Laparoscopic Surgery

Question 1

What are the benefits of minimally invasive surgery?

Answer 1

• Reduced length of hospital stay:
• Lower risk of hospital-acquired infections.
• Reduced cost to the hospital.
• Increased efficiency and patient throughput.
• Decreased risk of complications e.g. postoperative pulmonary complications and venous thromboembolism.
• Smaller wound size means less local tissue damage and reduced pain.
• Improved cosmesis.

Question 2

Are there any contraindications to minimally invasive abdominal surgery?

Answer 2

• Severe right-sided or biventricular cardiac failure: The increased intra-abdominal pressure leads to an increase in systemic vascular resistance, which in turn could cause a decrease in the patient’s cardiac output.
• Extreme hypovolaemic shock: The reduction in cardiac output may lead to severe cardiovascular instability and cardiac arrest.
• Poor surgical access.

Question 3

What is your analgesic plan for this patient?

Answer 3

• Preoperative: 1g paracetamol and 400mg ibuprofen orally if not contraindicated.
• Intraoperative: fentanyl boluses titrated to effect and local anaesthetic infiltration.
• Postoperative: fentanyl/morphine boluses in recovery titrated to effect; regular oral paracetamol and ibuprofen; oral tramadol if required for rescue analgesia; and an appropriate oral dose of morphine sulphate prior to discharge.

Question 4

The procedure is completed with no complications and the patient is transferred to recovery. Half an hour later you are asked to review her due to ongoing vomiting. What is your management?

Answer 4

• Carry out an assessment of the patient in recovery including observations and a review of the medication that the patient has received.
• Ensure adequate hydration (likely intravenous fluids if unable to tolerate oral).
• Reassure the patient and assess her nausea and pain.
• Consider further anti-emetic agents with multi-modal receptor
  targets and adequate management of their pain.

Question 5

What are the complications of postoperative nausea and vomiting?

Answer 5

• Increased length of stay in recovery and/or hospital.
• Unplanned hospital admission in day case patients.
• Dehydration and electrolyte imbalance.
• Aspiration of gastric contents.
• Wound dehiscence.
• Boerhaave syndrome (very rare).

Question 6

What are the criteria that should be met prior to discharge following day case surgery?

Answer 6

Medical factors
* Haemodynamically stable, awake, oriented and mobile.
* Able to eat and drink.
* Minimal or controlled nausea and pain.
* Wound site checked.

Social factors
* Accompanied by appropriate adult for next 24 hours.
* Access to a telephone.
* Adequate housing conditions and access to analgesia.
* Live within 30 minutes of a hospital with appropriate facilities.