Introduction
Cholecystectomy is commonly performed for gallstones and gallbladder problems. A laparoscopic cholecystectomy (LC) is a minimally invasive procedure to remove the gallbladder [1]. LC is currently used to treat cholecystitis, choledocholithiasis, biliary dyskinesia, biliary pancreatitis, and masses/polyps of the gallbladder [2]. The term “laparoscopic cholecystectomy” (LC March 1987) is used. In 1993, the National Institutes of Health Consensus Conference determined that LC had replaced open cholecystectomy (OC) as the “gold standard” for treating symptomatic gallbladder disease [3]. Over 80% of cholecystectomies are performed laparoscopically today. Carl Langenbuch performed the first cholecystectomy in Berlin on 15 July 1882 on a 42-year-old man. In Lyon, France, Philipe Moret performed the first c for symptomatic cholelithiasis [4]. The first study in Iraq evaluated predictive factors for difficult LC. Preoperative ultrasound can predict LC surgery difficulty [5]. Digestive diseases are the third most common illness, with the highest economic burden in the United States. Digestive illness caused by gallbladder disease is estimated to cost over a billion dollars in direct medical care. Approximately 10% of the population is affected by it, and it is more prevalent in women and the elderly. In 1984 gallstones were diagnosed in 776,000 patients, 485,000 of whom underwent cholecystectomy [6]. Today, LC is considered the gold standard of gallbladder surgery. In Iraq, OC is still widely practiced due to certain factors. Considering the unique characteristics of both types of surgery during the early postoperative period, we have an excellent opportunity to study their early postoperative course and complications. Complications can occur despite improved learning curves for surgeons performing LC. LC. has better morbidity, cosmetics, and complications than OC [7]. Western countries reported early complications in 1.5–2.92% of cases, while Eastern countries reported 1.5–6.5%. The purpose of this study is to evaluate the specific complications associated with LC, which we have been implementing in our teaching centre for the last 10 years. LC complications include haemorrhage, gall bladder perforation, bile leakage, stone spillage, bile duct injuries, perihepatic collections, external biliary fistulas, wound complications, foreign body inclusions, and adhesions [8]. Many complications can occur during LC, some of which are unique to this procedure and some of which are common to all laparoscopic surgery procedures. These include complications related to anaesthesia, peritoneal access, etc. The most common complications are vascular injuries, visceral injuries, cardiopulmonary complications, gas embolisms, and thrombocoagulation complications. Complications of LC include haemorrhage, bile leakage, bile duct injury, prehepatic collection, as well as external biliary fistulas, wound sepsis, haematomas, and foreign bodies. Due to procedural difficulties, patient factors, and unexpected adverse events, LC was converted to OC [9]. Postoperative complications can be prevented with preoperative education following LC. Postoperative information includes management of postoperative pain, nutrition, activity, and follow-up care. Longer hospital stays and a decrease in cognitive and functional ability are 2 symptoms of postoperative complications that lead to postoperative mortality. Hospital costs are significantly impacted by it [10]. Self-management encourages patients to take an active role in their healthcare [11]. The concept of self-care includes following treatment recommendations, managing symptoms, controlling weight, and adopting healthy lifestyles. These behaviours are promoted through self-care education [12]. Motivation and behaviour are influenced by self-efficacy beliefs, as are actions that impact one’s life [13]. An individual’s self-efficacy refers to their belief in their ability to plan and execute appropriate responses to future situations. In addition to how you feel about yourself, self-efficacy plays a role in achieving your goals in life and developing your character [14]. A cholecystectomy for gallstone disease is typically evaluated based on perioperative complications, morbidity, mortality, and long-term outcomes. After surgery, the patient’s satisfaction with the treatment, symptom resolution, and global imperatives for quality of life and prevention of postoperative complications are all important factors to consider [15].
Material and methods
A quantitative, quasi-experimental research design was used to achieve the early stated objectives. A study was conducted in surgical wards at AL-Diwaniyah hospitals and the Gastrointestinal Centre between 12 November 2022 and 15 March 2023. This study selected non-probability purposive samples of subjects. At AL-Diwaniya hospitals, each patient was interviewed (face-to-face). The sample size in the present study was 60 nurses, according to calculation of the sample size based on a confidence level of 95% and a margin of error 5%.
The study sample was carefully selected based on predefined criteria to ensure consistency and relevance to the research objectives. Inclusion criteria encompassed patients with benign gallbladder conditions undergoing cholecystectomy who were conscious, communicative, and willing to participate voluntarily. Additionally, only those who had not previously been exposed to any educational programs related to postoperative care were included. Patients diagnosed with any type of cancer were excluded to minimise potential confounding variables and maintain the focus on non-malignant surgical cases. The control group (A) consisted of 30 patients who received routine hospital care. The control group was not exposed to such an education program. Study group A consisted of 30 patients who received hospital care as well as an educational program about self-care after cholecystectomy.
Statistical analysis
The study instrument was composed of 2 parts: The first part focuses on sociodemographic characteristics – 10 multiple-choice questions were developed by the researcher, including age, gender, marital status, weight, monthly income, educational level, residence, occupation, and family history of gallbladder removal and gallbladder removal complications. The second part focused on patient knowledge of self-care following cholecystectomy. The study questionnaire was constructed through a review of the literature and related studies, experts, and scientific references, to assess patients’ knowledge about self-care post cholecystectomy for the studied subjects. The questionnaire consisted of 24 items pertaining to patients’ knowledge about self-care post-cholecystectomy. Multiple-choice questionnaires were scored as 0 for incorrect answers and 1 for correct answers. Two weeks after the lecture, the researcher evaluated the effectiveness of the educational program on patients’ knowledge about self-care post-cholecystectomy outcomes by using a questionnaire. A follow-up education program was implemented in surgical consultants at hospital departments and doctor clinics. A post-test was conducted from 10 January to 15 March 2023. Post-test results were compared with pre-test results. SPSS version 24.0 was used to analyse the data. Inferential data analysis included t-tests and ANOVA. Descriptive data analysis included frequency, percentage, and mean score (M.S).
Results
Distribution of study samples according to demographic data was presented in Table I. In Table II was reported effectiveness of self-care program for cholecystectomy patients among the pre- and post-test for study sample. Differences in relationship between socio-demographic variables of the study group with their knowledge (pre- and post-test) by ANOVA and t-test were presented in Table III.
Table I
Distribution of study samples according to demographic data
Table II
Effectiveness of self-care program for cholecystectomy patients among the pre- and post-test for study sample
| Score | N | M | SD | t | D f | P-value | Sig. |
|---|---|---|---|---|---|---|---|
| Pre-test and post-test knowledge (Study group) | 30 | 0.41 0.98 | 0.06 0.02 | 38.67 | 29 | < 0.001 | S |
| Pre-test and post-test knowledge (Control group) | 30 | 0.48 0.5 | 0.07 0.079 | 1.82 | 29 | 0.078 | N.S |
Table III
Differences in relationship between socio-demographic variables of the study group with their knowledge (pre- and post-test) by ANOVA and t-test
Discussion
There was a significant change in the mean of responses of the study group from the fail score to the pass score across all items related to their knowledge about cholecystectomy, indicating a positive improvement in their knowledge through education. Based on the current study, most of the patients studied did not have adequate knowledge of self-care after cholecystectomy regarding diet, activity, medications, drainage, wound care, surgery of complications, type of surgery, type of anaesthesia, breathing exercises, or the importance of preoperative preparation in relation to self-care after cholecystectomy. We drew the same opinion as that of Lilian, who advised that any patient who is undergoing a surgical procedure in general, or in particular, should be fully educated on the benefits and risks of surgery, as well as routine pre- and post-operative information [16]. According to the study’s results, the majority of participants provided incorrect answers before the educational program was implemented. The post-education program, however, resulted in participants having a higher level of knowledge; therefore, the patient knew little about preoperative care [17]. An evaluation of the effectiveness of educational programs in enhancing nurses’ knowledge in relation to nursing management before and after surgery found that there were huge differences between the knowledge of the study group in the pre-test and the post-test. Based on a p-value of 0.001, the average was accepted. Patients’ knowledge appears to have improved as a result of the education program [18]. Most of the patients studied did not understand the disease’s nature, preoperative care, postoperative care, complications, or self-care after discharge. Patients’ level of knowledge and nurses’ as a source of knowledge also had a statistically significant positive correlation [19].
This research implemented a standardised multimodal analgesic protocol for managing postoperative pain. During the initial 24 to 48 h following surgery, patients were administered intravenous paracetamol (1 g every 8 h) alongside ketorolac (30 mg every 12 h). This strategy was chosen for its demonstrated effectiveness in alleviating postoperative discomfort while reducing the risk of opioid-related side effects. Furthermore, the protocol was in accordance with the enhanced recovery after surgery (ERAS) guidelines applicable to abdominal surgeries, such as LC. According to the ERAS recommendations, non-opioid analgesics should be used to promote early mobilisation and reduce complications following minimally invasive abdominal surgery [20]. The combination of IV paracetamol and IV parecoxib IV seems to be equivalent to IV paracetamol and intramuscular pethidine in patients undergoing LC. Both combinations of postoperative analgesics exceed the paracetamol monotherapy and ought to be subsequently favoured in LC. Moreover, our think about affirms the idea of a noteworthy opioid saving impact of parecoxib in postoperative torment administration after laparoscopic cholecystectomy [21]. The primary findings indicate that IV paracetamol is an essential component of multimodal postoperative pain management. Several pharmacological treatments were identified as effective in controlling pain: magnesium sulphate and dexamethasone demonstrated anti-inflammatory advantages; ondansetron delivered analgesic properties; gabapentinoids and a2-agonists mitigated central sensitisation; local anaesthetics supplied focused pain alleviation; antidepressants tackled neuropathic discomfort; and NSAIDs were shown to be effective for inflammatory pain. Likewise, non-pharmacological methods and new technologies also played a role in managing post-LC pain, emphasising the necessity for a comprehensive approach to its treatment. More extensive research is required to inform pain management post LC. Future investigations should concurrently compare various treatments and include larger patient populations. This method will aid in determining the best pain management strategies. Additionally, it will offer clearer perspectives on the safety and effectiveness of different pain medications in similar clinical scenarios [22]. The integration of postoperative analgesic therapy comprising intravenous paracetamol and intravenous parecoxib is found to be comparable to the regimen of intravenous paracetamol and intramuscular pethidine in individuals undergoing thyroid surgical procedures. Both analgesic combinations provide superior efficacy when contrasted with paracetamol monotherapy, and they should consequently be favoured in the context of thyroidectomy. Moreover, our investigation substantiates the hypothesis regarding a substantial opioid-sparing effect associated with parecoxib in the management of postoperative pain following thyroidectomy [23]. A prospective observational study indicated that low levels of Butyrylcholinesterase (BChE) on the first and third days following surgery were correlated with an elevated risk of developing surgical site infections (SSIs), although no association with sepsis was found. Additional prospective studies are necessary to further validate these findings [24].
One of the limitations of this research is that the study sample was not controlled, which may have affected the search results. Another limitation is that the current search was done in a certain period. Therefore, it is recommended that another study of different groups of cholecystectomy patients, taking as many participants as possible, as a way to follow-up and gain a better understanding of self-care after cholecystectomy.
Conclusions
The effectiveness of educational initiatives in increasing patient understanding of self-management after cholecystectomy is associated with improved clinical outcomes, fewer complications, and improved quality of life. Demographics, such as residence, family history of surgical complications, and prior surgical experience, have a significant impact on the level of knowledge acquired by patients, both before and after the surgery. For post-operative analgesia, a standardised multidrug regimen was instituted, including intravenous paracetamol and ketorolac, in accordance with the ERAS protocol. This strategy has shown that the need for opioid analgesics can be reduced while simultaneously reducing the need for pain medication. In addition, research suggests that non-opioid analgesics such as non-steroidal anti-inflammatory drugs and non-pharmacological approaches are essential for effective pain management. However, further extensive studies are urgently needed to evaluate different treatment options and refine treatment strategies.
