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.