POSTOPERATIVE BENEFITS AND CONSEQUENCES OF LAPAROSCOPY
Implicit in the decision to use the laparoscopic approach is the
assumption that the intraoperative consequences of pneumoperitoneum described in
the previous sections are counterbalanced by multiple postoperative benefits. In
contrast to laparotomy, improved and more rapid recovery, reduced postoperative fatigue,
[161]
[162]
and
a
heightened feeling of well-being are commonly reported and reflect better maintenance
of homeostasis.[3]
[161]
Stress Response
In patients undergoing cholecystectomy, the laparoscopic approach
allows for a reduction of the acute-phase reaction seen after open cholecystectomy.
Plasma concentrations of C-reactive protein and interleukin-6, which reflect the
extent of tissue damage, are significantly lower after laparoscopy compared with
laparotomy.[3]
[161]
[163]
[164]
[165]
The metabolic response (e.g., hyperglycemia, leukocytosis) is also reduced after
laparoscopy. As a consequence, nitrogen balance and immune function might be better
preserved.[166]
[167]
[168]
[169]
Laparoscopy
avoids prolonged exposure and manipulation of the intestines and decreases the need
for peritoneal incision and trauma. Consequently, postoperative ileus and fasting,
duration of intravenous infusion, and hospital stay are significantly reduced after
laparoscopy.[2]
[3]
[163]
[169]
[170]
[171]
The economic implications of these factors
are self-evident and beneficial.[172]
[173]
[174]
Surprisingly, whereas laparoscopy allows for a reduction of surgical
trauma, the endocrine response to laparoscopic and open cholecystectomy does not
differ significantly; plasma concentrations of cortisol and catecholamines,[3]
[161]
[175]
[176]
urinary concentrations of cortisol and catecholamine metabolites,[163]
and anesthetic requirements[3]
are similar after
both procedures. Combined general and epidural anesthesia for laparoscopic cholecystectomy
does not result in a decreased stress response compared with general anesthesia alone.
[175]
Several hypotheses can be invoked to explain
these observations. Pain and discomfort from peritoneal stretching, hemodynamic
disturbances, and ventilatory changes induced by pneumoperitoneum may contribute
to the stress response of laparoscopy. Whereas parietal afference, which is markedly
reduced by laparoscopy, appears to be an important stimulus for postoperative hyperglycemia,
visceral nociception, less affected by laparoscopy, may contribute more to adrenocortical
stimulation.[161]
The intraoperative stress response,
however, can be reduced by preoperative administration of α2
-agonists.
[88]
[110]
[111]
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