Topic: Intrauterine Fetal DeathGeneral Objective: After 1 hour and 30 minutes of lecture-discussion, the Level III students will be able to acquire basic knowledge, gain beginning skills and develop positive attitude, apply basic procedures and appreciate interventions rendered to the patient with Intrauterine Fetal Death.Specific ObjectivesContentMethodologyTime AllotmentResourcesEvaluation

Specifically, the students will be able to:

1.) discuss the overview of Biliary Surgery;

2.) define related terms;

3.) review the anatomy and physiology of the systems involved;

4.) trace the pathophysiology;

5.) integrate the conceptual framework;

6.) enumerate the complications and signs and symptoms of Bile Surgery;

7.) list the diagnostic tests done;

8.) determine the medical management;

9.) apply the nursing management of Biliary Surgery;

10.) Enumerate the possible nursing diagnoses;

11.) state the prognosis;

Prayer

Pre-conditioning Activity

Laparoscopic gallbladder removal has been performed in thousands of patients throughout the world and is a very safe procedure. Gallbladder removal should be performed by laparoscopic surgery when possible. In contrast to laparoscopic gallbladder surgery, laparoscopic procedures on the bile duct are rarely performed by biliary surgeons since they are technically very difficult. Since the bile duct is located deep in the abdomen the incisions for open bile duct surgery are long and large incisions. These incisions are usually associated with a lot of discomfort and require recovery period of 4 to 12 weeks. The majority of patients who undergo open surgery stay in hospital for 4 to 10 days after surgery compared to patients who undergo laparoscopic surgery and stay in hospital for 1 to 3 days after surgery. Laparoscopic proceduresprovide many advantages to the patient over conventional open surgery. Some of the benefits of laparoscopic surgery are much less discomfort after the surgery since the incisions are much smaller, quicker recovery times, shorter hospital stays, earlier return to full activities and much smaller scars. Furthermore, there may be less internal scarring when the procedures are performed with laparoscopic surgery compared to standard open surgery. There are kinds of bililary surgery, these are laparoscopic cholecystectomy, Laparoscopic common bile duct exploration, Laparoscopic bile duct bypass, resection of choledocal cyst, and laparoscopic whipple operation.Very few centers in the USA offer laparoscopic surgery for bile duct diseases. Laparoscopic surgery for bile duct diseases require expertise in advanced laparoscopic techniques and in complex open biliary procedures. These procedures are preferably performed in specialized centers that do a high volume of open and laparoscopic procedures by biliary surgeons skilled in bile duct surgery.

Laparoscopy- is an operation performed in theabdomenorpelvisthrough smallincisions(usually 0.51.5cm) with the aid of a camera. It can either be used to inspect and diagnose a condition or to perform surgery.

Laparoscopic Cholecystectomy- In this procedure the gall bladder is removed by laparoscopic techniques. The usual indications for removal of the gall bladder for laparoscopic cholecystectomy include the presence of gallstones in the gall bladder and small benign tumors called gallbladder polyps.

Laparoscopic common bile duct exploration- In this procedure, stones in the bile duct are removed by laparoscopic techniques. In patients with gallstones small stones can pass from the gallbladder into the bile duct. Stones in the bile duct can cause obstruction leading to the development of jaundice and pancreatitis (inflammation of the pancreas). The treatment is removal of the gallbladder.

Laparoscopic bile duct bypass- In patients who have strictures (narrowing) of the bile duct, the drainage of bile into the intestine is blocked and the bile accumulates in the blood causing jaundice. Bile duct strictures can be caused by benign (non-cancerous) or cancerous conditions.

Resection of choledocal cyst- Choledocal cysts develop from abnormal dilatation of the bile duct that is usually congenital in origin. Choledocal cysts can lead to the development to of jaundice, pancreatitis and cancer in some patients if left untreated for many years.

Laparoscopic whipple operation- laparoscopic Whipple operation for selected patients with ampullary tumors.

Cholangitis- Cholangitis is an infection of the common bile duct, the tube that carriesbilefrom the liver to the gallbladder and intestines. Bile is a liquid made by the liver that helps digest food.

Cholecystitis - Cholecystitis is inflammation of the gallbladder that occurs most commonly because of an obstruction of the cystic duct from cholelithiasis.

Biloma- An encapsulated collection of bile within the abdomen. A biloma may form if there is bile duct disruption, as from alaparoscopic cholecystectomy.

choledocal cyst- represent congenital disproportionate cystic dilatations of thebiliary tree. Diagnosis relies on the exclusion of other conditions as a cause of biliary duct dilatation: (i.e. tumour,gallstoneor inflammation as the cause).

ANATOMY AND PHYSIOLOGY OF THE GALLBLADDERThe gallbladder is part of the digestive system. It is a small, pear-shaped organ on the right side of the body, under the right lobe of the liver.The body can function without the gallbladder. If doctors need to remove it because of disease, there are no serious long-term effects and the body can still digest food.

StructureThe gallbladder is about 7.510 cm (34 inches) long and about a 2.5 cm (1 inch) wide.The gallbladder is made up of layers of tissue: mucosa- the inner layer of epithelial cells (epithelium) and lamina propria (loose connective tissue) a muscular layer a layer of smooth muscle perimuscular layer- connective tissue that covers the muscular layer serosa- the outer covering of the gallbladderThe gallbladder, liver and small intestine are connected by a series of thin tubes or ducts. The common hepatic duct drains bile from the liver through the left and right hepatic ducts. The cystic duct joins the gallbladder to the common bile duct. The common bile duct is where the hepatic and cystic ducts meet and connect to the small intestine.The gallbladder and bile ducts are also called the biliary system or biliary tract.FunctionThe gallbladder stores and concentrates bile, a yellowish-green fluid made by the liver. Bile helps the body digest fats. Bile is mainly made up of: bile salts bile pigments (such as bilirubin) cholesterol waterThe liver releases bile into the hepatic duct. If the bile is not needed for digestion, it flows into the cystic duct and then into the gallbladder, where it is stored. The gallbladder can store about 4070 mL (814 teaspoons) of bile. The gallbladder absorbs water from the bile, making it more concentrated. When bile is needed for digestion after a meal, the gallbladder contracts and releases it into the cystic duct. The bile then flows into the common bile duct and is emptied into the small intestine, where it breaks down fats.

ANATOMY AND PHYSIOLOGY OF THE BILE DUCTS

The liver, gallbladder and small intestine are connected by a series of thin tubes called bile ducts. The bile ducts are part of the digestive system. The bile ducts and gallbladder are also part of the biliary system, or biliary tract.

StructureThe common bile duct is a very thin tube, about 1012.5 cm (45 inches) long. A series of ducts come together to finally form the common bile duct: Many tiny tubules within the liver collect bile from the liver cells. These tiny tubules come together to form small ducts. These small ducts then join together into larger ducts that form the right and left hepatic ducts. The right and left hepatic ducts exit the liver and join to form the common hepatic duct. The common hepatic duct and the cystic duct join to form the common bile duct. The cystic duct connects the gallbladder (a small organ that stores bile) to the common bile duct. The common bile duct passes through the pancreas before it empties into the first part of the small intestine (duodenum). The lower part of the common bile duct joins the pancreatic duct to form a channel called the ampulla of Vater or it may enter the duodenum directly.Intrahepatic bile ductsThe bile ducts within the liver are called intrahepatic bile ducts. These small ducts join together into larger ducts, ending in the left and right hepatic ducts. The right and left lobes of the liver are drained by these ducts. Information on intrahepatic bile duct cancer can be found in theliver cancerchapter.Extrahepatic bile ductsThe extrahepatic bile ducts are outside the liver. The extrahepatic ducts include the part of the right and left hepatic ducts that are outside the liver, the common hepatic duct and the common bile duct. (The cystic duct is also outside the liver, but cancers of the cystic duct are grouped with gallbladder cancers.)The extrahepatic bile ducts may be further divided based on their location: perihilar bile ducts The hilum or hilar area is the area where the right and left hepatic ducts leave the liver and join to form the common hepatic duct. It also includes the point where the cystic duct joins the common hepatic duct. Because these ducts are close to the liver, they may be referred to as the proximal extrahepatic bile ducts. distal extrahepatic bile duct The distal extrahepatic bile duct includes the common bile duct. It is farther away from the liver, between the junction of the cystic duct to the common hepatic duct and the ampulla of Vater (but does not include these structures).

FunctionThe extrahepatic bile ducts are part of a network of ducts that carry bile from the liver and gallbladder to the small intestine. Bile is a yellowish-green fluid made by the liver. Bile flows from the liver, through the hepatic ducts, into the cystic duct and to the gallbladder, where it is stored.Bile helps digest the fat in foods. Bile is mainly made up of: bile salts bile pigments (such as bilirubin) cholesterol water

If the bile is not needed for digestion, it flows into the cystic duct and then into the gallbladder, where it is stored. When bile is needed to digest food, the gallbladder contracts and releases bile into the cystic duct. The bile then flows into the common bile duct and is emptied into the small intestine, where it breaks down fats.

Cholecystitis is most commonly caused by the presence of gallstones. These stones may block the cystic duct which consequently results in bile stasis and secondary bacterial infection and inflammation. Still there are even cases of cholecystitis without the presence of gallstones. This medical condition is serious and if left untreated may lead to gallbladder necrosis and rupture.Pathophysiology of Acute Cholecystitis caused by GallstonesThis is one of the most common forms of acute cholecystitis. The inflammation develops rapidly and the disease progresses rapidly. The disease is caused by the presence of gallstones. There may be one or even several gallstones in the gallbladder and they may vary in structure and appearance.Once the gallstones block the cystic duct the bile accumulates inside the gallbladder. This leads to inflammation and what follows is bacterial superinfection which contributes to the symptoms and signs of the disease. The inflammation leads to distension of the gallbladder and this may eventually result in its swelling of the cells lining of the inner surface of the gallbladder. Consequent ischemia of the gallbladder wall eventually leads to necrosis of the gallbladder wall. This condition is known as gangrenous cholecystitis. In this stage of the disease the gallbladder must be surgically removed as soon as possible since it may rupture and cause serious complications.

(separate paper)

Acute Bile Duct Injury results in short-term complications such as biloma, bile peritonitis, sepsis, multiple organ dysfunction syndrome, external biliary fistula, cholangitis, liver abscess, and others. These complications if not properly managed may be associated with mortality as high as 5% . Laparoscopic cholecystectomy is also associated with a higher risk of vascular injury to the hepatic artery and portal vein which further increases the mortality. Acute Bile duct injury and the ensuing biliary fistula may evolve into a biliary stricture. If the biliary stricture is not appropriately managed, the complications of intrahepatic lithiasis, secondary biliary cirrhosis, portal hypertension, and end stage liver disease may follow Adequate and proper training in a laparoscopic surgery, delineation of biliary anatomy in Calot's triangle (critical view) by careful surgical dissection, and if need be by intra-operative cholangiography (IOC), judicious use of electrocautery, avoiding blind application of clips, and cautery in case of bleeding in the Calots triangle are some of the measures to avoid a BDI. The primary cause of error according to one report was visual perceptual illusion in 97% of the cases. Fault in technical skill was present in only 3% of injuries. Knowledge and judgment error contributed but were not the primary causeSymptomsA person with biliary colic usually complains of an ache or a feeling of pressure in the upper abdomen. This pain can be in the center of the upper abdomen just below the breastbone, or in the upper right part of the abdomen near the gallbladder and liver. In some people, the abdominal pain spreads back toward the right shoulder blade. Many people also have nausea and vomiting.Because symptoms of biliary colic usually are triggered by the digestive system's demand for bile, they are especially common after fatty meals. The symptoms also can occur when a person who has been fasting suddenly breaks the fast and eats a very large meal.Risk factors; Patent related rsk factors: Age & sex Anatomical variations (biliary and vasculature) Severty of dsease : Acute ,chronc cholecystts,empyema and mrzz syndrome,.. prevous surgery wth adhesons. Obesty Surgeon related rsk factors Lack of experence Msdentfcaton of blary anatomy Intraoperatve bleedng Over confdant surgeon Improper terpretaton of oc Improper lateral retracton (insufficient or excess lack of converson nto OC n dffcult cases)

Diagnostic Tests done

How is a Biliary Obstruction Diagnosed? A variety of tests are available for the patient with possible biliary obstruction. These include:

blood test: provides a complete blood count (CBC) and liver function tests. Blood tests can usually rule out certain conditions, such as cholecystitis (inflammation of the gallbladder); cholangitis (infection of the common bile duct); and an increased level of conjugated bilirubin (waste product of the liver), liver enzymes, and alkaline phosphatase. Any of these may indicate a loss of bile flow.

ultrasonography: usually the first investigation performed on anyone suspected of a biliary obstruction. Allows for easy visualization of gallstones.

Medical management

antibiotics, ursodeoxycholic acid to encourage bile flow, fat soluble vitamin supplementation and nutritional support.

Patients should be managed on a case-by-case basis. 1-4% of asymptomatic patients develop problems related to gallstones annually, so the odds are in favour of a 'watch and wait' policy. Younger patients tend to develop complications more frequently because they have a longer time for the gallstones to cause problems and smaller stones cause more problems than larger ones, as they are more likely to become dislodged.Biliary colic and acute cholecystitis - these are conditions which will usually respond to an opioid such as morphine or pethidine given parenterally and/or diclofenac by suppository. These routes will overcome difficulties in absorption caused by vomiting. Pain continuing for over 24 hours or accompanied by fever usually necessitates hospital admission. It is generally considered that patients who require antibiotics should have them intravenously in hospital. There is no evidence base to support the use of oral antibiotics at home, except where the patient has been discharged from hospital after a course of intravenous antibiotics but without having had surgical removal of the stones. One study also supported current guidelines that antibiotics before elective cholecystectomy were unnecessary.

Nursing management

The nurse can play a major role in assisting the grieving family. With skilful intervention, the bereaved family may be better prepared to resolve their grief and move forward. To assis families in the grieving process, include the following measures: Provide accurate, understandable information to the family Encourage discussion of the loss and venting of feelings of grief and guilt Provide the family with baby mementos and pictures to validate the reality of death Allow unlimited time with the stillborn infant after birth to validate the death; provde time for the family members to be together and grieve; offer the family the opportunity to see, touch, and hold the infant. Use appropriate touch, such as holding a hand or touching a shoulder. Inform the chaplain or the religious leader of the familys domination about the death and request his or her presence. Assis the parents with the funeral arrangements or disposition of the body. Provide the parents with brochures offering advice about how to talk to other siblings about the loss. Make community referrals to promote a continuum of care after discharge.

Acute pain and discomfort related to surgical incision Impaired gas exchange related to the high abdominal surgical incision (if traditional surgical cholecystectomy was performed) Impaired skin integrity related to altered biliary drainage after surgical intervention (if a T-tube was inserted because of retained stones in the common bile duct or another drainage device was employed) Imbalanced nutrition, less than body requirements, related to inadequate bile secretion Deficient knowledge about self-care activities related to incision care, dietary modifications (if needed), medications, and reportable signs or symptoms (eg, fever, bleeding, vomiting)

PrognosisCholecystectomy is an effective way to treat recurrent gallstones or gall bladder inflammation (cholecystitis). There are no dietary restrictions after removal of the gallbladder and no long-term consequences, although bile duct stones can form weeks, months, or years after cholecystectomy. Recovery time for laparoscopic cholecystectomy is one night in the hospital and a few days rest at home; open cholecystectomy is major surgery involving a 2- to 7-day hospital stay and several weeks at home (NDDIC). After recovery from surgery, most individuals have no more symptoms related to the original condition. Laparoscopic cholecystectomy is associated with a 0.1% mortality rate, while open surgery is associated with a 0.5% mortality rate; highest mortality is found among older individuals (Naqesh-Bandi). The less invasive laparoscopic procedure is associated with less pain, a shorter hospital stay, and a shorter recovery period than the open procedure. Cholecystectomy for cancer of the gallbladder, bile ducts, or pancreas is usually for comfort only. High mortality rates are associated with these types of cancers.

Lecture Discussion

Lecture Discussion

Lecture Discussion

Lecture Discussion

Lecture Discussion

Lecture Discussion

Lecture Discussion

Lecture Discussion

Lecture Discussion

Lecture Discussion

10 minutes

10 minutes

10 minutes

10 minutes

5 minutes

2 minutes

3 minutes

10 minutes

10 minutes

10 minutes

http://www.surgery.usc.edu

http://www.surgery.usc.edu

Human anatomy and physiology

Lippincott Williams & Wilkins Pathophysiology: A 2-in-1 Reference for Nurses

Diseases Database

healthline.com

http://www.ncbi.nlm.nih.gov/pmc/articles

healthline.com

Medical Disability Advisor

Question and Answer

Question and Answer

Question and Answer

Question and Answer

Question and Answer

Question and Answer

Question and Answer

Question and Answer

University of Cebu Lapu-Lapu and MandaueA.C. Cortes Ave. Looc, Mandaue City, Cebu

A Resource Unit onBiliary Surgery

Submitted By:Maturan, Neil PhilipNarvasa, Evan JaimePanares, Mary JanePatalingjug, Ana MariePerez, AirenePerral, Olive ThereseRoble Shella MarieSico, BeahJeith EuniceTillor, ElsaYtol, Novrey Rose

Submitted To:Ms. Mila E. Marikit, RN, MAN