Performing a Safe Laparoscopy - III

Postoperative Recovery Enhancement Measures

• Preoperative Education: Patient preoperative education is essential in reducing preoperative anxiety and postoperative performance.

To View and Download Patient Education Files specific to each laparoscopic procedure, click this text.

• Exercises

Postoperative exercise is crucial in improving the postoperative performance of these patients. We instruct every patient undergoing an interventional laparoscopy to ad minimum walk at least a mile a day for at least ten days. We always encourage additional or more intensive, strenuous activities. The exception is patients who have undergone a Laparoscopic Abdominal Perineal Resection, these patients should have NO restrictions of their physical activities (within reason). Particularly, patients recovering from a laparoscopic inguinal hernia repair should be encouraged to work-out and exercise as much as possible.

• The NSAI Agents vs Narcotics

  Narcotics analgesics are prescribed to patients for the first 48 hours of the postoperative course. Afterwards, patients are asked to use over the counter ADVIL® (Ibuprofen) for the next ten days.

  All patients are given Toradol ™ 60 mg IM immediately preoperatively.[Mixter CG et al: Surg Endosc, 1997, 11: 351-353]

• The Use of Incentive Spirometer for Lengthy Upper Abdominal Laparoscopic Procedures (over one hour of operating time): Decreased lung expansion and postoperative atelectasis will inevitably occur in these patients. It is essential to prescribe incentive spirometry every hour for the first 24-48 hours and then every four hours for three days thereafter.

• The Question of Routine DVT Prophylaxis: Although most authors recommend the routine use of pneumatic intermittent stockings to prevent venous thrombosis and subsequent embolic sequelaes, our analysis of 2389 interventional laparoscopies demonstrated that only one patient developed a DVT without further morbidity. Thus, we only recommend the use of these stocking in patients at high risk for such complications. We define such high risks as: 1) Coagulopathies, 2) Previous DVT, 3) Planned long, laparoscopic procedures (over 90 to 120 minutes), 4) Bedridden patients.

These instruments are used in almost all advanced interventional laparoscopic procedures. In addition, the surgeon should always keep in mind an electrocautery source can always be connected to any re-usable or disposable grasper whenever needed.

Our electrocautery instrument of choice is the VALLEYLAB Electrocautery Interchangeable Hook with suction aspiration and a hand control/switch.

For certain procedures, (i.e. dissection of the short gastric vessels during a laparoscopic Nissen Fundoplication) an ultrasonic powered ULTRASHEARS is used. This instrument has an oscillating blade which can cut and coagulate at different settings. In addition, this device does coagulate large blood vessels safely when compared to a standard electrocautery source. The ULTRASHEAR* Intrument does generate a mist of cells in the intraabdominal cavity. Recent studies are demonstrating it can be used for oncologic laparoscopic dissection as it does not appears to release viable maligant cells in the intra-abdominal cavity [Nudka CC et al: SURG ENDOSC 1998-12-8-1031]

One of the most exciting experimental product being tested at this time is the so called, "Biological Glue" i.e. CoStasis*. Introduced as having futuristic capabilities it is being billed from a entero-colic sealant to an superlative hemostatic agent. Only time will tell if this product will live up to our expectations.