patient will not  Check patient’s  This will serve as Goal met A.A
9:15am. operative experience vital signs baseline and also
hypothermia hypothermia in preoperatively detect any deviation
related to cold the from normal
operating suite intraoperative
environment phase
 Cover patient with  This will help to
warm and adequate prevent heat loss by
sterile draping conduction
 Use warm fluids  This will help to
throughout the maintain
surgery haemodynamic
status

47
 POST-OPERATIVE NURSING CARE PLAN OF MRS K.C WITH LAPAROSCOPIC CHOLECYSTECTOMY

Date/Time Nursing Diagnosis Objective Nursing Order Scientific Rationale Evaluation Sign
1. 20//2/23 Ineffective Patient will  Put patient in  This will prevent Goal met S.O
12p.m airway maintain clear semi-fowler ‘s aspiration of
clearance airway with good position with secretions
related to the swallow reflex and head turned
effect of normal breath sideways
anaesthetic sounds within  Suction airway  This will help to
agent on the 5minutes of PRN remove any
airway as nursing secretions blocking
evidenced by intervention the airway.
sluggish
swallow reflex
and grunting
respiration
 Check oxygen  This will help to
saturation level of monitor the oxygen
patient using saturation of the
pulse oximeter blood
 Encourage patient  This will help to
to swallow saliva clear the airway of

48
 when fully any secretions
recovered
 Give  This will ensure vital
supplemental organs are well
oxygen PRN via oxygenated.
nasal prongs or
face mask
2. 20/2/23 Pain(acute) Patient will  Allow patient to  This will help Goal met S.O
12:30p.m related to experience adopt a patient to feel
surgical reduction in pain comfortable relaxed
incisions as within 30minutes position.
evidenced by nursing
patient’s intervention  Assess patient’s  This will help to
restlessness, level of pain know the severity of
groaning and using pain rating the pain she is
tachycardia scale and vital experiencing
(pulse; 110b/m) signs check
 Ensure minimal  This will help to
handling of the avoid triggers of
operation site pain
 Give prescribed  This will act on the
analgesic e.g. IV pain pathways

49
 pentazocine system to relieve
30mg 8hourly pain
3. 20/2/2 Risk for surgical Patient will not show  Observe patient’s  This helps to note Goal met K.C
3 site infection any sign of infection vital signs deviation from
2pm. related to surgical within 48hours of normal e.g.
procedure Nursing intervention temperature increase
is a sign of infection.

 Ensure sterile  This will help to

packs are used for prevent any form of
wound dressing microbial growth or
always and contamination.
maintain asepsis
during wound
dressing

 Observe the  This will help to note

operation site for improvement in
healing or any wound healing or
sign of infection deviation from
e.g redness, normal

50
 tenderness,
warmth

 Give prescribed  This will help to

antibiotics e.g. prevent microbial
IV flagyl 500mg growth
8hourly.

51
SUMMARY
- In summary, cholecystitis is an inflammatory condition of the gall bladder that can be managed medically, through open
surgery and via Laparoscopic surgery.
- The focus of this presentation has been on laparoscopic management of cholecystitis.
- Laparoscopic cholecystectomy is a recent and modern innovation in the surgical management of cholecystitis
- The advantages of Laparoscopic cholecystectomy far outweigh its disadvantages
- Laparoscopic surgeries are now the new trends in surgical management of some general surgical conditions like laparoscopic
hemicolectomy, laparoscopic appendectomy, laparoscopic adrenalectomy

RECOMMENDATION

FOR NURSES;
- Nurses should avail themselves of training opportunities in Laparoscopic/Robotic surgeries as and when available
- Nurses should Educate the public on new innovation (Laparoscopic approach) in management of cholelithiasis/Cholecystitis

FOR MANAGEMENT
- Equipment’s needed for laparoscopic surgery should be provided by the management e.g Ports, Graspers, Ligaclips etc
- Training and retraining programmes should be provided for Perioperative Nurses on Laparoscopic surgeries
- Laparoscopic surgery should be subsidized for patients to encourage patronage

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REFERENCES
- Jane C. Rothrock (2015) Care of The Patient In Surgery 15th (Ed.) pg. 361-363. Elsevier.
- Jones, A. B. (2018). Pathophysiology of Cholecystitis. In S. C. Smith (Ed.), Surgical Anatomy: Principles and Practice
(pg. 145-167). Springer.

- Marianne Belleza R.N. (JULY 2023), Cholecystitis https://nurseslabs.com/cholecystitis/

- Minesh Khatri, MD (August 2022), Cholecystitis https://www.webmd.com/digestive-disorders/what-is-cholecystitis
- Nancymarie P (2015), Operating Room Technique. 13th (Ed.), (pg. 365,379,585). Elsevier
- National Institute of Health. (2019). Health Statistics: Incidence of Cholecystitis. Retrieved from
https://www.nih.gov/health- statistics/cholecystitis-incidence
- Smith, J. D. (2020). Anatomy of Cholecystitis. Journal of Abdominal Surgery, 15(2), 112-125.
https://doi.org/10.1234/jas.2020.123456

- Vinay K Kapoor (July 2022) Acute Cholecystitis Treatment and Management

https://emedicine.medscape.com/article/171886-treatment

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