Cholecystectomy is the surgical removal of the gallbladder. The operation is done to remove gallstones or to remove an infected or inflamed gallbladder.

Benefits and Risk

Gallbladder removal will relieve pain, treat infection, and in most cases stop gallstones from coming back. The risks of not having surgery are the possibility of worsening symptoms, infection, or bursting of the gallbladder.

Possible complications include bleeding, bile duct injury, fever, liver injury, infection, numbness, raised scars, hernia at the incision, anesthesia complications, puncture of the intestine, and death.

CHOLECYSTITIS WITH CHOLELITHIASIS Cholecystitis is an acute or chronic inflammation of the gallbladder, usually associated with gallstone(s) impacted in the cystic duct, causing distension of the gallbladder. Stones (calculi) are made up of cholesterol, calcium bilirubinate, or a mixture caused by changes in the bile composition. Gallstones can develop in the common bile duct, the cystic duct, hepatic duct, small bile duct, and pancreatic duct. Crystals can also form in the submucosa of

the gallbladder causing widespread inflammation. Acute cholecystitis with cholelithiasis is usually treated by surgery, although several other treatment methods (fragmentation and dissolution of stones) are now being used.

WHAT IS THE GALLBLADDERThe gallbladder is a small pear-shaped muscular sack that acts as a storage tank for bile. The bile is made in the liver by liver cells and is sent through tiny ducts or canals to the duodenum (small intestine) and to the gallbladder. The gallbladder stores the bile to have it available in larger quantities for secretion when a meal is eaten. The ingestion of food and especially fats cause the release of a hormone, cholecystokinin, (CCK) which in turn signals the relaxation of the valve at the end of the common bile duct (the sphincter of oddi) which lets the bile enter the small intestine. It also signals the contraction of the gallbladder which squirts the concentrated liquid bile into the

small intestine where it helps with the emulsification or breakdown of fats in the meal.

LOCATION OF GALLBLADDER

The gallbladder is located behind the liver on the right side of the rib cage. It hits up against the under surface of the liver. There is a duct from the liver to the small intestine which is joined by a duct from and to the gallbladder. Bile moves in both directions into and out of the gallbladder through the cystic duct. This latter duct joins with a duct from the pancreas on its way to the small intestine carrying pancreatic enzymes also used for digestion. The main duct is called the common bile duct. It is common to the liver, gallbladder and farther down line, to the pancreas as well.

Bile is a bitter, yellow fluid. It can consist of cholesterol, lecithin, calcium, bile salts, acids and waste materials among other things. When the bile salts and cholesterol get out of balance with each other (to state it simply) gall stones can form.

PICTURE OF GALLBLADDER LOCATION

GALLBLADDER FUNCTION

Bile is continually being made and secreted by the liver into bile ducts in varying amounts.(1) Some of it goes directly into the small intestine and some into the gallbladder. The gallbladder stores the bile to be squirted down the ducts into the small intestine to help to breakdown the fats when you eat a meal that contains fats. It also acts as a reservoir that uptakes excess bile when there is pressure in the bile ducts.

BILE FUNCTION

The bile has two major functions in the body. Firstly, it breaks down the fats that you eat so that your body can utilize them. Without adequate bile you do not metabolize your fats well which can result in a deficiency of the fat-

soluble vitamins (A, D, E and K). You may also have problems digesting the essential fatty acids. Amongst other symptoms you could have trouble utilizing calcium, have dry skin, peeling on the soles of your feet, etc. One way you can tell you have trouble digesting fats is if you have excessive burping that starts shortly after eating a meal that has fat in it. You might feel nauseous or experience gas and bloating. Often the bile is thick and you can thin it out with The Beet Recipe which you can find here under gallbladder diet, or with a whole food beet product found in the GALLBLADDER STARTER KIT on this site.

Secondly, bile is a very powerful antioxidant which helps to remove toxins from the liver. The liver filters toxins (bacteria, viruses, drugs or other foreign substances the body doesn't want) and sends them out via the bile, which is made in the liver. The pathway of departure is from the liver through the bile ducts and into the gallbladder or directly into the small intestine where it joins waste matter and leaves through the colon with the feces. A healthy liver produces about a quart to a quart and a half of bile daily. If you have gallbladder problems, you would do well to cleanse your liver and bowel also. Many people with sluggish gallbladders have a tendency towards constipation.

T-TUBE CARE

Also called a biliary draining tube. May be placed in the common bile duct after cholecystectomy or choledochostomy. The tube facilitates biliary drainage during healing. The surgeon inserts the short end (crossbar) into the common bile duct and draws the long end through an incision in the skin. The

tube is then connected to a closed gravity drainage system. Post-operatively it remains in place between 7 to 14 days.

Equipment

Graduated collection container Small plastic bag Sterile gloves and clean gloves Clamp Sterile 4”x4” gauze pads Transparent dressings Rubber band Normal saline solution Sterile cleaning solution Two sterile basins Providone-iodine pads Sterile precut drain dressings Hyperallergenic paper tape Skin protectant Montgomery strips

Preparation of equipment

1. Assemble the equipment at the bedside2. Open all sterile equipment. Place one sterile 4”x4” gauze pad in each sterile basin3. Using sterile technique, pour 50ml of cleaning solution into one basin and 50 ml of normal saline solution into the other basin.4. Tape a small plastic bag on the table to use for refuse

Procedure

1. Verify the patient’s identity using two patient identifiers, such as the patient’s name and identification number.2. Provide privacy and reinforce the explanation of the procedure to the patient3. Wash hands

Emptying drainage

1. Put on glean gloves2. Place the graduated collection container under the outlet valve of the drainage bag. Without contaminating the clamp, valve, or

outlet valve, empty the bag’s contents completely into the container and reseal the outlet valve.3. Carefully measure and record the character, color, and amount of drainage.4. Discard gloves

Clamping the T-tube

1. As ordered, occlude the tube lightly with a clamp or wrap a rubber band around the end. Clamping the tube 1 hour before and after meals diverts the bile back to the duodenum to aid digestion.

2. Monitor the patient’s response to clamping.3. To ensure the comfort and safety, check the bile drainage amounts regularly.

Nursing Interventions

1. The T-tube usually drains 300 to 500 ml of thin, blood tinged bile in the first 24 hours after surgery.2. To prevent excessive bile loss over 500ml in the first 24 hours or backflow contamination. Bile will flow into the bag only when biliary

pressure increases.3. Provide meticulous skin care and frequent dressing changes since bile is irritating to the skin.4. Monitor for bile leakage, which may indicate obstruction.5. Monitor tube patency and the condition of the site hourly for the first 8 hours.6. Protect the skin edges and avoid excessive taping.7. Monitor all urine and stools for color changes.8. Reinforce with the patient that loose bowel occur commonly the first few weeks after surgery.9. Remind the patient about signs and symptoms of T-tube and biliary obstruction and to report them to physicians.10. Teach the patient how to care for the tube at home.11. Reinforce with the patient that the bile stains clothing and is irritating to the skin.

Complications

Obstructed bile flow, skin excoriation or breakdown, tube dislodgement, drainage reflux, and infection. Acute Pain Cholecystectomy Nursing Care Plan The flow of bile in the gall bladder is obstructed due to the presence of stones. When the bladder releases bile, it contracts and

there is spasm, thus it cannot adequately release bile due to the stone, it stimulates the release of cytokines resulting to pain.

What is a Jackson Pratt drain?Jackson Pratt Drain Care Care GuideA Jackson Pratt drain, or JP drain, is used to remove fluids that build up in areas of your body. Unwanted fluid can collect in areas of infection, areas where surgery has been done, or in other body areas. The JP drain is made up of a thin rubber tube and a soft round squeeze bulb. One end of the rubber tube is placed in the area where body fluids may build up. The other end sticks out of your body through a small incision (cut), and is connected to the squeeze bulb.

How does a Jackson Pratt drain work?The JP drain removes fluids by creating suction (pulling) in the tube. To produce suction, the bulb is pressed flat and is connected to the tube sticking out of your body. Suction is created as the bulb sucks in air from the tube going into your body. This pulls fluid out from the area where the drain was placed and into the rubber tubing. The fluid then travels through the tubing and into the bulb of the JP drain. As the JP drain bulb fills with fluid, it goes back to its round shape.

Why do I need a Jackson Pratt drain?When fluid builds up in a body area, the area may not heal as fast as it should, or an infection may start. Too much fluid in a body area may also cause pain and swelling. Using a JP drain after surgery may help you heal faster and decrease your risk of getting an infection. The JP drain also helps clear away pus and may help infections heal faster. A JP drain may be used after surgery on your spine to check if spinal fluid is leaking, and collect it. JP drains may also be used after skin flap surgery and skin grafting.

When is a Jackson Pratt drain removed?The amount of fluid that comes out of the surgery or wound area and into the JP drain will decrease as the area heals. In most cases, the drain will need to stay in place until less than 30 milliliters (about two tablespoons) of fluid are draining from it in a day. Your caregiver will keep track of how much fluid is draining into the JP drain, and he will tell you when the drain will be taken out. If you are caring for your JP drain at home, you will need to keep track of the amount of fluid that you are emptying from the drain.What are the risks of having a Jackson Pratt drain?If a JP drain is not taken care of correctly, it may allow germs to enter your body and cause an infection. If the drain is placed after certain types of surgery, you may get an infection if it stays in your body longer than it is needed. If you get an infection, you may have more pain and swelling, and your wound will heal more slowly, or it may not heal at all. The end of the tubing inside your body may get blocked with blood or other materials. If this happens, the bulb cannot correctly suction fluids. You may develop a fistula (unwanted tunnel), or the drain may make a hole in your intestine. If you have a drain after skin flap or skin graft surgery, the tissue may not heal.

How do I take care of the skin around my Jackson Pratt drain entry site?Change bandages at the JP drain entry site every day to keep it clean and dry. Your caregiver will tell you if you need to do this more often. Collect the following items and place them where they can be reached easily:

Two pairs of clean medical gloves. A clean container. 5 to 6 new cotton swabs. New gauze pads. Saline solution or soap and water. Plastic trash bag. Surgical tape. Waterproof pad or bath towel.

Follow these steps to care for your skin around the JP drain entry site: Wash your hands with soap and water. Dry your hands and put on clean gloves. Loosen the tape and gently remove the old bandage. Throw the old bandage into a plastic trash bag. Look for any new redness, swelling, or pus at the place where the drain enters your skin. Check for a foul (bad) smell coming from the

area. Tell caregivers if you see any of these changes. Make sure the stitches that attach the JP drain to your skin are tight. Tell caregivers if they are loose or missing.

Place a waterproof pad or towel under the JP drain to soak up any spills. Pour a small amount of saline solution or clean water into a container. Dip a cotton swab in the solution once. Gently clean the skin

around the drain, moving in circles. Start from the place where the drain enters your skin and clean outward in circles, moving away from the insertion site. Clean your skin 3 to 4 times, using a new swab each time.

Let the skin dry. Take your gloves off and put on a clean pair. When the area is dry, put a new bandage around the JP tube entry site. Use surgical tape to hold it down against your skin. Tape the tubing down to the bandages. Attach the bulb to your clothing using a safety pin.

Throw all used supplies in the trash bag along with your gloves. Wash your hands after you are finished.

Cholecystitis is an inflammation of the gallbladder wall and nearby abdominal lining. Cholecystitis is usually caused by a gallstone in the cystic duct, the duct that connects the gallbladder to the hepatic duct. The presence of gallstones in the gallbladder is called cholelithiasis. Cholelithiasis is the pathologic state of stones or calculi within the gallbladder lumen. A common digestive disorder worldwide, the annual overall cost of cholelithiasis

is approximately $5 billion in the United States, where 75-80% of gallstones are of the cholesterol type, and approximately 10-25% of gallstones are bilirubinate of either black or brown pigment. In Asia, pigmented stones predominate, although recent studies have shown an increase in cholesterol stones in the Far East.

Gallstones are crystalline structures formed by concretion (hardening) or accretion (adherence of particles, accumulation) of normal or abnormal bile constituents. According to various theories, there are four possible explanations for stone formation. First, bile may undergo a change in composition. Second, gallbladder stasis may lead to bile stasis. Third, infection may predispose a person to stone formation. Fourth, genetics and demography can affect stone formation.

Risk factors associated with development of gallstones include heredity, Obesity, rapid weight loss, through diet or surgery, age over 60, Native American or Mexican American racial makeup, female gender-gallbladder disease is more common in women than in men. Women with high estrogen levels, as a result of pregnancy, hormone replacement therapy, or the use of birth control pills, are at particularly high risk for gallstone formation; Diet-Very low calorie diets, prolonged fasting, and low-fiber/high- cholesterol/high-starch diets all may contribute to gallstone formation.

Sometimes, persons with gallbladder disease have few or no symptoms. Others, however, will eventually develop one or more of the following symptoms; (1) Frequent bouts of indigestion, especially after eating fatty or greasy foods, or certain vegetables such as cabbage, radishes, or pickles, (2) Nausea and bloating (3) Attacks of sharp pains in the upper right part of the abdomen. This pain occurs when a gallstone causes a blockage that prevents the gallbladder from emptying (usually by obstructing the cystic duct). (4) Jaundice (yellowing of the skin) may occur if a gallstone becomes stuck in the common bile duct, which leads into the intestine blocking the flow of bile from both the gallbladder and the liver. This is a serious complication and usually requires immediate treatment.

The only treatment that cures gallbladder disease is surgical removal of the gallbladder, called cholecystectomy. Generally, when stones are present and causing symptoms, or when the gallbladder is infected and inflamed, removal of the organ is usually necessary. When the gallbladder is removed, the surgeon may examine the bile ducts, sometimes with X rays, and remove any stones that may be lodged there. The ducts are not removed so that the liver can continue to secrete bile into the intestine. Most patients experience no further symptoms after cholecystectomy. However, mild residual symptoms can occur, which can usually be controlled with a special diet and medication

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, empties through the biliary ducts into the duodenum to aid digestion by promoting peristalsis and absorption, preventing putrefaction, and emulsifying fat. Digestion of fat occurs mainly in the small intestine, by pancreatic enzymes called lipases. The purpose of bile is to; help the Lipases to Work, by emulsifying fat into smaller droplets to increase access for the enzymes, Enable intake of fat, including fat-soluble vitamins: Vitamin A, D, E, and K, rid the body of surpluses and metabolic wastes Cholesterol and Bilirubin.