INDEX
• B & A Tips: Laparoscopy, before and after tips.
• Precautions: Laproscopic Surgeries.
• Precautions: Abdominal Surgical.
• Postoperative Care and Precautions ...
• Safety Report, Laproscopic Trocar Injuries.
• - Questions -: Laparoscopy Frequently Asked Questions ...
• Medical Policy: Laparoscopic, Endoscopic, Thoracoscopic Surgery.
• -- Limits -- : Approach Limits of Laproscopic.
• A Caution: Laparoscopic hepatectomy for hepatocellular carcinoma.

• -Focus-: Monographs on Toxins and Enhancers.

Laparoscopy: before and after tips. INDEX
http://endometriosis.org/resources/articles/laparoscopy-before-and-after-tips/
by Ellen Johnson

Laparoscopic surgery is different for everyone.
Each of us will have a different experience based on our expectations, the extent of surgery, the length of surgery, the surgeon, the facility, the nursing staff, how we respond to pain, and a variety of other factors.

Additionally, each person heals differently. What is true for one person may not be true for another.
Medical professionals may tell us it takes only a few days to recuperate from a laparoscopy.
Yet most of us have found that true healing takes much longer than that, usually several weeks.

Since few resources exist that discuss laparoscopy from a patient’s perspective, the following information was compiled to give women a better idea of what is involved before and after laparoscopy.

PAIN
When you come out of the anaesthesia in the recovery room, you may be in some pain.
If so, be sure to speak up so your pain can be properly managed. Coming out from anaesthesia will also make you feel cold.
Ask for more warm blankets if you’re chilled. You may also have a sore throat from the tube that’s put in your throat during surgery. If any symptom becomes bothersome, tell the nurse or doctor. In most cases, you’ll be given a prescription for pain medication to take at home. If possible, have this prescription filled prior to your discharge or very soon thereafter.

SHOULDER PAIN
One of the most disconcerting things about laparoscopy is the subsequent shoulder pain.
This is caused by the CO2 gas becoming trapped against the diaphragm. Heat and analgesics often bring relief.
Be assured that time will take care of this pain. For more information about how to manage shoulder pain, read our article about post-surgery ailments.

NAUSEA
It seems that most of us experience some nausea after laparoscopy.
Many medications exist to help with this. Some can be taken before surgery, some during, and some after.
Talk with your doctor and/or anaesthesiologist beforehand about the methods they use to minimise nausea.
Many (people) find that nausea is lessened when they lay flat.
Some natural remedies, such as ginger tea, may also alleviate nausea.
To be on the safe side, always ask your health care professional before taking any herbs or supplements.

LENGTH of RECOVERY
For the first two or three days following laparoscopy, most (people) are tired and groggy.
During this time, it helps to have a family member or friend remain close by.
You may want to put this person in charge of managing your medications for the first couple of days.
You will probably also need someone to fix your meals for a short time.

RECUPERATION during the first TWO WEEKS
Your doctor may restrict driving for two weeks following laparoscopy.
Intercourse, tub bathing, douching, and swimming will also be restricted.
Don’t expect too much of yourself for the first few days.
You will probably be very tired and need lots of naps.
However, be sure to get up and move around as you’re able.
You will recover more quickly if you move about.

INCISIONAL NUMBNESS
You may feel a “pins and needles” sensation at the incision site.
This is due to the nerves being cut. Over time, the nerves will heal and the sensation will subside.
If you have bothersome symptoms at the incision site, such as a knot, swelling, or redness, contact your doctor.

Precautions: Laproscopic Surgeries. INDEX
http://www.laparoscopicsurgeryinfo.com/precautions/

The biggest risk in laparoscopic gallbladder surgery is having an untrained surgeon.

This incidence of error and complications with laparoscopic gallbladder surgery became such a problem on the national level, that the National Institutes of Health (NIH) convened a conference to discuss the problem.

Basically they recognized that the risks of this surgery were a result of errors on the part of the surgeon in identifying the anatomy and in improperly cutting or clipping one duct instead of the other. Other problems were also noted.

The consensus of the conference was that the procedure was worthwhile, but proper training, supervision and experience were necessary to make it safe.

They also recognized a significant learning curve, as the incidence of complications and injury were far greater when a surgeon had performed less than 25 of these surgeries than after he or she had considerable experience.

Unfortunately, the conference did not recommend more stringent requirements or credentialing for those performing laparoscopic gallbladder surgery.

Thus, the best safety precaution is to find a surgeon who has received extensive training in the procedure and has extensive experience performing it.

Abdominal Precautions
Protecting Your Incision While You Heal. INDEX
http://www.fvfiles.com/521159.pdf
Copyright © 2011 Fairview Health Services.
All rights reserved. Artwork © 1995 by VHI.
Used with permission. SMARTworks 521159 – 05/13.

After surgery in your stomach or belly area, you must protect your incision (the surgery wound).
This will help you heal faster and prevent infection.

General guidelines
For at least 6 weeks after your surgery, there are two things you must avoid.

• Do not lift more than 10 pounds.
  Avoid heavy pushing or pulling. Take care when pushing with your arms to stand up.

• Do not strain your belly area.
  When you bend, sit up or twist, you could strain the area around your incision.
  Your therapist will show you how to move safely.

Moving in bed
When lying in bed, do not sit straight up.
If you need to roll in bed, roll like a log:

Keep your hips and shoulders in line as you roll.
Do not twist your body.

To change positions, use your legs to “bridge.”

Lie on your back and bend your knees.
Bring your feet toward your hips with your feet flat on the bed.

Use leg strength to lift your hips up off the bed.

Do this to move toward the head or foot of the bed or to shift right or left.

Getting out of bed Do not sit straight up or twist.

Log roll to your side.
Bring your heels to the edge of the bed.

Start to move your feet off the bed.
Push up lightly with your elbow and move to sitting.

Getting into bed

Sitting on the edge of the bed, gently lower yourself to your side and bring your feet onto the bed.

Log roll from your side to your back.

Standing up

Use leg strength to scoot to the edge of the bed or chair.

Place your feet shoulder width apart.

Put your hands lightly on your knees, the bed or chair for balance, and use your leg strength to stand up.

Bathing

Follow your doctor’s directions for bathing and showering.

In general, do not take baths until your stitches or staples have been out for 48 hours.

When you are allowed to shower, avoid direct spray on your incision.
Clean the area by patting it. Do not rub.

Getting out of a tub may strain your stomach.
To avoid strain, shower or use a bath chair.

Do not strain to wash your lower legs and feet.
A sponge with a long handle can help.

Dressing

Do not wear clothes that rub on your incision.
Wear sweat pants, clothes with an elastic waist or a loose dress. Avoid jeans or belts.

Trying to reach your legs or feet can strain your stomach or rub on your incision.

Your therapist can show you ways to dress your lower body while avoiding strain.

Equipment like a reacher, sock aid or long shoe horn can help.

Activity

• You may do light exercise and household tasks as long as you avoid strain.

  • Do not lift more than 10 pounds.
    • A gallon of milk weighs about 8 pounds.
    • A bag of groceries weighs 10 to 12 pounds.
    • A full laundry basket weighs up to 25 pounds.
    
    

  • Stop any activities that cause strain or pain in your incision area.

  • Your energy level may be low when you first return home.
    Take rest breaks often and shorten activities if needed.
    
    

  • When you are with children or pets, stay within lifting restrictions.
    You may need to plan for help.
    Let children know that they must be gentle.
    
    

  • Modify activities, for example:
    • Have children climb into your lap instead of lifting them.
    • Use a stroller instead of carrying a child.
    • Find the best way to position a child for feeding, changing and so on.
    
    

  • Check with your doctor before you return to work, especially if your job is very physical or requires lifting.

  • The time to return to sex will vary.
    Consider how well you are healing, your energy level and comfort. Talk to your doctor.

Driving

Ask your doctor when you may drive.
Most people can start driving after they stop their pain medicine and feel strong enough.

Organ transplant patients cannot drive for two weeks after surgery.

Some medicines will affect your vision.
Make sure you can read traffic signs and see after dark before you drive.

You should wear a seat belt unless your doctor tells you not to.

Postoperative Care and Precautions
after Laparoscopic Surgery. INDEX
https://www.laparoscopyhospital.com/postoperative-care-after-laparoscopic-surgery.html

World Laparoscopy Hospital, 
Cyber City, DLF Phase II, Gurugram, 
NCR Delhi, 122 002, India
PHONES:
For Treatment: +919811912768
For General Enquiry: +91(0)124 - 2351555
Email: contact@laparoscopyhospital.com

After laparoscopic surgery, the patient must be careful and it is the duty of the surgeon and his team to give full instructions for post operative care after he is discharged from the hospital. After surgery regular follow ups are necessary till the surgeon is satisfied about the healing of the incision wound at the place of surgery. For this the patient need to visit his surgeon for follow up within the first or second week. This appointment is very much necessary as long term post operative care would be decided during these visits.

The stitches made to the incisions during the surgery need not have to be removed as they will dissolve by themselves in about two to six weeks.? Immediately after the surgery advice the patient to keep the incision site covered for about 48 hours. He can shower after that and pat the wet spot at the incision site with a soft towel using moderate force. It is better to keep the wound covered with adhesive bandage for added protection. Tell him to contact his surgeon immediately in case of any redness, discharge, or tenderness around the stitches as it needs the attention of the surgeon.

The incision wounds do not cause any scar except in a few cases where they develop as keloid scars.
Make your patient clear that it takes around a year for the incision wound to heal completely and during this period ask him to keep the incision site carefully without exposing to direct sunlight. Advise him to take as much rest as possible and switch to a healthy diet. He has to keep the incision clean.

There are certain things the patient has to avoid immediately after surgery. The patient should:

• Avoid driving a vehicle during the first 48 hours after the laparoscopic surgery
  ----- as he may feel drowsy effects of the anesthesia.

• Take rest during the day after surgery.

• After 24 hours he can do his normal works as long as he is not on any of the narcotic medications.

• Not take bath or shower within the first 48 hours after the surgery.

• Don't do cycling Jogging or sexual intercourse.

• Not go for a swim? in the ocean or in a swimming pool during the first two days of the surgery.

• Not get into a hot tub or Jacuzzi? at least for 2 weeks after the laparoscopy surgery.

• Drink as much fluids as possible to prevent dehydration.

• Not eat hard foods and stay to the light liquids, like apple juice, ginger ale, soup, toast etc
  ----- to prevent stomach upsets immediately after the surgery.

• Get back to the normal diet after two to three days when the patient feels alright.

• Drink more water to prevent constipation caused by pain medications.

Trocar Injuries, Laproscopic, Safety Report. INDEX
https://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm197339.htm
Laparoscopic Trocar Injuries:
A report from a U.S. Food and Drug Administration (FDA) Center for Devices and Radiological Health (CDRH)
Systematic Technology Assessment of Medical Products (STAMP) Committee: FDA Safety Communication
Finalized: November 7, 2003
Last updated: 10/06/2014

In order to perform a laparoscopic procedure, typically from two to four or five trocars, or access ports, are inserted into the abdominal cavity to allow entry of the required laparoscopic instruments. Insertion of these trocars carries a risk for life-threatening injury. Between 1997 and mid-2002, FDA received more than 1300 laparoscopic trocar-associated injury reports, including reports of approximately 30 deaths.

The number and breadth of laparoscopic procedures has increased steadily since the late 1980s.
Each year, more than 2 million patients undergo laparoscopic procedures in the U.S. ...

Hemorrhage due to vessel injury and infection secondary to bowel injury, especially when diagnosis is delayed, are the most serious complications and the most likely to result in death. ...

Injuries appear to occur most frequently during insertion of trocars into the abdomen or pelvis.
Several studies suggest that the initial trocar insertion is the most dangerous aspect of trocar use, and possibly the most dangerous step in minimally invasive surgery. A 1996 study (6) found that 83% of vascular injuries, 75% of bowel injuries, and 50% of local hemorrhage injuries were caused during primary trocar insertion.

Corson noted that major vessel injuries are almost invariably operator error and that delayed recognition of injury in patients older than 59 was significantly associated with fatal outcome. ... A 1996 study indicated that operator experience had the greatest effect on rate of vascular injuries and a lesser effect on visceral injuries. ...

Minimally invasive surgery typically involves use of multiple trocars and cannulas.
The first trocar inserted, or primary trocar, is used to place a cannula through which a laparoscope is inserted to view internal structures. Other, secondary, trocars provide for insertion of other instruments such as biopsy forceps, etc. The primary trocar is typically inserted using either a “blind” puncture or a Hasson (“cut-down,” or open) method.

Before inserting the primary trocar some general surgeons and most gynecologists introduce carbon dioxide gas into the abdominal cavity (creating pneumoperitoneum) through a Veress needle - a process called insufflation. Insufflation elevates and holds the abdominal wall away from internal structures. In 1998 ECRI (16) estimated that 40% of surgeons used Veress needle insufflation prior to primary trocar insertion, while 30% used a direct (no insufflation) trocar insertion method, and 30% used the Hasson method. The literature does not indicate a difference in complication rates for direct entry versus a preliminary pneumoperitomeum.

The blind insertion of the primary trocar uses a technique referred to as a “controlled jab.”
The force required can vary from patient to patient and from trocar to trocar depending upon the sharpness of the trocar blade. The laparoscopist must apply sufficient force under adequate control to stop the trocar movement upon penetration. The amount of force required may correlate with the risk of injury. Injuries may occur twice as often when associated with difficult trocar insertion.

Corson et al reported that the force required to insert reusable trocars was twice that for disposable trocars. This is due to the fact manufacturers use different alloys (that are compatible with autoclaving) for reusable trocars than for disposable trocars. The alloys used for reusable trocars are difficult to sharpen and do not allow for as sharp cutting edges as are found on the disposable trocars. Hence the force necessary for insertion is greater for reusable trocars. ...

We found that reliable data on trocar injury rates are elusive; locating both numerator data and denominator data is problematic. We found that the most frequently cited studies are retrospective, including reviews of patient records and device user surveys. Additionally, neither published data nor FDA adverse event surveillance data are adequate to associate trocar injuries with specific device types or brands. Data from surveys and government studies suggest that injuries are under-reported. FDA adverse event surveillance data reveal that adverse event reports frequently lack the device model and brand name and that the involved device is seldom evaluated for defects or malfunction. ...

Trocar use requires considerable training, practice, skill, manual dexterity, adequate muscular strength, knowledge of the associated risks, and careful patient selection. Debate continues over the protection provided by fail-safe features in preventing trocar related injury (shields, optics, radially-expanding designs). Due to their unique design and use issues, trocars with these features may require additional training, knowledge, or skill. ...

Questions: Laparoscopy, Frequently Asked Questions ... INDEX
https://www.acog.org/~/media/For%20Patients/faq061.pdf
FREQUENTLY ASKED QUESTIONS, FAQ06, SPECIAL PROCEDURES
July 2015 by the American College of Obstetricians and Gynecologists

... What are the risks associated with laparoscopy?
Laparoscopy can take longer to perform than open surgery.
The longer time under anesthesia may increase the risk of complications.
Sometimes complications do not appear right away but occur a few days to a few weeks after surgery.
Problems that can occur with laparoscopy include the following:

1. Bleeding or a hernia (a bulge caused by poor healing) at the incision sites
2. Internal bleeding
3. Infection
4. Damage to a blood vessel or other organ, such as the stomach, bowel, bladder, or ureter

....

Medical Policy: Laparoscopic, Endoscopic, Thoracoscopic Surgery. INDEX
https://www.bcidaho.com/providers/medical_policies/adm/mp_100108.asp
Blue Cross of Idaho
Reviewed by consensus/4:2002

As used in this policy, endoscopic surgery is a general term describing a form of minimally invasive surgery in which access to a body cavity is achieved through several small percutaneous incisions. The surgery is performed using specialized instrumentation inserted through the incisions (i.e., trocar sites) and guided by the use of a fiberoptic endoscope that provides visualization of the body cavity on a video screen.

In endoscopic surgery, the surgeon does not have direct visualization of the surgical field, and thus endoscopic techniques require specialized skills compared to the corresponding open surgical techniques. Endoscopic surgery may also refer to the use of a fiberoptic endoscope inserted through a body orifice into a body cavity such as the gastrointestinal tract, bronchi, uterus, or bladder. These applications of endoscopic surgery are not addressed by this policy.

While endoscopic surgery is a general term, laparoscopic, thoracoscopic, and arthroscopic surgery describe endoscopic surgery within the abdomen, thoracic cavity, and joint spaces, respectively. In most instances, the endoscopic technique attempts to duplicate the same surgical techniques and principles as the corresponding open techniques, with the only difference being surgical access. For example, laparoscopic cholecystectomy, performed since 1990, espouses the same surgical principles as open cholecystectomy. The advantages of endoscopic surgery include shorter hospital stays and more rapid recovery such that the patient may be able to return to work promptly. Disadvantages include a longer operative time, particularly if the surgeon is early on the learning curve for these new techniques.

Some endoscopic approaches entail novel surgical principles, and thus raise issues of safety and effectiveness apart from the safety and effectiveness of the endoscopic approach itself. For example, open herniorrhaphy is typically done from an inguinal approach, while laparoscopic herniorrhaphy involves a unique abdominal approach. In other procedures, the surgical dissection can be done entirely with endoscopic guidance, but the resulting surgical specimen may be too large to remove through the small trocar incision. Novel approaches have been devised to overcome this limitation.

For example, in laparoscopic splenectomy or nephrectomy, the resected specimens are placed into a bag intra-abdominally, morcellated, and then removed through a small muscle-splitting incision.

Similarly, laparoscopic colectomy specimens can be removed through either a muscle-splitting incision, or transanally for distal specimens.

In most instances it is assumed that an endoscopic approach is a direct substitution for the corresponding open approach. However, the decreased morbidity of endoscopic surgeries in general may broaden the patient selection criteria for certain surgeries. For example, open gastric fundoplication is typically limited to those patients who have failed medical management with H-2 blockers and antimotility agents.

Now, however, laparoscopic fundoplication may be considered an alternative to lifelong medical management.
Similarly, open plantar fasciotomy is typically reserved for those symptomatic patients who have failed a prolonged attempt at conservative management. The decreased morbidity of an endoscopic approach may prompt a shortened period of conservative management. ...

Approach Limits of Laproscopic. INDEX
http://bges.net/wp-content/uploads/2010/04/2011_April8_WarmUp_NavezBenoit_SBO.pdf
Limits of Laparoscopic approach in SBO (Small Bowel Obstruction)
B. NAVEZ --- 22 slides --- 2011-04-08
Department of Surgery and Abdominal Transplantation
St Luc University Hospital, Brussels, Belgium

ASBO, Adhesive Small Bowel Obstruction)

prophylactic surgery is useless

Clinical exam
Plain abdom film
CT Scan
Gastrographin test 

Review of 1061 cases: Surg Endosc 2007; 21: 1945-1949

19 studies
Adhesions 83%
SB injuries :

intraop : 45
postop : 9
Early recurrence : 2%

... Increased bacterial access was observed as a result of the mechanical effect of the hyperpressure associated with the highly septic contents of the occluded bowel . The important risk of the dissemination following accidental peroperative perforation requires extreme caution in the laproscopic management of late occlusions of the small intestine. ...

Predictive factors for successful laparoscopic adhesiolysis
• Number of previous laparotomies < 2
• Non-median previous laparotomy
• Appendectomy as previous surgical treatment causing adhesions
• Unique band adhesion
• Early laparoscopy within 24 hours from the onset of symptoms
• Experience of the surgeon

Best cases for Laparoscopic approach
• « Limited » previous abdominal surgery (App !)
• Proximal obstruction (CT Scan !)
• Bowel diameter < 5 cm
• Moderate abdominal distension (preop nasogastric tube)
• No necrosis , no peritonitis
• Single band or bowel adherent to ant. abdo. wall

A Caution: Laparoscopic hepatectomy for hepatocellular carcinoma. INDEX
https://www.deepdyve.com/lp/wiley/
laparoscopic-hepatectomy-for-hepatocellular-carcinoma-a-caution-ZO72wiZkfR
Authors: Koea, Jonathan; Gane, Edward; McCall, John
Anz Journal of Surgery | DeepDyve
Published: Jan 1, 2005

Abstract.
Laparoscopic hepatectomy for hepatocellular carcinoma: a caution.

In the last decade advances in laparoscopic surgical techniques have revolutionized the management of a number of common surgical conditions notably gallstone related disease, gastro-oesophageal reflux and the staging of gastro-intestinal malignancies.

Laparoscopic liver resection for malignancy has been regarded with skepticism because of difficulties related to safe parenchymal transection, intraoperative assessment of margins, concern about the phenomenon of port site metastases and the potential catastrophic consequences of major vascular injury. However, an experimental study of laparoscopic hepatectomy was published in 1993 with the first human case reported in 1995. Further investigations indicated that laparoscopic hepatectomy for hepatocellular carcinoma (HCC) could be performed safely and was associated with a decreased rate of postoperative hepatic decompensation, ascites and wound related problems.

On routine screening an asymptomatic 57 year old man with a history of type 2 diabetes mellitus was found to be hepatitis B surface antigen (HbsAg) positive, antibody to hepatitis B surface antigen (anti-HBs) positive, hepatitis B e antigen (HbeAg) negative, antibody to hepatitis B e antigen (anti-Hbe) positive, and antibody to hepatitis B core antigen (anti-Hbcore) positive. Quantification of circulating HBV DNA > 200 000 showed ...