laparoscopic laser cholecystectomy

Patient care

The nurse or surgeon explains to the patient that this type of surgery will not be used if the patient is pregnant or has had extensive abdominal surgery (because of concern for adhesions), severe acute cholecystitis, a palpable gallbladder, evidence of a stone in the common bile duct, or a bleeding problem. The patient is also told that the surgeon, using the endoscopic technique, will be able to remove the gallbladder without unsightly scarring, leaving only four (or less) small punctures, which reduces the risk for wound complications (infection, hematoma, separation). Risks for other complications (pneumonia, thrombophlebitis, urinary retention, and paralytic ileus) are also decreased because the procedure enables early mobility and may avoid use of parenteral analgesia. Patients will experience less pain and immobility, require less narcotic analgesia, be discharged on the same or on the next day, and be able to return to their usual activities (including work) within 7 days. Preoperative preparation, which usually is similar to that for any other abdominal surgery, is explained.

Postoperatively, the patient is stabilized during a brief stay in postanesthesia and then is transported to a surgical observation unit. The patient is offered clear liquids (carbonated beverages are avoided because they may cause distension and abdominal pressure). If the patient tolerates liquids, the IV is removed, and the patient is offered a regular diet. Analgesics are administered orally as prescribed as soon as the patient can take liquids. A parenteral narcotic (which may cause drowsiness, reduced intestinal motility, and/or vomiting) is given only if the patient continues to feel pain after taking an analgesic. Once the patient is comfortable, he is helped to walk because early ambulation speeds recovery. The patient is usually fully awake and walking within 3 or 4 hr of arrival on the unit. If he experiences shoulder pain, a heating pad may be applied. The surgeon, however, usually removes the carbon dioxide at the end of the procedure to prevent this problem. The nurse evaluates the patient's readiness for discharge, which usually can occur if the patient is afebrile, walking, eating, and voiding, and has stable vital signs with no evidence of bleeding or bile leakage. To assess for the latter risks, the patient is observed for severe pain and tenderness in the right upper quadrant, an increase in abdominal girth, leakage of bile-colored drainage from the puncture site, a fall in blood pressure, and increased heart rate

The patient is instructed to keep the adhesive bandages covering the puncture site clean and dry. He may remove them the next day and bathe or shower as usual. The patient most likely will require little analgesia, but a prescription is given for use as needed. He is reminded to pace activity according to energy level. While no special diet is required, the patient may wish to avoid excessive fat intake and gas-forming foods for 4 to 6 weeks. He should return to the surgeon for follow-up evaluation as directed and report any vomiting, abdominal distention, signs of infection, and new or worsening pain.