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HIT/111 HIT111 HIT 111 Week 4 Discussion

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HIT 111 Week 4 Discussion Digestive and Urinary Systems Case Studies Class, in this thread we will be looking at digestive and urinary systems and their related patient encounters. The purpose of this thread is to familiarize you with the Key Concepts found in TerminalCourse Objective (TCO) 5. You must address all of the questions located after the example of case study and patient encounter of Bernard Collins. Operative Report Preoperative Diagnosis: Acute cholecystitis Postoperative Diagnosis: Acute cholecystitis with partially gangrenous gallbladder Operation: Laparoscopic converted to open cholecystectomy Anesthesia: General Estimated Blood Loss: 150 cc Urine Output: 100 cc Intravenous Fluids: 2500 cc of lactated Ringer’s Complications: None Findings: A partially gangrenous but mostly inflamed gallbladder with up to 1 cm thick gallbladder wall and multiple (greater than 50–100) small stones, each measuring approximately 2–4 mm Description of Procedure: The patient was brought into the OR and placed in the supine position on the operating table. After successful endotracheal intubation, general anesthesia was safely achieved. Her entire abdomen was prepped with Betadine and draped in a sterile fashion. A 2.5-cm supraumbilical transverse incision was made for placement of a Verres needle to achieve pneumoperitoneum and the intra-abdominal cavity was insufflated with CO2 with difficulty. After the fascia on each side of the midline was secured with stay sutures, a knife blade was used to open the fascia and the 10-mm trocar was placed at this site. Upon insertion of the laparoscopic camera, no bowel injury was detected. A 10-mm trocar was then placed in the epigastric position at the midline. Two 5-mm ports were placed in the right upper quadrant, one around the nipple line just below the costal margin and the other around the anterior axillary line again below the costal margin. Through one of the 5-mm ports, an endoscopic needle attached to a 60-cc syringe was inserted in order to aspirate the content within the lumen of the gallbladder, which appeared to be extremely inflamed with what appeared to be a very thick peritoneal layer around the gallbladder. Further dissection was made with a dissector introduced through the epigastric port. When the dissection was carried out down to the level of the gallbladder neck/cystic duct junction, the inflammation of the tissue around this region was so severe that it precluded a safe dissection of this area. The operation was therefore converted from laparoscopic to open cholecystectomy. After the instruments and trocars, as well as the camera, were withdrawn from the incision sites, a skin incision was made between the epigastric site and the superior right upper quadrant 5-mm port site. The peritoneum was safely entered through this right subcostal incision. A Michotte retractor was placed cranially in order to retract the superior part of the operative field. Prior to opening the subcostal incision, the umbilical port site was closed at the fascial layer using a figure-of-eight suture. With the Michotte retractor in place, the superior portion of the wound was retracted open and several Mikulicz pads were placed within the abdomen to push the small bowel, colon, and stomach away from the operative field. A Kelly clamp was then placed over the fundus of the gallbladder and the peritoneum was scored with electrocautery. The gallbladder was then dissected off of the liver bed using electrocautery from the fundus down toward the neck. Portions of the peritoneal layer were approximately 1-cm thick. Several neovascularizations were noted within this thickened, inflammatory layer of tissue. Hemostasis was achieved using electrocautery. Several larger vessels from the neovascularization were ligated off with suture ties. Much of the gallbladder was shelled off of this inflammatory layer on the liver bed. The cystic artery was identified and ligated and divided b

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