Postoperative
care
The postoperative care of patients after
laparoscopic surgery is generally very straightforward with a very low incidence
of pain or other problems. The most common routine postoperative symptoms are
a dull upper abdominal pain, nausea and pain around the shoulders (referred from
the diaphragm). It is a good general rule that if the patient develops a fever
or tachycardia or complains of severe pain at the operation site, something is
wrong and they should be kept under close observation. In that case routine
investigation should include full blood count, liver function tests, amylase
and, probably, an ultrasound of the upper abdomen to detect fluid collections.
If bile duct leakage is suspected an endoscopic retrograde
cholangiopancreatography (ERCP) may be needed. In cases of doubt, relaparoscopy
or laparotomy should be performed earlier rather than later. Death following
technical errors in laparoscopic cholecystectomy has often been associated with
a long delay in deciding to reexplore the abdomen.
In
the absence of problems the patient should be fit for discharge within 24 hours.
They should be given instructions to telephone the unit or their general
practitioner and to return to the hospital if they are not making satisfactory
progress.
Nausea
About half of the patients after laparoscopic
surgery experience some degree of nausea and rarely this is severe. It usually
responds to an antiemetic such as ondansetron and settles within 12—24 hours.
It is made worse by opiate analgesics and these should be avoided.
Shoulder pain
The patient should be warned about this
preoperatively and told that the pain is referred from the diaphragm and not due
to a local problem in the shoulders. It can be at its worse 24 hours after the
operation. It usually settles within 2—3 days and is relieved by simple
analgesics such as paracetamol.
Abdominal pain
Pain in one or other of the port site wounds
is not uncommon and is worse if there is haematoma formation. It usually
settles very rapidly. Increasing pain after 2 or 3 days may be a sign of
infection and occasionally antibiotics are indicated.
Analgesia
A 100-mg diclofenae suppository should be
given at the time of the operation. This may be repeated two or three times
postoperatively for more severe pain. Otherwise paracetamol 500—1000 mg
4-hourly usually suffices. Opiate analgesics cause nausea and should be avoided
unless the pain is very severe. In that case suspect a postoperative
complication (as above). The majority of patients requires between one and four
doses of I g of paracetamol postoperatively.
Orogastric tube
An orogastric tube may be placed during the
operation if the stomach is distended and obscuring the view. It is not necessary
in all cases. It should be removed as soon as the operation is over and before
the patient regains consciousness.
Oral fluids
There is no significant ileus after
laparoscopic surgery, except in resectional procedures such as colectomy or
small bowel resection. Patients can start taking oral fluids as soon as they are
conscious. They usually do so 4—6 hours after the end of the operation.
Oral feeding
Providing the patient has an appetite a light
meal can be taken 4—6 hours after the operation. Some patients remain slightly
nauseated at this stage but almost all eat a normal breakfast on the morning
after the operation.
Patients
will require advice about what they can eat at home. They should be told they
can eat a normal diet but should avoid excess. It seems sensible to keep off
high-fat meals for the first week, although there is no clear evidence that this
is necessary.
Urinary
catheter
If a urinary catheter has been placed in the
bladder during the operation it should be removed before the patient regains
consciousness. The patient should be warned of the possibility and symptoms of
postoperative cystitis and told to seek advice in the unlikely event of these
occurring.
Drains
Some surgeons drain the abdomen at the end of
laparoscopic cholecystectomy, although there is controversy about this. If a
drain is placed to vent the remaining gas and peritoneal fluid it should be
removed within 1 hour of the operation. If it has been placed because of
excessive hepatic bleeding or bile leakage it should be removed when that
problem has resolved, usually after 12—24 hours. Continued blood loss from a
drain is an indication for re-exploring the abdomen.
Discharge from
hospital
Some surgeons discharge a proportion of their
patients on the day of surgery but most are kept in overnight and discharged
next morning. The patient should not be discharged until they are seen to be
comfortable and eating and drinking satisfactorily. They should be told that if
they develop abdominal pain or other severe symptoms they should return to the
hospital or to their general practitioner.
Skin sutures
If nonabsorbable sutures or skin staples have
been used these can be removed from the port sites after 48 hours.
Mobility and
convalescence
Patients can get out of bed to go to the
toilet as soon as they have recovered from the anaesthetic and they should be
encouraged to do so. Such movements are remarkably pain free when compared with
the mobility achieved after an open operation. Similarly, patients can cough
actively and clear bronchial secretions and this helps to diminish the incidence
of chest infections. Many patients are able to walk out of hospital on the
evening of their operation, and almost all are fully mobile by the following
morning. Thereafter the postoperative recovery is variable. Some patients
prefer to take things quietly for the first 2 or 3 days interspersing increasing
exercise with rest. After the third day patients have undertaken increasing
amounts of activity. The average return to work is about 10 days.