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Patients Profile
Case No.:23832
Name: C.B
Age: 28
Address: Poblacion Bontoc, Mountain Province
Gender: Male
Pre-op diagnosis: Multiple Cholelitiasis
Post-op diagnosis: Multiple Cholelitiasis
Operation Performed: Open Cholecystectomy
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Anatomy and Physiology:
Gallbladder is a muscular organ that serves as a reservoir for
bile, present in most vertebrates. In humans, it is a pear-
shaped membranous sac on the undersurface of the right lobe of
the liver just below the lower ribs. It is generally about 7.5
cm (about 3 in) long and 2.5 cm (1 in) in diameter at its
thickest part; it has a capacity varying from 1 to 1.5 fluid
ounces. The body (corpus) and neck (collum) of the gallbladder
extend backward, upward, and to the left. The wide end (fundus)
points downward and forward, sometimes extending slightly beyond
the edge of the liver. Structurally, the gallbladder consists of
an outer peritoneal coat (tunica serosa); a middle coat of
fibrous tissue and unstriped muscle (tunica muscularis); and an
inner mucous membrane coat (tunica mucosa). The gallbladder lies
in a shallow depression on the interior surface of the liver, to
which it is attached by loose connective tissue. Its wall is
composed largely of smooth muscle. The gallbladder is connected
to the common bile duct by the cystic duct.
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The function of the gallbladder is to store bile, secreted by
the liver and transmitted from that organ via the cystic and
hepatic ducts, until it is needed in the digestive process. The
gallbladder, when functioning normally, releases bile through
the biliary ducts into the duodenum to aid digestion by
promoting peristalsis and absorption, preventing putrefaction,
and emulsifying fat. During storage, a large portion of the
water in bile is absorbed through the walls of the gallbladder,
so that bile in the gallbladder is five to 10 times more
concentrated than that originally secreted by the liver. When
food enters the duodenum, the gallbladder contracts and the
sphincter of oddi relaxes. Relaxation of this sphincter allows
the bile to enter the intestine. This response is mediated by
secretion of the hormone cholecystokin-pancreozymin (CCK-PZ)
from the intestinal wall.
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Pathophysiology:
A.Narrative form:
Cholesterol, a normal constituent of bile, is insoluble in
water. Its solubility depends on bile acids and lecithin
(phospholipids) in bile. In gallstone- prone patients, there is
decreased bile acid synthesis and increased cholesterol
synthesis in the live, resulting in bile supersaturated with
cholesterol, which precipitates out of the bile to form stones.
The cholesterol- saturated bile predisposes to the formation of
gallstones and acts as an irritant that produces inflammatory
changes in the gallbladder.
Two to three times more women than men develop cholesterol
stones and gallbladder disease; affected women are usually older
than 40 years of age, multiparous, and obese patient. Stone
formation is more frequent in people who use oral
contraceptives, estrogens, or clofibrate; these medications are
known to increase biliary cholesterol saturation. The incidence
of stone formation increases with age as a result of increased
hepatic secretion of cholesterol and decreased bile acid
synthesis.
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B.Schematic form:Predisposing Factors:
Advanced Age
Gender
Ileal
Resection/Disease
Race
Genetics
Precipitating Factors:
Obesity/ Overweight
Pregnancy/
Contraception
Frequent Starvation,
total
parenteral nutrition
Clofibrate Use
Diet/
Weight loss
Decreased
level of Bile
Acids
Increased levels
of fat in
The blood stream
Synthesis of
cholesterol
In the liver
Excretion of
cholesterol
to the bile
Ratio of bile salts &
lecithin with
cholesterol is no
longer within the
area of solubility
Cholesterol concentration >
Solubility capacity of the
bile
No formation of mixed
miccelles
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Lithogenic bile/ supersaturated
bile (creamy)
Mucoprecipitates of organic &
inorganic calcium salts become
nucleation sites
Nucleation and production of
cholesterol monohydrate crystals
Large cholesterol stones
Extrusion of stones from
gallbladder
Impaction at cystic and bile duct
Distention of
billiary and
fundus of
gallbladder
Forceful
contraction
of
gallbladder
Spasms of
smooth muscle
in the duct
PAIN
Bile not excreted to duodenum
Backflow of the bile and goes to
the circulation
Levels of
bilirubin/
bile
pigments in
the
circulation
Conversion
of bilirubin
to
urobilinogen
in the
intestines
Excretion of
urobinilogen
in the stool
Grayish
stool
Fat not emulsified
No absorption
of fat in the
intestines
y Nausea andVomiting
y Fullnessy Indigestiony Vit. ADEK
Increased
renal
excretion
Dark urine
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Preparation of the patient:
A.Skin preparation:
Begin at the intended sight of incision, either right subcostal,
right paramedian, or midline, extending from the axilla to the
pubic symphysis and down to the table on the sides.Skin isprepared with appropriate antiseptic solution (povidone iodine
solution) at least 1/2-1 hour before surgery and just before
surgery.
B.Draping:4 folded towels and a laparotomy sheet, sterile sheets are used
to cover all of the body except the operation site and adhesive
drapes are stuck on the operation site.
Position of patient during induction of anesthesia:
Lateral position: patient
begins in supine position. Rolled onto side- operative side up.
Bottom leg flexed; top leg straight. Bottom arm on armboard, top
arm on special arm support or pillow. Head supported in
alignment with body.
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Position of the patient during the surgery:
Supine position:a position of the body:
lying down with the face up, as opposed to the prone position,
which is face down, sometimes with the hands behind the head or
neck. When used in surgical procedures, it allows access to the
peritoneal, thoracic and pericardial regions; as well as the
head, neck and extremities. Using terms defined in the
anatomical position, the dorsal side is down, and the ventral
side is up.
C.AnesthesiaSubarachnoid block or Spinal anesthesia is an
extensive nerve block that is produced into the
subarachnoid space at the lumbar level, usually between L4
and L5. It produces anesthesia of the lower extremities,
perineum, and lower abdomen. For lumbar puncture procedure,
the patient usually lies on the side in a knee- chest
position. Sterile technique is used as a spinal puncture is
made and medication is injected through the needle. As soon
as the injection has been made, the patient is positioned
on her back. The spread of anesthetic agent and the level
of anesthesia depend on the amount of fluid injected, the
speed with which it is injected, the positioning of the
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patient affecter the injection, and the specific gravity of
the agent.
Discussion of the Procedure:
The incision is right subcostal. The abdominal cavity is entered
in the usual manner. The gallbladder is grasped. The cystic
duct, cystic artery, and common bile duct are exposed. The
surgeon must be aware of anomalies of these structures. The
cystic artery is clamped using two right angle clamps and
ligated with a suture passed on a long instrument or by clips,
as is the cystic duct. The gallbladder is mobilized by incising
the overlying peritoneum and after local dissection is removed.
The underlying liver bed may be reperitonealized. A drain may be
employed exiting a stab wound and secured to the skin with a
stitch. The wound is closed layer by layer. The skin is closed
with interrupted stitches.
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INSTRUMENTATION
Retractors:
Army navy retractor
- Held at one to shallow or superficial incisions.Richardson retractor
- Used to pull layers of tissue aside in deep abdominal orchest incision.
Deaver
- Used to retract deep abdominal or chest incisions.
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Doyen:
- Used by surgeons to either actively separate the edges of asurgical incision or wound, or can hold back underlying
organs and tissues, so that body parts under the incision
may be accessed.
Forceps:
Tissue forceps
- An instrument with one or more fine teeth at the tip ofeach blade for controlling tissues during surgery,
especially during suturing.
Thumb forceps
- The forceps used for grasping soft tissue; used especiallyduring suturing.
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Scissors:
Mayo (curved)
- designed for cutting body tissues near the surface of the
wound.
- used for cutting heavy fascia and sutures.
Mayo (straight)
- Used to cut suture and supplies.Metzenbaum
- Is more delicate than Mayo scissors which is used to cutdelicate tissues.
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Clamps:
Towel clip
- Used to hold towels and drapes in place.Allis
- Give surgeons the freedom to access internal organs andstructures with minimal damage to the overlying tissues.
These forceps can grasp, hold, move or lock a tissue into a
specific position so the surgeon can concentrate on the
area requiring the surgical procedure. The locking and non-
locking options give surgeons more options and flexibility.
Right-angle or Mixter
- provides a straight surface to cut along when dividing tissue
that has been occluded.
- used to clamp hard-to-reach vessels and to place sutures
behind or around a vessel.
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Straight clamp:
- They may be used for occluding blood vessels, manipulating[tissues], or for assorted other purposes.
Curvedclamp:
- They may be used for occluding blood vessels, manipulating[tissues], or for assorted other purposes.
Needle holder
- Locks the needle in place, allowing the user to maneuverthe needle through various tissues.
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Miscellaneous:
Knife or blade holder (#3)
- Used to cut superficial tissue.
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Others:
The dissection is started from gall bladder downwards.
Anterior and posterior peritoneal leaves are stripped off
gently. Cystic duct is gradually exposed by stripping fibrous
bands and lymphatics. A lymph node is usually a land mark for
cystic artery. Cystic artery is similarly exposed and
skeletonised. It is critical that no structure is divided until
the cystic duct and cystic artery are unequivocally identified.
The fundus of gall bladder is then pushed in lateral and
cephalad direction. This maneuver exposes the entire gall
bladder, cystic duct and porta hepatis.
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