Abstract

During our clinical time a surgery was being performed to remove the gallbladder in which the opportunity was granted for me to witness. This surgery consisted of numerous incisions, steady handed work within the right upper quadrant of the abdomen, and multiple different machines in order to ensure patient comfort and safety during the procedure. Gallstones and liver spots were seen during the procedure and after the removal of the gallbladder in total. The reason for the removal and more detailed experiences will be shared in the body of the paper below.

Keywords: gallstone, gallbladder, anesthesia, surgery

The gallbladder is located in the right upper quadrant, below the liver slightly, right of the stomach, and above the duodenum (Workman, 2018). It is a medium/small sized hollow organ that creates bile among other things to help the stomach process fats. The pancreas lies between the duodenum and stomach and can be seen somewhat during the procedure depending on how far down the laparoscopy moves. The gallbladder functions almost like an assistant to the stomach when absorbing fat (Osmosis, 2017). Releasing bile when we eat fatty foods in order for us to digest and absorb them easier. However sometimes if we eat too much fatty foods or if we get sick etc. our gallbladder can become supersaturated with cholesterol. This means that the bile has so much cholesterol that the bile salts and acids cannot hold anymore in solution, therefore the cholesterol comes out of the bile as a complete solid creating the "gallstone" or cholelithiasis. Gallstones can lead to acute or chronic calculous cholecystitis which results in inflammation from the gallstones (Osmosis, 2017). The reason surgery is often performed is because the gallbladder may rupture causing peritonitis or infection to the surrounding organs. Peritonitis is the inflammation of the peritoneal sac or cavity and can be life threatening if not caught quickly.

The surgical approach used was the laparoscopic technique. The other method is titled "open" method (Colombia University, 2012). The laparoscopic method could be explained as a small incision made in the patient's abdomen over the gallbladder to remove it from the cavity of the abdomen (Staff, 2019). This is done using the laparoscopy which is a long metal rod equipped with a camera at one end to view internal structures. This allows the surgeon to view internal organs in detail and with clarity. As clean as that sounds however, it can still be complicated and messy.

The "open" technique could be explained as an opening made exposing the gallbladder and surrounding organs, removing it, and suturing the skin back together (Colombia University, 2012). This method leaves a bigger scar, causes more pain to the patient, and yields a longer recovery time (Colombia University, 2012). The laparoscopic method is by far the most common method used, yields the shortest recovery time, and causes much less pain to the patient because it is much less invasive than the open method. The open method is only used if the laparoscopic method cannot be done (ex; unexpected inflammation, scar tissue, injury, or bleeding during surgery). Both surgeries are performed under general anesthesia and patients are typically intubated (Staff, 2019).

The procedure cannot be initiated until the patient signs an informed consent form, the doctor and other health care professionals have been consulted, and the patient meets the basic criteria to have the surgery performed (Workman, 2018). Patients are typically NPO six to eight hours prior to surgery depending on the facility-with minimal amount of water to sip on approximately two hours before the surgery with their prescribed medication. Patients are typically given muscle relaxers, anesthesia, pain medicine, nausea medication, and electrolytes during the surgery. Before the surgery starts, the surgeon makes a final check with the circulating nurse consisting of; right patient, right procedure, and right site.

After the pre-op procedures are complete, it is time to initiate surgery. During the surgery the surgeon makes a very small midline puncture at the umbilicus (Workman, 2018). The abdominal cavity is then insufflated with three to four liters of carbon dioxide resulting in improved pulmonary and cardiac function. The laparoscopy is attached to the video camera therefore all the internal organs can be seen after the insufflation is complete. The organs can be seen on screens in the surgical room from the laparoscopy. The gallbladder is then dissected from the liver bed using cauterization or careful cuts made by laparoscopic bipolar scissors. The cystic artery and ducts are ligated by clips. If any bile or residue is leaked from the gallbladder during this procedure, suction must be used to extract the contents, so peritonitis does not occur. After the gallbladder is disconnected from surrounding organs and the clips are placed, a retrieval pouch is used to salvage the organ (Workman, 2018).

The closure of the procedure consists of monitoring the patient's vitals while suturing the small incisions shut using whatever suturing method the surgeon prefers. Before the surgeon sutures the small incisions, the carbon dioxide must be let mostly out of the patient's abdominal cavity (Staff, 2019). After that is ensured, the CRNA monitors most vitals and anesthetic care while the surgeon is focused on suturing the small incisions back together. When the sutures are made, the CRNA removes the intubation then shortly after slowly tapers off the anesthesia.

The patient upon arrival to the recovery room is not fully awake. The patient does not regain consciousness until about 15 minutes after the procedure ends. The patient is alert, slightly confused, and irritated. The patient experiences right upper abdominal soreness, but no signs of nausea or throat pain are noted due to the nausea medication given pre-operatively. The patient is agitated very easily after awakening and asks for pain medication due to right upper abdominal pain.

Typical post anesthesia orders are as follows: (Practice Parameters, 2019)

- q 15 minute vitals

- Note pain score on arrival and discharge from unit

-Check injection site for hematoma, bleeding, etc.

-Discontinue heparin lock if fluids are tolerated

-Must void before discharge

-Must meet with M.D. before discharge

References

Colombia University Department of Surgery. (2012, August 28). What is a Cholesystectomy? [Video].YouTube.

Osmosis. (2017, February 20). Gallstones (cholelithiasis) - causes, symptoms, diagnosis, treatment & pathology [Video]. YouTube.

Practice Parameters, C. S. (2019). ​Standards for Postanesthesia Care. Retrieved September 20, 2020, from https://www.asahq.org/standards-and-guidelines/standards-for-postanesthesia-care

Staff, H. (2019). Open Gallbladder Surgery for Gallstones. Retrieved September 20, 2020, from https://www.uofmhealth.org/health-library/hw106994

Workman, I. &. (2018). Medical Surgical Nursing. St. Louis, MO: Elsevier.