LAPAROSCOPIC CHOLECYSTECTOMY Laparoscopic cholecystectomy is a procedure in which the gallbladder is removed by laparoscopic techniques.

Laparoscopic surgery also referred to as minimally invasive surgery describes the performance of surgical procedures with the assistance of a video camera and several thin instruments. Laparoscopy (from Greek lapara, "flank or loin", and skopein, "to see, view or examine") is an operation performed in the abdomen or pelvis through small incisions with the aid of a camera. During a laparoscopic surgical procedure, small incisions of up to half an inch are made and plastic tubes called ports are placed through these incisions. The camera and the instruments are then introduced through the ports which allow access to the inside of the patient. The camera transmits an image of the organs inside the abdomen onto a television monitor.The surgeon is not able to see directly into the patient without the traditional large incision. The video camera becomes a surgeon s eyes in laparoscopy surgery, since the surgeon uses the image from the video camera positioned inside the patient s body to perform the procedure. Advatages: Benefits of minimally invasive or laparoscopic procedures include less post operative discomfort 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 in a minimally invasive fashion compared to standard open surgery. PROCEDURE Many thousands of laparoscopic cholecystectomy have been performed and this operation has an excellent safety record. Some of the important steps in the operation are as follows:
 

 

General anesthesia is utilized, so the patient is asleep throughout the procedure. An incision that is approximately half an inch is made around the umbilicus ( belly button), three other quarter to half inch incisions are made for a total of four incisions. Four narrow tubes called laparoscopic ports are placed through the tiny incisions for the laparoscopic camera and instruments. A laparoscope (which is a long thin round instrument with a video lens at its tip) is inserted through the belly button port and connected to a special camera. The laparoscope provides the surgeon with a magnified view of the patient's internal organs on a television screen. Long specially designed instruments are inserted through the other three ports that allow your surgeon to delicately separate the gallbladder from its attachments to the liver and the bile duct and then remove it through one of the ports from the abdomen. Your surgeon may occasionally perform an X-ray, called a cholangiogram, to exam for stones in the bile duct. After the gallbladder is removed from the abdomen then the small incisions are closed.

Contraindications: In a small number of patients if excessive scarring is present or the anatomy of the structures is not clear then for safety reasons the surgeon may decide too convert the operation to an open surgical operation through a traditional large surgical incision. Less than 5% of all laparoscopic cholecystectomy procedures are converted to open procedures. The decision to convert to an open operation is strictly based on patient safety. Factors that may increase the risk of converting to the "open" procedure include obesity, a history of prior abdominal surgery causing dense scar tissue, acute cholecystitis or bleeding problems during the operation. Complications:

Complications of a laparoscopic cholecystectomy are infrequent and the vast majority of laparoscopic gallbladder patients recover and quickly return to normal activities. Some of the complications that can occur include bleeding, infection, leakage of bile in the abdomen, pneumonia, blood clots, or heart problems. Surgical injury to an adjacent structures such as the common bile duct, duodenum or the small intestine may occur rarely and may require another surgical procedure to repair it. If the gallbladder is accidentally or deliberately opened during the procedure stones may fall out of the gallbladder and in to the abdomen that may give rise to later scarring. Nursing Care: BEFORE SURGERY Provide routine preoperative care as ordered . Reinforce teaching about the procedure and postoperative expectations, including pain management, deep breathing, andmobilization. Preoperative teaching reduces anxiety and promotes rapid postoperative recovery. AFTER SURGERY Provide routine postoperative recovery care as outlined in. Assist to chair at bedside as allowed.Early mobilization promotes lung ventilation and circulation, reducing the potential for postoperative complications. Advance oral intake from ice chips to regular diet as tolerated. Oral intake can be rapidly resumed due to minimal disruption of the gastrointestinal tract during surgery. Provide and reinforce teaching: pain management, incision care, activity level, postoperative follow-up appointments. With early discharge, the client and family assume responsibility for the majority of postoperative care. A clear understanding of this care and expected needs reduces anxiety and the risk of postoperative complications. Initiate follow-up contact 24 to 48 hours after discharge to evaluate adequacy of pain control, incision management, and discharge understanding. Contact following discharge provides an opportunity to evaluate care and reinforce teaching. History: Laparoscopic cholecystectomy was developed and popularized in the United States by Dr. Eddie Joe Reddick in 1989. It was a natural outgrowth of laparoscopic surgery being done by gynecologists and arthroscopic surgery done by orthopaedic surgeons many years prior to 1989. As this minimally invasive surgery was being developed and applied to gall bladder surgery many instruments had to be developed and then modified to accommodate the needs specific to biliary tract surgery. In addition surgical methodology had to be modified as better techniques were developed to accomplish a safe, efficent cholecystectomy. During this evolving process which continues today the entire general surgical community had to be trained and monitored to use this minimally invasive approach in such a way that assured safety and efficacy in the general population . By late 1990 and early 1991 many surgeons were performing laparoscopic cholecystectomies using the following technique: The Procedure: a) After induction of general anesthesia an oral-gastric tube is placed to decompress the stomach and a foley catheter is used to drain the bladder of urine. b) A small incision is made near the umbilicus and a needle (Veress) is inserted blindly into the peritoneal cavity. c) Carbon dioxide is introduced in the peritoneal cavity through the Veress needle which is now insufflated to 15mm mercury pressure. d) A trocar/port is placed into the now insufflated peritoneum and a laparoscope is introduced into the peritoneum which allows the inside of the peritoneum to be projected onto video screens on either side of the operating table.

e) Three additional trocar ports are now placed in the right upper quadrant under direct vision, two are 5mm in diameter and one is 10mm in diameter. It is through these ports that laparoscopic instruments, i.e., graspers, dissectors, scissors, etc. are introduced to separate the gallbladder from the liver bed and the biliary free. This is accomplished in the following fashion: 1) The end of the gallbladder is grasped and pushed up toward the diaphragm. This places the cystic dust and cystic artery on stretch and permits the necessary separation of these structures prior to ligating them. Unfortunately when the end of the gall bladder is placed on stretch it can tent up the common bile duct to which it is attached. To avoid this tenting up of the common bile duct and to gain better exposure of the cystic duct, common duct, cystic artery area (Triangle of Calot), a second grasping instrument is now used to grasp the proximal portion of the gall bladder (Hartmann's pouch) and retract it inferiorolaterally. This now opens up the cystic duct-common duct junction and allows for safe identification and dissection of this area. 2) Once the cystic duct, common bile duct and cystic artery have been clearly identified and dissected free of each other and other fibrous and fatty tissue, it is now safe to ligate and divide the cystic duct and the cystic artery. This is done by inserting a clipping instrument through the 10mm port and placing two clips proximally and distally then cutting between the clips. With this accomplished the gall bladder is then separated from the liver by dividing the peritoneum between the liver and the gall bladder using electrocautery. The electrocautery can be attached to any number of dissecting instruments designed for this purpose. Sharp dissection with electrocautery or laser light is very effective in both separating the gall bladder from the liver bed and stopping any bleeding which may be encountered during this part of the operation. 3) Once the gall bladder has been safely separated from the cystic duct, cystic artery and liver bed it is grasped and pulled out through one of the larger 10mm ports. Complications: Early in the national experience with laparoscopic cholecystectomy it became apparent that some surgeons who were in the early phases of their training would misidentify the anatomy and inadvertently clip and divide the common bile duct thinking it to be the cystic duct. In many instances this would result in complete obstruction of the common bile duct which would require a second operation to correct. Often these injuries were not noted at the time of the initial procedure and therefore a delay in the diagnosis of the problem often resulted. Other problems of much less consequence have also been identified to occur following laparoscopic cholecystecomy. This includes entering the gall bladder and spilling stones and bile into the peritoneal cavity, failure to diagnose stones in the common bile duct, cystic duct clips falling off leading to bile peritonitis, holes being poked in the cystic dust while doing x-rays of the biliary tree (cholangiography), holes poked into the intestine or mesentery by either the needle used to fill the peritoneum with CO2 (Verness needle) or one of the trocars used to introduce the ports.