Introduction
An intraoperative cholangiogram (IOC) is a diagnostic imaging procedure performed during gallbladder surgery, usually a cholecystectomy, to visualize the bile ducts. This procedure plays a crucial role in identifying stones, strictures, or other abnormalities in the biliary tree, ensuring the safe and effective removal of the gallbladder.
Historical Background
The practice of performing cholangiograms dates back to the early 20th century. It was initially introduced as a means to reduce the incidence of bile duct injuries and to ensure complete removal of gallstones. With advancements in surgical techniques and imaging technologies, the intraoperative cholangiogram has become an integral part of modern laparoscopic cholecystectomy.
Indications for Intraoperative Cholangiogram
There are several indications for performing an intraoperative cholangiogram, including:
- Suspected Common Bile Duct Stones: Patients with a history of jaundice, pancreatitis, or abnormal liver function tests may have stones in their common bile duct that need to be identified and removed.
- Anomalies in Biliary Anatomy: IOCs help surgeons to map out the biliary anatomy, reducing the risk of inadvertently injuring the bile ducts during surgery.
- Confirmation of Bile Duct Clearance: To ensure that all stones have been removed and that the bile ducts are free of obstructions, an IOC can be performed.
Procedure
The intraoperative cholangiogram is typically performed as follows:
- Once the gallbladder is exposed, a small incision is made in the cystic duct.
- A catheter is then inserted into the cystic duct, and contrast dye is injected.
- X-ray images are taken to visualize the flow of the dye through the bile ducts, highlighting any obstructions or abnormalities.
Interpretation of Results
The images obtained from the IOC are carefully examined for:
- Presence of Stones: Stones appear as filling defects in the bile ducts on X-ray images.
- Biliary Anatomy: The normal anatomy includes the common bile duct, cystic duct, and hepatic ducts. Variations in anatomy can be identified and documented.
- Obstructions or Strictures: Any narrowing or blockage in the bile ducts can be detected and addressed.
Benefits of Intraoperative Cholangiogram
The intraoperative cholangiogram offers several benefits, including:
- Reduced Risk of Bile Duct Injury: By clearly visualizing the bile ducts, surgeons can avoid accidental injury during gallbladder removal.
- Improved Detection of Stones: Stones in the common bile duct can be identified and removed, reducing the risk of postoperative complications.
- Better Surgical Outcomes: The use of IOC can lead to more accurate and successful surgeries, with fewer complications and a quicker recovery time for patients.
Risks and Complications
While the intraoperative cholangiogram is generally safe, there are some risks and potential complications, including:
- Allergic Reaction to Contrast Dye: Some patients may have an allergic reaction to the contrast dye used in the procedure.
- Infection: There is a small risk of infection at the site of the catheter insertion.
- Radiation Exposure: Although minimal, there is some exposure to radiation during the X-ray imaging.
Nursing Care of Patient with Intraoperative Cholangiogram
Preoperative Nursing Care
Patient Education
Before the intraoperative cholangiogram (IOC), it is crucial to educate the patient about the procedure. Explain the purpose, benefits, and potential risks associated with IOC. Inform the patient about the use of contrast dye and the possibility of an allergic reaction. Reassure them about the minimal radiation exposure and the steps taken to minimize it.
Allergy Assessment
Conduct a thorough assessment of the patient’s allergy history, particularly focusing on any known allergies to contrast dyes or iodine. If an allergy is present, notify the surgical team to consider alternative options or premedication protocols to prevent an allergic reaction.
Preoperative Preparation
Ensure the patient is adequately prepared for surgery. This includes confirming that preoperative fasting guidelines have been followed and that any preoperative medications have been administered as prescribed. Verify the patient’s consent for the IOC and provide emotional support to alleviate anxiety.
Intraoperative Nursing Care
Assisting the Surgical Team
During the procedure, assist the surgical team by preparing and handling the necessary instruments and supplies for the IOC. Ensure that the contrast dye and catheter are readily available and that all equipment is functioning correctly.
Monitoring Patient Status
Continuously monitor the patient’s vital signs and overall status throughout the procedure. Be vigilant for any signs of an allergic reaction to the contrast dye, such as hives, itching, or difficulty breathing. Promptly inform the surgical team of any abnormalities or changes in the patient’s condition.
Maintaining Aseptic Technique
Maintain strict aseptic technique to prevent infection at the site of catheter insertion. Ensure that the surgical field is sterile and that all instruments and supplies are handled with care. Monitor for any signs of infection during and after the procedure.
Postoperative Nursing Care
Monitoring for Complications
After the procedure, closely monitor the patient for any signs of complications, such as infection, allergic reactions, or issues related to the IOC. Assess the insertion site for redness, swelling, or discharge, indicating a possible infection.
Pain Management
Provide appropriate pain management to ensure the patient’s comfort during the recovery period. Administer analgesics as prescribed and assess the patient’s pain levels regularly. Offer non-pharmacological pain relief methods, such as positioning and relaxation techniques.
Patient Education and Discharge Planning
Before discharge, educate the patient on what to expect during the recovery period and any signs of complications that should prompt them to seek medical attention. Provide instructions on wound care and inform the patient about the importance of follow-up appointments for continued monitoring.
REFERENCES
- Haisley KR, Hunter JG. Gallbladder and the Extrahepatic Biliary System. In: Brunicardi F, Andersen DK, Billiar TR, et al, eds. Schwartz’s Principles of Surgery. 11th ed. McGraw-Hill Education; 2019.
- Lai HY, Tsai KY, Chen HA. Routine intraoperative cholangiography during laparoscopic cholecystectomy: application of the 2016 WSES guidelines for predicting choledocholithiasis. https://pubmed.ncbi.nlm.nih.gov/33523267/) Surg Endosc. 2022 Jan;36(1):461-467.
- Hope WW, et al. (2016). Clinical spotlightreview: Intraoperative cholangiography.
https://www.sages.org/publications/guidelines/sages-clinical-spotlight-review-intraoperative-cholangiography/ - International Journal of Surgery, Volume 8, Issue 8, 2010, pp. 602-605: “Role of Intra Operative Cholangiogram in current day practice.”
- Intraoperative cholangiography in cholecystectomy: A systematic review and assessment of medical, economic, social and ethical aspects [Internet]. Stockholm: Swedish Agency for Health Technology Assessment and Assessment of Social Services (SBU); 2018 Aug 18. (SBU Assessment, No. 292.) Available from: https://www.ncbi.nlm.nih.gov/books/NBK573264/
- Journal of the American Medical Association, Volume310, Issue 8, August 28, 2013: “Laparoscopic Cholecystectomy, Intraoperative Cholangiograms, and Common Duct Injuries.”
- Temperley HC, O’Sullivan NJ, Grainger R, Bolger JC. Is the use of a routine intraoperative cholangiogram necessary in laparoscopic cholecystectomy? (https://pubmed.ncbi.nlm.nih.gov/36710125/)Surgeon. 2023 Oct;21(5):e242-e248.
Stories are the threads that bind us; through them, we understand each other, grow, and heal.
JOHN NOORD
Connect with “Nurses Lab Editorial Team”
I hope you found this information helpful. Do you have any questions or comments? Kindly write in comments section. Subscribe the Blog with your email so you can stay updated on upcoming events and the latest articles.
