Which outcome should the nurse identify for the client scheduled to have a cholecystectomy?

Preprocedural Planning

Antibiotic prophylaxis

Numerous studies have found no significant differences in the rate of surgical-site infection (SSI) when perioperative antibiotics were compared with placebo in patients undergoing elective cholecystectomy. [57, 58, 59]

A systemic review by Sanabria et al assessed the use of antibiotic prophylaxis in laparoscopic cholecystectomy. [60] The review concluded that the available evidence was not sufficient either to support or to rule out the use of antibiotic prophylaxis to reduce SSIs. However, larger, randomized clinical trials are needed.

Although some surgeons use antibiotics followed by surgery for patients with acute cholecystitis, this approach has not been studied in a randomized, controlled fashion. Published studies comparing different lengths of antibiotic courses in patients with acute cholecystitis who undergo cholecystectomy have shown no benefit to a longer course of antibiotics. [61]

Combined cholecystectomy

Laparoscopic cholecystectomy is sometimes done in conjunction with other intra-abdominal surgery, but such pairing should be considered only when surgical exposure is adequate, the patient’s condition is satisfactory, and operating time is not unduly prolonged. Several other abdominal and pelvic surgical procedures can be combined with laparoscopic cholecystectomy 

The duration of hospital stay for a patient who undergoes a combined procedure is similar to that for a patient who undergoes a single procedure. Thus, the patient has the benefit of receiving surgical therapy for two coexisting conditions concurrently while experiencing substantially less perioperative morbidity than would have been expected with two discrete procedures. Combined procedures also appear to be cost-effective both for patients and for hospital services. [62, 63]

Equipment

Equipment typically required for laparoscopic cholecystectomy includes the following:

• Light source, preferably with two video monitors (for the surgeon and the assistant)

• Laparoscope (telescope), 0° or 30° (preferred)

• Standard gas insufflation equipment

• Hasson trocar

• Trocars, 5 mm (2)

• Subxiphoid trocar, 11 mm (this can be replaced with another 5-mm trocar if a 5-mm laparoscopic clip applier is available)

• Blunt graspers

• Maryland dissector and L-hook cautery

• Electrocautery equipment

• Laparoscopic suction irrigator

• Laparoscopic clip applier

• Endoscopic ligature loop (eg, Endoloop; Ethicon Endo-Surgery, Blue Ash, OH)

• Cotton swab affixed to a 5-mm shaft (eg, Endo Peanut; Covidien, Mansfield, MA)

• Endoscopic retrieval pouch (eg, Endo Catch; Covidien, Mansfield, MA)

Many surgeons do not routinely use a Foley catheter for laparoscopic cholecystectomy.

Patient Preparation

Anesthesia

Because pneumoperitoneum is necessary for laparoscopic cholecystectomy, general anesthesia with intubation is routinely required. Case reports of epidural anesthesia [64] and a pilot study comparing spinal anesthesia with general anesthesia in young, thin, healthy patients showed no significant differences in outcome. [65] Further studies involving acute cholecystitis and an older patient population are needed.

Positioning

For this procedure, the patient should be in the supine position. Peripheral intravenous lines are inserted, and electrocardiography (ECG), pulse oximetry, and blood pressure monitors are placed. The patient is intubated and general anesthesia initiated.

The patient’s arms are abducted or tucked comfortably at the sides. The two laparoscopic towers are situated on either side of the patient’s trunk, toward the head. The surgeon stands on the patient’s left, and the assistant who holds the laparoscope stands on the left of the surgeon to the patient's left. An additional assistant stands on the patient's right to hold and retract the gallbladder fundus (and thus the liver).

Monitoring & Follow-up

The postoperative course is generally uncomplicated. If the cholecystectomy was done as an elective procedure, patients can be discharged the same day and usually should regain their normal level of physical activity within 1 week. Patients should expect some degree of postoperative discomfort around the port sites but should nonetheless be alert for any signs or symptoms (eg, fever, uncontrolled vomiting, extreme pain or jaundice) that could be manifestations of complications. [66]

All patients who have undergone laparoscopic cholecystectomy should have a follow-up visit within 1-2 weeks postoperatively. The histopathologic report should be checked to ensure that an incidental cancer is not missed. After that initial postoperative check, patients should be seen on an individual basis as needed.

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Author

Danny A Sherwinter, MD Attending Surgeon, Department of Mimially Invasive Surgery and Bariatrics, Associate Program Director, Department of Surgery, Maimonides Medical Center; Director of Minimally Invasive and Bariatric Surgery, American Society for Metabolic and Bariatric Surgery (ASMBS) Center of Excellence

Danny A Sherwinter, MD is a member of the following medical societies: American College of Surgeons, American Society for Metabolic and Bariatric Surgery, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoscopic and Robotic Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

Stalin Ramakrishnan Subramanian, MD Resident Physician, Department of Medicine, Brookdale University Hospital and Medical Center

Disclosure: Nothing to disclose.

Chief Editor

Vinay K Kapoor, MBBS, MS, FRCSEd, FICS, FAMS Professor of HPB Surgery, Mahatma Gandhi Medical College and Hospital (MGMCH), Jaipur, India

Vinay K Kapoor, MBBS, MS, FRCSEd, FICS, FAMS is a member of the following medical societies: Association of Surgeons of India, Indian Association of Surgical Gastroenterology, Indian Society of Gastroenterology, Medical Council of India, National Academy of Medical Sciences (India), Royal College of Surgeons of Edinburgh

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Pfizer Sanofi.

Acknowledgements

Jerzy M Macura, MD Chief of Advanced Laparoscopic Surgery, Director of Bariatric Surgery, Maimonides Medical Center

Jerzy M Macura, MD is a member of the following medical societies: American Society for Metabolic and Bariatric Surgery, American Society of Abdominal Surgeons, and Society of American Gastrointestinal and Endoscopic Surgeons

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

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