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 Comments: Excellent paper. It’s obvious that you put quite a bit of work into this. Unfortunately, your paper needs adequate citations in the body of the text to meet our standards on plagiarism. You need to cite each textbook from your bibliography whenever you quote or use some information from the textbook or other resource. For example, writing (Jones 285) after the quote or information used means that you got it from the book whose author was Jones and the info came from page 285.

 Laparoscopic cholecystectomy is a procedure in which laparoscopic techniques remove the gallbladder. It is the standard of care for symptomatic gallbladder disease, of which most are performed for symptomatic cholelithiasis. Other indications include acute cholecystitis, biliary dyskinesia, and gallstone pancreatitis.

Describe the reasons a patient might have the selected surgical procedure

The typical reason a cholecystectomy is a treatment of choice is inflammatory changes of gallbladder or blockage of bile flow by gallstones. Symptomatic cholelithiasis is the most common reason where gallstones in the gallbladder are blocking the bile flow and cause inflammation. The patient usually complains of episodic epigastric pain and right upper quadrant pain that radiates to the right shoulder. This pain is found to occur several hours after heavy meals and the patient experiences nausea, vomiting, bloating, fever, and right upper quadrant tenderness. Another condition is acute cholecystitis, where inflammation and symptoms are more prominent. The patient may have a fever, constant pain, positive Murphy’s sign, or leukocytosis. Acute cholecystitis may be caused by calculous biliary tract disease with confirmed gallstones in the abdominal US. Acute acalculous cholecystitis usually occurs in critically ill patients, those with prolonged total parenteral nutrition, and some immunosuppressed patients. Patients with episodes of right upper quadrant pain (which are ‘classic’ for biliary pain without evidence of cholelithiasis of US or ERCP) may also be referred for laparoscopic cholecystectomy. Gallstone pancreatitis (when small stones pass through the cystic duct) confirmed by cholangiography is another indication for laparoscopic cholecystectomy.

Describe the reasons a patient might be disqualified for this surgery and the options for the patient if any

A patient might be excluded for laparoscopic cholecystectomy due to acute general conditions that are a contraindication for any surgery such as an acute cardiac failure, uncontrolled hypertension, acute renal failure, pneumonia, etc. The condition should be treated by a primary care provider or specialist and the patient should be stable prior surgery. Additional contraindications may include the inability to tolerate general anesthesia, significant portal hypertension, uncorrectable coagulopathy, and multiple prior operations.

List the diagnostic tests and lab work that an attending surgeon might order and describe the meaning of the results

The diagnostic tests are part of preoperative procedures and ordered to rule out possible adverse health conditions that may negatively affect surgery outcome. Diagnostics tests include hematologic studies, lab work,

 and images. Hematologic studies should include a complete blood cell (CBC) count with differential, liver function panel, amylase, and lipase. CBC may reveal polymorphonuclear leukocytosis that is associated with acute cholecystitis or any other inflammation of the gallbladder. In severe cases, mild elevations of liver enzymes may be caused by inflammatory injury of the adjacent liver. Patients with cholangitis and pancreatitis have abnormal laboratory test values.

An acute increase in the level of liver transaminases (alanine and aspartate aminotransferases), followed within hours by a rising serum bilirubin level, is associated with choledocholithiasis caused by acute common bile duct (CBD) obstruction. Commonly the higher the bilirubin level, the greater the predictive value for CBD obstruction. CBD stones are present in approximately 60% of patients with serum bilirubin levels greater than 3 mg/dL. It is recommended to repeat testing over hours to days to evaluate patients with gallstone complications. Improvement of the levels of bilirubin and liver enzymes may indicate a spontaneous passage of an obstructing stone. Conversely, rising levels of bilirubin and transaminases with the progression of leukocytosis in the face of antibiotic therapy may indicate ascending cholangitis with the need for urgent intervention. Blood culture results are positive in 30-60% of patients with cholangitis.

Another part of lab work is urine analysis to rule out infection for urinary-genital tracts.

Diagnostic Images include abdominal radiography (XR), ultrasonography (US), computed tomography scanning (CT), magnetic resonance imaging (MRI), technetium-99m (99m Tc), hepato-imino diacetic acid scintigraphy (HIDA scan), endoscopic retrograde cholangiopancreatography (ERCP), and percutaneous transhepatic cholangiography (PTC).

Abdominal XR is the part of a regular evaluation of gallbladder diseases. The main role of plain films in evaluating patients with suspected gallstone disease is to exclude other causes of acute abdominal pain, such as intestinal obstruction, visceral perforation, renal stones, or chronic calcific pancreatitis. Upright and supine abdominal XR are occasionally helpful in establishing a diagnosis of gallstone disease.

Ultrasounds (US) are very useful for diagnosing uncomplicated acute cholecystitis and gallstone disease. It is the most commonly used, most sensitive, and highly recommended procedure. In addition, abdominal US is noninvasive, inexpensive, simple, rapid, safe in pregnancy, and it does not expose the patient to harmful radiation or intravenous contrast. Gallstones appear as echogenic foci in the gallbladder. They move freely with positional changes and cast an acoustic shadow. The sonographic markers of acute cholecystitis include gallbladder wall thickening (>5 mm), pericholecystic fluid, gallbladder distention (>5 cm), and a sonographic Murphy sign. The presence of multiple criteria increases its diagnostic accuracy.

 Computed tomography (CT) scanning is more expensive and less sensitive than US for the detection of gallbladder stones, though it is superior to US for the demonstration of gallstones in the distal common bile duct. CT scanning is often used in the workup of abdominal pain, as it provides excellent images of all the abdominal viscera. CT can be used in diagnostic challenges, for the detection of intrahepatic stones or recurrent pyogenic cholangitis.

MRI is recommended as secondary imaging test when US does not provide a definite diagnosis. Though MRI with magnetic resonance cholangiopancreatography (MRCP) is an excellent imaging study for noninvasive identification of gallstones anywhere in the biliary tract, including the common bile duct, it’s costly and in need for sophisticated equipment and software.

HIDA scintigraphy is occasionally useful in the differential diagnosis of acute abdominal pain, and it is highly accurate for the diagnosis of cystic duct obstruction. HIDA is normally taken up by the liver and excreted into bile, where it fills the gallbladder and can be detected with a gamma camera. Failure of HIDA to fill the gallbladder, while flowing freely into the duodenum, is indicative of cystic duct obstruction. A non-visualized gallbladder on a HIDA scan in a patient with abdominal pain supports a diagnosis of acute cholecystitis.

ERCP permits radiographic imaging of the bile ducts. In this procedure, an endoscope is passed into the duodenum and the papilla of Vater is cannulated. Radiopaque liquid contrast is injected into the biliary ducts, providing excellent contrast on radiographic images. Stones in bile appear as filling defects in the opacified ducts. Currently, ERCP is usually performed in conjunction with endoscopic retrograde sphincterotomy and gallstone extraction.

PTC may be the modality of choice in patients in whom ERCP is difficult (e.g., those with previous gastric surgery or distal obstructing CBD stone), in the absence of an experienced endoscopist, and in patients with extensive intrahepatic stone disease and cholangiohepatitis. A long large-bore needle is advanced percutaneously and transhepatically into an intrahepatic duct and cholangiography is performed.

List the incisions available to the surgeon and include their advantages and disadvantages

There are several incisions could be applied by surgeon: midline upper incision, paramedian incision, and subcostal incision. In the case of a laparoscopic cholecystectomy, the surgeon commonly performs small 25 mm incisions in midepigastrium, umbilicus, and along the right costal margin insertion of four trocars.

In midline upper incision surgeon going through the following layers: skin, superficial fascia –fatty layer (Camper’s fascia), subcutaneous fat, superficial fascia – membranous layer (Scarpa’s fascia), fascia (linea alba), abdominal peritoneum.

 In a paramedian incision, the surgeon goes through the following layers: tissue layers of the skin, superficial fascia –fatty layer (Camper’s fascia), subcutaneous fat, superficial fascia – membranous layer (Scarpa’s fascia), anterior rectus muscles, rectus fascia, abdominal peritoneum.

Subcostal – skin, superficial fascia –fatty layer (Camper’s fascia), subcutaneous fat, superficial fascia – membranous layer (Scarpa’s fascia), externa oblique muscle, internal oblique muscle, transverses abdominis muscle, fascia, abdominal peritoneum

Muscle layer – externa oblique muscle, internal oblique muscle, transverses abdominis muscle

5) Describe other considerations to include anything else that might help someone to understand the operation 6) Describe the anatomy of the incisional layers as they relate to the selected surgical procedure

Laparoscopic cholecystectomy is usually performed with 4 trocars: two 10 mm trocars in the midepigastrium and umbilicus and two 25-mm trocars along the right costal margin. Some surgeons use a 5-mm camera and trocar in the epigastrium, and two or three port techniques have been described, but are not the norm. Incisions are made through layers skin, superficial fascia –fatty layer (Camper’s fascia) subcutaneous fat, superficial fascia – membranous layer (Scarpa’s fascia), fascia (linea alba), and abdominal peritoneum.

7) Describe the anatomy and physiology of the structure that will be actually removed or surgically modified

Cholecystectomy is surgical procedure of removal of the gallbladder. The gallbladder is a thin-walled sac usually placed between both hepatic lobes consisting of three anatomic parts: the fundus, corpus, and infundibulum. The gallbladder ends in the cystic duct that is a passive conduit that in humans has a diameter of about 7 mm with a mucosa containing spiral valves (valves of Heister). This duct drains into the common bile duct without a sphincteric structure. The common bile duct courses through the head of the pancreas ending in the sphincter of Oddi, as it penetrates the duodenal wall where it forms the ampulla of Vater.

The biliary tract is functionally integrated with the digestive tract by neurohormonal mechanisms in the fasting and digestive phases. The liver secretes bile continuously into the intrahepatic ducts flowing into the extrahepatic ducts. The gallbladder is filled with the aid of the sphincter of Oddi where the bile is stored and concentrated in the fasting state and emptied during all three phases of the digestive periods. In the interdigestive period, about 10% of the hepatic bile can drain into the duodenum occurring during intervals between the phasic contractions of the sphincter of Oddi (diastolic periods) when the secreted bile raises the ductal pressures above the sphincter of Oddi basal pressures. The remaining 90% of bile is redirected toward the cystic duct to be stored in the gallbladder. The entry of bile distends the gallbladder by passive and active mechanisms. During the fasting period, the gallbladder maintains a moderate tonic contraction that is

 superimposed with nonpropulsive and propulsive contractions. In the digestive period strong gallbladder contractions and sphincter of Oddi relaxation lead to the high rates of bile discharge flowing into the common bile duct and duodenum.

8) Describe the related anatomical structures for selected surgical procedure

The gallbladder is shaped like a pear, with its tip opening into the cystic duct. The gallbladder is divided into three sections: the fundus, body, and neck. The fundus is the rounded base, angled so that it faces the abdominal wall. The body lies in a depression in the surface of the lower liver. The neck tapers and is continuous with the cystic duct, part of the biliary tree. The gallbladder fossa, against which the fundus and body of the gallbladder lie, is found beneath the junction of two hepatic segments. The cystic duct unites with the common hepatic duct to become the common bile duct. At the junction of the neck of the gallbladder and the cystic duct, there is an out-pouching of the gallbladder wall forming a mucosal fold known as “Hartmann’s pouch”.

9) Describe the blood supply to and the drainage from the structure. Where does it come from? How does it enter the operative area and where is it located near and on the structure itself?

The common hepatic artery, branch of the celiac trunk, supplies blood to the liver and gallbladder along with the stomach, small intestine, and pancreas. The common hepatic artery further divides into three more branches, with the proper hepatic artery supplying blood to the liver, gallbladder, and part of the stomach. The common hepatic artery further bifurcates into the left and right hepatic arteries to deliver blood the left and right sides of the liver.

As the right hepatic artery approaches the gallbladder, it branches off to form the cystic artery, which supplies the gallbladder and cystic duct with oxygenated blood tissues of the liver and gallbladder.

The cystic artery is usually branching out in the Calot’s triangle and has a variable length and enters the gallbladder in the neck or body area. Although classically, the artery traverses the triangle almost in its center, it can occasionally be very close or even lower than the cystic duct.

It usually gives off an anterior or superficial branch and a posterior or deep branch near the gallbladder. When the point of dissection is very close to the gallbladder, surgeon may have to separately ligate the two branches. Also, if the presence of a posterior branch is not appreciated, it can cause troublesome bleeding during posterior dissection. In addition, the cystic artery gives of direct branches to the cystic duct.

There is the incidence of RHA variation that seems common enough for description and may be as high as 50%. The RHA normally courses behind the bile duct and joins the right pedicle high up in the Calot’s triangle. It may come very close to the gallbladder and the cystic duct in the form of the ‘caterpillar’ or ‘Moynihan’s’ hump. If

 such a hump is present, the cystic artery in turn is very short. In this situation the RHA is either liable to be mistakenly identified as the cystic artery or torn in attempts to ligate the cystic artery. The ensuing bleeding in turn predisposes to biliary injury.

10) Describe the nervous supply as it relates to selected surgical procedure

The hepatic nodes are responsible for the lymphatic drainage of the region. Innervation of the gallbladder consists of sympathetic fibers from the celiac plexus, parasympathetic fibers from the vagus nerve (CN X) and sensory fibers from the right phrenic nerve. Adrenergic and noncholinergic nonadrenergic nerves mediate the active relaxation or accommodation of the gallbladder that is gradually induced by the incoming bile.

11) Describe how the patient is prepared in the Operating Room for the surgery. Include such things as patient comfort

Preoperative preparation includes measures for prophylaxis against deep venous thrombosis as sequential compression devices and subcutaneously administered heparin. Another measure of infection prophylaxis is administration of a first-generation cephalosporin prophylactically. The stomach is routinely decompressed with an orogastric tube after induction of general anesthesia.

Positioning in the operating room is important for patient’s safety and surgery outcome. Patient’s position is usually supine on the operating table. The arms may be extended, or may be tucked at the side. Tucking the right arm facilitates intraoperative cholangiography, since there is less impediment to positioning the C-arm.

The surgeon usually stands at the left side of the patient, while the first assistant stands to the right. A second assistant may be used on the surgeon’s side to hold the laparoscopic camera. As a rule, two monitors are used and placed on the right and left of the patient near the head.

safety precautions, IV lines,

skin prep, draping, etc.

An orogastric tube is placed after induction of anesthesia. Most surgeons place sequential compression stockings to avoid venous stasis. Some surgeons place a Foley catheter in the bladder, though urinary catheterization is rarely used.

12) Describe in detail the selected surgical procedure to include:

 a) Incision: Describe the incision layer-by-layer. Also explain what the assistant would be doing. Opening Technique

During the trocar insertion, skin and subcutaneous tissue are incised in a line over the linea alba. Small bleeding vessels, “bleeders,” are coagulated and Linea alba and extraperitoneal fat are incised to the peritoneum. Peritoneum usually entered at a point closest to the umbilicus to avoid injury to the bladder below or the falciform ligament above.

b) Surgery: Describe the surgery step by step in detail. Your research will have to be taken from books that teach the procedure to surgeons which will help get the necessary depth of understanding of the procedure that a well trained Surgical Assistant needs.

Laparoscopic Cholecystectomy could be described in several steps.

The surgeon places the first 10 mm trocar at the umbilicus. After an infraumbilical incision is made, the open technique is used to gain access to theperitoneal cavity and a 11 mm Hasson port is secured to the fascia with a 0 Vicryl suture. Pneumoperitoneum is set to a pressure of 15 mmHg.

The surgeon then inserts the laparoscope and performs a general exploration of the abdomen. A 30-degree laparoscope allows more flexibility in obtaining a complete view of all structures in the portal area and decreases the risk of injury to the ducts.

The patient should be placed in reverse Trendelenburg position and rotated on the operating table with the left side down. Under laparoscopic visual control, the surgeon places two 5-mm trocars along the right costal margin. The usual location is two fingerbreadths below the costal margin at the midclavicular and anterior axillary lines. These trocars should be approximately 8 to 10 cm apart. Exact position may need to be modified depending upon patient habitus.

The fourth trocar will be the main operating trocar, so good placement is crucial. The most common location for the fourth trocar is epigastric, at least 10 cm from the laparoscope. The trocar is placed under laparoscopic visual control and should be directed to the right of the falciform ligament as it enters the abdominal cavity.

Next step would be exposing Calot’s triangle. Grasping forceps, passed through the 5 mm ports by the assistant, are used to lock and retract the fundus of the gallbladder in a lateral and cephalad direction so that the entire right lobe of the liver is retracted as well. A second 5 mm grasping forcep is used to distract the infundibulum

 laterally away from common bile duct and common hepatic bile duct. The gallbladder may be immediately apparent or may be surrounded by omental adhesions.

Adhesions to the underside of the liver and gallbladder may contain omentum, colon, stomach, or duodenum and hence may be dissected with care. Vascular adhesions may be divided with hook cautery. Calot’s lymph node overlying the cystic artery is swept away, sometimes requiring brief cautery to obtain hemostasis. If the gallbladder is acutely inflamed and tense, the surgeon should decompress it before attempting to grasp it. The surgeon passes a Veress needle through the abdominal wall under laparoscopic visual control and uses the graspers (closed) to lift the liver and elevate the gallbladder. The surgeon then stabs the gallbladder with the Veress needle, connects the needle to suction, removes the Veress needle and places the fundoscopic grasper on the stab wound to hold it closed during retraction.

After fundus of the gallbladder is exposed, the first assistant grasps the fundus with an atraumatic locking grasper passed through the most medial of the right subcostal ports. The assistant pushes the gallbladder over the liver toward the right shoulder, opening the subhepatic space and exposing the infundibulum of the gallbladder.

The surgeon or assistant then places a second atraumatic grasper on the gallbladder at its base. This grasper is generally also a locking grasper, although some surgeons will prefer a nonlocking grasper. Throughout dissection, the direction of traction by this infundibular grasper is critical to prevent errors in identification of the ductal structures in this area. Surgeon retracts the infundibulum laterally to expose Calot’s triangle. In the two-handed technique, the surgeon retracts the infundibulum with the left hand and dissects through the epigastric port with the right hand. Alternatively, the assistant may control both graspers and the surgeon maneuvers the camera with the left hand.

The surgeon begins dissection directly adjacent to the gallbladder and takes down any additional adhesions to the base of the gallbladder sharply. The surgeon then identifies the cystic duct, where it enters the gallbladder, so that the gallbladder should be seen to funnel down and terminate in the cystic duct.

Next step is to move the infundibular grasper backward and forward, from side to side, so that the gallbladder-cystic duct junction may be carefully delineated. A useful alternative technique is the “fundus-first” or “top-down” technique, useful for a severely inflamed gallbladder.

After dissecting omental adhesions away from the gallbladder, the fundus is separated from the liver with a diathermy hook or dissecting forceps, leaving a peritoneal rim with wich to grasp and retract the liver cranially. Alternatively, a malleable retractor can be placed through the lateral port to retract the liver cephalad. The gallbladder is dissected away from the liver edge with a blunt dissecting forceps or cautery hook or spatula.

 If a stone is impacted in Hartmann’s pouch, it may be dislodged into the body of the gallbladder or removed by incising the pouch on the side away from the duct and removing the stone so that the entire circumference of the cystic duct-gallbladder junction can be viewed.

Next step is to place a clip as close to the gallbladder as possible and two similar clips on the cystic duct and leave enough space between the sets of clips to make it possible to divide the duct with scissors. It is important be careful not to retract the cystic duct so forcefully that the clips impinge on the cystic duct-common duct junction.

Then the surgeon’s assistant should reposition the infundibular grasper to grasp the gallbladder adjacent to the cystic duct and use this grasper to retract the gallbladder anteriorly and laterally so that the surgeon can expose the cystic artery by gentle spreading and dissecting with a Maryland dissector or laparoscopic right-angle lamp. The cystic artery will be noted to terminate by running onto the gallbladder, and visible pulsations may be observed. Generally, 1 cm of length is necessary for safe division.

The surgeon divides the cystic artery with clips, leaving a minimum of two clips on the cystic artery stump. Division of the cystic artery will generally permit the gallbladder to be pulled farther away from the porta hepatitis by traction on the infundibular grasper. When the gallbladder is dissected virtually free from the liver bed but a few strands remain, inspect the gallbladder bed and ducts for evidence of bleeding.

The surgeon’s assistant irrigates with saline, but takes care not to suction directly on the cystic duct or artery stumps to prevent clip dislodgment. After achieving hemostasis, surgeon divides the remaining attachment of the gallbladder to the liver, places a gallbladder grasper through one of the 10-mm trocars and grasps the gallbladder at or near the cystic duct. The surgeon or assistant removes the gallbladder from the abdomen, sometimes using a specimen bag if the gallbladder is thick-walled or infected. Frequently bile or stones must be aspirated from the gallbladder before it can be withdrawn through the trocar site. Open the gallbladder outside the abdominal wall and suction bile from it.

After the gallbladder has been removed, the surgeon replaces the epigastric trocar and inspect the surgical site for bleeding. Irrigate the surgical field, and aspirate the irrigant from the the subphrenic space and other areas.

If a drain is desired, it can be placed through one of the lateral trocar sites. Pass an atraumatic grasper into the abdomen through the lateral trocar. The surgeon’s assistant passes the “outside” end of the drain into the abdomen through the epigastric trocar, grasps the “outside” end of the drain and pulls it out of the abdomen, along with the trocar, clamps the drain to avoid loss of pneumoperitoneum, and positions the tip of the drain in the subhepatic space.

 c) Wound closure: Describe the wound closure layer-by-layer. Describe the type of suture materials and needles are used. Name the suturing techniques that are used and by whom. (ie: running vs interrupted, simple vs complex)

Surgeon’s assistant removes the trocars and closes the wounds in the usual fashion, injects the trocar sites with a long-acting anesthetic to minimize pain and facilitate early discharge from the hospital.

Each incision is irrigated with saline solution and closed in layers. The fascia at the umbilical incision is closed with a 0 absorbable suture. The skin incision at each port site is closed with a 0-4 subcuticular absorbable suture or skin staples.

Closing Technique

Peritoneum and fascia closed with 0 synthetic absorbable or nonabsorbable suture

Subcutaneous tissue may be approximated with 2-0 absorbable suture

Skin is closed with interrupted 4-0 nylon subcuticularly, or with staples

Peritoneum closed separately with a continuous 2-0 absorbable suture or incorporated with other layers Fascia closed with #0 or #1 braided nonabsorbable sutures placed 1 cm apart

Skin closed with 4-0 nylon, 4-0 subcuticular absorbable sutures, or skin staples

d) Dressings/Drains: How is the wound dressed? How and where are drains placed if applicable?

As part of postoperative care pneumatic compression devices and/or subcutaneous heparin may be continued. Continued use of antibiotics is at the discretion of the surgeon, although it is usually not necessary. Patients are usually able to tolerate liquids and solid food within 24 hours after operation. The majority of uncomplicated cases are performed as outpatient surgery with patients being discharged home the same day.

13) List the Bibliography to include: The name of the book, name of the author(s), the pages referenced, the publish

1. Atlas of Minimally Invasive Surgery, 2005. Daniel B. Jones, Benjamin E. Schneider, Shishir K. Maithel. Edition 1, Publisher: Cine-Med, Inc. Woodbury, CT, USA

2. The SAGES Manual: Fundamentals of Laparoscopy, Thoracoscopy and GI Endoscopy. 2006. 2nd Edition, Carol E.H. Scott-Conner (Editor). Publisher: Springer, NY, USA

 3. Current Diagnosis and Treatment Surgery 14/E / Edition 14. 2015. Gerard M. Doherty. Publisher: McGraw-Hill Professional Publishing

4. Surgical Technology: Principles and Practice, 7e 7th Edition. 2005. by Joanna Kotcher Fuller. Publisher: Saunders Elsevier, St. Louis, M

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