Topic: Intrauterine Fetal Death

General Objective: After 1 hour and 30 minutes of lecture-discussion, the Level III students will be able to acquire basic knowledge, gain beginning skills and develop positive
attitude, apply basic procedures and appreciate interventions rendered to the patient with Intrauterine Fetal Death.
Specific
Objectives

Content

Methodology

Time
Allotment

Resources

Evaluation

http://ww
w.surgery.
usc.edu

Question
and
Answer

Prayer
Pre-conditioning Activity
Specifically, the
students will be
able to:

1.) discuss the

overview of
Biliary Surgery;

Lecture
Discussion
Laparoscopic gallbladder removal has been performed in thousands of patients throughout the world
and is a very safe procedure. Gallbladder removal should be performed by laparoscopic surgery when
possible. In contrast to laparoscopic gallbladder surgery, laparoscopic procedures on the bile duct are
rarely performed by biliary surgeons since they are technically very difficult. Since the bile duct is
located deep in the abdomen the incisions for open bile duct surgery are long and large incisions.
These incisions are usually associated with a lot of discomfort and require recovery period of 4 to 12
weeks. The majority of patients who undergo open surgery stay in hospital for 4 to 10 days after
surgery compared to patients who undergo laparoscopic surgery and stay in hospital for 1 to 3 days
after surgery. Laparoscopic procedures provide many advantages to the patient over conventional open
surgery. Some of the benefits of laparoscopic surgery are much less discomfort after the surgery 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 with laparoscopic surgery compared to standard open surgery. There are

10 minutes

2.) define
related terms;

kinds of bililary surgery, these are laparoscopic cholecystectomy, Laparoscopic common bile duct
exploration, Laparoscopic bile duct bypass, resection of choledocal cyst, and laparoscopic whipple
operation.
Very few centers in the USA offer laparoscopic surgery for bile duct diseases. Laparoscopic surgery
for bile duct diseases require expertise in advanced laparoscopic techniques and in complex open
biliary procedures. These procedures are preferably performed in specialized centers that do a high
volume of open and laparoscopic procedures by biliary surgeons skilled in bile duct surgery.

Laparoscopy- is an operation performed in the abdomen or pelvis through

small incisions (usually 0.51.5 cm) with the aid of a camera. It can either be used to inspect
and diagnose a condition or to perform surgery.

Laparoscopic Cholecystectomy- In this procedure the gall bladder is removed by laparoscopic

techniques. The usual indications for removal of the gall bladder for laparoscopic
cholecystectomy include the presence of gallstones in the gall bladder and small benign tumors
called gallbladder polyps.

Laparoscopic common bile duct exploration- In this procedure, stones in the bile duct are
removed by laparoscopic techniques. In patients with gallstones small stones can pass from the
gallbladder into the bile duct. Stones in the bile duct can cause obstruction leading to the
development of jaundice and pancreatitis (inflammation of the pancreas). The treatment is
removal of the gallbladder.

Laparoscopic bile duct bypass- In patients who have strictures (narrowing) of the bile duct, the
drainage of bile into the intestine is blocked and the bile accumulates in the blood causing
jaundice. Bile duct strictures can be caused by benign (non-cancerous) or cancerous
conditions.

Resection of choledocal cyst- Choledocal cysts develop from abnormal dilatation of the bile
duct that is usually congenital in origin. Choledocal cysts can lead to the development to of
jaundice, pancreatitis and cancer in some patients if left untreated for many years.

10 minutes
Lecture
Discussion

http://ww
w.surgery.
usc.edu

Question
and
Answer

3.) review the

anatomy and
physiology of
the systems
involved;

Laparoscopic whipple operation- laparoscopic Whipple operation for selected patients with
ampullary tumors.

Cholangitis- Cholangitis is an infection of the common bile duct, the tube that carries bile from
the liver to the gallbladder and intestines. Bile is a liquid made by the liver that helps digest
food.

Cholecystitis - Cholecystitis is inflammation of the gallbladder that occurs most commonly

because of an obstruction of the cystic duct from cholelithiasis.

Biloma- An encapsulated collection of bile within the abdomen. A biloma may form if there is
bile duct disruption, as from a laparoscopic cholecystectomy.

choledocal cyst- represent congenital disproportionate cystic dilatations of the biliary tree.
Diagnosis relies on the exclusion of other conditions as a cause of biliary duct dilatation: (i.e.
tumour, gallstone or inflammation as the cause).

10 minutes
Lecture
Discussion

Human
Question
anatomy
and
and
Answer
physiology

ANATOMY AND PHYSIOLOGY OF THE GALLBLADDER

The gallbladder is part of the digestive system. It is a small, pear-shaped organ on the right side of the
body, under the right lobe of the liver.
The body can function without the gallbladder. If doctors need to remove it because of disease, there
are no serious long-term effects and the body can still digest food.

Structure
The gallbladder is about 7.510 cm (34 inches) long and about a 2.5 cm (1 inch) wide.
The gallbladder is made up of layers of tissue:

mucosa- the inner layer of epithelial cells (epithelium) and lamina propria (loose connective
tissue)

a muscular layer

o a layer of smooth muscle

perimuscular layer- connective tissue that covers the muscular layer

serosa- the outer covering of the gallbladder

The gallbladder, liver and small intestine are connected by a series of thin tubes or ducts.

The common hepatic duct drains bile from the liver through the left and right hepatic ducts.

The cystic duct joins the gallbladder to the common bile duct.

The common bile duct is where the hepatic and cystic ducts meet and connect to the small
intestine.

The gallbladder and bile ducts are also called the biliary system or biliary tract.
Function
The gallbladder stores and concentrates bile, a yellowish-green fluid made by the liver. Bile helps the
body digest fats. Bile is mainly made up of:

bile salts

bile pigments (such as bilirubin)

cholesterol

water

The liver releases bile into the hepatic duct. If the bile is not needed for digestion, it flows into the
cystic duct and then into the gallbladder, where it is stored. The gallbladder can store about 4070 mL
(814 teaspoons) of bile. The gallbladder absorbs water from the bile, making it more concentrated.

When bile is needed for digestion after a meal, the gallbladder contracts and releases it into the cystic
duct. The bile then flows into the common bile duct and is emptied into the small intestine, where it
breaks down fats.

ANATOMY AND PHYSIOLOGY OF THE BILE DUCTS

The liver, gallbladder and small intestine are connected by a series of thin tubes called bile ducts.
The bile ducts are part of the digestive system. The bile ducts and gallbladder are also part of the
biliary system, or biliary tract.

Structure
The common bile duct is a very thin tube, about 1012.5 cm (45 inches) long. A series of ducts

come together to finally form the common bile duct:

Many tiny tubules within the liver collect bile from the liver cells.

These tiny tubules come together to form small ducts. These small ducts then join together into
larger ducts that form the right and left hepatic ducts.

The right and left hepatic ducts exit the liver and join to form the common hepatic duct.

The common hepatic duct and the cystic duct join to form the common bile duct. The cystic
duct connects the gallbladder (a small organ that stores bile) to the common bile duct.

The common bile duct passes through the pancreas before it empties into the first part of the
small intestine (duodenum). The lower part of the common bile duct joins the pancreatic duct
to form a channel called the ampulla of Vater or it may enter the duodenum directly.

Intrahepatic bile ducts

The bile ducts within the liver are called intrahepatic bile ducts. These small ducts join together into
larger ducts, ending in the left and right hepatic ducts. The right and left lobes of the liver are drained
by these ducts. Information on intrahepatic bile duct cancer can be found in the liver cancer chapter.
Extrahepatic bile ducts

4.) trace the

pathophysiolog
y;

The extrahepatic bile ducts are outside the liver. The extrahepatic ducts include the part of the right
and left hepatic ducts that are outside the liver, the common hepatic duct and the common bile duct.
(The cystic duct is also outside the liver, but cancers of the cystic duct are grouped with gallbladder
cancers.)
The extrahepatic bile ducts may be further divided based on their location:

perihilar bile ducts

o The hilum or hilar area is the area where the right and left hepatic ducts leave the liver
and join to form the common hepatic duct. It also includes the point where the cystic
duct joins the common hepatic duct. Because these ducts are close to the liver, they
may be referred to as the proximal extrahepatic bile ducts.

10 minutes
Lecture
Discussion
Lippincott Question
Williams
and
& Wilkins Answer
Pathophysi
ology: A
2-in-1
Reference
for Nurses

distal extrahepatic bile duct

o The distal extrahepatic bile duct includes the common bile duct. It is farther away from
the liver, between the junction of the cystic duct to the common hepatic duct and the
ampulla of Vater (but does not include these structures).

5.) integrate the

conceptual
framework;

5 minutes
Lecture
Discussion
6.) enumerate
the
complications
and signs and
symptoms of
Bile Surgery;

Question
and
Answer
Function
The extrahepatic bile ducts are part of a network of ducts that carry bile from the liver and gallbladder
to the small intestine. Bile is a yellowish-green fluid made by the liver. Bile flows from the liver,
through the hepatic ducts, into the cystic duct and to the gallbladder, where it is stored.
Bile helps digest the fat in foods. Bile is mainly made up of:

bile salts

bile pigments (such as bilirubin)

Diseases
Database

cholesterol

water

If the bile is not needed for digestion, it flows into the cystic duct and then into the gallbladder, where
it is stored. When bile is needed to digest food, the gallbladder contracts and releases bile into the
cystic duct. The bile then flows into the common bile duct and is emptied into the small intestine,
where it breaks down fats.
Cholecystitis is most commonly caused by the presence of gallstones. These stones may block the
cystic duct which consequently results in bile stasis and secondary bacterial infection and
inflammation. Still there are even cases of cholecystitis without the presence of gallstones. This
medical condition is serious and if left untreated may lead to gallbladder necrosis and rupture.
Pathophysiology of Acute Cholecystitis caused by Gallstones
7.) list the
diagnostic tests
done;

2 minutes
Lecture
Discussion

This is one of the most common forms of acute cholecystitis. The inflammation develops rapidly and
the disease progresses rapidly. The disease is caused by the presence of gallstones. There may be one
or even several gallstones in the gallbladder and they may vary in structure and appearance.
Once the gallstones block the cystic duct the bile accumulates inside the gallbladder. This leads to
inflammation and what follows is bacterial superinfection which contributes to the symptoms and
signs of the disease. The inflammation leads to distension of the gallbladder and this may eventually
result in its swelling of the cells lining of the inner surface of the gallbladder. Consequent ischemia of
the gallbladder wall eventually leads to necrosis of the gallbladder wall. This condition is known as
gangrenous cholecystitis. In this stage of the disease the gallbladder must be surgically removed as

Question
and
Answer
3 minutes
Lecture
Discussion

healthline.
com

8.) determine
the medical
management;

soon as possible since it may rupture and cause serious complications.

Question
and
Answer
http://ww
w.ncbi.nlm
.nih.gov/p
mc/articles

(separate paper)

10 minutes

9.) apply the

nursing
management of
Biliary Surgery;

Acute Bile Duct Injury results in short-term complications such as biloma, bile peritonitis, sepsis,
multiple organ dysfunction syndrome, external biliary fistula, cholangitis, liver abscess, and others.
These complications if not properly managed may be associated with mortality as high as 5% .
Laparoscopic cholecystectomy is also associated with a higher risk of vascular injury to the hepatic
artery and portal vein which further increases the mortality. Acute Bile duct injury and the ensuing
biliary fistula may evolve into a biliary stricture. If the biliary stricture is not appropriately managed,
the complications of intrahepatic lithiasis, secondary biliary cirrhosis, portal hypertension, and end
stage liver disease may follow Adequate and proper training in a laparoscopic surgery, delineation of
biliary anatomy in Calot's triangle (critical view) by careful surgical dissection, and if need be by
intra-operative cholangiography (IOC), judicious use of electrocautery, avoiding blind application of
clips, and cautery in case of bleeding in the Calots triangle are some of the measures to avoid a BDI.
The primary cause of error according to one report was visual perceptual illusion in 97% of the cases.
Fault in technical skill was present in only 3% of injuries. Knowledge and judgment error contributed
but were not the primary cause
Symptoms

Lecture
Discussion

Question
and
Answer

10 minutes

A person with biliary colic usually complains of an ache or a feeling of pressure in the upper
abdomen. This pain can be in the center of the upper abdomen just below the breastbone, or in the
upper right part of the abdomen near the gallbladder and liver. In some people, the abdominal pain
spreads back toward the right shoulder blade. Many people also have nausea and vomiting.
10.) Enumerate
the possible
nursing
diagnoses;

Because symptoms of biliary colic usually are triggered by the digestive system's demand for bile,
they are especially common after fatty meals. The symptoms also can occur when a person who has
been fasting suddenly breaks the fast and eats a very large meal.
Risk factors;
Patent related rsk factors:

11.) state the

prognosis;

Lecture
Discussion

Age & sex

Anatomical variations (biliary and vasculature)

Severty of dsease : Acute ,chronc cholecystts,empyema and mrzz

syndrome,..

prevous surgery wth adhesons.

Obesty

Surgeon related rsk factors

Lack of experence

Msdentfcaton of blary anatomy

Intraoperatve bleedng

Over confdant surgeon

10 minutes
Lecture
Discussion

healthline.
com

Medical
Disability
Advisor

Improper terpretaton of oc

Improper lateral retracton (insufficient or excess lack of converson nto OC n

dffcult cases)

Diagnostic Tests done

How is a Biliary Obstruction Diagnosed? A variety of tests are available for the patient with possible
biliary obstruction. These include:
blood test: provides a complete blood count (CBC) and liver function tests. Blood tests can usually
rule out certain conditions, such as cholecystitis (inflammation of the gallbladder); cholangitis
(infection of the common bile duct); and an increased level of conjugated bilirubin (waste product of
the liver), liver enzymes, and alkaline phosphatase. Any of these may indicate a loss of bile flow.
ultrasonography: usually the first investigation performed on anyone suspected of a biliary
obstruction. Allows for easy visualization of gallstones.

Medical management
antibiotics, ursodeoxycholic acid to encourage bile flow, fat soluble vitamin supplementation and
nutritional support.
Patients should be managed on a case-by-case basis. 1-4% of asymptomatic patients develop problems
related to gallstones annually, so the odds are in favour of a 'watch and wait' policy. Younger patients
tend to develop complications more frequently because they have a longer time for the gallstones to
cause problems and smaller stones cause more problems than larger ones, as they are more likely to
become dislodged.

Biliary colic and acute cholecystitis - these are conditions which will usually respond to an opioid
such as morphine or pethidine given parenterally and/or diclofenac by suppository. These routes will
overcome difficulties in absorption caused by vomiting. Pain continuing for over 24 hours or
accompanied by fever usually necessitates hospital admission. It is generally considered that patients
who require antibiotics should have them intravenously in hospital. There is no evidence base to
support the use of oral antibiotics at home, except where the patient has been discharged from hospital
after a course of intravenous antibiotics but without having had surgical removal of the stones. One
study also supported current guidelines that antibiotics before elective cholecystectomy were
unnecessary.

Nursing management
The nurse can play a major role in assisting the grieving family. With skilful intervention, the bereaved
family may be better prepared to resolve their grief and move forward. To assis families in the
grieving process, include the following measures:
Provide accurate, understandable information to the family
Encourage discussion of the loss and venting of feelings of grief and guilt
Provide the family with baby mementos and pictures to validate the reality of death
Allow unlimited time with the stillborn infant after birth to validate the death; provde time for
the family members to be together and grieve; offer the family the opportunity to see, touch,
and hold the infant.
Use appropriate touch, such as holding a hand or touching a shoulder.
Inform the chaplain or the religious leader of the familys domination about the death and
request his or her presence.
Assis the parents with the funeral arrangements or disposition of the body.
Provide the parents with brochures offering advice about how to talk to other siblings about the
loss.
Make community referrals to promote a continuum of care after discharge.

Acute pain and discomfort related to surgical incision

Impaired gas exchange related to the high abdominal surgical incision (if traditional surgical
cholecystectomy was performed)

Impaired skin integrity related to altered biliary drainage after surgical intervention (if a T-tube
was inserted because of retained stones in the common bile duct or another drainage device
was employed)

Imbalanced nutrition, less than body requirements, related to inadequate bile secretion

Deficient knowledge about self-care activities related to incision care, dietary modifications (if
needed), medications, and reportable signs or symptoms (eg, fever, bleeding, vomiting)

Prognosis
Cholecystectomy is an effective way to treat recurrent gallstones or gall bladder inflammation
(cholecystitis). There are no dietary restrictions after removal of the gallbladder and no long-term
consequences, although bile duct stones can form weeks, months, or years after cholecystectomy.
Recovery time for laparoscopic cholecystectomy is one night in the hospital and a few days rest at
home; open cholecystectomy is major surgery involving a 2- to 7-day hospital stay and several weeks
at home (NDDIC). After recovery from surgery, most individuals have no more symptoms related to
the original condition. Laparoscopic cholecystectomy is associated with a 0.1% mortality rate, while
open surgery is associated with a 0.5% mortality rate; highest mortality is found among older
individuals (Naqesh-Bandi). The less invasive laparoscopic procedure is associated with less pain, a
shorter hospital stay, and a shorter recovery period than the open procedure. Cholecystectomy for

cancer of the gallbladder, bile ducts, or pancreas is usually for comfort only. High mortality rates are
associated with these types of cancers.

University of Cebu Lapu-Lapu and Mandaue

A.C. Cortes Ave. Looc, Mandaue City, Cebu

A Resource Unit on

Biliary Surgery
Submitted By:
Maturan, Neil Philip
Narvasa, Evan Jaime
Panares, Mary Jane
Patalingjug, Ana Marie
Perez, Airene
Perral, Olive Therese
Roble Shella Marie
Sico, BeahJeith Eunice
Tillor, Elsa
Ytol, Novrey Rose

Submitted To:

Ms. Mila E. Marikit, RN, MAN