MODULE 13 Biliary Surgery RPN2023.pdf

Module 13: Biliary Surgery Suggested Alexander’s Care of the Patient in Surgery (2022) Chapter 12 Readings Tighe (2015) Instrumentation for the Operating Room p.49 - 52 ORNAC Standards 2023 Learning...

Module 13: Biliary Surgery Suggested Alexander’s Care of the Patient in Surgery (2022) Chapter 12 Readings Tighe (2015) Instrumentation for the Operating Room p.49 - 52 ORNAC Standards 2023 Learning Describe the anatomy of the gall bladder, pancreas, spleen and liver. Outcomes Understand the purpose of biliary surgeries and basic procedural considerations. Differentiate between various biliary surgeries including spleen, liver, and gallbladder. Understand the transplant process in Canada and Death in the Operating Room Biliary Anatomy The pictures below are a good reference for understanding the Hepatic Tree (blood supply), the anatomy of the spleen and pancreas, and the Celiac Axis. Hepatic Tree Module 13: Biliary  Anatomy of Spleen and Pancreas Celiac Axis The Celiac Axis (trunk) originates off the aorta and has 3 branches that supply blood to many organs. It is important to note these branches and their blood supplies, especially when completing surgeries involving (or removing) specific organs. The 3 branches include: Left Gastric: esophageal and lesser curvature of the stomach Splenic: pancreatic, short gastric, left gastropiploic splenic branches Common hepatic: gastroduodenal, right gastropiploic, left and right hepatic, cystic The Triangle of Calot is an anatomic landmark in the surgical removal of the gallbladder. It includes the “3 C’s”: 1. Cystic Duct 2. Common Hepatic Duct 3. Cystic Artery Perioperative Nursing Considerations Nursing Assessment Patients undergoing a biliary specific surgery will receive a GA and be intubated using an ETT. Pain control interventions will be patient specific. Blood Replacement Patients may require extensive tissue dissection in highly vascular areas resulting in the need for blood transfusion. Orders and availability of blood products must be confirmed pre-, intra-, and post-operatively. The RPN should be prepared in the scrub role with hemostatic agents, such as hemoclips, sutures, ties, sponges, Gelfoam, Surgicel, etc. to anticipate any critical surgical needs. Patient Positioning The surgical procedure determines the patient’s intraoperative position. A patient who is undergoing biliary surgery are placed in the supine position. Refer to the ORNAC Standards and the positioning performance checklist for appropriate practices. The perioperative nurse ensures that the patient return electrode pad is applied, forced-air warming blanket is placed on the patient if appropriate and heel protection is noted. The safety strap must be checked and secured. Surgical Count All cases, open or laparoscopic will have a Major Initial Count, Major Closing Count (open), and Minor Final Count (open or lap) Initial Count (major) → Closing Count (open=major) → Final Count (minor)  Surgical Interventions Cholecystectomy (Open or Laparoscopic) This is the surgical procedure to remove the gallbladder due to chronic inflammation (cholecystitis) or gall stones (cholelithiasis). The gold standard is a laparoscopic approach. In the rare occasion where it is done open, or the case is quickly converted to open once it is started, a intraoperative cholangiogram (ERCP) may be done intraoperatively and will require the use of X-Ray. For both approaches, the surgeon will identify the entire biliary tree, ligate the cystic artery and duct, and free the gall bladder to be extracted. It is imperative the surgeon prevents bile spillage in the abdominal cavity. Instrumentation and Equipment - MIS Tower and sterile laparoscope with light source and insufflation tubing - Laparoscopic and open general surgery instruments - 2x 5mm trocars - These trocars will be on the right lateral side of the abdomen - 2x 10 – 12mm Hassan trocars (size is surgeon preference dependent) - These trocars will be for the Paraumbilical and Subxiphoid abdominal landmarks Patient Positioning: Patients are generally placed supine in a 30-degree, reverse Trendelenburg position, and possibly in combination with a lateral tilt with the right side up to assist with visualization of the organ. The table will have a foot support at the bottom of the table to prevent the patient sliding down the OR table. The surgeon may stand on the patients left or place the patient’s legs in stirrups and stand between them. Procedural Considerations: Visceral or vascular injury with any trocar placement for any laparoscopic surgery. With CO2 insufflation, the gas may diffuse into the patient’s bloodstream and cause respiratory acidosis, elevated BP, bradycardia, or the development of a gas embolism. Complications: Bile leak into the abdomen, bile duct injury (more common in laparoscopic), jaundice, infection, or bleeding. Operative Procedure 1. Skin incision with a blade (#11) 2. Pneumoperitoneum is created 3. 10-12mm hassan trocar is inserted through supraumbilical incision (Umbilical Port) and is secured with an O-Polysorb/Vicryl. This is the main camera port. 4. 3 other trocars are inserted (Subxiphoid and 2 on the right side: Lateral and Medial) *These trocar sites are for atraumatic graspers, L-hook, scissors, and allis 5. Gallbladder is retracted with an atraumatic grasper, exposing the Triangle of Calot 6. Hemoclips are used on the cystic artery and it is divided 7. Cholangiogram may be completed 8. Gallbladder is dissected off the liver 9. Gallbladder is removed through umbilical port with an endocatch or specimen retrieval bag 10. Peritoneal cavity is decompressed and port sites are closed. Intraoperative Cholangiogram Endoscopic Retrograde Cholangeopancreatography (ERCP) is a procedure to diagnose and treat problems in the biliary tract. This is usually a preoperative intervention and uses an endoscope which is guided with X-Ray through the mouth, down the esophagus, stomach, and into the duodenum. A catheter is then passed through the scope and the surgeon will inject a contrast dye which will highlight the biliary structures and provide good visualization of any blockages (stones, tumors, etc) on the X-Ray. Intraoperative Cholangiogram is a similar test to the ERCP; however it is done intraoperatively during the surgery. The surgeon will clip the cystic duct (direct connection to gallbladder) which will prevent any bile from flowing out. The surgeon will then pass a catheter into the cystic duct and inject the contrast dye medium to again, highlight any blockages (stones, tumors, etc.) on the X-Ray. If this is confirmed, the stones will be removed through a Choledochotomy (opening of the common bile duct). The scrub nurse will have two syringes, one with saline and one with a dye. Ensure your syringes are labelled properly! The picture below shows the ERCP catheter. Flexible Stone Forceps (pictured below) will be used to remove stones laparoscopically under X- Ray guidance. Open Method Stones will be retrieved using the Randall Stone Forceps that are found on the Gallbladder (Biliary) Extra instrument tray. Common Biliary Anastomoses Choledochoduodenostomy Anastomosis of the common bile duct to the duodenum to reestablish the flow of bile into the intestinal system. Choledocojejunostomy Anastomosis of the common bile duct to the jejunum to reestablish the flow of bile into the intestinal system. Almost always, surgeons will attach something to the jejunum as it is longer (5 to 7 feet) and much more mobile for the surgeon to move.  Surgery of the Pancreas Anatomy The pancreas is situated retroperitoneal, behind the stomach and in front of the vertebrae. It is a vital organ with both an exocrine and endocrine function: Exocrine: The Duct of Wirsung secretes pancreatic enzymes into the duodenum. Endocrine: The Islets of Langerhan excrete the hormones glucagon and insulin directly into the bloodstream. Review the pancreatic anatomy and blood supply that comes from the celiac axis. A reminder the 3 branches of the celiac axis are the hepatic, splenic and left gastric arteries. These branches in turn directly supply the pancreas. There is not direct pancreatic artery from the axis. Drainage or Excision of Pancreatic Cysts Pancreatic cysts are localized collections of pancreatic secretions in a cystic structure. The preferred method of treatment is internal drainage by: 1. Cystojejunostomy (use of Roux-en-Y jejunal limb) 2. Cystogastrostomy (drainage into the stomach) 3. Cystoduodenostomy (drainage into the duodenum) The method used will be dependent on the location of the cyst. Laparoscopic Whipple Resection Also known as a Pancreaticoduodenectomy. Pancreatic cancer (ductal adenocarcinoma) constitutes 80% of all pancreatic cancers. Most originate in the “head” of the pancreas (exocrine gland), obstruct the bile duct, and extend to the duodenum, intestines and spine. Regional lymph nodes are affected, and metastatic sites include the liver and lungs. It has a very poor prognosis because by the time the symptoms appear, the tumor has already spread. A Whipple can be done if the cancer is localized in the head of the pancreas. The Pylorus preserving is the method used most often as it gives the patient a much better quality of life. The purpose after removing the tumour is to reestablish the continuity of the biliary, pancreatic and GI tract systems. Three Anastomoses will be completed: 1. Hepaticojejunostomy (Choledochojejunostomy) 2. Pancreaticojejunostomy 3. Gastrojejunostomy (*or Duodenojejunostomy for Pylorus Preserving Whipple) PHOTO A - Head of pancreas removed - Portion of duodenum and pylorus preserved - Distal half of common bile duct preserved Pancreatic Transplant Transplantation of a donor pancreas into a patient with Type 1 Diabetes. 1. Pancreas Transplant Alone (PTA)- if the patient has functioning kidneys.  2. Simultaneous Pancreas-Kidney Transplant (SPK)- if patient has uncontrolled diabetes that lead to chronic kidney failure) 3. Pancreas After Kidney Transplant (PAK) – Pancreatic transplant shortly after kidney transplant is completed. If a patient with insulin dependent diabetes undergoes a successful pancreatic transplant, it may eliminate the need for frequent glucose monitoring and hypoglycemic events. The patient will be on lifelong immunosuppressants regardless after a transplant. Procedural Considerations: Most Pancreatic Transplants are SPK. Care is required for patient positioning as this is a long procedure and the patient diabetes cases care to include skin and tissue integrity. Blood glucose levels are carefully monitored. Blood and blood products are ordered and warmed as pre anesthetic requirements. Figure Below: Donor pancreas anastomosed to proximal jejunum to facilitate exocrine (enteric) drainage. Donor kidney anastomosed to femoral vessels and ureteroneocystostomy.  Spleen Anatomy The purpose of the spleen is to filter and destroy old and damaged blood cells, produces white blood cells and lymphocytes to prevent infections, stores blood and platelets that assist in blood clotting factors. The spleen is located in the upper left quadrant, behind the stomach and is protected by the 10th, 11th, and 12th ribs. The arterial blood supply is from the Aorta with the division at the celiac axis and the splenic artery. The splenic vein drains into the portal system. The arterial and venous blood supply must be ligated to do a splenectomy. Surgical Interventions Splenectomy Splenectomy is the removal of the spleen as a result of trauma, malignant conditions, tumors, splenomegaly, hemolytic anemia, viral or bacterial infections. Procedural Considerations: This can be done open or laparoscopic. In a splenectomy, the splenorenal, splenocolic, and gastroplenic ligaments are clamped and divided first. The Splenic artery is then clamped and ligated to permit the disengorgement of blood from the spleen and facilitate return of venous blood to the circulatory system. The splenic vein is then clamped, divided, and ligated. Blood Replacement: Patients may require extensive tissue dissection in highly vascular areas resulting in the need for blood transfusion. Orders and availability of blood products must be confirmed pre-, intra-, and post-operatively. The RPN should be prepared in the scrub role with hemostatic agents, such as hemoclips, sutures, ties, sponges, Gelfoam, Surgicel, etc. to anticipate any critical surgical needs. Blood Supply during a splenectomy: Note the splenic vein becomes part of the portal vein taking nutrients over to the liver The spleen is covered with peritoneum and is supported by 3 major ligaments including the: Colon, Stomach and Kidney. These ligaments are cut and tired when completing a splenectomy.  Liver Anatomy The liver is in the right upper quadrant of the abdominal cavity and is covered by an external covering called the “Glisson Capsule.” The Hepatic artery maintains the arterial (oxygenated) blood supply. Venous blood form the stomach, intestines, spleen and pancreas travels to the liver by the portal vein and branches. The hepatic venous system returns deoxygenated blood to the heart through the inferior vena cava. The liver is essential in metabolizing carbohydrates, proteins, and fats into glycogen stores which regulates blood glucose levels. Procedural Considerations: Laparotomy, Biliary instruments, vascular instruments, self- retaining retractors (Bookwalter), surgical staplers are used. Instruments to measure portal pressure, special BLUNT liver needles for suturing liver. Harmonic Scalpel or CUSA (ultrasonic cutters) may also be used. Intraoperative ultrasound is used to guide surgery. The risk for blood loss is also very high. Blood Replacement: Patients may require extensive tissue dissection in highly vascular areas resulting in the need for blood transfusion. Orders and availability of blood products must be confirmed pre-, intra-, and post-operatively. The RPN should be prepared in the scrub role with hemostatic agents, such as hemoclips, sutures, ties, sponges, Gelfoam, Surgicel, etc. to anticipate any critical surgical needs.  Surgical Interventions Hepatic Resections Resection of the liver is primarily for primary tumors, benign conditions (hepatolithiasis), and metastatic tumors. The portion of the liver that is removed is based on the affected part and lobe. The picture below accurately shows the divisions of the liver. Liver Transplantation Liver transplantation is the implantation of a liver from a donor (living or deceased) into a recipient. The procedure includes retrieving the liver form the donor, removing the recipient’s liver (hepatectomy) and implanting the donor liver through reanastomosis of the hepatic arteries and veins. This procedure is for patients with chronic liver disease, primary cancer, etc. Patient’s will be on lifelong immunosuppressants. The liver tissue can regenerate itself. For living-related transplants, a portion of the donor’s liver can be excised (donor) and it will eventually regenerate itself. Liver Anastomoses The hepatic artery, portal vein, common bile duct and inferior vena cava (IVC) are dissected in the native liver. These vessels, along with the Suprahepatic VC, are then clamped and the native liver is removed. The donor liver is placed in the right upper abdomen and revascularized to the vena cava and portal vein with a permanent vascular suture. The clamps on the portal vein, SHVC, IHVC are released and tissue profusion or vessel leaks/bleeding are examined. The anastomosis of the Hepatic Artery begins followed by the reconstruction of the common bile duct. Again, the anastomoses are checked for profusion and leaks. The following re-anastomoses are completed: 1. Hepatic Artery to Hepatic Artery 2. Portal Vein to Portal Vein 3. Biliary re-anastomoses between donor and recipient 4. Hepatic venous anastomosis will be considered Organ Retrieval Surgery The Operating Room staff plays a crucial role in the process of organ recovery. Donated organs must be removed under optimal conditions for a successful transplantation. Organs are transplanted into recipients that are selected based on an extensive physiological qualification and coordination by the Trillium Gift of Life Transplant Coordinator, the surgeon and the charge nurse. Prior to the arrival of the donor in the operating room: - Brain death, and time, is declared and patient’s chart is signed by the surgeons. - Signed consent for organ donation by the legal next of kin will be in the patient’s chart, including which organs are to be donated. - The coroner’s signature will also be on the consent (if applicable) Organ Procurement and Preservation The organs are mobilized with cannulas put in for insitu cooling. Each surgical specialty will have a designated surgeon to remove the desired organ. The organs are removed in the following order: heart, lungs, liver, and kidneys. Bones, skin and eyes are done after the ventilator has been terminated. All Operating Rooms have specific policies regarding Organ Retrieval and transplant. Although you may be working in a hospital that does not do transplants, you still may encounter an organ retrieval, of which the organs will be transported to another hospital. Organ Donation Types of Donors: 1) Neurological Determination of Death (NDD) 2) After Circulatory Death (DCD) Perioperative Nursing Considerations: Maintenance of Aseptic Technique is CRITICAL!!!!! The following are completed based on hospital policy: Surgical count Communication and planning Coordinating team members Accurate identification of the recipient and donor tissue/organ Completion of Surgical Safety Checklist Operating Room Deaths Intraoperative death is can result from preexisting comorbidities or diagnoses (ASA score), reactions to anesthesia medications, sustained traumatic injuries, and unsuccessful CPR. It is imperative the patient receive dignified, respectful and appropriate care postmortem. Death in the OR can occur in pediatric, adult, and geriatric population. Although this is a rare event that may occur, the perioperative team must be able to support the patient and family. Effective communication is essential. The surgical team informs the family and usually a coroner will also be present. The perioperative nurse will prepare the body in the OR to be transported back to the unit or directly to the morgue. If the family wishes to see the body, a private area will be used, and the perioperative nurse will remain with the family during this time for support. A spiritual care provider may also be contacted. Critical incident debriefing should be provided to the perioperative staff to discuss the case, interventions, and provide support to one another during this emotional and stressful time. Refer to ORNAC 2021 p. 5-22