When should analgesics be administered after an abdominal cholecystectomy is performed?
Laparoscopic cholecystectomy (LC) is very commonly performed nowadays, and it has now completely replaced open cholecystectomy in the management of biliary lithiasis. Although it is minimally invasive surgery, pain in postoperative period is always major concern as it increases perioperative stress, morbidity, and hospital stay. Show
There are two components involved in pain after LC; the visceral component is due to tissue damage in anterior abdominal wall during the insertion of trocar and shoulder tip pain due to diaphragmatic irritation caused by Spillage of blood or bile and peritoneum stretching caused by pneumoperitoneum. There are several methods employed in the management of postoperative pain after LC such as conventional systemic analgesics, including paracetamol, non-steroidal anti-inflammatory drugs, systemic opioids, thoracic epidural analgesia, low-pressure pneumoperitoneum, and warm air with all having its side effects . Transversus abdominis plane (TAP) block has got a substantial role in postoperative analgesia after abdominal surgery because deposition of local anesthetics in transversus abdominis fascial plane can produce sensory block over the anterior abdominal wall from T7 to L1. Many clinical studies reported beneficial effects of TAP but results were mainly connected to lower abdominal surgery. Since the major part of pain after LC derives from abdominal wall incisions, some trials investigated TAP block as potential analgesic option. Some studies showed that TAP block can reduce opioid requirements and pain scores but the results were not conclusive enough because many differences in study designs. The ultrasound-guided (USG) subcostal transversus abdominis plane block (STAP), first described by Hebbard 2008, is a variation of TAP which successfully solve the problem of unreliable supraumbilical distribution of the block. Results obtained in a few small studies showed significantly better analgesia after LC compare to traditional opioid analgesia, port-site infiltration and standard TAP. Intraperitoneal (IP) instillation of local anaesthetics around the operative site is used as an analgesic technique on the assumption that conduction from visceral sites is obstructed and may lessen the intensity of referred pain to the shoulder (C3, C4) which results from irritation of diaphragmatic innervations, i.e., phrenic nerve (C3, C4, C5) and diaphragmatic stretching due to gaseous distension, in the postoperative period. Narchi I' et al., as early as in 1991 had reported that instillation of local anaesthetic (80 mL of bupivacaine 0.125%, epinephrine (1:200,000) under the right diaphragm reduced shoulder pain after minor gynaecologic laparoscopy. Dexmedetomidine is a selective, short acting, agonist of the α2-adrenergic receptors. It has high affinity to α2-adrenergic receptors (more than eight-fold) and lower affinity to α1-receptors, compared with other α2-agonists agents, besides its great selectivity to α2A-adrenergic receptors, which is responsible for its analgesic effect. It has been used clinically as an adjunct to anesthesia and analgesia, and it is useful for painful surgical procedure and ICU sedation. Surgical removal of the gallbladder is considered an extremely effective form of treatment for gallstones. In addition to an appropriate surgical procedure conducted by expert surgeon, postoperative care plays an essential role in a fast recovery and quick return to daily life while preserving patient’s quality of life in the long run. Postoperative care after gallbladder removal surgery (cholecystectomy)After gallbladder removal surgery, it is highly recommended to follow these advices:
Recovery at home after surgery
Diet modificationThe gallbladder is a small pouch located under the liver. Its main function is storing bile produced by the liver. Some people might be concerned about foods after having their gallbladders surgically removed. In fact, most patients who underwent cholecystectomy can live worry-free regarding their daily diet as the liver still produces adequate amount of bile which is necessary for the digestive process. Instead of having bile stored in the gallbladder, once your gallbladder is removed after cholecystectomy, the bile produced by the liver flows directly into the small intestine, allowing continued digestion of fats. Nevertheless, the amount of fat intake each meal profoundly affects the digestion process. Despite there is no standard diet that people should follow after gallbladder removal surgery, it is best to limit fatty and greasy foods. An excess fat can potentially cause fat indigestion manifested by dyspepsia, bloating and diarrhea, especially a few months after surgery. To maintain a good health after gallbladder surgery, it is vital to strictly follow these eating tips:
Being physically activeAfter surgery it is important to take an active role in the recovery phase. Preoperative and postoperative rehabilitation care will be conducted by rehabilitation specialists and multidisciplinary team aiming at improving patient’s quality of life while accelerating recovery to achieve a quick return to daily life and activities.
Practicing good sleep hygieneTo maintain a regular sleep routine after surgery, following these tips seems beneficial:
Staying away from aggravating factorsTo remain as healthy as possible after surgery, it is highly recommended to:
Abnormal signs and symptoms that need medical attention after surgeryIf any of these warning signs arise after surgery, immediate medical assistance must be sought:
The ERAS Program – An accelerator of rapid recovery after surgeryEnhanced Recovery after Surgery Program or ERAS refers to patient-centered, multidisciplinary team developed pathways for surgeries to reduce the patient’s surgical stress, promote early mobilization, re-establish oral feeding, optimize physiologic function and alleviate pain or discomfort. Conducted prior to, during and after surgery, the ultimate goal of ERAS is to achieve a fast recovery while minimizing pre- and postoperative complications. This significantly leads to a shorter hospital stay and a quick return to daily life and activities with a full range of motion. Supported by cutting-edge technology and appropriate surgical approaches, the ERAS Program is conducted by a multidisciplinary team, consisting of surgeons, rehabilitation and nutrition specialists, physiotherapists, nurses and pharmacists highly specialized in surgical care. As patient-centered approach, the ERAS Program has been designed to improve the recovery process throughout patient’s journey. The program starts from a full medical examination and assessment of medical conditions. In high-risk patients, e.g. elderly patients or patients with multiple underlying diseases that could affect the surgical outcome, surgical planning will be further discussed among different specialists in order to design the best possible procedure suitable for each individual. Pre-operative assessment will be conducted and relevant care, e.g. treatment of hematological problems such as anemia, nutrition support, quitting smoke, blood sugar control will apply, ensuring a physical fitness prior to surgery. Different exercises and pre-rehabilitation programs to strengthen the muscles will be introduced to each individual under close supervision of internal medicine and rehabilitation specialists. In addition, the pharmacist needs to review all current medications and supplements that might affect patient’s safety during surgery. To maintain a normal physiological function, fasting will be required as minimal as possible. Due to advanced technology in minimally invasive surgery, laparoscopic cholecystectomy (LC) has become a gold standard among eligible cases. Cutting-edge technology used in LC involves the use of three-dimensional (3D) HD vision system and 4K ultra-high definition which provides detailed images of gallbladder and surrounding organs in all dimensions. Furthermore, indocyanine green (ICG) fluorescence imaging technology can clearly view the boundary of lesion and adjacent organs during the operation, leading to less damages to the surrounding tissue. With smaller incisions, in comparison to conventional approach, LC results in less pain, fewer risks and postoperative complications, faster recovery time and shorter hospital stay. Concerning pain control and prevention of undesired effects after surgery, the anesthesiologist manages pain that widely varies from person to person by using multimodal analgesia while reducing side effects of anesthesia and morphine drugs. Moreover, other related issues, including nausea and vomiting induced by anesthesia, optimal body temperature and fluid administration will be efficiently managed by a multidisciplinary team. ERAS program also recommends early removal of urinary drainage to reduce the risk of catheter-associated urinary tract infections. Monitored and advised by nutrition specialists, early oral feeding should be applied as soon as possible, enabling an improved bowel movement. Postoperative immobility can potentially induce local venous stasis caused by accumulation of clotting factors, resulting in blood clot formation which is firmly associated with an increased risk of venous thrombosis – blockage of a vein caused by blood clot (thrombus). Delayed mobilization has been also linked with impaired lung function and respiratory complications. ERAS program advocates early mobilization starting on the first day after surgery to counteract catabolic changes and maintain muscle strength. Prior to hospital discharge, postoperative instructions, including wound care and home medications will be given. It is important that the patients need to follow post-operative appointments as scheduled, enable the surgeon to monitor surgical outcome and check on recovery. For emergencies, patients can reach the hospital around-the-clock via given contact. ERAS program is considered a multimodal perioperative care pathway designed to achieve early recovery after surgical procedures. The key elements of ERAS are comprised of patient and family education, general health optimization prior to operation, pre-rehabilitation, minimal fasting, multimodal analgesia with appropriate use of opioids, early mobilization, early removal of urinary drainage, quick initiation of oral feeding and fast recovery. Apart from excellent surgical outcome with less postoperative complications, patient’s quality of life and a quick return to normal activities are taken into the consideration. What medications are given after cholecystectomy?Drug classes that may be considered in the medical management of patients with postcholecystectomy syndrome include bulking agents, gastrointestinal (GI) antispasmodic agents, bile acid sequestrants, histamine H2 antagonists, and proton pump inhibitors (PPIs).
What pain medication is prescribed after gallbladder surgery?Pain Relief After Surgery
Take 1-2 oxycodone 5mg (or Dilaudid 2mg) tablets every 3 hours as needed for discomfort that remains after taking Tylenol & Advil.
Can you give morphine after cholecystectomy?Conclusion: Suppository morphine administration is more effective than placebo to reduce pain and analgesic requirements after laparoscopic cholecystectomy.
How do you deal with pain after cholecystectomy?Conclusions: We recommend basic analgesic techniques: paracetamol + NSAID or cyclooxygenase-2 specific inhibitor + surgical site local anaesthetic infiltration. Paracetamol and NSAID should be started before or during operation with dexamethasone (GRADE A). Opioid should be reserved for rescue analgesia only (GRADE B).
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