Why is a Ryle's (nasogastric) tube used in patients undergoing laparoscopic cholecystectomy?

Routine Nasogastric Tube Placement in Laparoscopic Cholecystectomy is NOT Recommended

Nasogastric tubes should NOT be routinely placed in patients undergoing laparoscopic cholecystectomy, as they provide no clinical benefit and increase complications including respiratory infections, patient discomfort, and delayed return of bowel function. 1

Evidence Against Routine NG Tube Use

Lack of Clinical Benefit

• A Cochrane meta-analysis of 33 trials with over 5,000 patients undergoing abdominal surgery found that routine nasogastric decompression does not accomplish any of its intended goals and should be abandoned in favor of selective use 2
• Patients without nasogastric tubes had earlier return of bowel function and fewer pulmonary complications compared to those with routine tube placement 2
• The Enhanced Recovery After Surgery (ERAS) Society explicitly states there is no rationale for routine insertion of a nasogastric tube during elective colorectal surgery except to evacuate air that may have entered the stomach during mask ventilation prior to intubation 1

Increased Complications with Routine Use

• Routine nasogastric decompression increases the risk of fever, atelectasis, and pneumonia 1
• Pharyngolaryngitis and respiratory infections occur more frequently when postoperative nasogastric decompression is used 1
• Patients with nasogastric tubes experience significantly higher rates of sore throat and nausea 3
• Gastroesophageal reflux is increased during laparotomy if nasogastric tubes are inserted 1

No Impact on Surgical Outcomes

• Anastomotic leak rates are identical between patients with and without nasogastric tubes 2
• A study of over 2,000 patients found that nasogastric decompression use declined from 88% to 10% without any increase in patient morbidity or mortality 1
• In a randomized trial of 197 patients undergoing elective abdominal surgery, only 2 patients without routine decompression subsequently required tube placement 3

When NG Tubes ARE Indicated (Selective Use)

Therapeutic Indications Only

• Patients presenting with ileus at the time of surgery 1
• Patients with gross intestinal edema at the end of the procedure 1
• Patients who develop postoperative vomiting that cannot be controlled with antiemetics (occurs in approximately 4.5-8% of cases) 3, 4

Intraoperative Use Only

• If a nasogastric tube is placed intraoperatively to evacuate air from mask ventilation, it should be removed before reversal of anesthesia 1

Management Strategy for Laparoscopic Cholecystectomy

Standard Approach

• Do not place a nasogastric tube routinely 1
• Use ondansetron for prevention of postoperative nausea and vomiting 1
• Monitor patients for signs of intolerance (nausea, vomiting, distension) 1

If Vomiting Occurs Postoperatively

• First-line: Antiemetic therapy 1
• Second-line: Only if vomiting persists and cannot be controlled with medications, consider therapeutic nasogastric tube placement 1, 3
• This selective approach results in only 4.5-8% of patients requiring tube insertion 3, 4

Common Pitfalls to Avoid

• Do not place NG tubes "just in case" - The evidence clearly shows this increases harm without benefit 2
• Do not leave intraoperative NG tubes in place - Remove them before extubation 1
• Do not confuse laparoscopic with open surgery - While some surgeons historically used NG tubes after open cholecystectomy (20% in one survey), this practice is not evidence-based 3
• Evaluate daily if a tube was placed therapeutically - Remove as soon as the indication resolves 1