TABLE 846 Complications of Laparoscopy

The evaluation of abdominal pain after cholecystectomy depends on the clinical condition of the patient. If there are signs of peritoneal irritation or fever, an injury to the biliary system is likely. The patient should have a CT scan of the abdomen in addition to a CBC, electrolyte measurements, liver function tests, and a serum lipase test. ERCP will be required to identify the site of the injury; however, a collection of bile can be seen in a CT scan. Depending on the ERCP results, reoperation may be necessary. Small collections of bile may require only observation or percutaneous drainage.

Patients presenting soon after cholecystectomy with pain, pancreatitis, and/or jaundice may have retained common duct stones. If the CT scan does not reveal an intraabdominal collection of fluid, an ERCP should be performed. Endoscopic sphincterotomy is usually an effective means of dealing with retained stones. Patients presenting late after cholecystectomy with fever, pain, and jaundice may have bile duct stricture. Diagnosis requires ERCP. While stents are usually tried at first, surgical repair may be necessary. A more recent concern has been the spillage of gallstones into the peritoneal cavity at the time of surgery. Initially, such stones were thought to be innocuous. However, they have been linked to abdominal pain, pelvic pain, dysmenorrhea, intraabdominal abscess, colocutaneous fistula, and implantation into the ovary with subsequent infertility.14

OIHER LAPAROSCOPIC SURGERIES Laparoscopic techniques are now being used for an increasing number of procedures. In addition to cholecystectomy, they have been used for appendectomy, colon resection, antireflux surgery, herniorrhaphy, fundoplication, and most gynecologic surgical procedures, including hysterectomy. Ihe complications associated with these procedures have not been completely identified; however, they are likely to be similar to those seen with cholecystectomy.

SIOMAS Ihe two most common stomas placed are the ileostomy and the colostomy. Problems with these stomas can be quite debilitating. Most complications are related to technical errors as to where the stomas are placed; however, there can be problems of new disease within the stoma (e.g., Crohn's disease or cancer). Possible complications include ischemia and stomal necrosis, peristomal skin irritation, peristomal hernia, and stomal prolapse.

Ischemia and stomal necrosis are manifested very early in the postoperative course. Ihe cause is inadequate blood supply to the stoma. Normally, the stoma is pink, without any evidence of cyanosis. Any evidence of compromised blood flow requires surgical evaluation.

Peristomal maceration and skin destruction are most likely secondary to a poor seal of the stomal appliance. Consultation with an enterostomal therapist for a properly fitting appliance is indicated.

Prolapse can occur with both ileostomies and colostomies. Ihe cause is usually inadequate fixation of the intraabdominal portion or too large an abdominal wall opening. Patients present with the stoma protrusion, with or without pain. Ihe stoma must be examined to determine viability. Ihe stoma should be pink and painless. Reduction should be attempted if the tissue is viable, followed by consultation with a surgeon. Definitive therapy requires surgical revision.

Parastomal hernias are secondary to too large an abdominal wall opening. As with any hernia, the physician should determine whether the hernia is incarcerated, attempt reduction, and consult a surgeon. Definitive therapy requires local reconstruction of the orifice.

COLONOSCOPY Potential complications of colonoscopy include hemorrhage, perforation, retroperitoneal abscess, pneumoscrotum, pneumothorax, volvulus, postcolonoscopy distention, bacteremia, and infection.

Hemorrhage is the most common complication and can be secondary to the polypectomy procedures, biopsies, laceration of the mucosa by the instrument, or tearing of the mesentery or spleen. If the bleeding is intraluminal, the patient will present with rectal bleeding. Patients with mesenteric or splenic injury will present with signs of intraabdominal bleeding. Ireatment of intraluminal bleeding depends on the magnitude of hemorrhage. Signs of intraabdominal bleeding require emergency laparotomy.

Perforation of the colon with pneumoperitoneum usually is evident immediately but can also take several hours to manifest. Perforation is usually secondary to intrinsic disease of the colon (e.g., diverticulitis) or to vigorous manipulation during the procedure. Most patients will require immediately laparotomy; however, in some patients presenting late (1 to 2 days later) without signs of peritonitis, expectant management may be appropriate.

RECIAL SURGERY Patients who have undergone hemorrhoidectomy frequently have problems with postoperative urinary retention, the management of which has been previously discussed. Ihree other problems that can occur are constipation, rectal hemorrhage, and rectal prolapse.

Ihe management of constipation in a patient who has undergone rectal surgery is no different from that of any other patient with constipation. Gentle rectal examination is indicated, and enemas can still be used. Posthemorrhoidectomy rectal hemorrhage can occur immediately postoperatively but may also be delayed (4 ± 2 days).15 Proposed causes of delayed bleeding include sepsis of the pedicle, disruption of a clot, and sloughing of tissue. 16 Ihe patient may present with minimal bleeding or massive hemorrhage. While ligation of the affected vessel is needed, a temporary tamponade with a Foley catheter may be helpful.

Patients may present with mucosal prolapse or complete rectal prolapse. Mucosal prolapse occurs when the surgeon has not removed all redundant mucosa during hemorrhoidectomy and is much more common than rectal prolapse. Local treatment by a surgeon is usually corrective. Rectal prolapse can occur after any anorectal surgical procedure and probably is related to injury of the puborectalis muscle. Ihe patient will present with the sensation of protrusion and may complain of pain. Ihe treatment is reduction and surgical consultation.

Infection following anorectal surgery is surprisingly uncommon. Ihe patient usually complains of increasing pain and fever. Examination of the area is necessary to detect an abscess or cellulitis. Fournier's gangrene may follow anorectal surgery. If this is suspected, broad-spectrum parenteral antibiotics are given immediately. Ihe patient requires immediate surgical debridement.

Constipation Prescription

Constipation Prescription

Did you ever think feeling angry and irritable could be a symptom of constipation? A horrible fullness and pressing sharp pains against the bladders can’t help but affect your mood. Sometimes you just want everyone to leave you alone and sleep to escape the pain. It is virtually impossible to be constipated and keep a sunny disposition. Follow the steps in this guide to alleviate constipation and lead a happier healthy life.

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