Operative stress response is reduced after laparoscopic compared to open cholecystectomy - The relationship with postoperative pain and ileus

Our objective was to determine the least invasive surgical procedure; to do this we compared postoperative pain, duration of ileus, and level of neuro hormonal stress response after laparoscopic cholecystectomy (LC) and open c holecystectomy (OC). Postoperative recovery of patients was faster after LC than OC but comparison of the neurohormonal stress response after laparosc opic and open surgical procedures revealed conflicting results. Forty-one c onsecutive patients with noncomplicated gallstones were randomized for LC ( N = 25) and OC (N = 16). The stress level was evaluated in patients before surgery by the Hamilton anxiety scale. Postoperative pain was assessed by a visual analogic scale (VAS) pain score and by the amount of analgesic drug s (propacetamol) administered, while the duration of ileus was determined b y the delay between surgery and the time to first passage of flatus as well by the colonic transit time (CTT) measured by radiopaque markers. Plasma c oncentrations of anti-diuretic hormone (ADH), adrenocorticotropic hormone ( ACTH), p-endorphin (BE), neurotensin (NT), and aldosterone (Ald) were measu red before and during surgery as well as 2 and 5 hr after the surgery (DO) and on the day following surgery (D1). Urinary cortisol (uCOR) and urinary catecholamine metabolites were assessed before surgery, during DO, and on D 1. Patient characteristics, the duration of surgery, and the doses of anest hetic drugs were not different in LC and OC. In LC patients the VAS pain sc ore and the doses of postoperative antalgics were lower (P < 0.05), the tim e to first passage of flatus was shorter (P < 0.001), and the CTT tended to be shorter (54 +/- 12 hr vs 81 +/- 17) compared to OC patients. Patients w ho required the highest doses of postoperative antalgics had the longest de lay to first passage of flatus (P < 0.01). During surgery, all neurohormona l parameters increased compared to the preoperative period (P < 0.05), and only plasma NT concentrations were lower during LC than OC (P < 0.05).:Duri ng the postoperative period, ACTH, BE, Aid, catecholamines, and uCOR concen trations were lower in LC than in OC (P < 0.05). Concentrations of hormonal parameters were higher when the duration of surgery increased (P < 0.05). A greater need for propacetamol to relieve pain was associated with a great er increase in BE, ACTH, and urinary catecholamine levels (P < 0.05-P < 0.0 05). When the time to first passage of flatus was delayed, levels of BE, AC TH, and catecholamines and NT concentrations were increased (P < 0.05-P < 0 .005) In conclusion, LC is less invasive because this surgical procedure in duces a shorter neurohormonal stress response than OC, even if the peropera tive response is not different. Postoperative pain levels and the duration of ileus are associated with BE, ACTH, and catecholamine levels and NT conc entrations, suggesting the importance of hormones in postoperative function al recovery.