The effect of the analgesic regime plays a major role on the surgical outcome. The analgesic regime should be effective and allow early mobilization. The use of long-acting opioids should be avoided. Regular paracetamol (acetaminophen) and nonsteroidal anti-inflammatory agents can be used unless contraindicated. Regional blocks help modulate the stress response to surgery and improve the return of gut function after open surgery [10]. Epidurals still are used extensively in open surgery but can cause postoperative hypotension, immobility, and increased postoperative intravenous fluid loading. Local anesthetic catheter techniques such as wound infusers and transabdominal plane blocks are being increasingly utilized. In laparoscopic surgery, the use of epidural analgesia has been shown to lengthen hospital stay, and spinal analgesia and local anesthetic techniques seem to be superior because analgesic requirements can usually be addressed by oral analgesia at 12–24 h.

The stress response to surgery is complex and involves many pathways. Although, traditionally, much emphasis is placed on reducing the stress response, it is clear that there are ­evolutionary reasons why humans have a stress response. We therefore discuss modulation of the stress response rather than obtunding it because some form of healing response is necessary and unavoidable because of local inflammatory effects. The factors that are part of the ER pathway that help modulate the stress response fall into several groups, but it is the sum of these that is important to a patient making an early recovery and having increased well-being. Important factors include:

During laparoscopic resections, the patient is often positioned in a steep head-down position for pelvic surgery. It is imperative to position the patient carefully and to wrap his or her arms and place jelly padding on any areas likely to be subject to a pressure effect because the patient may be in this position for a prolonged period of time. Yellofin stirrups (Allen Medical Systems, Acton, MA) can increase the stability of the patient’s position because they support and hold the legs, avoiding pressure on the calves. Any sliding sheets used to transfer the patient should be removed, and the use of shoulder supports can stop the patient from sliding down the operating table. The steep head-down position as shown in Fig. 47.2 has marked effects on the patient’s physiology, ­particularly when combined with insufflation of the peritoneum.

The increase in afterload has the effect of decreasing stroke volume. Work by Levy et al. [8, 26] has shown that in fluid-optimized patients, this increase in afterload is sustained for approximately 20–25 min and follows a similar pattern despite whether the patient has a regional block. After this time, the systemic vascular resistance drifts back to more normal levels. There is an increase in both left and right ventricular filling pressures and an elevation of pulmonary pressures and vascular resistance [26]. Changing ventilator parameters and increasing positive end-expiratory pressure with the resultant increase in mean airway pressure may expose the right ventricle to a particularly high workload. Increases in right ventricular workload also have been demonstrated in transesophageal echocardiography and are due to ventilation and carbon dioxide (CO₂) pneumoperitoneum [27, 28]. In the head-down position, therefore, care should be exercised if changing ventilator parameters to increase mean airway intrathoracic pressures because this will increase the work being done by the right ventricle.

During a CO₂ pneumoperitoneum, there is increased abdominal wall compliance and a reduction of lung volume due to the pressure exerted on the diaphragm. Respiratory mechanics are disrupted with less excursion of the diaphragm. Therefore, ventilation pressures need to be increased to achieve the same tidal volumes before insufflation. Furthermore, it is being increasingly recognized that long laparoscopic procedures (longer than 4 h) with the patient in the head-down position can cause problems that do not occur during open surgery. The steep head-down position and pneumoperitoneum can lead to venous engorgement of the head due to reduction in venous return. A rise in arterial CO₂ is accompanied by a rise in cerebral blood flow, which can further exacerbate the problem [29]. This may lead to confusion and an altered level of consciousness in the patient postoperatively, and there have been reports of patients requiring ventilation postoperatively to control intracranial pressure secondary to cerebral edema.

Most patients can be discharged from the recovery area to a ward environment. Certain groups of patients should be considered for postoperative monitoring, including flow-directed studies and targeted oxygen delivery for 12 h. These include the following groups:

The first 12 h postoperatively is important to determining cellular response to injury and the healing process, and careful management during this time may decrease the incidence of complications. A study by Pearse et al. [30] demonstrated reduced complications with the use of target-driven oxygen delivery during the first 12 h postoperatively with fluid boluses and, if necessary, a dopexamine infusion. It is still unclear if this benefits fluid-optimized patients without an oxygen debt who have undergone elective surgery.

Postoperative lung function is improved by good analgesia, optimal positioning, and early mobility. Levy et al. [24] have shown that there were only small differences in lung function (peak expiratory flow rate and forced expiratory volume in 1 s) in patients with or without a regional block undergoing laparoscopic surgery, and all groups had a reduction in function. In open surgery, pulmonary function is improved with epidural analgesia. Increasing mobility and early walking is the most effective way of improving lung function.

The risk of venous thromboembolism during the perioperative period can last several weeks into the postoperative period after the patient has been discharged [31–33]. Before surgery, each patient should have an individual risk score calculated; higher scores are associated with greater risk, and independent risk factors for deep vein thrombosis or pulmonary embolism include a history of deep vein thrombosis, known thrombophilia, the presence of cancer, age older than 60 years, and prolonged immobilization after surgery [34

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