Case Study on Laparoscopic Hepatic Resection

This case study focuses on the care of a patient who underwent laparoscopic hepatic resection. It analyzes the key patient safety and communication and teamwork issues that arise during the patient's surgical journey. The essay includes a description of the patient's history, the indication for surgery, and an analysis of the pre-operative, intra-operative, and post-operative phases.

Subject:
Case study on a patient undergoes Laparoscopic Hepatic resection.
Pre-operative
Intra-operative
Post-operative
Review the care of a patient who underwent minimally invasive procedure. Analyze the
key patient safety and communication and teamwork issues, that arise during the
patient’s surgical journey.
In the introduction, clearly describe the purpose of your paper, and how the paper is to be
presented and organized. In the body of the essay, briefly describe the patient’s history to
establish the indication/s for surgery. The paper should then continue with an analysis of
the patient’s surgical journey from admission to the operating suite (pre-operative phase),
the surgery (intraoperative phase) until discharge from PACU (postoperative phase).
The 3 key safety issues –
Consent, Communication, teamwork.
OTHER IMPORTANT POINTS
-2500 minimum word count
-Harvard referencing style
-20-25 references.

-At least one intext reference for 100-150 words.
- need to paraphrase the given essay. (this essay meet rest of all criteria)
-Don’t change any of the scenarios (highlighted with blue) Paraphrase only.
-Avoid/check plagiarism.
ESSAY
Introduction
The aim of this descriptive essay being descriptive one is to outline and describe vividly
the three important safety keys, that is consent, communication, and teamwork

considered when a patient is to undergo some. Basically, these are among the issues that
need to be put into consideration as the patient goes through the three phases that are pre-
operative phase where the patient is prepared for the procedure, intra-operative phase
which is normally during the time when the procedure is being done and post-operative
phase which includes the care to be given to the patients as he/she recovers from the
procedure. The purpose of the perioperative nursing is to provide care and supporting the
patient as well not forgetting the patient’s family of the patient undergoing surgical or
other invasive procedures in making decisions and meeting the patient’s needs (Rothrock,
2018). The main purpose of ensuring that the patient goes through the three perioperative
phases is to have a positive outcome at the long run. A brief description of the rationales
pertaining to these three phases will be given. The descriptive paper will therefore be
divided into the mentioned three phases each discussed separately. The chosen patient for
this case is a patient who underwent laparoscopic liver resection. The essay will, slightly
outline his past medical history and the current health status and the indication for the
procedure. Outlining their past medical history plus their current medical history, the
presenting illness that has led to the indication for the surgery procedure will also be
provided. Finally, a conclusion on the whole matter will follow.
According to Treadwell, Lucas, and Tsou, 2014, pp.299-318), the WHO has come up
with a surgical safety checklist, and developed some guidelines which guide the
healthcare providers starting with the surgeon to perform safe surgery that is safe and
infection free. Having their objective being saving lives of the patients undergoing
surgical procedures and prevent surgical mishaps such as asepsis (WHO 2009).
Nationally, the Australian College of Perioperative Room Nurses (ACORN) has a

publication that is comprehensive, it covers the standards for perioperative care to be
observed and followed by the nurse in practice. These standards have an assurance of
delivering an utmost quality surgical health care in Australia (ACORN 2016). In order to
have an assurance that the patients are protected from adverse effects that might come up
after the surgical procedures, Australian hospitals adheres to the National Safety and
Quality Health Service (NSQHS) standards. These standards are designed to ensure
quality standards of care are met by the healthcare providers. Many of the Australian
hospital policies governing the procedures are closely related to the national standards
and other frameworks and this in return ensures there is maximum protection to the
patient during her post-operative care.
The case scenario.
The case is about a 51-year-old female, Mrs. X, booked in for elective laparoscopic liver
resection for Hepatic Resection. Referred from a local general practitioner to general
surgeon’s outpatient clinic approximately one month prior with weight loss, loss of
appetite and occasional nausea and intermittent abdominal pain. Ultrasound, CT and
MRI and the blood report revealed Mrs. x got an early stage of hepatocellular carcinoma
the localized tumor was 4cm and it was located in the left lateral section. Therefore, a
discussion between the patient and the doctor. Resulted to a decision of removal of the
affected liver portion to prevent further spreading of carcinoma. This intervention would
also decrease the symptoms and improve her health condition. Mrs. X is usually well.
Social history for Mrs. X shows that she is married. She is an alcoholic and a smoker. She
has a body mass index (BMI) of 30. She has a history of being allergic to penicillin. Mrs.
X’s overall health assessment lead into selection of a laparoscopic procedure as the best

choice to which would give a detailed clinical diagnosis. Among the advantages of
laparoscopy to the patient include decreased amount of time the patient would stay in the
hospital (Twaij et al., 2014 p. 8274). This reduces risk of infection from the hospital-
acquired infections which may include Methicillin-resistant Staphylococcus aureus,
Acinetobacter baumannii and Clostridium difficile. When Laparoscopic procedure is
performed it leads into small incisions that require short time in healing hence the quicker
recovery.
Overview of Hepatocellular carcinoma (HCC).
Hepatocellular carcinoma is a primary malignancy of the liver which normally occurring
to those occur to those with chronic liver disease or cirrhosis. The hepatic stem cells are
believed to be the cells of origin of the malignancy. (Oikawa, 2016, pp.645-651). The
tumor, therefore, progress expanding locally, spreading throughout the liver and distantly
to the other surrounding organs as well. The hepatocellular carcinoma is characterized by
necrosis, inflammation of the liver, and regeneration of the liver tissue. Effective
management for the hepatocellular carcinoma is transplantation. The other treatments
include resection, radiofrequency ablation and potentially systemic with anti-cancer drugs
such as sorafenib.
After hepatocellular carcinoma has been resected, a 5-year survival rate is normally
reported to be 30%-50%. If hepatocellular carcinoma is caught early it can be cured with
surgery and or a transplant. In cases where it has not been cured, treatment and support
care can help the patient live a little bit longer.
Laparoscopic liver resection is considered the ideal method of treatment in this case this
is because with respect to tumors, classical indications for laparoscopic liver resection is

the tumor having a diameter less than 5cm and can be located in areas with easy technical
access to laparoscopy (Tranchart and Dagher, 2014, pp 107-115).
Preoperative phase
The preoperative phase which is the first phase, begins after the client has decided to
undergo surgery and ends when that patient is wheeled into surgery. It involves actions to
be taken for X. For this case it started with the admission which took place including
completion of the comprehensive nursing history and physical assessment, drinking and
eating restrictions prior to surgery stated and adhered to strictly. Considerations involving
all the functional body systems, vital signs taken and documented appropriately and a
check-list finalized. Basically, it was all about preparing Mrs. X for the surgical
procedure. This preparation prior to any surgical procedure is ideal and should not be
assumed or done inappropriately. A thorough preoperative assessment plus effective
education prepares the patient for the procedure and what to expect following the
procedure. Medical history gotten during the preoperative assessment can determine
whether the client is legible for the procedure the patient is medically fit to undergo the
scheduled surgery. According to Pritchard (2012, p.56), the patient should be well
prepared both mentally and physically for the surgical procedure. If the identified risks
are manageable them the nurse conveys them to the appropriate clinicians and the other
healthcare providers who will be involved in one way or the other with the patient. This
ensure keenness and alertness throughout the intraoperative and postoperative phases.
Mrs. X arrived at the holding bay area where the day surgery nurse followed a handed her
over to the anesthetic nurse. The patient handing over is normally followed by patient

identification whereby the name and the patient’s IP number are confirmed thoroughly
ensuring that the procedure is performed to the expected patient. In cases where the
patient is unconscious, she must wear an ID wristband for identification purposes and this
number should be used for all the procedures and interventions in identifying the patient
(Rothrock, 2018). Allergies are identified if in case the patient is allergic to any
medication which might be involved during the entire procedure or even after the
procedure. Fasting times are confirmed if the patient went through the nil per oral before
the procedure is initiated. Consent for the surgery procedure was then confirmed by both
the patient and the immediate next of kin with the patient at that time. Aseptic techniques
should be considered to avoid any form of infection to the patient, and any other relevant
details is taken into considerations (Hamlin et al., 2010). Improper handing over and
ineffective communication at this stage has the potential to cause harm, increasing the
number of errors occurring or increasing adverse events if the procedure is done to the
wrong patient (Bagian, Douglas & Paull, 2018, pp.125-12). Furthermore, this type of
standardized handover characterized by effective communication between the healthcare
professionals, aids continuity of care and reduces the likeliness of important details
concerning the patient from being missed (Leighton-Robinson 2016, pp.245-253).
During checking in the pre-op area, the anesthetic nurse found the patient's consent is
been signed but not dates on the consent. A new grad nurse brought the patient to theatre
and seems she is unaware of the importance of date in the consent. the anesthetic nurse
was a senior nurse in the department and she knew how important the date on the consent
is. An anesthetic nurse asks the patient about the procedure he understands the procedure
and he said he signed the consent in front of the surgeon at the outpatient department the

week before. The anesthetic nurse explained the newly grad nurse about the importance
of consent and let the ward nurse go. The anesthetic nurse asks the surgical fellow and
ask him to correct the consent.
According to Mulsow et al., (2012), the importance of informed consent prior to surgery
is to protect the patient. A capable adult cannot be forced to undergo a procedure that is
life-threatening. It, therefore, enables the patient to make a decision before she undergoes
a specific treatment.
Intraoperative phase.
This phase begins when the patient is admitted to the operating room going all the way to
the anesthesia administration time, time for the performance of the surgical procedures
and ends the time the patient is transported to the recovery room. Mrs. X was reassured
by the anesthetic nurse, appropriate monitoring commenced and she was successfully
anesthetized. Her airway was secured with an ET tube. An intravenous line was placed in
situ. Prior to this, further checkups took place such as confirming identity of Mrs. X, to
make sure that the procedure is done to the right patient. All this confirmation is normally
done before any form of skin incision. Before all these the team which was to take part in
the procedure had previously checked the anesthetic machine if it was functioning
properly without any fault. Moreover, the team also availed all the equipment for
maintaining a patent airway. Good preparation for anesthesia is necessary to prevent
potential complications along the process. After all these, it was time for the procedure to
start and Mrs. X was now ready for the procedure and the surgical team started their
work. As the procedure was in progress, safe surgical preparation by way of preventing

pressure areas for the patient was minimized by careful positioning of the patient on the
operating table with use of aids for comfort (Barnett, Bartalot & Nezhat, 2019 pp 71-83).
Active warming was started. To decrease the development of the deep vein thrombosis,
and clot formation, sequential compression sleeves were then applied to the patient’s legs
over compression stockings. Warm electric blanket(cocoon)placed on the top of the
patient to prevent hypothermia. To decrease the risk factors of development of infection,
or minimizing the spread of the hospital acquired bacteria in between the procedure,
Padgette, (2017, pp 614-618) outlines that the surgical team should wash their hands
thoroughly and disinfect them, should put on the right attire and be in a position of
maintaining aseptic techniques through out to minimize the spread of infection. The scrub
and scout nurses prepare the sterile trolley with necessary instruments and equipment up
to the surgeons’ preferences. Surgical site infections are a crucial concern and are
associated with substantial incidences of morbidity and mortality and longer length of
stay in hospital According to Allegranzi et al., (2016, pp. e288-e303), prophylactic
administration of antibiotics can be done after the surgery to prevent infection as well.
Just before the initiation of the procedure, scrub nurse handed off all the leads and realize
they got a different diathermy machine which cannot accommodate ligasure, which is the
main instrument uses during operation. The theatre technician was one of the junior
members of the technician team and this was his first major liver case. The circulating
nurse listed all the types of equipment need for the case to the technician prior to the case,
but he forgot to organize the proper diathermy machine suitable for ligasure. In this
particular institution got two types of diathermy machine, old diathermy machine cannot
accommodate the ligasure. as soon as the team realized the mistake team members were

trying to get a proper machine. it took a while to swap the machine from some other
theatres and it causes a little delay. An organization where both emergency and surgical
procedures are performed, has to have regular theatre staff. According to Murphy (2012),
Vincent & Amalberti, 2016). They outlined that human errors in the perioperative phases
can be due to lack of staffing, added workload pressures, time constraints and too many
interruptions (Vincent & Amalberti, 2016).
A focus on surgical safety, effective communication network among the healthcare
providers is particularly relevant to decrease the complications of surgical care that have
become a major cause of death and disability worldwide.
Post-operative phase
Laparoscopic liver resection patients are often transferred to the recovery room after the
surgery. When Mrs. X arrived at the recovery room, an effective handover took place
between the anesthetic nurse from the operating room to the, the recovery nurse in the
recovery room. Effective communication was evident between the two nurses and all the
information regarded post-operative care was understood. Information about the drugs
which were administered in the operating room were mentioned which included
cefazolin, fentanyl, dexamethasone and ondansetron. Some were for managing post-
operative emesis, and some to manage post-operative pain. Side effects for these drugs
requires acute management. The patients’ vital signs including blood pressure, heart rate,
temperature and respiratory rate should be maintained within their normal ranges. Despite
the thorough management and effective handing over, the patient had two episodes of
Retching and vomiting. She has received 10mls of Pain Protocol. The consultant

anesthetist was then called to review the patient. More anti emetics were ordered they
included ondansetron, metoclopramide, prochlorperazine, and hydromorphone. After 2
hours, she was discharged and got transferred to HDU. Postoperative patient's safety can
be put at increased risk during the handing over processes because of the high level of
surveillance needed at this critical point. The fact handovers ‘…occur in dynamic
environments where providers are multitasking heightens the potential for medical errors
and loss of information’ (Rose, 2016). Optimal patient care relies on adequate
communication during handing over between the anesthetist and the post-operative nurse.
Poor handing over with minimal clarification of some information on how the patient
should be cared for in the first few hours post operatively can result in poor outcomes for
the patient (Bagian, Douglas & Paull 2018, pp.125-127). The nurse in the recovery room
should therefore be skilled and keen enough in noticing any missing information
concerning the care for the patient handed to him/her. It is the recovery nurse's
responsibility to observe, assess and remedy any probable surgical/anesthetic concerns to
prevent harm to the patient (Kozieł et al., 2015, pp.207-212).
Conclusion.
As I conclude, the descriptive essay has therefore described the perioperative phases and
all the interventions to be implemented during the three phases foe better patient care
outcome. The complexity of the phases has been observed and it requires the nurses to
observe the guidelines and standards as they give out care to the patient. There should be
many important safety checkups, health care guidelines and procedures taught to the
nursing staff. They should also be incorporated in the national healthcare standards and

be implemented when caring for the patients. This way they will therefore prevent harm
to the patient and enhance their chances of a favorable surgical outcome. The essay has
vividly described all that happened to Mrs. X as she was going through the three phases.
Without implementation of safety in caring for the patient put in practice, there is a
greater chance of serious ramifications to the patient and the patient receiving sub-
optimal care then. It is therefore evident that potential for errors and poor-quality
healthcare services can be minimized by assessing the patient effectively, appropriate
handing over by observing all the required protocols and effective communication
between the healthcare professionals. The essay has described how the healthcare
professionals worked together and ensured that Mrs. X received safe, high quality and
appropriate care throughout her perioperative phases.

References.
Allegranzi, B., Zayed, B., Bischoff, P., Kubilay, N.Z., de Jonge, S., de Vries, F., Gomes,
S.M., Gans, S., Wallert, E.D., Wu, X. and Abbas, M., 2016. New WHO
recommendations on intraoperative and postoperative measures for surgical site infection
prevention: an evidence-based global perspective. The Lancet Infectious
Diseases, 16(12), pp. e288-e303
Australian Commission on Safety and Quality in Health Care, 2012. Safety and quality
improvement guide standard 6: Clinical handover.
Bagian, J.P. and Paull, D.E., 2018. Handovers during anesthesia care: patient safety risk
or opportunity for improvement?. Jama, 319(2), pp.125-127.
Bagian, J.P. and Paull, D.E., 2018. Handovers during anesthesia care: patient safety risk
or opportunity for improvement?. Jama, 319(2), pp.125-127.
Barnett, V., Bartalot, A.N. and Nezhat, C.H., 2019. Operating Room Setup and Patient
Positioning for Non-obstetric Surgery During Pregnancy. In Non-Obstetric Surgery
During Pregnancy (pp. 71-83). Springer, Cham.
Care, P., 2010. Emergency Department. Report from the Primary Care Foundation.
Hamlin, L., Davies, M., Richardson-Tench, M. and Sutherland-Fraser, S.,
2016. Perioperative Nursing-EBook-epub: An Introduction. Elsevier Health Sciences
Kozieł, D., Stępień, R.B., Głuszek-Osuch, M. and Głuszek, S., 2015. Nursing care in fast-
track surgery strategy. Medical Studies/Studia Medyczne, 31(3), pp.207-212.
Mulsow, J.J., Feeley, T.M. and Tierney, S., 2012. Beyond consent—improving
understanding in surgical patients. The American Journal of Surgery, 203(1), pp.112-120.

Oikawa, T., 2016. Cancer stem cells and their cellular origins in primary liver and biliary
tract cancers. Hepatology, 64(2), pp.645-651
Padgette, P., 2017. Understanding and improving surgical hand hygiene
compliance. AORN journal, 105(6), pp.614-618
Pritchard, M.J., 2012. Pre-operative assessment of elective surgical patients. Nursing
standard, 26(30).
Robinson, N.L., 2016. Promoting patient safety with perioperative hand-off
communication. Journal of PeriAnesthesia Nursing, 31(3), pp.245-253.
Rose, M., 2016. Factors Influencing Patient Safety During Postoperative
Handover. AANA Journal, 84(5).
Rothrock, J.C., 2018. Alexander's Care of the Patient in Surgery-E-Book. Elsevier Health
Sciences
Rothrock, J.C., 2018. Alexander's Care of the Patient in Surgery-E-Book. Elsevier Health
Sciences.
Tranchart, H. and Dagher, I., 2014. Laparoscopic liver resection: a review. Journal of
visceral surgery, 151(2), pp.107-115
Treadwell, J.R., Lucas, S. and Tsou, A.Y., 2014. Surgical checklists: a systematic review
of impacts and implementation. BMJ Qual Saf, 23(4), pp.299-318
Twaij, A., Pucher, P.H., Sodergren, M.H., Gall, T., Darzi, A. and Jiao, L.R., 2014.
Laparoscopic vs open approach to resection of hepatocellular carcinoma in patients with
known cirrhosis: systematic review and meta-analysis. World Journal of
Gastroenterology: WJG, 20(25), p.8274.

Vincent, C. and Amalberti, R., 2016. Safer healthcare. Cham: Springer International
Publishing