Handbook of Medical-Surgical Nursing
4th Edition

Cholecystectomy
When drug therapy, dietary changes, and supportive treatments fail to control gallbladder or biliary duct disease, the patient’s gallbladder may need to be removed. Known as a cholecystectomy, this procedure helps restore biliary flow from the liver to the small intestine. The procedure may be performed either as abdominal surgery, which uses one large abdominal incision, or as a laparoscopic
P.178

procedure, which uses several small abdominal incisions.
After gallbladder resection, choledochoduodenostomy (anastomosis of the common bile duct to the duodenum) or choledochojejunostomy (anastomosis of the common bile duct to the jejunum) may be necessary to restore biliary flow.
Procedure
Both abdominal and laparoscopic cholecystectomies are performed under general anesthesia. An abdominal cholecystectomy begins with a right subcostal or paramedial incision. The surgeon then surveys the abdomen and uses laparotomy packs to isolate the gallbladder from the surrounding organs. After identifying biliary tract structures, he may use cholangiography or ultrasonography to help identify gallstones. Using a choledoscope, he directly visualizes the bile ducts and inserts a Fogarty balloon-tipped catheter to clear the ducts of stones.
The surgeon ligates and divides the cystic duct and artery and removes the entire gallbladder. Typically, he performs a choledochotomy: the insertion of a T tube into the common bile duct to decompress the biliary tree and prevent bile peritonitis during healing. He may also insert a Penrose drain into the ducts. After completion of the surgery and, if necessary, implantation of the T tube, the surgeon removes blood and debris from the abdomen, closes the incision, and applies a dressing.
For a laparoscopic cholecystectomy, the surgeon begins by making a small incision just above the umbilicus and injecting either carbon dioxide or nitrous oxide into the abdominal cavity. This inflates the abdomen and lifts the abdominal wall away from the abdominal organs, allowing the surgeon to identify the gallbladder readily. He then connects a trocar to an insufflator and inserts it through the incision. Next, he passes a thin, flexible optical instrument, called a laparoscope, through the trocar. The laparoscope allows the surgeon to view the intra-abdominal contents.
At this time, the patient is placed in Trendelenburg’s position. This causes the small intestines to fall out of the pelvis, making room for the initial needle and trocar insertion. Then, while looking through the laparoscope, the surgeon makes three incisions in the patient’s right upper quadrant: one 2″ (5 cm) below the xiphoid process in the midline; one 1″ (2.5 cm) below the right costal margin in the midclavicular line; and one in the anterior axillary line at the level of the umbilicus.
While continuing to look through the laparoscope, the surgeon passes instruments through the three incisions in the right upper quadrant. He uses these to clamp and then tie off the cystic duct and to excise the gallbladder. The gallbladder is then removed through the umbilical opening. After this, the surgeon sutures all four incisions and places a dressing over each one.
Complications
Although relatively rare, complications from cholecystectomy can be grave. Peritonitis, for instance, may occur from obstructed biliary drainage and resultant leakage of bile into the peritoneum. Postcholecystectomy syndrome, marked by fever, jaundice, and pain, may occur. As in all abdominal surgeries, postoperative atelectasis may result from hampered respiratory excursion if an abdominal surgical approach was used. If a laparoscopic approach was used, bile duct or small-bowel injury may occur during introduction of the trocar.
Other complications include superficial wound infection, prolonged ileus, urine retention, and retained gallstones.
Key nursing diagnoses and patient outcomes
Ineffective breathing pattern related to guarded respirations caused by one or more incisions in the right upper quadrant of the abdomen. Based on this nursing diagnosis, you’ll establish these patient outcomes. The patient will:
  • not exhibit any signs of hypoxia, such as restlessness, shortness of breath, and confusion
  • regain and maintain a normal breathing pattern.
P.179

Risk for infection related to potential for leakage of biliary drainage into the abdominal cavity. Based on this nursing diagnosis, you’ll establish these patient outcomes. The patient will:
  • have a normal temperature, white blood cell count, and liver function studies; these values will remain normal
  • exhibit an incision that’s clean and free from inflammation and purulent drainage
  • not experience any signs and symptoms of peritonitis, such as abdominal distention and increased abdominal pain.
Acute pain related to one or more surgical incisions. Based on this nursing diagnosis, you’ll establish these patient outcomes. The patient will:
  • verbalize a decrease in pain within 24 hours
  • express relief from pain after analgesic administration
  • become pain-free after healing is complete.
Nursing interventions
With a cholecystectomy patient, your major roles include instruction and care tailored to the patient’s condition.
Before surgery
  • Explain the planned surgery to the patient, using clear, simple terms and diagrams. Reassure him that the surgery will relieve his symptoms. Also reassure him that his recovery should be rapid and uneventful and that he should be allowed to resume his full range of activities within 4 to 6 weeks.
  • If the patient is scheduled for an abdominal surgical approach, warn the patient that, after surgery, he’ll have a nasogastric (NG) tube in place for 1 to 2 days and an abdominal drain at the incision site for 3 to 5 days. If appropriate, tell him that a T tube will be inserted in the common bile duct during surgery to drain excess bile and allow removal of retained stones. Explain that the T tube may remain in place for up to 2 weeks, depending on the surgery, and that he may be discharged with it still in place.
  • If the patient is scheduled for a laparoscopic approach, tell the patient that an indwelling urinary catheter will be inserted into his bladder and an NG tube into his stomach after general anesthesia has been administered. Reassure him that these tubes will be removed in the postanesthesia room following the procedure. Explain that he’ll have three small incisions in the right upper quadrant of his abdomen and one small incision in his umbilicus. Each of these incisions will be covered with a small sterile dressing postoperatively. Also inform him that he may be discharged the day of surgery or the day after.
  • Teach the patient how to perform coughing and deep-breathing exercises to prevent postoperative atelectasis, which can lead to pneumonia. Tell him that an analgesic can be administered before these exercises to relieve discomfort.
  • Monitor and, if necessary, help stabilize the patient’s nutritional status and fluid balance. Such measures may include administering vitamin K, blood transfusions, or glucose and protein supplements. Twenty-four hours before surgery, administer only clear liquids. Then, after midnight the night before surgery or as ordered, withhold all food and fluid.
  • Administer preoperative medications and assist with insertion of an NG tube.
  • Ensure that the patient or a responsible family member has signed a consent form.
After surgery
  • When the patient returns from surgery, place him in low Fowler’s position. As ordered, attach the NG tube to low intermittent suction. Monitor the amount and characteristics of drainage from the NG tube as well as from any abdominal drains. Check dressings frequently and change as necessary.
  • If the patient has a T tube in place, frequently assess the position and patency of the tube and drainage bag. The drainage bag should be level with his abdomen to prevent excessive drainage. Also note the amount and characteristics of drainage; bloody or blood-tinged bile normally occurs for only the first few hours after surgery. Report excessive drainage (greater than 500 ml after 48 hours) immediately.
    P.180

    Provide meticulous skin care around the tube insertion site to prevent irritation.
  • After a few days, expect to remove the NG tube, if present, and begin to introduce foods: first liquids, then gradually soft solids. As ordered, clamp the T tube for an hour before and an hour after each meal to allow bile to travel to the intestine to aid digestion. If the patient has had a laparoscopic cholecystectomy, expect him to begin clear liquids when fully recovered from general anesthesia and to resume his normal diet the day of or the day after surgery.
  • Be alert for signs of postcholecystectomy syndrome (such as fever, abdominal pain, and jaundice) and other complications involving obstructed bile drainage. For several days after surgery, monitor vital signs and record intake and output every 8 hours. If any complications occur, report them to the physician, and collect urine and stool samples for laboratory analysis of bile content.
  • Assist the patient with ambulation on the first postoperative day, unless contraindicated. Have him cough, deep-breathe, and perform incentive spirometry every 4 hours; as ordered, provide analgesics to ease discomfort during these exercises. Assess his respiratory status every 2 hours to detect hypoventilation and signs of atelectasis.
Home care instructions
  • If the patient is being discharged with a T tube in place, show him how to care for it, stressing the need for meticulous tube care.
  • Tell the patient to immediately report any signs of biliary obstruction: fever, jaundice, pruritus, pain, dark urine, and clay-colored stools.
  • Tell the patient that, although there are typically no dietary restrictions, he may wish to avoid excessive fat intake for 4 to 6 weeks and then gradually add them to his diet as tolerated.