Laparoscopic cholecystectomy minimally impairs postoperative cardiorespiratory and muscle performance

What should be the ideal time for ischemic preconditioning in a laparoscopic rat model?

BACKGROUND

Pneumoperitoneum (Pp) induces an ischemia and reperfusion (I/R) injury as a result of released oxidative stress markers. Ischemic preconditioning (IP) is one of the used methods to reduce the harmful effects of Pp, which is a mechanism for reducing organ I/R injury by a brief period of organ ischemia. The aim of this study was to investigate the ideal time for IP in the laparoscopic model.

METHODS

Thirty-two rats were assigned into four groups: group 1 (control, n = 8) was subjected to a sham operation. Group 2 (5-minutes IP, n = 8) was subjected to 5 minutes of Pp with 15 mm Hg of pressure followed immediately by 5 minutes of deflation, and after that, 60 minutes of Pp with 15 mm Hg, followed by 60 minutes of deflation. Group 3 (10-minutes IP, n = 8) was subjected to 10 minutes of Pp and 10 minutes of deflation. Group 4 (Pp only, n = 8) was subjected to 60 minutes of Pp with 15 mm Hg of pressure, followed by 60 minutes of deflation. At the end of the experiment, plasma malondialdehyde (MDA) values, the oxidative stress marker, and plasma-reduced glutathione (GSH) levels, the marker showing antioxidant activity, were determined.

RESULTS

Highest plasma MDA values were in group 4 (Pp only), followed by groups 2 and 3 and group 1 (P = 0.181). In addition, IP groups had almost the same values for MDA. Plasma GSH levels in the control group were significantly higher than those in the IP groups and the Pp-only group (P < 0.001). Similarly, as in MDA levels, no difference was found between plasma GSH levels of the IP 5-minutes and IP 10-minutes groups.

CONCLUSIONS

Five minutes of the IP model may be as reliable as 10 minutes of the IP model. In that case, 5 minutes of IP can be more suitable in reducing I/R injury in laparoscopy.

Evaluation of the response of cortisol, corticotropin and blood platelets kinetics after laparoscopic and open cholecystectomy

PURPOSE

To compare the behavior of serum cortisol and ACTH levels and platelet kinetics after laparoscopic and open cholecystectomy.

METHODS

In this prospective study, 31 patients with symptomatic cholelithiasis submitted to elective cholecystectomy, 17 by the laparoscopic route and 14 by the open route, were compared. Peripheral blood samples were collected on admission of the patient, during anesthetic induction, and 2, 6, 12, 24 and 48 hours after the surgical incision. Platelets were counted in hematoxylin-eosin-stained specimens under a light microscope at 100x magnification. Cortisol and ACTH were measured by chemiluminescence.

RESULTS

Cortisol and ACTH levels showed a significant increase (p < 0.05) within the first hours after surgery compared to preoperative values. At 2 hours, a significantly higher cortisol concentration was observed in the laparoscopic group compared to the open surgery group (p = 0.0365). A return to basal levels during the later postoperative periods (24 and 48 hours) was only observed for ACTH, while serum cortisol continued to be elevated during the same period, being significantly higher in the open surgery group than in the laparoscopic group (p24 = 0.0248 and p48 = 0.032). Different platelet response curves were obtained for the two groups, but their levels were normal at all times studied. No significant difference (p > 0.05) between the post- and preoperative periods was observed for either group.

CONCLUSION

A hormonal response was observed for both procedures studied, but the surgical stress was higher and longer lasting in open surgery compared to the laparoscopic approach. However, no significant variation in platelet kinetics in response to tissue injury was observed between the two procedures.

Sequential periods of preconditioning decrease laparoscopy-related elevations in hepatic TNF-alpha and IL-6 levels in rats

BACKGROUND

Laparoscopy induces an ischemia/reperfusion (I/R) injury that elicits the production of inflammatory cytokines. The aim of this study was to test whether laparoscopic preconditioning (LP) could change hepatic inflammatory response.

MATERIALS AND METHODS

Twenty-four male Spraque Dawley rats were assigned into one of three experimental groups: the control group (C) was subjected to sham operation; the I/R group was subjected to 60 minutes of pneumoperitoneum followed by 45 minutes of desufflation; and the ischemic preconditioning (IP) group was subjected to preconditioning prior to the induction of I/R. Preconditioning was defined as two cycles of 5 minutes of pneumoperitoneum followed immediately by 5 minutes of desufflation. Hepatic tumor necrosis factor alpha (TNF-alpha) and interleukin (IL)-6 levels were evaluated as an inflammatory response.

RESULTS

Hepatic TNF-alpha levels increased in the I/R group compared with the C group (9.64 +/- 0.77 pg/mg protein vs. 6.53 +/- 0.48 pg/mg protein, P < 0.01). The decreased TNF-alpha levels in the IP group were not statistically significant when compared to the I/R group (8.09 +/- 0.74 pg/mg protein). Hepatic IL-6 levels increased in the I/R group compared to the C group (4.17 +/- 0.31 pg/mg protein vs. 2.93 +/- 0.20 pg/mg, P < 0.05). IP reduced the hepatic IL-6 levels significantly compared to the I/R group (3.31 +/- 0.22 pg/mg protein vs. 4.17 +/- 0.31 pg/mg protein, P <0.05).

CONCLUSION

Laparoscopy induces cytokine response in various organs including the liver. LP could alter the production of cytokines prior to sustained laparoscopic procedures. Preconditioning may be advisable, especially for elderly or other patients with hepatic, renal, or cardiac dysfunction. Further studies are needed to adapt this concept to clinical settings.

Randomized clinical trial of open versus laparoscopic cholecystectomy in the treatment of acute cholecystitis

BACKGROUND

The aim of this prospective trial was to determine whether surgical approach (open versus laparoscopic) had an impact on morbidity and postoperative recovery after cholecystectomy for acute cholecystitis.

METHODS

Seventy patients who met the criteria for acute cholecystitis were randomized to open or laparoscopic cholecystectomy. The type of operation was unknown to the patient and all hospital staff involved in the postoperative care.

RESULTS

The two groups were similar with respect to demographic and clinical characteristics. There were no significant differences in rate of postoperative complications, pain score at discharge and sick leave. In eight patients a laparoscopic procedure was converted to open cholecystectomy. Median operating time was 90 (range 30-155) and 80 (range 50-170) min in the laparoscopic and open groups respectively (P = 0.040). The direct medical costs were equivalent in the two groups. Although median postoperative hospital stay was 2 days in each group, it was significantly shorter in the laparoscopic group (P = 0.011).

CONCLUSION

Cholecystectomy for acute cholecystitis can be performed by either laparoscopic or open techniques without any major clinically relevant differences in postoperative outcome. Both techniques offer low morbidity and rapid postoperative recovery.

A systematic review and meta-analysis of the incidence and severity of postoperative fatigue

OBJECTIVE

Postoperative fatigue is common following major abdominal surgery. Less is known about its prevalence in other surgical subgroups, and about its long-term prognosis. A systematic review of prospective cohort studies was conducted to clarify these issues.

METHOD

Studies were identified from an extensive literature search. Overall estimates of pre- to postoperative change in fatigue severity and the incidence of clinically significant postoperative fatigue were calculated using meta-analyses.

RESULTS

Eighty-one cohorts were identified. Type of surgery was found to be a possible predictor of fatigue severity, with major abdominal, gynaecological, cardiac and minor surgery apparently associated with greater fatigue than orthopaedic surgery. Limited data were available regarding the long-term persistence of postoperative fatigue.

CONCLUSION

Postoperative fatigue appears to be an important problem following only certain forms of surgery. Why this is so remains unclear, and further work using better fatigue questionnaires is now required to confirm these differences.

Laparoscopic versus open left lateral hepatic lobectomy: a case-control study

BACKGROUND

After technical advances in hepatic surgery and laparoscopic surgery, some teams evaluated the possibilities of laparoscopic liver resections. The aim of our study was to assess the results of laparoscopic left lateral lobectomy (bisegmentectomy 2-3) and to perform a case-control comparison with the same operation performed by open surgery.

STUDY DESIGN

From 1996 to 2002, 60 laparoscopic resections were performed in selected patients, including 18 left lateral lobectomies. The resected lesions were benign tumors, hepatocellular carcinomas with compensated cirrhosis, and metastases. Surgical procedures were performed with a harmonic scalpel, an ultrasonic dissector, linear staplers, and portal pedicule clamping when necessary. Results were compared with those of patients who underwent open left lateral lobectomies selected from our liver resection database in a case-control analysis. Both groups were similar for age, type and size of the tumor, and presence of underlying liver disease.

RESULTS

Compared with laparotomy, laparoscopic left lateral lobectomies were associated with a longer surgical time (202 versus 145 minutes, p < 0.01), a longer portal triad clamping (39 versus 23 minutes, p < 0.05), and a decreased blood loss (236 versus 429 mL, p < 0.05). There were no deaths in either group, and the morbidity rates were 11% in the laparoscopic group and 15% in the open group. There were no specific complications of hepatic resection after laparoscopy (no hemorrhage, subphrenic collection, or biliary leak), but some were observed in the open group.

CONCLUSIONS

This study demonstrates the safety of laparoscopic left lateral lobectomy. Despite longer operation and clamping time, without any clinical consequences, the laparoscopic approach was associated with decreased blood loss and absence of specific complications of the hepatic resection.

Recovery after uncomplicated laparoscopic cholecystectomy

BACKGROUND

After laparoscopic cholecystectomy, the duration of convalescence is 2 to 3 weeks with an unclear pathogenesis. This study was undertaken to analyze postoperative recovery after uncomplicated elective laparoscopic cholecystectomy.

METHODS

Twenty-four consecutive unselected employed patients were followed up prospectively from 1 week before to 1 week after outpatient laparoscopic cholecystectomy. Daily computerized monitoring of physical motor activity and sleep duration and night sleep fragmentation (actigraphy), subjective sleep quality, pulmonary function, pain, and fatigue were registered. Treadmill exercise performance (preoperatively and at postoperative days 2 and 8) and nocturnal pulse oximetry at the patients' homes (preoperatively and postoperative nights 1-3) were completed.

RESULTS

Median age was 41 years (range, 21-56). Compared with preoperatively, levels of physical motor activity, fatigue, and pain scores were normalized 2 days after operation. Subjective sleep quality was significantly worsened on the first postoperative night, and sleep duration was significantly increased on the first 2 postoperative nights. There were no significant perioperative changes in actigraphy night sleep fragmentation, incidence of self-reported awakenings or nightmares/distressing dreams, exercise performance, or nocturnal oxygenation. Pulmonary peak flow measurements were normalized the day after operation.

CONCLUSION

After uncomplicated outpatient laparoscopic cholecystectomy, there is no pathophysiologic basis for recommending a postoperative convalescence of more than 2 to 3 days in otherwise healthy younger patients.

Laparoscopic liver resections: a feasibility study in 30 patients

OBJECTIVE

To assess the feasibility and safety of laparoscopic liver resections.

SUMMARY BACKGROUND DATA

The use of the laparoscopic approach for liver resections has remained limited for technical reasons. Progress in laparoscopic procedures and the development of dedicated technology have made it possible to consider laparoscopic resection in selected patients.

METHODS

A prospective study of laparoscopic liver resections was undertaken in patients with preoperative diagnoses including benign lesion, hepatocellular carcinoma with compensated cirrhosis, and metastasis of noncolorectal origin. Hepatic involvement had to be limited and located in the left or peripheral right segments (segments 2-6), and the tumor had to be 5 cm or smaller. Surgical technique included CO2 pneumoperitoneum and liver transection with a harmonic scalpel, with or without portal triad clamping or hepatic vein control. Portal pedicles and large hepatic veins were stapled. Resected specimens were placed in a bag and removed through a separate incision, without fragmentation.

RESULTS

From May 1996 to December 1999, 30 of 159 (19%) liver resections were included. There were 18 benign lesions and 12 malignant tumors, including 8 hepatocellular carcinomas in cirrhotic patients. Mean tumor size was 4.25 cm. There were two conversions to laparotomy (6.6%). The resections included 1 left hepatectomy, 8 bisegmentectomies (2 and 3), 9 segmentectomies, and 11 atypical resections. Mean blood loss was 300 mL. Mean surgical time was 214 minutes. There were no deaths. Complications occurred in six patients (20%). Only one cirrhotic patient developed postoperative ascites. No port-site metastases were observed in patients with malignant disease.

CONCLUSION

Laparoscopic resections are feasible and safe in selected patients with left-sided and right-peripheral lesions requiring limited resection. Young patients with benign disease clearly benefit from avoiding a major abdominal incision, and cirrhotic patients may have a reduced complication rate.

Intensive care unit admissions following laparoscopic surgery: what lessons can be learned?

BACKGROUND

Laparoscopic surgery has been widely embraced, often without adequate data concerning the range and incidence of complications. In the present series, our experience of complications requiring Intensive Care Unit (ICU) admission following laparoscopic surgery is described.

METHODS

The records of patients requiring ICU admission at John Hunter Hospital (JHH) following laparoscopic surgery over a 39 month period were retrospectively reviewed by an independent multidisciplinary panel.

RESULTS

Twenty-three ICU admissions were identified. Twenty-one followed general surgical laparoscopic procedures and two followed gynaecological laparoscopies. Ten cases were operated on initially at JHH and 13 were transferred from other hospitals. During the study period, 2444 laparoscopic surgical cases were performed at JHH; 725 general surgical procedures (1.37% admitted to ICU) and 1719 gynaecological procedures (no ICU admissions). Twelve cases suffered surgical complications (including five gastrointestinal tract perforations and three biliary tract injuries) and 11 cases were admitted for non-surgical problems. In 75% of surgical complications there was delay in diagnosis of more than 24 h. The duration of ICU stay for surgical complications (16.4 days) was significantly longer than for the non-surgical group (3.9 days).

CONCLUSION

There was a greater likelihood of ICU admission following general surgical rather than gynaecological laparoscopy. Fifty-two per cent of the admissions were for surgical complications. Surgical complications are characterized by delay in diagnosis and longer ICU admission periods. Strategies to prevent some of these complications are discussed.

A case-control study of postoperative pulmonary complications after laparoscopic and open cholecystectomy

Postoperative pulmonary complications (PPC) are common after upper abdominal surgery. The objective of this case-control study was to compare the incidence of PPC after laparoscopic cholecystectomy (LC) and open cholecystectomy (OC) within a tertiary care center. Patients were accrued from two sequential clinical trials that evaluated the role of incentive spirometry in the prevention of PPC after abdominal surgery. Included for study were patients with gallstones undergoing elective surgery who had an American Society of Anesthesiologists (ASA) classification < 3. All patients included in the study were encouraged to use an incentive spirometer at least 10 times each hour while awake. Patients with chronic bronchitis were excluded from study, as were patients who received other forms of physical therapy. OC was performed through either a transverse or an oblique incision. There was an equitable dispersion of putative risk factors for PPC between the groups at baseline. PPC were defined as clinical features consistent with collapse/consolidation, an otherwise unexplained temperature above 38 degrees C, plus either confirmatory chest radiology or positive sputum microbiology. The incidence of PPC was 2.7% (1/37) after LC and 17.2% (10/58) after OC (p < 0.05). It is concluded that PPC are less common after laparoscopic cholecystectomy than after open cholecystectomy.