Overcoming the Postoperative Pain in Laparoscopic Surgery
Laparoscopic surgery is clearly a wonder of modern era of surgical care. Who would have thought that such a wide variety of minimally invasive surgical procedures could be performed with the assistance of a video camera as the surgeon’s “eyes”, several thin instruments, and only tiny incisions needed on the patient?
Hysterectomy, Ovarian cystectomy, Gall bladder removal, appendicitis, bariatric surgery like gastric bypass, hernia repair, or GERD treatment are some of the most common reasons for using laparoscopic surgery today. The benefits for patients are many including a faster recovery, less pain, shorter hospital stay, and smaller invisible scars both internally and externally.
Although laparoscopic and robotic surgery is overwhelmingly successful, the laparoscopic surgery experience could be enhanced significantly for the patient with a simple post-operative protocol, which, most doctors sadly don’t bother to perform. This oversight persists even though solid research has demonstrated a significant reduction in post-operative laparoscopic pain with the need for strong narcotics greatly reduced or even eliminated.
Hence, it is up to the patient to be informed and find a surgeon willing to go the extra post-operative mile when it comes to laparoscopic surgery.
Laparoscopic or Da Vinci Robotic Surgery: What Most Patients Don’t Know?
When laparoscopic or robotic surgery is performed, the first incision that is made allows the passage of a needle into the potential space of the abdominal cavity, taking care to good vision of the organs. Through this long, thin Veress needle, gas is pumped directly into the patient’s abdominal cavity.
The addition of CO2 gas to the abdomen essentially blows it up like a balloon, lifting the abdominal wall above the internal organs to create clearer viewing space for the surgeon to perform his/her work. Addition of gas to the abdominal cavity also creates sufficient room for the laparoscopic instruments without the need for large incisions. CO2 Gas is slowly and continually pumped into the abdomen to maintain this “gas dome” until laparoscopic or robotic surgery is complete.
Minimal Access surgeons prefer carbon dioxide (CO2) gas for this purpose of laparoscopic or robotic surgery. CO2 is used because it is a natural component of breathable air, common to the normal human body, and can be rapidly absorbed by tissue and blood for removal from the body by the respiratory and excretory systems. CO2 is 200 time more absorbable than O2 and 20 time more absorbable than room air. Carbon dioxide is also non-flammable. This is very important in laparoscopic or robotic surgery because of the electrosurgical devices commonly used during all minimal access surgery.
Pneumoperitoneum the addition of CO2 gas to a patient’s abdominal cavity is important for the success of the minimal access operation, the downside is that it causes immense pain and extended suffering after the laparoscopic or robotic procedure is over. Pain is because it takes time for the CO2 gas to be absorbed by the patient’s tissues and released via respiration or the excretory system. This sometimes excruciating post-op pain caused exclusively by the gas used during surgery, not the laparoscopic surgery itself, can take several forms depending on where the excess gas settles:
Intraperitoneal pain: Sometime If the excess gas is trapped outside of the intestines during pneumoperitoneum, but inside the abdominal cavity, it can irritate the lining of the abdominal organs or sometimes the organs themselves due to HCO3 formation causing sharp abdominal pains that can last for days or even weeks after the laparoscopic surgery is complete.
Shoulder and chest pain: During Laparoscopic or robotic surgery if the excess gas becomes trapped against the diaphragm muscle itself, the vagus nerve can be affected which can cause pain when breathing or intense shoulder and chest pain.
After laparoscopic surgery, the typical treatment for this frequently debilitating pneumoperitoneum pain post-laparoscopic surgery is usually strong narcotic medicines with their many dangerous side effects and risks for addiction. In addition, once a patient stops using narcotics for pain, it can take occasionally many weeks or even months to detoxify them from the body.
There is Simple Solutions for Post-Op Laparoscopic Gas Pain:
The amazing thing about the CO2 gas pain experienced by nearly all people who have laparoscopic surgery or robotic surgery on the abdominal or pelvic region is that it can be prevented! Some surgeons are already doing the right thing and routinely removing the CO2 gas carefully in a very simple post-op procedure as part of their standard of care, but, believe it or not, most do not!
Condemning your patient to pain that is likely to be excruciating that will require narcotics to handle until it dissipates several days to a week or more later when all you have to do is something very simple to prevent it that is backed up by solid evidence based research?
These two methods for removing the gas after laparoscopic surgery are: Pulmonary recruitment maneuver (PRM) which is a term for expanding the lungs fully using a conventional ventilator or high-frequency oscillation device while the patient is in a supine or prone position. This full and complete lung expansion forces the gas out of the abdominal cavity from the open surgical ports.
Infusion of saline solution – A simpler and probably more cost effective alternative involves the use of a saline infusion which fills the abdomen with warm saline at the end of laparoscopic or robotic surgery. Since CO2 is lighter than saline, it rises and escapes through the open ports. Research suggests that use of saline is more effective overall than PRM. Local anaesthetic agents can also be sprayed over the diaphragm. Both of these approaches work well and are backed up by research as being highly effective for preventing patient distress from trapped gas.
The Journal of the Society of Laparoendoscopic Surgeons published a study in 2009 where 40 patients were randomly enrolled into one of the following 2 groups. Nineteen patients entered Group I where the residual CO2 was evacuated by abdominal compression and served as the study control group. The remaining 21 patients entered Group II, where the residual CO2 was evacuated by pumping warm saline into the abdomen until it spilled out of the open ports. Nurses, blind to the patient’s grouping, recorded shoulder pain scores twice daily.
The results were conclusive. “Abdominal filling with saline at the end of laparoscopic surgery effectively evacuates residual CO2 thus preventing post laparoscopic shoulder pain.” In another study published by the Journal Archives of Surgery, a randomized, controlled trial was conducted at Taipei Veterans General Hospital from August 1, 2009, through June 30, 2010. One hundred fifty-eight women undergoing laparoscopic surgery for benign gynaecologic lesions were randomly assigned to 3 groups: 53 patients to the pulmonary recruitment manoeuvres (PRM) group, 54 patients to the intraperitoneal normal saline infusion group, and 51 patients to the control group. The pain each patient experienced was evaluated post-op at 12, 24 and 48 hours. The research concluded that post-op shoulder pain was significantly reduced in the group that received the saline infusion compared with either the PRM or control groups.
Both the PRM and saline infusion approaches significantly reduced the frequency of upper abdominal pain compared with the control group. Hence, while both pulmonary recruitment manoeuvres and a saline infusion into the peritoneal cavity effectively reduced pain after laparoscopic surgery, the saline solution appeared to be better overall for both upper abdominal pain and shoulder pain.
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