LAPAROSCOPY AFTERCARE RISKS
Category: General Surgery
Abstract : Aftercare Following laparoscopy, patients are required to remain in a recovery area until the immediate effects of anesthesia subside and until normal voiding is accomplished (especially if a urinary catheter was used during the surgery). Vital signs are monitored to ensure that there are no reactions to anesthesia or internal injuries present. There may be some nausea and/or vomiting, which m
Aftercare
Following laparoscopy, patients are required to remain in a recovery area until the immediate effects of anesthesia subside and until normal voiding is accomplished (especially if a urinary catheter was used during the surgery). Vital signs are monitored to ensure that there are no reactions to anesthesia or internal injuries present.
There may be some nausea and/or vomiting, which may be reduced by the use of the propofol anesthetic for healthy patients undergoing elective procedures such as tubal ligation, diagnostic laparoscopy, or hernia repair. Laparoscopy is usually an outpatient procedure and patients are discharged from the recovery area within a few hours after the procedure. For elderly patients and those with other medical conditions, recovery may be slower. Patients with more serious medical conditions, or patients undergoing emergency laparoscopy, an overnight hospital stay or a stay of several days may be required. Discharged patients will receive instructions regarding activity level, medications, postoperative dietary modifications, and possible side effects of the procedure.
It may be helpful to have a friend or family member present when these instructions are given, as the aftereffects of anesthesia may cause some temporary confusion. Postoperative instructions may include information on when one might resume normal activities such as bathing, housework, and driving. Depending on the nature of the laparoscopic procedure and the patient’s medical condition, daily activity may be restricted for a few days and strenuous during administration of anesthesia may cause some soreness. Additionally, shoulder pain may persist as long as 36 hours after surgery. Pain-relieving medications and antibiotics may be prescribed for several days postoperatively.
Patients will be instructed to watch for signs of a urinary tract infection (UTI) or unusual pain; either may indicate organ injury. It is important to understand the difference between normal discomfort and pain, because pain may indicate a problem. Patients may also experience an elevated temperature, and occasionally postlaparoscopy syndrome; this condition is similar in appearance to peritonitis (marked by abdominal pain, constipation, vomiting, and fever) that disappears shortly after surgery without antibiotics. However, any postoperative symptoms that cause concern for the patient should be discussed with the doctor, so that any fears can be alleviated and recovery can be accomplished. Due to the after-effects of anesthesia, patients should not drive themselves home. It is advisable for someone to stay with the patient for a few hours following the procedure, in case complications arise. Injury to an organ might not be readily apparent for several days after the procedure.
The physical signs that should be watched for and reported immediately include:
• fever and chills
• abdominal distension
• vomiting
• difficulty urinating
• sharp and unusual pain in the abdomen or bowel
• redness at the incision site, which indicate infection
• discharge from any places where tubes were inserted or incisions were made
Additional complications may include a urinary tract infection (resulting from catheterization) and minor infection of the incision site. An injury to the ureter may be indicated by abdominal distention or a pain in the flank. Additional testing may be required if a complication is suspected.
Risks
Complications may be associated with the laparoscopy procedure in general, or may be specific to the type of operation that is performed. Patients should consult with their doctors regarding the types of risks that are specific for their procedures. The most serious complication that can occur during laparoscopy is laceration of a major abdominal blood vessel resulting from improper positioning, inadequate insufflation (inflation) of the abdomen, abnormal pelvic anatomy, and too much force exerted during scope insertion. Thin patients with well-developed abdominal muscles are at higher risk, since the aorta may only be an inch or so below the skin. Obese patients are also at higher risk because more forceful and deeper needle and scope penetration is required. During laparoscopy, there is also a risk of bleeding from blood vessels, and adhesions may require repair by open surgery if bleeding cannot be stopped using laparoscopic instrumentation. In laparoscopic procedures that use electrosurgical devices, burns to the incision site are possible due to passage of electrical current through the laparoscope caused by a fault or malfunction in the equipment.
Complications related to insufflation of the abdominal cavity include gas inadvertently entering a blood vessel and causing an embolism, pneumothorax, or subcutaneous emphysema. One common but not serious side effect of insufflation is pain in the shoulder and upper chest area for a day or two following the procedure. Any abdominal surgery, including laparoscopy, carries the risk of unintentional organ injury (punctures and perforations). For example, the bowel, bladder, ureters, or fallopian tubes may be injured during the laparoscopic procedure. Many times these injuries are unavoidable due to the patient’s anatomy or medical condition. Patients at higher risk for bowel injury include those with chronic bowel disease, PID, a history of pervious abdominal surgery, or severe endometriosis. Some types of laparoscopic procedures have a higher risk of organ injury. For instance, during laparoscopic removal of endometriosis adhesions or ovaries, the ureters may be injured due to their proximity to each other.
Several clinical studies have shown that the complication rate during laparoscopy is associated with inadequate surgeon experience. Surgeons who are more experienced in laparoscopic procedures have fewer complications than those performing their first 100 cases.
Normal results
In diagnostic laparoscopy, the surgeon will be able to see signs of a disease or condition (for example, endometriosis adhesions; ovarian cysts; diseased gallbladder) immediately, and can either treat the condition surgically or proceed with appropriate medical management. In diagnostic laparoscopy, biopsies may be taken of tissue in questionable areas, and laboratory results will govern medical treatment. In therapeutic laparoscopy, the surgeon performs a procedure that rectifies a known medical problem, such as hernia repair or appendix removal. Because laparoscopy is minimally invasive compared to open surgery, patients may experience less trauma and postoperative discomfort, have fewer procedural complications, have a shorter hospital stay, and return more quickly to daily activities. The results will vary, however, depending on the patients’s condition and type of treatment.
Morbidity and mortality rates
Laparoscopic surgery, like most surgeries, is not without risk. Risks should be thoroughly explained to the patient. Complications from laparoscopic surgeries arise in 1–5% of the cases, with a mortality of about 0.05%. Complications may arise from the laparoscopic entry during procedure, and the risks vary depending on the elements specific to a particular procedure. For example, the risk of injury to the common bile duct in laparoscopic biliary surgery is 0.3–0.6% of cases. The factors that contribute to morbidity are currently under study and debate. Injury may occur to blood vessels and internal organs. Some studies examining malpractice data indicate that trocar injury to the bowel or blood vessels may account up to one-fourth of laparoscopic medical claims. It has been suggested that these injuries can be reduced by alterations in the placement and use of the Verses needle, or by using an open technique of trocar insertion in which a blunt cannula (non-bladed) is inserted into the abdominal cavity through an incision. The insertion of secondary trocars may be of particular interest as a risk factor. There is still some debate, however, as to which method of trocar insertion is most appropriate in a particular situation, as no technique is without risk. The most commonly cited injury in laparoscopic malpractice claims has been injury to the bile duct (66%). Proper identification of this structure by an experienced surgeon, or by a cholangiogram, may reduce this type of injury. Other areas of the body may be injured during access including the stomach, bladder, and liver. Hemorrhages may also occur during the operation.
Laparoscopic entry injuries have been the subject of recent study. Data collected from insurance companies and medical device regulation indicate that bowel and vascular injuries may account for 76% of the injuries that occur when a primary port is created. Delayed recognition of bowel injuries was noted to be an important factor in mortality. The risk of possible injury or death in laparoscopy depends on such factors as the anatomy of the patient, the force of entry, and the type operative procedure being performed.
Alternatives
The alternatives to laparoscopy vary, depending on the medical condition being treated. Laparotomy (open abdominal surgery with larger incision) may be pursued when further visualization is needed to treat the condition, such as in the case of pain of severe endometriosis with deeper lesions. For those female patients with pelvic masses, transvaginal sonography may be a helpful technique in obtaining information about whether such masses are malignant, assisting in the choice between laparoscopy or laparotomy.
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