Abdominal lift for laparoscopic cholecystectomy

Effects of low and standard intra-abdominal pressure on systemic inflammation and immune response in laparoscopic adrenalectomy: A prospective randomised study

BACKGROUND:

The advantages of laparoscopic adrenalectomy (LA) over open adrenalectomy are undeniable. Nevertheless, carbon dioxide (CO₂) pneumoperitoneum may have an unfavourable effect on the local immune response. The aim of this study was to compare changes in the systemic inflammation and immune response in the early post-operative (p.o.) period after LA performed with standard and low-pressure CO₂ pneumoperitoneum.

MATERIALS AND METHODS:

We studied, in a prospective randomised study, 51 patients consecutively with documented adrenal lesion who had undergone a LA: 26 using standard-pressure (12-14 mmHg) and 25 using low-pressure (6-8 mmHg) pneumoperitoneum. White blood cells (WBC), peripheral lymphocyte subpopulation, human leucocyte antigen-DR (HLA-DR), neutrophil elastase, interleukin (IL)-6 and IL-1, and C-reactive protein (CRP) were investigated.

RESULTS:

Significantly higher concentrations of neutrophil elastase, IL-6 and IL-1 and CRP were detected p.o. in the standard-pressure group of patients in comparison with the low-pressure group (P < 0.05). A statistically significant change in HLA-DR expression was recorded p.o. at 24 h, as a reduction of this antigen expressed on the monocyte surface in patients from the standard group; no changes were noted in low-pressure group patients (P < 0.05).

CONCLUSIONS:

This study demonstrated that reducing the pressure of the pneumoperitoneum to 6-8 mmHg during LA reduced p.o. inflammatory response and averted p.o. immunosuppression.

The future

Practical relevance:

Laparoscopic surgery minimizes tissue trauma and speeds recovery, but its uptake into veterinary clinical practice has been slow.

Clinical challenges:

Laparoscopy is distinctly different from traditional open surgery and a reduced working area and loss of depth perception are among the challenges that the surgeon must get to grips with. Indeed, it is often lack of the necessary skills, rather than the cost of equipment, that presents the greatest obstacle.

Audience:

This article is aimed at practitioners keen to embrace minimally invasive surgery and advises on how to develop excellence in laparoscopic skills. It makes the case for simulation training and outlines methods that can be instituted in practice at low cost and with comparatively little time expenditure. It also describes technological advances that have already increased the success of veterinary ‘keyhole’ surgery, as well as those that look promising for the future.

Evidence base:

Simulation training has been an intense area of research and publication within the past 15 years. This article draws on that evidence base and the experience gained by the author and her research team, which is at the forefront of efforts to develop laparoscopic training for veterinarians.

Percutaneous cholecystostomy for high-risk surgical patients with acute calculous cholecystitis

BACKGROUND

The management of people at high risk of perioperative death due to their general condition (high-risk surgical patients) with acute calculous cholecystitis is controversial, with no clear guidelines. In particular, the role of percutaneous cholecystostomy in these patients has not been defined.

OBJECTIVES

To compare the benefits (temporary or permanent relief of symptoms) and harms (recurrence of symptoms, procedure-related morbidity) of percutaneous cholecystostomy in the management of high-risk individuals with symptomatic gallstones.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded to December 2012 to identify the randomised clinical trials. We also handsearched the references lists of identified trials.

SELECTION CRITERIA

We included only randomised clinical trials (irrespective of language, blinding, or publication status) addressing this issue.

DATA COLLECTION AND ANALYSIS

Two review authors collected data independently. For each outcome, we calculated the P values using Fisher's exact test or mean difference (MD) with 95% confidence intervals (CI).

MAIN RESULTS

We included two trials with 156 participants for this review. The comparisons included in these two trials were percutaneous cholecystostomy followed by early laparoscopic cholecystectomy versus delayed laparoscopic cholecystectomy (1 trial; 70 participants) and percutaneous cholecystostomy versus conservative treatment (1 trial; 86 participants). Both trials had high risk of bias. Percutaneous cholecystostomy with early laparoscopic cholecystectomy versus delayed laparoscopic cholecystectomy: There was no significant difference in mortality between the two intervention groups (0/37 versus 1/33; Fisher's exact test: P value = 0.47). There was no significant difference in overall morbidity between the two intervention groups (1/31 versus 2/30; Fisher's exact test: P value = 0.61). This trial did not report on quality of life. There was no significant difference in the proportion of participants requiring conversion to open cholecystectomy between the two intervention groups (2/31 percutaneous cholecystostomy followed by early laparoscopic cholecystectomy versus 4/30 delayed laparoscopic cholecystectomy; Fisher's exact test: P value = 0.43). The mean total hospital stay was significantly lower in the percutaneous cholecystostomy followed by early laparoscopic cholecystectomy group compared with the delayed laparoscopic cholecystectomy group (1 trial; 61 participants; MD -9.90 days; 95% CI -12.31 to -7.49). The mean total costs were significantly lower in the percutaneous cholecystostomy followed by early laparoscopic cholecystectomy group compared with the delayed laparoscopic cholecystectomy group (1 trial; 61 participants; MD -1123.00 USD; 95% CI -1336.60 to -909.40). Percutaneous cholecystostomy versus conservative treatment: Nine of the 44 participants underwent delayed cholecystectomy in the percutaneous cholecystostomy group. Seven of the 42 participants underwent delayed cholecystectomy in the conservative treatment group. There was no significant difference in mortality between the two intervention groups (6/44 versus 7/42; Fisher's exact test: P value = 0.77). There was no significant difference in overall morbidity between the two intervention groups (6/44 versus 3/42; Fisher's exact test: P value = 0.49). The number of participants who underwent laparoscopic cholecystectomy was not reported in this trial. Therefore, we were unable to calculate the proportion of participants who underwent conversion to open cholecystectomy. The other outcomes, total hospital stay, quality of life, and total costs, were not reported in this trial.

AUTHORS' CONCLUSIONS

Based on the current available evidence from randomised clinical trials, we are unable to determine the role of percutaneous cholecystostomy in the clinical management of high-risk surgical patients with acute cholecystitis. There is a need for adequately powered randomised clinical trials of low risk of bias on this issue.

Optimizing working-space in laparoscopy: measuring the effect of mechanical bowel preparation in a porcine model

BACKGROUND

Adequate working space is a prerequisite for safe and efficient minimal access surgery. No objective data exist in literature about the effect of mechanical bowel preparation (MBP) on working space in laparoscopic surgery. We objectively measured this effect with computed tomography in a porcine laparoscopy model.

METHODS

Using standardized anesthesia, twelve 20-kg pigs without MBP and eight 20-kg pigs with MBP were studied with computed tomography at intra-abdominal pressure (IAP) levels of 0, 5, 10, and 15 mmHg. Volumes and dimensions of the pneumoperitoneum were measured on reconstructed CT images and compared between the pigs with and those without MBP.

RESULTS

A reproducible and statistically significant increase of approximately 500 ml in pneumoperitoneum volume was found in the MBP group at all levels of IAP. This represents a 43 % relative increase at a pneumoperitoneum pressure of 5 mmHg, 21 % at IAP 10 mmHg, and 18 % at IAP 15 mmHg. Peak inspiratory pressure was lower at IAP 0 and 5 mmHg in the MBP group. Anteroposterior diameter in the group with MBP was lower at 0 mmHg, but abdominal dimensions were similar in both groups at all other IAPs. This shows that the gain in working space is due to a diminished volume of the intra-abdominal content and not to compression or displacement of the bowel.

CONCLUSIONS

MBP increases working space by reducing bowel content. Especially at low intra-abdominal working pressures, the increase in working space associated with MBP could represent an important benefit in challenging laparoscopic surgery.

Abdominal lift for laparoscopic cholecystectomy

BACKGROUND

Laparoscopic cholecystectomy (key-hole removal of the gallbladder) is now the most often used method for treatment of symptomatic gallstones. Several cardiopulmonary changes (decreased cardiac output, pulmonary compliance, and increased peak airway pressure) occur during pneumoperitoneum, which is now introduced to allow laparoscopic cholecystectomy. These cardiopulmonary changes may not be tolerated in individuals with poor cardiopulmonary reserve.

OBJECTIVES

To assess the benefits and harms of abdominal wall lift compared with pneumoperitoneum in patients undergoing laparoscopic cholecystectomy.

SEARCH METHODS

We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded until January 2012.

SELECTION CRITERIA

We included all randomised clinical trials comparing abdominal wall lift (with or without pneumoperitoneum) versus pneumoperitoneum.

DATA COLLECTION AND ANALYSIS

We calculated the risk ratio (RR), rate ratio (RaR), or mean difference (MD) with 95% confidence intervals (CI) based on intention-to-treat analysis with both the fixed-effect and the random-effects models using RevMan software.

MAIN RESULTS

For abdominal wall lift with pneumoperitoneum versus pneumoperitoneum, a total of 156 participants (all with low anaesthetic risk) who underwent elective laparoscopic cholecystectomy were randomised in six trials to abdominal wall lift with pneumoperitoneum (n = 65) versus pneumoperitoneum only (n = 66). One trial which included 25 patients did not state the number of patients in each group. All six trials had a high risk of bias. There was no mortality or conversion to open cholecystectomy in any of the patients in the trials that reported these outcomes. There was no significant difference in the rate of serious adverse events between the two groups (2 trials; 2/29 events (0.069 events per patient) versus 2/29 events (0.069 events per patient); rate ratio 1.00; 95% CI 0.17 to 5.77). None of the trials reported quality of life, the proportion of patients discharged as day-patient laparoscopic cholecystectomies, or pain between four and eight hours after the operation. There was no significant difference in the operating time between the two groups (4 trials; 53 patients versus 54 patients; 13.39 minutes longer (2.73 less to 29.51 longer) in the abdominal wall lift with pneumoperitoneum group and 100 minutes in the pneumoperitoneum group).For abdominal wall lift versus pneumoperitoneum, a total of 774 participants (the majority with low anaesthetic risk) who underwent elective laparoscopic cholecystectomy were randomised in 18 trials to abdominal wall lift without pneumoperitoneum (n = 332) versus pneumoperitoneum (n = 358). One trial which included 84 patients did not state the number of patients in each group. All the trials had a high risk of bias. There was no mortality in any of the trials that reported this outcome. There was no significant difference in the rate of serious adverse events between the two groups (6 trials; 5/172 events (weighted number of events per patient = 0.020 events) versus 2/171 events (0.012 events per patient); rate ratio 1.73; 95% CI 0.35 to 8.61). None of the trials reported quality of life or pain between four and eight hours after the operation. There was no significant difference in the proportion of patients who underwent conversion to open cholecystectomy (11 trials; 5/225 (weighted proportion 2.3%) versus 7/235 (3.0%); RR 0.76; 95% CI 0.26 to 2.21). The operating time was significantly longer in the abdominal wall lift group than the pneumoperitoneum group (16 trials; 6.87 minutes longer (4.74 to 9.00 longer) in the abdominal wall lift group; 75 minutes in the pneumoperitoneum group). There was no significant difference in the proportion of patients who were discharged as day-patient laparoscopic cholecystectomy patients (2 trials; 15/31 (weighted proportion 48.5%) versus 9/31 (29%); RR 1.67; 95% CI 0.85 to 3.26).

AUTHORS' CONCLUSIONS

Abdominal wall lift does not seem to offer an advantage over pneumoperitoneum in any of the patient-oriented outcomes for laparoscopic cholecystectomy in patients with low anaesthetic risk. It may increase costs by increasing the operating time. Hence it cannot be recommended routinely. The safety of abdominal wall lift is yet to be established. More research on the topic is needed because of the risk of bias in the included trials and because of the risk of type I and type II random errors because of the few patients included in the trials. Such trials ought to include patients at higher anaesthetic risk. Furthermore, such trials ought to include blinded assessment of outcome measures.

[Anesthesia for laparoscopic interventions]

Laparoscopic techniques are used in many surgical disciplines and have partially become a standard procedure. Cholecystectomy is performed laparoscopically in 90% of cases. During a pneumoperitoneum changes occur which have a large influence on physiological homeostasis. Furthermore there are specific complications of laparoscopy which can have severe consequences. For adequate management the anesthetist has to be aware of both in order to react in the correct way.

Gasless laparoendoscopic single-site surgery with abdominal wall lift in general surgery: initial experience

BACKGROUND

Laparoendoscopic single-site surgery (LESS) was motivated by the desire to make minimally invasive surgery even more "minimal." We performed gasless laparoendoscopic single-site surgery (GLESS) with abdominal wall lift (AWL) for cholecystectomy and fenestration of liver cyst. This study aims to assess the safety and feasibility of the techniques.

METHODS

From June to December 2009, 18 cases of gasless laparoendoscopic single-site cholecystectomy (GLESC) and 4 cases of fenestration of liver cyst (GLESF) were performed in Qilu Hospital of Shandong University, Shandong, China. Subcutaneous abdominal wall lifting system, LAP protector, flexible laparoscopes, and bent and articulating instruments were used during the procedures. Clinical data regarding patient demographics, operating time, blood loss, complications, and postoperative hospital stay were collected and analyzed retrospectively in the study.

RESULTS

17 cases of GLESC and 4 cases of GLESF were performed successfully, and 1 case of GLESC was converted to laparoendoscopic single-site cholecystectomy using AWL combined with low-pressure pneumoperitoneum. Mean body mass index was 23.7 ± 3.1 kg/m(2) for GLESC and 22.9 ± 1.5 kg/m(2) for GLESF. Mean operating time was 64 ± 17 min for GLESC and 101 ± 10 min for GLESF. Mean blood loss was 8 ± 3 ml for GLESC and 24 ± 11 ml for GLESF. Despite minor wound complication, no postoperative complications were observed during mean follow-up of 118 and 95 days for GLESC and GLESF, respectively.

CONCLUSION

GLESS with AWL is safe and feasible for cholecystectomy and fenestration of liver cyst. The techniques provide satisfactory operative field exposure and an easier access method for LESS. Instrument collisions are greatly ameliorated both extra- and intracorporeally through use of flexible laparoscopes and bent and articulating instruments. This may prove to be a better approach for LESS techniques.

Value of laparoscopic appendectomy in the elderly patient

BACKGROUND

Acute appendicitis (AA) in elderly patients (60 years of age and older) is a challenging problem associated with significant morbidity and mortality when perforation is present. We hypothesized that laparoscopic appendectomy (LA) would enable an earlier correct diagnosis and have advantages in elderly patients.

METHODS

We performed a retrospective review of patients who underwent laparoscopic appendectomy for suspected AA. Data of elderly patients were compared to data of younger patients (18 to <60 years of age).

RESULTS

Fifty-four LA were performed in elderly patients and 423 in younger patients. Patients over the age of 60 years had more co-morbidities and required more frequent use of anticoagulants. Preoperative imaging (ultrasound or computerized tomography) was significantly more frequent in elderly patients (36% versus 15%), and was associated with a higher rate of confirmation of acute appendicitis (78% versus 55%), which allowed a decrease in the rate of negative surgical explorations to 4.1% in elderly patients compared to 10.2% in younger patients. Complicated appendicitis and conversions were more frequent in the elderly patients. This resulted in prolonged operative time and longer hospital stay for this group. The overall complication rate was equivalent in the two groups, without differences in the occurrence either of infectious complications or of complications related to surgical site. There were no deaths following appendectomy in our series.

CONCLUSIONS

Laparoscopic appendectomy is safe in the elderly population and is not associated with any increase in morbidity. The high incidence of complicated appendicitis in elderly patients affects operative time and length of hospital stay following laparoscopic appendectomy, and it can also lead to an increased rate of conversion to an open procedure. Use of preoperative abdominal computerized tomography scan is mandatory in elderly patients to provide an early diagnosis and to decrease unnecessary surgical exploration when acute appendicitis is suspected.

Low pressure versus standard pressure pneumoperitoneum in laparoscopic cholecystectomy

BACKGROUND

A pneumoperitoneum of 12 to 16 mmHg is used for laparoscopic cholecystectomy. Lower pressures are claimed to be safe and effective in decreasing cardiopulmonary complications and pain.

OBJECTIVES

To assess the benefits and harms of low pressure pneumoperitoneum compared with standard pressure pneumoperitoneum in patients undergoing laparoscopic cholecystectomy.

SEARCH STRATEGY

We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded until November 2008 for identifying randomised trials using search strategies.

SELECTION CRITERIA

Only randomised clinical trials, irrespective of language, blinding, or publication status were considered for the review.

DATA COLLECTION AND ANALYSIS

Two authors independently identified trials and independently extracted data on mortality, morbidity, conversion to open cholecystectomy, pain, analgesic requirement, operating time, hospital stay, patient satisfaction, additional measures to increase vision, and cardiopulmonary parameters. We calculated the risk ratio (RR), mean difference (MD), or standardised mean difference (SMD) with 95% confidence intervals (CI) using both the fixed-effect and the random-effects models with RevMan 5 based on available case-analysis.

MAIN RESULTS

Fifteen trials randomised 690 patients to low pressure (n = 336) and standard pressure (n = 354). All the trials were of high risk of bias. There was no difference in the mortality, morbidity, or conversion to open cholecystectomy between the groups. The intensity of pain was lower in the low pressure group at various time points. The incidence of shoulder pain was lower in the low pressure group (RR 0.53; 95% CI 0.31 to 0.90). The analgesic consumption was also lower. The operating time was similar between the groups (MD 2.30 minutes; 95% CI 0.42 to 4.18). Because of the high risk of bias due to incomplete outcome data in seven trials, it was not possible to conclude about the safety of low pressure pneumoperitoneum.

AUTHORS' CONCLUSIONS

Low pressure pneumoperitoneum appears effective in decreasing pain after laparoscopic cholecystectomy. The safety of low pressure pneumoperitoneum has to be established.

Assessing the appropriate use of laparoscopic surgery for hepatobiliary diseases

BACKGROUND

The range of indications for laparoscopic surgery has widened since it was first introduced. The aim of the present study was to develop standards for the appropriate use of laparoscopic surgery in patients with choledocholithiasis or cholelithiasis.

METHOD

We conducted a study following the RAND appropriateness method (RAM) to develop criteria for hepatobiliary laparoscopy. A panel comprised of 7 experts rated the appropriateness of a set of indications, from 1 (very inappropriate) to 9 (very appropriate). The panelists performed ratings in 2 rounds. The first round was performed independently by every expert. The second round took place during a face-to-face meeting. According to the median of panelists' ratings and agreement criteria, every indication was classified as appropriate, uncertain, or inappropriate.

RESULTS

In the first round, 112 (46.7%) indications were judged as appropriate, 102 (42.5%) as uncertain, and 26 (10.8%) as inappropriate. In the second round, 99 indications (48.5%) were considered as appropriate, 81 (39.7%) as uncertain, and 24 (11.8%) as inappropriate. Disagreement between panelists decreased in the second round compared with the first round. Thirteen indications were rated as disagreement (6.4%), 125 as uncertain (61.3%), and 66 as agreement (32.3%), while in the first round, the results and proportions were 44 (18.3%), 132 (55.0%), and 64 (26.7%), respectively.

CONCLUSIONS

By using RAM, the panel was able to develop detailed explicit appropriateness criteria for the proper application of hepatobiliary laparoscopy. The criteria may be used prospectively to help in making clinical decisions or retrospectively to assess the overuse of clinical procedures.