Case: 41 year old G1 P1 is recovering in the hospital’s “same day surgery” unit immediately after an operative laparoscopy for lysis of pelvic adhesions and laser vaporization of endometriosis. While waking up, the patient vomits 3-4 times and has significant nausea.
Question: Is nausea and vomiting common after a laparoscopy? What causes the nausea and vomiting?
Answer: Unfortunately, many women do have nausea and some vomiting after laparoscopic surgery.
The reasons for these symptoms often remain unclear. The symptoms may be related to the CO2 gas that is used to create the pneumoperitoneum (presence of air or gas within the peritoneal cavity of the abdomen). A pneumoperitoneum is necessary during operative laparoscopy to allow visualization of the abdominal and pelvic organs. These symptoms may also be a side effect of the narcotic pain medications that are used perioperatively to control discomfort.
Nausea and vomiting may also be due to gastrointestinal (GI) inflammation or GI damage. A viral gastroenteritis (stomach flu) can cause these symptoms. Irritation of the bowel during the operative laparoscopy can also cause the symptoms.
An uncommon but potentially serious cause of nausea and vomiting is inadvertent injury to the bowel during the surgery. The signs and symptoms of a bowel injury are often nonspecific. However, when the bowel is injured during surgery the symptoms usually progress in severity over time rather than subside, often involve considerable abdominal discomfort, and often are associated with a fever.
If the nausea and vomiting persists or if there is a suspicion of an injury to the bowel, then careful followup with the surgeon is very important.
Case: 40 year old G0 is postoperative day 1 (following an operative laparoscopy for laser vaporization of endometriosis) and has persistent right greater than left sided shoulder pain whenever she sits or stands up. Otherwise, she feels fine.
Question: What generally causes the shoulder pain after laparoscopy and how should it be treated?
Answer: Shoulder pain is not uncommon after laparoscopy.
The phrenic nerve is involved with movement of the diaphragm (a dome shaped partition that separates the thoracic cavity containing the lungs and heart from the abdominal cavity) up and down to aid with respiration (breathing). The phrenic nerve also is a sensory nerve for the shoulder region.
When there is gas or air trapped in the abdomen after surgery this gas generally moves upward. When standing or sitting up, the gas often makes its way to rest under the diaphragm of the lungs and irritates the phrenic nerve. The postoperative patient usually perceives “free” gas within the abdomen causing irritation of the phrenic nerve as shoulder pain (since this nerve is a sensory nerve for the shoulder).
The surgeon should try to remove as much of the CO2 gas as possible at the end of the laparoscopic procedure through the trocar and incision sites. Sometimes it is not possible to remove all of the gas and some gas may become trapped in the abdomen when the incisions are sutured. The amount of trapped gas is usually very small if the surgeon tries to remove all of the gas. The patient generally metabolizes the CO2 gas that becomes trapped in the abdomen within a few days of surgery.
Changing positions may relieve the shoulder pain that is caused by CO2 gas. Rather than remaining upright (where the gas floats upward to rest under the diaphragm) the patient can elevate her hips (possibly using a prop like a pillow) while lying down so that the gas recollects in the lower abdomen or pelvis. When the gas no longer irritates the phrenic nerve the shoulder pain often resolves.
Case: 42 year old G0 is recovering on postoperative day 1 following an operative laparoscopy for lysis of pelvic adhesions and a fimbrioplasty (surgical opening of the distal end of the fallopian tube). She generally feels well and is pain free except for pain around her incision sites.
Question: How can the pain at the incision sites be reduced?
Answer: The pain associated with incisions in the abdominal wall is usually due to either the skin (where sensory nerves are abundant and may be inflamed) or the peritoneal lining of the abdomen (where sensory nerves are also abundant and may be inflamed). There are few sensory nerves in the tissue of the abdominal wall between the skin and the inner peritoneal lining.
The incision sites are generally not very tender after laparoscopic surgery. If the incisions are tender, then the inflammation that often causes the discomfort can usually be relieved with a brief course of non-steroidal anti-inflammatory agents (such as ibuprofen). A heating pad can also be applied to the region of the pain and is sometimes helpful.
If the incisions are red, swollen, warm to the touch, leaking pus or a malodorous (foul smelling) discharge, or more than just a bit tender then the surgeon would generally want to examine the area to determine whether there is an infection.
If an infection develops within the incision sites then appropriate treatment should be initiated. Local skin infections are generally treated effectively with the daily application of an antiseptic agent (such as half strength hydrogen peroxide in water or half strength betadine in water). If the signs of infection do not subside within a few days, then the doctor would generally re-examine the sites.
If a deeper infection develops within the abdominal wall then more aggressive treatment may need to be considered. Close follow-up with the surgeon is always a good idea.
Case: 26 year old G0 is recovering in the same day surgery unit (of the hospital) immediately following operative laparoscopy and operative hysteroscopy. She is able to eat crackers without nausea or vomiting, ambulate (walk) to and from the bathroom without discomfort, and generally feels ok. However, she is not able to void (urinate) spontaneously (by herself).
Question: When should postoperative difficulty with voiding (urinating) be considered a problem that needs to be treated and how can this be treated?
Answer: Following operative laparoscopy a patient may have transient (temporary) difficulty urinating. Postoperative difficulty with urination is uncommon.
The reason for this difficulty is usually not completely understood but appears to be associated with the effect of anesthetic medication on the muscular wall of the bladder. Additionally, the urethra of the bladder (the small tubular structure that measures about 3 cm in length in women that drains urine from the bladder) may be somewhat swollen since a Foley catheter (a rubber catheter with a balloon tip that is placed in the bladder using sterile technique when continuous drainage is desired) is generally placed in the bladder during surgery.
If a postoperative patient does not have a Foley catheter, is receiving adequate fluid (usually via an intravenous IV catheter), and is unable to void (completely) for several (4 or 5) hours following laparoscopy then the bladder (lower abdomen) should be palpated (examined with a hand or fingers). If the bladder is distended (or the exam is unable to determine distension), the bladder should be emptied with a catheter and the volume of residual urine determined. When the volume of residual urine is greater than 75-100 mL it is excessive.
Often a patient is able to resume spontaneous voiding once the distended bladder is emptied with a Foley catheter. Whenever a patient remains unable to void spontaneously, a Foley catheter with a leg bag may be left in place in order to drain the bladder overnight. The catheter can usually be removed the next day with a return of spontaneous bladder function.