laparoscopic cholecystectomy

1. Pre-operative: Opening & Back Table Setup

(From the "Opening" checklist)

Opening Sterile Field & Checks

  • Opening: Open back table and basin

  • Instrument Inspection:

  • Check indicators once instruments are opened

  • Verify tamper tags are placed on the side and not tampered with

  • Verbalize: Say "Indicator tapes have changed" (referring to the instruments in the wrap)

  • Team Checks:

  • Check indicators of the other instrument tray before removing the instruments

  • Have the nurse check the wrapping of the other instruments

  • Ensure you are aware if the nurse is checking the wraps when she starts to open instruments

  • Setup & Supplies

  • Open gown and glove

Sutures:

Sutures UR6

4 Monocryl -- PS 2

  • Mayo Stand Prep:

Mayo step up -- tuck right side of mayo

  • Place towel

  • Back Table:

  • Reinforce back table

  • Get instruments and set up as normal, putting each item where it goes

2. Instrumentation Setup

(From handwritten notes)

  • Trocar Setup

  • Trocar

  • Attach the inflation tube (Fill trocar with Carbon Dioxide)

  • Add local (2% Lidocaine with Epi)

  • XL Trocar

  • Transitional Mayo Stand

  • Alligator clamp (x2) endo

  • Endo Shears = Cut

  • Maryland

  • 2 Rochester Peans

  • Endo Catch

  • 5mm Syringe (for trocar)

  • Obturator Hasson trocar

  • Endo Clips

3. Starting the Procedure (Cut Down)

  • Medication & Count

  • Medication First: Local (2% Lidocaine with Epi)

  • Count

  • Cut Down Steps

  • Incision made with #11 blade on #7 needle driver (handle)

  • Dissect with Metz

  • Retract using Kochers / "S" retractors to grab the fascia, and Weitlaner

  • Stop bleeding with the Bovie (Coagulation) \leftarrow use Raytec

Suture

  • Suturing Fascia

  • Use 0-Vicryl suture for fascia

  • Use Bonney forceps and Kochers to grab fascia (rat tooth)

  • Tag the suture with Crile

  • Cut the suture with Straight Mayo scissors

  • Put suture in # slot in the red book

4. Procedure Steps (Intra-operative)

Part 2: Dissection

  • Connect the green cord to the Right angle (Cauterize the gallbladder)

  • Looking for the: Cystic artery, Cystic duct, and avoiding the Common bile duct

  • Rule: 3 Clips, 1 Cut = Endo shears and Alligators

  • Cut

  • Insert the XL trocar step up

  • Locking alligator (Black)

  • Local medication (2% Lidocaine with Epi) -> Put local in syringe with Hypo

Sequence: Clip – Clip – Clip – Cut (4-0 monocryl, 0-vicryl mentioned nearby)

Gallbladder Removal Sequence

  • XL (Trocar) \rightarrow Locking alligator (black)

  • Epi 2% Lidocaine (Local)

  • Cut

  • Balloon trocar

  • Inject 50cc of air in trocar

  • Local (2% Lidocaine with Epi)

  • Incision

  • Trocar step up: Alligator \rightarrow Maryland

  • Hand the Endo Catch

  • Hand the Rochester Pean to stretch incision for gallbladder

  • Put trocar back in

  • Pull out gallbladder

  • hand Rochester Pean

5. Closing the Case

Part 3: Closing Steps

  • Use 0-Vicryl to suture fascia with Mayo needle holder (Hegar)

  • Leave Mayo scissors

  • Add local medication

  • Suture the skin with 4-0 Monocryl on Webster needle holder

  • Use Adson forcep for skin

  • Hand Mayo scissor to cut suture

  • Closing Mayo Setup

  • Wet Raytec and Dry Raytec

  • 4-0 Monocryl suture (for skin)

  • Straight Mayo (to cut the suture)

  • Hemostat (Crile)

  • Adson forcep (hold skin)

  • All local (2% Lidocaine with Epi and Saline)

  • 5cc Syringe

  • Dressing (Dermabond)

  • Mayo Scissors

  • Cup of medication

  • All medication

  • Counts (Perform during closing)

  • Raytec

  • Suture

  • Blade

  • Bovie

  • Fred (Anti-fog)

  • Asepto

  • Repeat for Final Count

6. End of Case & Clean Up

"Case is Over" Protocol

  • Wet Raytec

  • Dry Raytec

  • Dermabond (Note: Dermabond is not sterile, wait 3 minutes)

Patient Care & Room Turn

  • Patient First

  • Remove all the cords

  • Push the backtable to the wall

Ask the CNA for the drape

  • Protect the incisions

  • Roll drape all the way down to the feet

  • Leave the Patient with dignity (Cover up Patient)

  • Sharps & Waste

  • Put the Sharps away

  • Throw suture and blades away

  • Hypo (needle) stays in the red book

Tell Circulator how much medication was used

( Count from the syringe first )