Vomiting following laparoscopic cholecystectomy - Forum

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Lady Surgeon

Vomiting following laparoscopic cholecystectomy - Ärzteforum

Post#1 »

I have been doing lap chol for last two years now. We use carbondioxide for insufflation at 2-3L/min gas flow and at intraabd pressure of 12 mm. Almost all my patients have several episodes of vomiting in the first 6 hours post. op. In my opinion the CO2 is the reason for it but I don't have the facts.
My questions are:
1. Is it a recognised complication.
2. How do you avoid it.

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Re: Vomiting following laparoscopic cholecystectomy - Ärzteforum

Post#2 »

As a chief resident in genreal surgery, I have seen many approaches to laprascopic cholecystectomy, and among the seven hospitals where I rotate, a wide variation in the incidence of postoperative nausea. And I have come to the conclusion that the anesthetic has much more to do with the incidence of postop nausea than anything the surgeon does.

I recently completed a rotation at a children's hospital, and this hospital had begun performing palrascopic surgery only 20 months prior. The anesthesiologists prefer a gas induction, with palcement of IVs, foleys, and lines under gnereal anesthesia. We had a terrible postop nausea problem after lap chole, causing some patients to stay 3-4 days! I suggested to one anesthesiologist that we try IV induction on our adolescent patients who were undergoing laprascopic surgery, and he chose propofol and versed, with non-depolarizing paralytics. Not an ounce of vomitus has hit the floor since in these patients.

Nausea is more severe in all patients in whom volatile anesthetics are not allowed to diffuse off prior to reawakening; I believe some of the volatile agents end up in the pneumoperitoneum, and are then reabsorbed by the patient, even as they are awakened.

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Lady Surgeon

Re: Vomiting following laparoscopic cholecystectomy - Ärzteforum

Post#3 »

I'll show it to the Prof and get back to you. Nausea post lap chole is recognised, occurs in about 40% without antiemetics. Ways of reducing it are
Desufflate all the gas
Give prophylactic antiemetics (ondansetron is twice as effective as metoclopramide in controlled studies)
No opiate analgesia pre or per op
Take the ng tube out while they are still asleep
Shoulder tip pain can be helped with subdiaphragmatic marcaine per-op (evidence from controlled studies but benefit for lap chole not tested)

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Re: Vomiting following laparoscopic cholecystectomy - Ärzteforum

Post#4 »

I just became a fan of ondansetron too, just about two weeks ago when my breast CA patient on her fifth chemotherapy did not feel any nausea but previously she wanted to quit chemotherapy because of the nausea.


Re: Vomiting following laparoscopic cholecystectomy - Ärzteforum

Post#5 »

I have been doing lap. chole for the last five years and have not encountered this problem in particular. Just few questions:

1. What preop medications you use.
2. Ask your anaesthetist about the anaesthetics and intra-op medications.
3. Do you use OG tube with suction intraop.
4. Do you position your patient in reverse trendelenberg.
5.What is the average time of your lap. chole.
May be one of these questions may solve your problem.


Re: Vomiting following laparoscopic cholecystectomy - Ärzteforum

Post#6 »

At a former hospital, I had a lot of problems with post-lap chole vomiting. We had a single anesthetist and an occasional alternate. The vomiting mostly occured with our regular anesthetist, who always blamed it on me and insisted that I was not properly removing the CO2 from the abdomen. I rarely had post-op nausea and vomiting with the relief anesthetist. I researched the problem and came up with several articles from the Anesthesia literature, which I found helpful (which our regular anesthetist refused to follow). Anyhow, since I have moved to South Dakota (1 regular Anesthesiologist, 2 regular Anesthetists, plus at least 5 relief Anesthetists), I have not had the problem (occasional vomiting, yes, but far less and not persistent).


Re: Vomiting following laparoscopic cholecystectomy - Ärzteforum

Post#7 »

Based on what you're telling, there's no difference with what we do, however I can say that vomiting is not frecuent in our patients. An advise: CHANGE THE ANESTHETIST !


Re: Vomiting following laparoscopic cholecystectomy - Ärzteforum

Post#8 »

What sort of anaesthetics are being given to your patients? Do they get any form of opiates by the anaesthetists at any stage? I have found that anaesthetists are reluctant to give up opiates in laparopscopic surgery and this results in significant nausea which prevents early return to eating. This may even be given as a shot before reversal.


Re: Vomiting following laparoscopic cholecystectomy - Ärzteforum

Post#9 »

I would concur with Mr. Willson - a pre-operative shot of Demerol, none during the case, Zofran 4 mg during the case, IV Toradol while closing and again in six hours, before discharge, and bupivicaine in the trocar sites and they do well.

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