Perioperative management - diagnostic laparoscopy for adhesion zone, lavage cytology, biopsy sampling, second look operation

• Assessment of tumor recurrences
• Evaluation of therapeutic success
• Prevention or treatment of adhesions
• Suspicion of suture insufficiency, abscesses, or bleeding
• Evaluation in case of suspected remaining infection sites
• Evaluation of intestinal or vascular anastomoses
• Evaluation for remaining endometriosis sites
• Planned reoperation: If the initial surgery could not be completed due to time or complication reasons, e.g., in tumor removals.

Second-look operations thus serve to review and, if necessary, improve a first operation, especially in complicated cases or oncological patients.

• History: Pre-existing conditions, medication intake (e.g., anticoagulants)
• Fasting: at least 6 hours before the operation
• Preoperative laboratory tests: blood count, coagulation status, electrolytes (depending on the patient)
• ECG, possibly chest X-ray (for high-risk patients)
• Discontinuation/adjustment of certain medications (e.g., blood thinners)
• Preoperative antibiotic prophylaxis (if needed)

• Explanation of the Procedure: Diagnostic laparoscopy is used to examine the abdominal cavity using a camera through small incisions.
• Indication: Explanation of the reason for the procedure, e.g., unclear abdominal pain, suspicion of tumors, endometriosis, adhesions, etc.
• Alternative Procedures: Mention of possible alternatives such as CT, MRI, or ultrasound, if applicable.

Procedure Course

• Incision Technique: Smaller skin incisions (usually in the navel area), or in the area of the Palmer's point if adhesions are suspected. Additional incisions if necessary for the introduction of instruments.
• Gas Insufflation: Use of CO₂ gas to create pneumoperitoneum for better visibility in the abdominal cavity.
• Duration: Explanation that the duration can vary, but usually lasts 30–90 minutes.
• Anesthesia: Performed under general anesthesia, explanation of anesthesia risks.
• Risks and Complications
• General Surgical Risks: Bleeding, infections, wound healing disorders, scar formation.
• Injury to Internal Organs: Possible injury to the intestine, bladder, blood vessels, or other abdominal organs.
• Gas Embolism: Very rare but possible complication due to CO₂ gas.
• Thrombosis/Embolism: Risk factors for blood clot formation.
• Need for Conversion to Open Surgery (Laparotomy): If visibility is poor or complications arise.
• Postoperative Complaints: Shoulder pain due to CO₂ residues, nausea, abdominal pain.
• Postoperative Measures
• Pain Management: Possible need for pain medication.
• Restrictions: Physical rest for a few days, no heavy lifting or sports activities.
• Follow-up Care: Possibly removing stitches, wound control, and regular doctor visits to monitor recovery.

Prospects of Success and Limitations

• Diagnostic Accuracy: Note that a definitive diagnosis cannot always be made.
• Therapeutic Interventions: Possibility that small therapeutic measures (e.g., releasing adhesions, biopsies) can be performed during laparoscopy if a finding is made.

Consent

• Voluntariness: The patient must understand that they are undergoing the surgery voluntarily and can withdraw consent at any time.
• Documenting the Consultation: The consultation must be thoroughly documented, and the patient must give their consent in writing.

This detailed explanation ensures that the patient fully understands the risks, benefits, and alternatives of laparoscopy.

• Monitoring in the recovery room: Vital signs, level of consciousness
• Pain management: Analgesics as needed
• Early mobilization for thrombosis prophylaxis
• Diet progression: Depending on condition, fluids, light food
• Monitoring of drains (if placed)
• Wound control: Checking for bleeding, infections
• Instruction on wound care and mobilization
• Thrombosis prophylaxis (depending on patient and risk factors)

Wound Care and Healing

• Dressing Change: Instructions on how and when to change the dressing. Usually daily or when the dressing is soiled.
• Wound Monitoring: Instruct the patient to regularly check for redness, swelling, bleeding, or signs of infection (e.g., pus, severe pain).
• Stitches and Bandages: Information on when the stitches will be removed (usually after 7-10 days) and how long bandages should remain on the wounds.

Physical Rest

• Rest and Activity: Recommendation to rest physically for the first few days after surgery and avoid lifting heavy objects. Gradual increase in physical activity, light walks to promote circulation.
• Sports and Strenuous Activities: Sports activities and physical exertion (e.g., heavy lifting) should be avoided for about 2-4 weeks, depending on individual healing progress.

Pain Management

• Pain Medication: Information on taking pain medications (e.g., acetaminophen, ibuprofen). Clear instructions on how often and in what dosage they should be taken.
• Postoperative Pain: Explain that mild pain and discomfort are normal, especially due to CO₂ insufflation (e.g., shoulder pain, bloating).

Nutrition and Bowel Function

• Postoperative Nutrition: After laparoscopy, a quick dietary build-up is usually recommended, starting with light food and adequate fluid intake.
• Bloating and Constipation: The patient should be informed about possible bloating or delayed bowel movements after surgery. It may be advisable to take mild laxatives if constipation occurs.

Signs of Complications

The patient must know which symptoms require immediate medical attention:

• Fever: Possible indication of an infection.
• Severe or Persistent Pain: Especially in the abdominal or wound area.
• Swelling, Redness, Pus at the wound: Indication of an infection or wound healing disorder.
• Nausea or Vomiting: Especially when associated with severe abdominal pain, may indicate a complication such as bowel obstruction.
• Shortness of Breath, Chest Pain, Dizziness: Possible signs of a pulmonary embolism or thrombosis.

Thrombosis Prophylaxis

• Thrombosis Prophylaxis at Home: If the patient has an increased risk of thrombosis (e.g., immobilized patients), continuation of medication-based thrombosis prophylaxis (e.g., heparin) at home should be discussed.

Follow-up Appointment

• Follow-up Examination Appointment: The patient should receive a fixed appointment for follow-up, usually about 1–2 weeks after the procedure. Here, wound healing is checked, stitches are removed, and any complaints are discussed.
• Laparoscopy Results: If tissue samples were taken during the procedure (e.g., biopsies), the patient must be informed about when to expect the results.

Return to Work

• Incapacity for Work: Depending on the job and healing progress, the patient will be on sick leave for 1–2 weeks. Patients with physically demanding jobs should be incapacitated for longer.
• Office Work: Light office work can often be resumed after a few days, depending on well-being.