Osteopathic Manipulative Treatment for a Recognizable Pattern of Somatic Dysfunction Following Laparoscopic Cholecystectomy

Mandalyn Mills; Karlin Sevensma; Jamie Serrano

doi:10.7556/jaoa.2020.111

Abstract

Context: Previous literature has demonstrated the prevalence and socioeconomic impact of postoperative pain in surgery patients. Somatic dysfunction has been demonstrated as a cause, but literature documenting osteopathic manipulative treatment (OMT) in surgery patients is lacking.

Objective: To describe typical patterns of and common treatments for somatic dysfunction in patients following laparoscopic cholecystectomy.

Methods: The authors retrospectively reviewed the billing records of all patients over 18 years of age who underwent laparoscopic cholecystectomy by a single surgeon and had postoperative outpatient OMT for right-side pain linked to somatic dysfunction between 2006 and 2018 at a community hospital in Grand Rapids, Michigan. Patients who underwent open cholecystectomy, who did not have documented somatic dysfunction, or had somatic dysfunction unrelated to their biliary disease were excluded.

Results: Nine patients were selected for inclusion in this retrospective case series. All patients in the study demonstrated anterior right lower rib pain corresponding to posterior lower rib dysfunctions and rotated right and side-bent left thoracic spine dysfunctions between T5 and T11. Pain was successfully managed with muscle energy, high-velocity, low-amplitude, or soft tissue OMT.

Conclusion: Postoperative pain following laparoscopic cholecystectomy can be related to right-sided thoracic and rib dysfunctions. This is important for early diagnosis of surgical patients with somatic dysfunction and initiation of appropriate OMT to decrease morbidity related to pain, functional status, and quality of life.

While postoperative complications are a common subject of research and quality improvement efforts, chronic pain following surgery can be easily overlooked. Chronic pain is detrimental to patient wellness because of the substantial psychiatric, socioeconomic, and physiologic impact on patients.¹ Persistent pain is multifactorial in the surgical patient. The prevalence of persistent pain depends on the type of surgery, devices used or implanted, and the patient's anatomy. The cause of persistent postoperative pain can be visceral, somatic, mental, referred, or any combination of these.^2,3 Previous literature^4,5 has demonstrated that patients with preoperative comorbid conditions, particularly chronic pain, will be more likely to have prolonged pain postoperatively. Previous research⁶ has also demonstrated the effects of the acute pain response following surgery on the body and its impact on protracted pain. In this study, we focused on the origin of acute pain postoperatively, specifically following a common general surgery operation, laparoscopic cholecystectomy.

The osteopathic profession continues to grow; as of 2019, more than 121,000 DOs were practicing in the US, with 3.6% specializing in general surgery.⁷ Osteopathically-trained surgeons have a unique opportunity to recognize and treat somatic dysfunction in the postoperative patient. While previous research⁸ has attempted to identify ways in which specialists use osteopathic manipulative treatment (OMT) in practice, specific data is lacking. OMT has been studied in the surgical world, but modern surgical techniques haven't always been included.^4,10,11 OMT has been shown to be useful in postoperative pain management, leading to decreased postoperative morbidity, faster return to function, and increased patient satisfaction.^11-13 Case reports¹⁴ have described the utility of OMT for biliary disease, including symptomatic cholelithiasis. Biliary disease has also been demonstrated to effect somatic pain perioperatively, particularly in patients with longstanding inflammation and symptoms; pain, nausea, bloating, and other chronic symptoms related to biliary colic and cholecystitis can lead to compensatory patterns of somatic dysfunction that can persist even after cholecystectomy.^2,9,10

One of the most common complaints postoperatively following laparoscopic cholecystectomy is persistent abdominal pain—specifically, right upper quadrant or right-sided pain.^15,16 In this retrospective case series, we review common patterns of somatic dysfunctions identified in patients following laparoscopic cholecystectomy by an osteopathic general surgeon (K.S.) and describe the types of OMT applied postoperatively to treat this subset of patients. We believe this project is important for early recognition and management of musculoskeletal (somatic) causes of postoperative pain, which can reduce long-term morbidity. Decreasing morbidity related to postoperative pain can contribute to earlier return to baseline mental and physical health, better quality of life, and improved functional status after surgery.

Methods

The Metro Health-University of Michigan Health Institutional Review Board (IRB) reviewed the protocol for this study and determined it to be a quality improvement project. Approval for the study was granted. Based on the IRB exemption, no consent was indicated or required.

We retrospectively reviewed billing records for patients older than 18 years who underwent laparoscopic cholecystectomy with a single osteopathic general surgeon (K.S.) between 2006 and 2018 at a community hospital in Grand Rapids, Michigan; 981 records were found. After searching those records for subsequent OMT by the same surgeon (K.S.), 22 patients remained. Patients who underwent open cholecystectomy, who did not have documented somatic dysfunction, or who had OMT for an unrelated disease (ie, extremity strain) were excluded. No prisoners, pregnant women, or children were evaluated in the study. After preliminary review of de-identified patient charts and application of exclusion criteria, 9 cases were selected for this case series.

Chart review was performed by the attending physician (K.S.) and 2 resident physicians in the Metro Health system. Patient demographics and diagnoses are presented in Table 1. OMT used in the treatment of somatic dysfunction included high-velocity, low-amplitude (HVLA), muscle energy, and myofascial techniques.

Table 1.

Patient Demographics and Diagnoses

Case	Age	Gender	Preoperative diagnosis	Pathology
#1	27	Female	Biliary dyskinesia	Chronic cholecystitis
#2	31	Female	Biliary dyskinesia	Chronic cholecystitis
#3	31	Female	Acalculous cholecystitis	Mild chronic cholecystitis
#4	31	Female	Right upper quadrant pain	Normal
#5	25	Female	Cholelithiasis	Cholelithiasis
#6	32	Female	Cholelithiasis	Cholelithiasis
#7	40	Female	Biliary dyskinesia	No pathologic abnormalities
#8	30	Female	Cholelithiasis	Cholelithiasis, cholesterolosis
#9	53	Female	Cholelithiasis	Chronic calculous cholecystitis

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Table 1.

Patient Demographics and Diagnoses

Case	Age	Gender	Preoperative diagnosis	Pathology
#1	27	Female	Biliary dyskinesia	Chronic cholecystitis
#2	31	Female	Biliary dyskinesia	Chronic cholecystitis
#3	31	Female	Acalculous cholecystitis	Mild chronic cholecystitis
#4	31	Female	Right upper quadrant pain	Normal
#5	25	Female	Cholelithiasis	Cholelithiasis
#6	32	Female	Cholelithiasis	Cholelithiasis
#7	40	Female	Biliary dyskinesia	No pathologic abnormalities
#8	30	Female	Cholelithiasis	Cholelithiasis, cholesterolosis
#9	53	Female	Cholelithiasis	Chronic calculous cholecystitis

Results

The 9 patients evaluated in this series represented approximately 1% of all patients treated with laparoscopic cholecystectomy by the attending surgeon. All patients had a documented diagnosis of somatic dysfunction postoperatively and had documented treatment with OMT. Of the 9 patients evaluated, all were women with a mean age of 33.3 years (range, 25 to 53 years). Each patient demonstrated similar somatic disease, with all 9 patients (100%) reporting pain in the right upper quadrant. Eight of 9 patients (89%) exhibited a rib or a thoracic spine dysfunction; 1 had lumbar dysfunction. Examination findings in the reviewed cases demonstrated posterior lower rib involvement and rotated right/sidebent left thoracic spine dysfunctions between T5 and T11. In addition to pain, 7 patients (77%) had nausea, 3 (33%) had vomiting, 2 (22%) had bloating, 3 (33%) had stool changes, 3 (33%) had food intolerance, and 1 (11%) had acid reflux.

All patients who demonstrated somatic dysfunction at their postoperative appointment were treated with OMT: 4 patients with HVLA alone, 3 patients with muscle energy alone, 1 with muscle energy and myofascial release, and 1 with a combination of muscle energy, HVLA, facilitated positional release (FPR), and articulatory techniques. The technique selected was dependent on patient tolerance and physician preference.

Eight patients (88%) verbally reported symptom improvement following treatment with OMT. One patient was treated by the attending physician without significant relief and was referred for a gastroenterology evaluation of persistent symptoms. Three additional patients without full relief of pain (despite reporting improvement in somatic dysfunction) were referred to an OMT specialist clinic for recurrent dysfunction following initial treatment. One patient initially reported partial relief of symptoms after OMT but was treated with additional supportive care and stretching exercises without specialist referral. Table 2 shows a summary of case findings, treatment, and results.

Table 2.

Patient Symptoms, Imaging Results, and Treatment Protocols

Case	Preoperative symptoms	Preoperative imaging	Postoperative imaging	Postoperative SD findings	Treatment	Symptom improvement	Posttreatment referrals
#1	RUQ pain, nausea, vomiting	RUQ US-WNL, HIDA with EF 16.9%	HIDA negative for bile leak	T6-T7 SD and right 6-7 rib posterior dislocation	Muscle energy, myofascial release	SD: yes Pain: yes	No
#2	RUQ pain, nausea, vomiting	RUQ US-WNL, HIDA with EF 10%	HIDA negative for bile leak	T7-T11 SD with right rotation	Muscle energy, HVLA, FPR, articulatory	SD: yes Pain: partial relief	Yes: OMT clinic
#3	RUQ pain, nausea, bloating, constipation	RUQ US with gallbladder wall thickening	No imaging	T6-T7 SD with right rotation	Muscle energy	SD: yes Pain: yes	No
#4	RUQ pain, fatty food intolerance, diarrhea	RUQ US-WNL, HIDA with EF 83%, EGD-WNL	No imaging	L2 SD with right rotation	HVLA	SD: yes Pain: yes	No
#5	RUQ pain with radiation, nausea, constipation	RUQ US with cholelithiasis, IOC negative for obstruction	No imaging	T5-T7 chronic group dysfunction	HVLA	SD: partial relief Pain: partial relief	Yes: OMT clinic
#6	RUQ pain, nausea, fatty food intolerance	RUQ US with cholelithiasis	CT abdomen/pelvis- WNL	T7 SD sidebent right rotated right	Muscle energy	SD: partial relief Pain: partial relief	Yes: OMT clinic
#7	RUQ pain, diarrhea, vague food intolerance, acid reflux	RUQ US-WNL, HIDA with EF 17.7%	CT abdomen/pelvis-WNL, HIDA negative for bile leak	T6-T8 SD with right rotation	HVLA	SD: yes Pain: partial relief	Yes: gastroenterology clinic
#8	RUQ pain, nausea, bloating	RUQ US with cholelithiasis	No imaging	T5-T7 SD	HVLA	SD: yes Pain: yes	No
#9	RUQ pain, nausea, vomiting	RUQ US with cholelithiasis	Abdominal US negative for biloma	T8-T11 SD with right rib 9-10 dysfunction	Muscle energy	SD: yes Pain: partial relief	No

Abbreviations: EF, ejection fraction; EGD, esophagogastroduodenoscopy; FPR, facilitated positional release; HIDA, hepatobiliary iminodiacetic acid scan; IOC, intraoperative cholangiogram; SD, somatic dysfunction, OMT, osteopathic manipulative therapy; RUQ, right upper quadrant; US, ultrasonography; WNL, within normal limits.

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Table 2.

Patient Symptoms, Imaging Results, and Treatment Protocols

Case	Preoperative symptoms	Preoperative imaging	Postoperative imaging	Postoperative SD findings	Treatment	Symptom improvement	Posttreatment referrals
#1	RUQ pain, nausea, vomiting	RUQ US-WNL, HIDA with EF 16.9%	HIDA negative for bile leak	T6-T7 SD and right 6-7 rib posterior dislocation	Muscle energy, myofascial release	SD: yes Pain: yes	No
#2	RUQ pain, nausea, vomiting	RUQ US-WNL, HIDA with EF 10%	HIDA negative for bile leak	T7-T11 SD with right rotation	Muscle energy, HVLA, FPR, articulatory	SD: yes Pain: partial relief	Yes: OMT clinic
#3	RUQ pain, nausea, bloating, constipation	RUQ US with gallbladder wall thickening	No imaging	T6-T7 SD with right rotation	Muscle energy	SD: yes Pain: yes	No
#4	RUQ pain, fatty food intolerance, diarrhea	RUQ US-WNL, HIDA with EF 83%, EGD-WNL	No imaging	L2 SD with right rotation	HVLA	SD: yes Pain: yes	No
#5	RUQ pain with radiation, nausea, constipation	RUQ US with cholelithiasis, IOC negative for obstruction	No imaging	T5-T7 chronic group dysfunction	HVLA	SD: partial relief Pain: partial relief	Yes: OMT clinic
#6	RUQ pain, nausea, fatty food intolerance	RUQ US with cholelithiasis	CT abdomen/pelvis- WNL	T7 SD sidebent right rotated right	Muscle energy	SD: partial relief Pain: partial relief	Yes: OMT clinic
#7	RUQ pain, diarrhea, vague food intolerance, acid reflux	RUQ US-WNL, HIDA with EF 17.7%	CT abdomen/pelvis-WNL, HIDA negative for bile leak	T6-T8 SD with right rotation	HVLA	SD: yes Pain: partial relief	Yes: gastroenterology clinic
#8	RUQ pain, nausea, bloating	RUQ US with cholelithiasis	No imaging	T5-T7 SD	HVLA	SD: yes Pain: yes	No
#9	RUQ pain, nausea, vomiting	RUQ US with cholelithiasis	Abdominal US negative for biloma	T8-T11 SD with right rib 9-10 dysfunction	Muscle energy	SD: yes Pain: partial relief	No

Abbreviations: EF, ejection fraction; EGD, esophagogastroduodenoscopy; FPR, facilitated positional release; HIDA, hepatobiliary iminodiacetic acid scan; IOC, intraoperative cholangiogram; SD, somatic dysfunction, OMT, osteopathic manipulative therapy; RUQ, right upper quadrant; US, ultrasonography; WNL, within normal limits.

The patients in the case series who reported immediate symptomatic relief following OMT were not scheduled for follow-up because their symptoms had resolved. The patient who reported partial relief of symptoms initially after OMT but was treated additionally with supportive care and stretching exercises without specialist referral reported improvement in symptoms, as confirmed during a short-term follow up appointment. Long-term pain relief for patients who were referred to OMT or gastroenterology specialists is unknown, as this group did not follow up with the surgeon after these referrals. All patients were instructed to follow-up as needed with the operating surgeon. No complications or adverse events were noted following application of OMT.

Discussion

Postoperative pain is an important subject because of the significant effect it has on patients’ health, finances, and psychological states. Careful history and physical examination must be performed when evaluating someone with persistent postoperative pain to rule out serious complications such as biliary obstruction, bile leak, common bile duct injury, and bleeding. Additional testing should be ordered as clinically warranted. Once urgent diseases have been ruled out, care must be taken to identify other sources of postoperative pain to target treatment.

The patients in our retrospective series exhibited similar patterns of somatic dysfunction on their right sides, particularly in the thoracic vertebrae. The sympathetic viscerosomatic reflex of the liver and biliary tree is associated with T5-10 on the right and with the gallbladder at T6 on the right. The Chapman point for the gallbladder is underlying anterior right 6^th rib.¹⁷ While some of the somatic dysfunctions documented in the cases are consistent with a viscerosomatic response, there were additional findings that could indicate alternative causes—specifically in the patient with lumbar somatic dysfunction. Postoperative pain can result from a variety of factors, including incisional pain, nerve injury or entrapment, pneumoperitoneum, intraoperative positioning, tissue manipulation, and metabolic changes, among others. Any of these can lead to physiologic derangements and anatomic or postural changes to compensate for acute pain. Preoperative pain from biliary disease, pain from surgery, and decreased postoperative mobility and respiratory excursion can also contribute to somatic dysfunction. Early recognition and timely treatment can increase mobility, recover respiratory excursion, and improve quality of life in addition to decreasing the duration of analgesic use and risk of chronic pain.^1,18,19 Due to the acute nature of the pain, the dysfunctions identified in this series responded well to HVLA. If a postoperative patient is unable to tolerate HVLA, muscle energy, and myofascial techniques are an acceptable alternative. Four patients in our study were unable to tolerate HVLA and were instead treated with the muscle energy technique.

Limitations to our retrospective case series include the low number of patients and the fact that all patients were treated in a single hospital system by a single provider. As mentioned previously, only 1% to 2% of patients who had laparoscopic cholecystectomies by the surgeon underwent OMT in this review. This may be in part due to low prevalence of somatic dysfunction, but it may also reflect underdiagnosis of somatic dysfunction in this patient population. These conjectures would be good topics for future studies.

An additional limitation was that there were no men who fit the inclusion criteria for the series. This may indicate higher incidence of somatic dysfunction in female patients; however, with low statistical power, this cannot be inferred from our data without additional investigation. Gallbladder disease is also more common in women, which may at least partially explain the absence of men in our sample. Retrospective analysis can also be subject to researcher bias and objective differences in examination or treatment compared with other osteopathic physicians. However, this study was designed to assist in developing preliminary data to identify common patterns of somatic dysfunction in laparoscopic cholecystectomy patients with persistent pain. The next step is to develop a prospective study with preoperative screening of a group of laparoscopic cholecystectomy patients to establish a baseline of somatic dysfunction. Patients will then be examined postoperatively to see whether and how their somatic dysfunction might have changed.

Conclusion

While somatic dysfunction is not a leading cause of persistent postoperative pain following laparoscopic cholecystectomy, it is an easily manageable cause. This retrospective case series documenting postoperative pain treatment with OMT serves to encourage surgeons to include this etiology in the differential diagnosis and initiate timely management. Early treatment of reversible causes of pain particularly in the acute setting can decrease pain, lead to earlier return of baseline function, and improve quality of life.

Author Contributions

All authors provided substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; all authors drafted the article or revised it critically for important intellectual content; all authors gave final approval of the version of the article to be published; and all authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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Table 1.

Patient Demographics and Diagnoses

Case	Age	Gender	Preoperative diagnosis	Pathology
#1	27	Female	Biliary dyskinesia	Chronic cholecystitis
#2	31	Female	Biliary dyskinesia	Chronic cholecystitis
#3	31	Female	Acalculous cholecystitis	Mild chronic cholecystitis
#4	31	Female	Right upper quadrant pain	Normal
#5	25	Female	Cholelithiasis	Cholelithiasis
#6	32	Female	Cholelithiasis	Cholelithiasis
#7	40	Female	Biliary dyskinesia	No pathologic abnormalities
#8	30	Female	Cholelithiasis	Cholelithiasis, cholesterolosis
#9	53	Female	Cholelithiasis	Chronic calculous cholecystitis

View Large

Table 1.

Patient Demographics and Diagnoses

Case	Age	Gender	Preoperative diagnosis	Pathology
#1	27	Female	Biliary dyskinesia	Chronic cholecystitis
#2	31	Female	Biliary dyskinesia	Chronic cholecystitis
#3	31	Female	Acalculous cholecystitis	Mild chronic cholecystitis
#4	31	Female	Right upper quadrant pain	Normal
#5	25	Female	Cholelithiasis	Cholelithiasis
#6	32	Female	Cholelithiasis	Cholelithiasis
#7	40	Female	Biliary dyskinesia	No pathologic abnormalities
#8	30	Female	Cholelithiasis	Cholelithiasis, cholesterolosis
#9	53	Female	Cholelithiasis	Chronic calculous cholecystitis

Table 2.

Patient Symptoms, Imaging Results, and Treatment Protocols

Case	Preoperative symptoms	Preoperative imaging	Postoperative imaging	Postoperative SD findings	Treatment	Symptom improvement	Posttreatment referrals
#1	RUQ pain, nausea, vomiting	RUQ US-WNL, HIDA with EF 16.9%	HIDA negative for bile leak	T6-T7 SD and right 6-7 rib posterior dislocation	Muscle energy, myofascial release	SD: yes Pain: yes	No
#2	RUQ pain, nausea, vomiting	RUQ US-WNL, HIDA with EF 10%	HIDA negative for bile leak	T7-T11 SD with right rotation	Muscle energy, HVLA, FPR, articulatory	SD: yes Pain: partial relief	Yes: OMT clinic
#3	RUQ pain, nausea, bloating, constipation	RUQ US with gallbladder wall thickening	No imaging	T6-T7 SD with right rotation	Muscle energy	SD: yes Pain: yes	No
#4	RUQ pain, fatty food intolerance, diarrhea	RUQ US-WNL, HIDA with EF 83%, EGD-WNL	No imaging	L2 SD with right rotation	HVLA	SD: yes Pain: yes	No
#5	RUQ pain with radiation, nausea, constipation	RUQ US with cholelithiasis, IOC negative for obstruction	No imaging	T5-T7 chronic group dysfunction	HVLA	SD: partial relief Pain: partial relief	Yes: OMT clinic
#6	RUQ pain, nausea, fatty food intolerance	RUQ US with cholelithiasis	CT abdomen/pelvis- WNL	T7 SD sidebent right rotated right	Muscle energy	SD: partial relief Pain: partial relief	Yes: OMT clinic
#7	RUQ pain, diarrhea, vague food intolerance, acid reflux	RUQ US-WNL, HIDA with EF 17.7%	CT abdomen/pelvis-WNL, HIDA negative for bile leak	T6-T8 SD with right rotation	HVLA	SD: yes Pain: partial relief	Yes: gastroenterology clinic
#8	RUQ pain, nausea, bloating	RUQ US with cholelithiasis	No imaging	T5-T7 SD	HVLA	SD: yes Pain: yes	No
#9	RUQ pain, nausea, vomiting	RUQ US with cholelithiasis	Abdominal US negative for biloma	T8-T11 SD with right rib 9-10 dysfunction	Muscle energy	SD: yes Pain: partial relief	No

Abbreviations: EF, ejection fraction; EGD, esophagogastroduodenoscopy; FPR, facilitated positional release; HIDA, hepatobiliary iminodiacetic acid scan; IOC, intraoperative cholangiogram; SD, somatic dysfunction, OMT, osteopathic manipulative therapy; RUQ, right upper quadrant; US, ultrasonography; WNL, within normal limits.

View Large

Table 2.

Patient Symptoms, Imaging Results, and Treatment Protocols

Case	Preoperative symptoms	Preoperative imaging	Postoperative imaging	Postoperative SD findings	Treatment	Symptom improvement	Posttreatment referrals
#1	RUQ pain, nausea, vomiting	RUQ US-WNL, HIDA with EF 16.9%	HIDA negative for bile leak	T6-T7 SD and right 6-7 rib posterior dislocation	Muscle energy, myofascial release	SD: yes Pain: yes	No
#2	RUQ pain, nausea, vomiting	RUQ US-WNL, HIDA with EF 10%	HIDA negative for bile leak	T7-T11 SD with right rotation	Muscle energy, HVLA, FPR, articulatory	SD: yes Pain: partial relief	Yes: OMT clinic
#3	RUQ pain, nausea, bloating, constipation	RUQ US with gallbladder wall thickening	No imaging	T6-T7 SD with right rotation	Muscle energy	SD: yes Pain: yes	No
#4	RUQ pain, fatty food intolerance, diarrhea	RUQ US-WNL, HIDA with EF 83%, EGD-WNL	No imaging	L2 SD with right rotation	HVLA	SD: yes Pain: yes	No
#5	RUQ pain with radiation, nausea, constipation	RUQ US with cholelithiasis, IOC negative for obstruction	No imaging	T5-T7 chronic group dysfunction	HVLA	SD: partial relief Pain: partial relief	Yes: OMT clinic
#6	RUQ pain, nausea, fatty food intolerance	RUQ US with cholelithiasis	CT abdomen/pelvis- WNL	T7 SD sidebent right rotated right	Muscle energy	SD: partial relief Pain: partial relief	Yes: OMT clinic
#7	RUQ pain, diarrhea, vague food intolerance, acid reflux	RUQ US-WNL, HIDA with EF 17.7%	CT abdomen/pelvis-WNL, HIDA negative for bile leak	T6-T8 SD with right rotation	HVLA	SD: yes Pain: partial relief	Yes: gastroenterology clinic
#8	RUQ pain, nausea, bloating	RUQ US with cholelithiasis	No imaging	T5-T7 SD	HVLA	SD: yes Pain: yes	No
#9	RUQ pain, nausea, vomiting	RUQ US with cholelithiasis	Abdominal US negative for biloma	T8-T11 SD with right rib 9-10 dysfunction	Muscle energy	SD: yes Pain: partial relief	No

Abbreviations: EF, ejection fraction; EGD, esophagogastroduodenoscopy; FPR, facilitated positional release; HIDA, hepatobiliary iminodiacetic acid scan; IOC, intraoperative cholangiogram; SD, somatic dysfunction, OMT, osteopathic manipulative therapy; RUQ, right upper quadrant; US, ultrasonography; WNL, within normal limits.

Osteopathic Manipulative Treatment for a Recognizable Pattern of Somatic Dysfunction Following Laparoscopic Cholecystectomy

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