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Cholecystectomy ( /klsstktmi/; plural: cholecystectomies) is the surgical removal of the gallbladder.

It is the most common method for treating symptomatic gallstones.[citation needed] Surgical options include the standard procedure, called laparoscopic cholecystectomy, and an older more invasive procedure, called open cholecystectomy.

Open surgery
A traditional open cholecystectomy is a major abdominal surgery in which the surgeon removes the gallbladder through a 5- to 7-inch incision. Patients usually remain in the hospital at least 2 to 3 days and may require several additional weeks to recover at home.

Laparoscopic surgery
Laparoscopic cholecystectomy has now replaced open cholecystectomy as the first-choice of treatment for gallstones and inflammation of the gallbladder unless there are contraindications to the laparoscopic approach. This is because open surgery leaves the patient more prone to infection.[1] Sometimes, a laparoscopic cholecystectomy will be converted to an open cholecystectomy for technical reasons or safety. Laparoscopic cholecystectomy requires several small incisions in the abdomen to allow the insertion of operating ports, small cylindrical tubes approximately 5 to 10 mm in diameter, through which surgical instruments and a video camera are placed into the abdominal cavity. The camera illuminates the surgical field and sends a magnified image from inside the body to a video monitor, giving the surgeon a close-up view of the organs and tissues. The surgeon watches the monitor and performs the operation by manipulating the surgical instruments through the operating ports. To begin the operation, the patient is placed in the supine position on the operating table and anesthetized. A scalpel is used to make a small incision at the umbilicus. Using either a Veress needle or Hasson technique the abdominal cavity is entered. The surgeon inflates the abdominal cavity with carbon dioxide to create a working space. The camera is placed through the umbilical port and the abdominal cavity is inspected. Additional ports are opened inferior to the ribs at the epigastric, midclavicular, and anterior axillary positions. The gallbladder fundus is identified, grasped, and retracted superiorly. With a second grasper, the gallbladder infundibulum is retracted laterally to expose and open Calot's Triangle (the area bound by the cystic artery, cystic duct, and common hepatic duct). The triangle is gently dissected to clear the peritoneal covering and obtain a view of the underlying structures. The cystic duct and the cystic artery are identified, clipped with tiny titanium clips and cut. Then the gallbladder is dissected away from the liver bed and removed through one of the ports. This type of surgery requires meticulous surgical skill, but in straightforward cases can be done in about an hour. Recently, this procedure is performed through a single incision in the patient's umbilicus. This advanced technique is called Laparoendoscopic Single Site Surgery or "LESS".

Procedural risks and complications

Laparoscopic cholecystectomy does not require the abdominal muscles to be cut, resulting in less pain, quicker healing, improved cosmetic results, and fewer complications such as infection and adhesions. Most patients can be discharged on the same or following day as the surgery, and can return to any type of occupation in about a week. Furthermore, flexible instruments are being used in laparoscopic surgery by some surgeons. Using the SPIDER surgical system, they can perform the cholestectomy through a single incision through the navel. These patients often recover faster than traditional methods, and have an almost invisible scar. An uncommon but potentially serious complication is injury to the common bile duct, which connects the gallbladder and liver. An injured bile duct can leak bile and cause a painful and potentially dangerous infection. Many cases of minor injury to the common bile duct can be managed non-surgically. Major injury to the bile duct, however, is a very serious problem and may require corrective surgery. This surgery should be performed by an experienced biliary surgeon.[2] Abdominal peritoneal adhesions, gangrenous gallbladders, and other problems that obscure vision are discovered during about 5% of laparoscopic surgeries, forcing surgeons to switch to the standard cholecystectomy for safe removal of the gallbladder. Adhesions and gangrene, of course, can be quite serious, but converting to open surgery does not equate to a complication. A Consensus Development Conference panel, convened by the National Institutes of Health in September 1992, endorsed laparoscopic cholecystectomy as a safe and effective surgical treatment for gallbladder removal, equal in efficacy to the traditional open surgery. The panel noted, however, that laparoscopic cholecystectomy should be performed only by experienced surgeons and only on patients who have symptoms of gallstones. In addition, the panel noted that the outcome of laparoscopic cholecystectomy is greatly influenced by the training, experience, skill, and judgment of the surgeon performing the procedure. Therefore, the panel recommended that strict guidelines be developed for training and granting credentials in laparoscopic surgery, determining competence, and monitoring quality. According to the panel, efforts should continue toward developing a noninvasive approach to gallstone treatment that will not only eliminate existing stones, but also prevent their formation or recurrence. One common complication of cholecystectomy is inadvertent injury to analogous bile ducts known as Ducts of Luschka, occurring in 33% of the population. It is non-problematic until the gall bladder is removed, and the tiny supravesicular ducts may be incompletely cauterized or remain unobserved, leading to biliary leak post-operatively. The patient will develop biliary peritonitis within 5 to 7 days following surgery, and will require a temporary biliary stent. It is important that the clinician recognize the possibility of bile peritonitis early and confirm diagnosis via HIDA scan to lower morbidity rate. Aggressive pain management and antibiotic therapy should be initiated as soon as diagnosed.

During Laparoscopic Cholecystectomy, gallbladder perforation can occur due to excessive traction during retraction or during dissection from the liver bed. It can also occur during extraction from the abdomen. Infected bile, pigment gallstones, male gender, advanced age, perihepatic location of spilled gallstones, more than 15 gallstones and an average size greater than 1.5 cm have been identified as risk factors for complications. Spilled gallstones can be a diagnostic challenge and can cause significant morbidity to the patient. Clear documentation of spillage and explanation to the patient is of utmost importance, as this will enable prompt recognition and treatment of any complications. Prevention of spillage is the best policy.[3]
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GENERIC NAME: Ketorolac BRAND NAME: Toradol CLASSIFICATION: Nonsteroidal anti-inflammatory agents, nonopioid analagesics DOSAGE: 30mg/amp1 amp IM MECHANISM OF ACTION: - Inhibits prostaglandin synthesis, producing peripherally mediated analgesia - Also has antipyretic and anti-inflammatory properties. - Therapeutic effect:Decreased pain INDICATION: Short term management of pain (not to exceed 5 days total for all routes combined) CONTRAINDICATIONS: - Hypersensitivity - Cross-sensitivity with other NSAIDs may existPre- or perioperative use - Known alcohol intoleranceUse cautiously in: 1) History of GI bleeding 2) Renal impair-ment (dosage reduction may be required) 3) Cardiovascular disease SIDE EFFECTS/ ADVERSE EFFECTS: - CNS: 1) drowsiness 2) abnormal thinking 3) dizziness 4) euphoria 5) headache-

- RESP: 1) asthma 2) dyspnea - CV: 1) edema 2) pallor 3) vasodilation - GI: 1) GI Bleeding 2) abnormal taste 3) diarrhea 4) dry mouth 5) dyspepsia 6) GI pain 7) nausea - GU: 1) oliguria 2) renal toxicity 3) urinary frequency - DERM: 1) pruritis 2) purpura 3) sweating 4) urticaria - HEMAT: 1) prolonged bleeding time - LOCAL: 1) injection site pain - NEURO: 1) paresthesia - MISC: 1) allergic reaction, anaphylaxis NURSING IMPLICATIONS/RESPONSIBILITIES: - Patients who have asthma, aspirin-induced allergy, and nasal polyps are at increased risk for developing hypersensitivity reactions. Assess for rhinitis, asthma, and urticaria. - Assess pain (note type, location, and intensity) prior to and 1-2 hr following administration. - Ketorolac therapy should always be given initially by the IM or IV route. Oral therapy should be used only as a continuation of parenteral therapy. - Caution patient to avoid concurrent use of alcohol, aspirin, NSAIDs, acetaminophen, or other OTC medications without consulting health care professional. - Advise patient to consult if rash, itching, visual disturbances, tinnitus, weight gain, edema, black stools, persistent headche, or influenza-like syndromes (chills,fever,muscles aches, pain) occur. - Effectiveness of therapy can be demonstrated by decrease in severity of pain. Patients who do not respond to one NSAIDs may respond to another.

Generic Name: Cefuroxime Axetil Cefuroxime Sodium Brand Name: Cefuroxime Axetil (Ceftin [P.O.]) Cefuroxime Sodium (Zinacef [Parenteral]) Available Forms: Cefuroxime Axetil Suspension: 125 mg / 5 ml, 250 mg / 5 ml Tablets: 125 mg, 250 mg, 500 mg Cefuroxime Sodium Infusion: 750 mg, 1.5 g premixed, frozen solution Injection: 750 mg, 1.5 g Indications: * Pharyngitis, tonsillitis, infections of the urinary and lower respiratory tracts, and skin and skinstructure infections caused by Streptococcus pneumoniae and S. pyogenes, Haemophillus influenzae, Staphylococcus aureus, Escherichia coli, Moraxella catarrhalis (including betalactamase-producing strains), Neisseria gonorrheae, and Klebsiella and Enterobacter species. * Serious lower respiratory tract infections, UTIs, skin and skin-structure infections, bone and joint infections, septicemia, meningitis, and gonorrhea * Uncomplicated UTIs * Otitis Media * Pharyngitis and Tonsillitis * Perioperative Prevention * Early Lyme Disease (erythema migrans) caused by Borrelia burgdorferi * Secondary bacterial infection of acute bronchitis * Uncomplicated gonorrhea * Acute bacterial maxillary sinusitis caused by Streptococcus pneumoniae or Haemophilus influenza (only strains that dont produce beta-lactamase) Mechanism of Action: Second-generation cephalosporin that inhibits cell-wall synthesis, promoting osmotic instability; usually bactericidal. Adverse Reactions: CV: phlebitis, thrombophlebitis GI: pseudomembranous colitis, nausea, anorexia, vomiting, diarrhea Hematologic: transient neutropenia, eosinophilia, hemolytic anemia, thrombocytopenia Skin: maculopapular and erythematous rashes, urticaria, pain, induration, sterile abscesses, temperature elevation, tissue sloughing at intramuscular injection site Other: hypersensitivity reactions, serum sickness, anaphylaxis.

Effects on Lab Test Results: * May increase ALT, AST, alkaline phosphatase, bilirubin, and LDH levels. May decrease hemoglobin and hematocrit level. * May increase PT and INR and eosinophil count. May decrease neutrophil and platelet counts. * May falsely increase serum or urine creatinine level in tests using Jaffe reaction. May cause false-positive results of Coombs test and urine glucose tests using cupric sulfate (Benedicts reagent or Clinitest). Contraindications and Cautions: * Contraindicated in patients hypersensitive to drug. * Use cautiously in patients hypersensitive to penicillin because of possibility of cross-sensitivity with other beta-lactam antibiotics. * Use with caution in breast-feeding women and in patients with history of colitis or renal sufficiency. Responsibilities: * Before administering, make sure patient is not allergic to penicillins or cephalosporins. * Absorption of cefuroxime axetil is enhanced by food. * Cefuroxime axetil tablets may be crushed if swallowing is a difficulty. Cefuroxime axetil tablets may be dissolved in small amounts of apple, orange or grape juice, even chocolate milk. However, drugs bitter taste is difficult to mask even with food. * High-fat meals increased drug bioavailability. * ALERT! Cefuroxime axetil film-coated tablet and oral suspension are not bioequivalent. * If large doses are given, therapy is prolonged, or patient is at high risk, monitor patient for signs and symptoms of superinfection. * Unlike other second generation cephalosporins, cefuroxime can cross the blood-brain-barrier. * ALERT! Do not confuse with other cephalosporins that sound alike. * Take medication as prescribed, even after feeling better. * Take oral form with food. * If suspension is being used, shake the container well before measuring dose. * Notify prescriber about rashes or superinfections. * Notify prescriber about loose stools or diarrhea.

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