Riverside College Inc.

Dr. Pablo O. Torre St. Capitol Subdivision

Bacolod City, Philippines 6100

AMBER MAE L. DEOCAMPO BSN 4-NIGHTINGALE (GRP. 3) Oct. 8, 2024

CHOLECYSTECTOMY, IOC (INTRAOPERATIVE CHOLANGIOGRAM)

INTRODUCTION:
A cholecystectomy is a common surgical procedure aimed at removing the gallbladder, a small
organ that plays a key role in digestion by storing bile. While it’s often performed to treat
gallstones and the painful symptoms they cause, this surgery can offer relief from discomfort and
prevent serious complications like infections or blockages. Whether done through minimally
invasive laparoscopic techniques or open surgery, cholecystectomy can transform the lives of
patients dealing with persistent gallbladder issues, allowing them to regain their comfort and
health.
DEFINITION:
Cholecystectomy is the surgical removal of the gallbladder. The operation is done to remove the
gallbladder due to gallstones causing pain or infection.
TREATMENT OPTIONS:
SURGICAL:
1. Laparoscopic Cholecystectomy- is a minimally invasive procedure used to remove the
gallbladder. It involves making three to four small incisions in the abdomen through
 which a laparoscope (a small camera) and specialized surgical instruments are inserted.
The surgeon views the operation on a screen and removes the gallbladder with precise
movements. This technique results in less postoperative pain, quicker recovery, and
shorter hospital stays. Patients who undergo laparoscopic cholecystectomy typically
experience faster healing and can return to normal activities within a week or two.
However, it requires specialized surgical skills and may not be suitable for patients with
severe inflammation or complications.
2. Open Cholecystectomy- on the other hand, is a more traditional approach to gallbladder
removal. It involves making a single large incision, usually about 4 to 6 inches long,
below the rib cage on the right side of the abdomen. Through this incision, the surgeon
directly accesses and removes the gallbladder. This method is often used when
laparoscopic surgery is not possible, such as in cases of complicated gallbladder disease,
infection, or scar tissue from previous surgeries. Recovery from an open cholecystectomy
is longer, often requiring a hospital stay of several days and a recovery period of four to
six weeks before resuming normal activities. While the open method allows for greater
visibility and control in difficult cases, it generally results in more postoperative pain and
a longer healing time.
NON-SURGICAL:
Gallstones affect about 1 in 7. Eighty percent of adults with gallstones are not bothered by
them and many go 20 years without symptoms. Current guidelines recommend watchful
waiting until they cause symptoms. If you have gallstones without pain, exercise at least 2-3
times each week to reduce your risk of cholecystitis. Eat more fruits and vegetable and less
sugar, carbohydrates and fats.

ANATOMY & PHYSIOLOGY:

The gallbladder is a hollow organ that sits beneath the liver and stores bile made in the liver. In
adults, the gallbladder measures approximately eight centimeters (3.1 in) in length and four
centimeters (1.6 in) in diameter when fully distended.
The gallbladder is divided into three sections:
 The fundus.
 The body.
 The neck.
The neck tapers and connects to the biliary tree via the cystic duct, which then joins the common
hepatic duct to become the common bile duct. At the neck of the gallbladder is a mucosal fold
where gallstones commonly get stuck.
Layers of the Gallbladder
There are several different layers of the gallbladder: the mucosa ( epithelium and lamina
propria), the muscularis, the perimuscular, and the serosa.
 The epithelium is a thin sheet of cells that is closest to the inside of the gallbladder.
 The lamina propria is a thin layer of loose connective tissue, which together with the
epithelium, forms the mucosa.
 The muscularis is a layer of smooth muscular tissue that helps the gallbladder contract
and squirt its bile into the bile duct.
 The perimuscular (meaning around the muscle) is a fibrous connective tissue layer that
surrounds the muscularis.
 The serosa is a smooth membrane that is the outer covering of the gallbladder.
INDICATIONS:
Cholecystectomy is indicated in the presence of gallbladder trauma, gallbladder cancer, acute
cholecystitis, and other complications of gallstones. More controversial are the indications for
elective cholecystectomy. To properly determine the indications for elective cholecystectomy, the
risk of the operation (taking into account the age and comorbid factors of the individual patient)
must be weighed against the risk of complications and death without operation (taking into
account the symptomatic status of the individual and the functional status of the gallbladder).
Cholecystectomy (or some other form of gallstone therapy) is indicated in most patients with
symptomatic cholelithiasis--especially those with non-functioning gallbladders.
Cholecystectomy is not indicated in most patients with asymptomatic stones.
RISKS:
A cholecystectomy carries a small risk of complications, which may include bile leak, bleeding,
and infection. There is also the potential for injury to nearby structures such as the bile duct,
liver, and small intestine. Additionally, the procedure poses risks associated with general
anesthesia, such as blood clots and pneumonia.

CONTRAINDICATIONS:
Surgery should be avoided in individuals with certain conditions, such as extreme obesity,
bleeding disorders that affect blood clot formation, and liver cirrhosis. These conditions increase
the risks and complications associated with surgical procedures.
SURGICAL INSTRUMENTS USED:
1. Scalpel: Makes the initial incision in the abdomen to access the gallbladder.
2. Ovum Forceps/Sponge Stick: Holds surgical sponges or gauze to clear blood and fluids,
maintaining visibility at the site.
3. Babcock Forceps: Atraumatic forceps for gently grasping the gallbladder and isolating
structures without damage.
4. Cherries: Used in surgical training for practicing tissue manipulation techniques.
5. Needle Holder: Holds needles for suturing during closure of the incision.
6. Deaver Retractor: Large retractor for holding back deeper tissues and organs for optimal
exposure.
7. Army Navy Retractor: Holds back incision edges to provide clear access to the gallbladder.
8. Kelly Curve/Straight Clamp: Used to grasp and manipulate the gallbladder and surrounding
tissues during dissection.
9. Mixter Forceps: Used for grasping and dissecting tissues, particularly in the surgical field.
10. Tissue Forceps: Grasp and manipulate tissues within the surgical field for dissection and
retraction.
11. Mayo Scissors: Heavy-duty scissors for cutting tougher tissues like fascia during the
procedure.
12. Straight Clamp: Secures tissues to facilitate manipulation and hemostasis in the surgical area.
13. Metzenbaum Scissors: Delicate scissors for precise dissection of soft tissues around the
gallbladder.
14. Richardson Retractor: Widens the surgical field by retracting tissues in deeper areas.
15. Rolled Gauze: Controls bleeding and absorbs fluids during the procedure.
ANESTHESIA USED:
General anesthesia is preferred for cholecystectomy because it ensures complete
unconsciousness, muscle relaxation, and control over ventilation, which are crucial for this upper
abdominal surgery. Spinal anesthesia may not provide adequate surgical conditions and airway
management for procedures involving significant abdominal manipulation.
PATIENT PREPARATION (BEFORE, DURING, & AFTER SURGERY):
 Preoperative Phase- Before surgery, the patient undergoes a medical assessment,
including history and lab tests. They receive education about the procedure and must be
NPO for 6–8 hours. Informed consent is obtained, and any necessary preoperative orders,
like antibiotics and site marking, are completed.
 Intraoperative Phase- During surgery, the patient is placed under general anesthesia for
comfort. Vital signs are continuously monitored. The surgical team performs the
cholecystectomy using laparoscopic or open techniques, ensuring proper positioning and
fluid management.
 Postoperative Phase- After surgery, the patient is moved to the recovery area for
monitoring until stable. Pain management is provided, and the patient receives
instructions on wound care and diet. They are educated about activity restrictions and
signs of complications to ensure a smooth recovery.
INTRAOPERATIVE CHOLANGIOGRAM OR IOC
Definition:
An intraoperative cholangiogram is a radiologic procedure performed during cholecystectomy to
visualize the biliary tree, using contrast dye injected into the cystic duct to assess for stones or
anatomical anomalies.

Indications:
 Suspected choledocholithiasis (bile duct stones)
 Abnormal liver function tests
 History of pancreatitis
 Intraoperative findings suggesting bile duct injury

Instruments:
  Cholangiography Catheter: A thin, flexible tube used to inject contrast dye into the bile
ducts during an intraoperative cholangiography procedure, allowing clear imaging of the
biliary system.
 Contrast Dye (Iodinated Contrast): A special dye containing iodine that is injected into
the bile ducts to make them visible on imaging, highlighting any abnormalities or
blockages.
 Fluoroscopy Machine or C-arm for Imaging: A medical imaging device that uses X-rays
to create real-time, dynamic images of the bile ducts during surgery, guiding the surgeon
in assessing the biliary system.
 Surgical Instruments for Cholecystectomy: A set of tools used during gallbladder removal
surgery, including scalpels, forceps, scissors, and laparoscopic equipment, enabling
precise dissection and removal of the gallbladder.
 Common instruments used during gallbladder removal include:

 Scalpel: A small, sharp blade used to make precise incisions in tissues.

 Trocars: Hollow tubes inserted into the abdomen to allow the introduction of
laparoscopic instruments.
 Laparoscopic Graspers: Long, thin instruments used to hold and manipulate
tissues during laparoscopic surgery.
 Laparoscopic Scissors: Special scissors used to cut tissues within the body
during minimally invasive procedures.
 Electrocautery Device: A tool that uses heat or electric current to cut tissues
and control bleeding.
 Clip Applier: Used to place surgical clips on the cystic duct and artery to
prevent bleeding during gallbladder removal.
 Suction/Irrigation Device: Used to clean the surgical area by removing fluids
or irrigating with saline to improve visibility.
Contraindications:
 Allergy to iodinated contrast dye
 Severe renal impairment (risk of contrast-induced nephropathy)
 Patient refusal or inability to cooperate during the procedure

Procedure Overview:
The surgeon injects contrast dye through the cholangiography catheter placed in the cystic duct.
Fluoroscopy is used to visualize the biliary tree, allowing assessment for stones or anomalies.
This information aids in decision-making during the surgery.
Risks:
 Bile Duct Injury: Although rare, the procedure may cause injury to the bile ducts, leading
to bile leakage or the need for additional surgery.
 Infection: Any invasive procedure carries a risk of infection, especially if sterile
techniques are compromised.
 Bleeding: There may be a small risk of bleeding, particularly if the bile ducts or nearby
blood vessels are damaged.
 Allergic Reaction: The contrast dye used in IOC may cause allergic reactions in some
patients.
 Radiation Exposure: There is minimal exposure to radiation during the procedure, which
might be a concern for pregnant patients or those with high cumulative radiation
exposure.

Benefits:
 Helps prevent postoperative complications
 Assists in identifying the presence of stones
 Improves surgical outcomes by providing crucial anatomical information

REFERENCES:
https://www.mayoclinic.org/tests-procedures/cholecystectomy/about/pac-20384818
https://my.clevelandclinic.org/health/procedures/21614-gallbladder-removal
https://www.nhs.uk/conditions/gallbladder-removal/