Laparoscopic versus minilaparotomy cholecystectomy: a randomised trial

The association of disability conditions with access to minimally invasive general surgery

BACKGROUND

Despite the high prevalence of disability conditions in the US, their association with access to minimally invasive surgery (MIS) remains under-characterized.

OBJECTIVE

To understand the association of disability conditions with rates of MIS and describe nationwide temporal trends in MIS in patients with disability conditions.

METHODS

We conducted a retrospective cohort study using the Nationwide Readmission Database (2016-2019). We included patients ≥18 years undergoing general surgery procedures. Our primary outcome was the impact of disability conditions on the rate of MIS. We performed 1:1 propensity matching, comparing patients with disability conditions with those without and adjusting for patient, procedure, and hospital characteristics. We performed a subgroup analysis among patients<65 years and with patients with each type of disability. We evaluated temporal trends of MIS in patients with disabilities. We identified predictors of undergoing MIS using mixed effects regression analysis.

RESULTS

In the propensity-matched comparison, a lower proportion of patients with disabilities had MIS. In the sub-group analyses, the rate of MIS was significantly lower in patients below 65 years with disabilities and among patients with motor and intellectual impairments. There was an increasing trend in the proportion of patients with disabilities undergoing MIS (p < 0.005). The regression analysis confirmed that the presence of a disability was associated with decreased odds of undergoing MIS.

CONCLUSIONS

This study characterizes the negative association of disability conditions with access to MIS. As the healthcare landscape evolves, considerations on how to equitably share new treatment modalities with a wide range of patient populations are necessary.

Laparoscopic Cholecystectomy Versus Open Cholecystectomy in Acute Cholecystitis: A Literature Review

Cholecystectomy is a common surgical procedure performed worldwide for acute cholecystitis. Acute cholecystitis occurs when the cystic duct is obstructed by a gallstone, which causes gallbladder distension and subsequent inflammation of the gallbladder. Acute cholecystitis is characterized by pain in the right upper quadrant, anorexia, nausea, fever, and vomiting. Cholecystectomy is the treatment of choice for acute cholecystitis. The two commonly performed types of cholecystectomies are open cholecystectomy and laparoscopic cholecystectomy. However, the approach of choice widely fluctuates with regard to various factors such as patient history and surgeon preference. It is imperative to understand the variations in outcomes of different approaches and how best they fit an individual patient when deciding the technique to be undertaken. This article reviews several studies and compares the two techniques in terms of procedure, mortality rate, complication rate, bile leak/injury rate, conversion rate, and bleeding rate.

Robot-assisted laparoscopic radical cystectomy with intracorporeal ileal conduit diversion versus open radical cystectomy with ileal conduit for bladder cancer in an ERAS setup (BORARC): protocol for a single-centre, double-blinded, randomised feasibility study

BACKGROUND

Radical cystectomy (RC) with urinary diversion is the recommended treatment for selected cases of non-metastatic high-risk non-muscle-invasive and muscle-invasive bladder cancer. It remains unknown whether robot-assisted laparoscopic cystectomy (RARC) offers any advantage in terms of safety compared to open cystectomy (ORC) in an Enhanced Recovery After Surgery (ERAS) setup. Blinded randomised controlled trials (RCTs) between RARC versus ORC have never been conducted in cystectomy patients. We will investigate the feasibility of conducting a double-blinded RCT comparing ORC with RARC with intra-corporal ileal conduit (iRARC) in an ERAS setup.

METHODS

This is a single-centre, double-blinded, randomised (1:1) clinical feasibility study for patients with non-metastatic high-risk non-muscle-invasive or muscle-invasive bladder cancer scheduled for cystectomy. All participants are recruited from Rigshospitalet, Denmark. The planned sample size is 50 participants to investigate whether blinding of the surgical technique is feasible. Participants and postoperative caring physicians and nurses are blinded using a pre-study designed abdominal dressing and blinding of the patient's electronic health record. Study endpoints are assessed 90 days postoperatively. The primary aim is to study the frequency and pattern of unplanned unblinding after surgery and the number of participants who cannot guess the surgical technique at the day of discharge. Eleven secondary endpoints are assessed: length of stay, days alive and out of hospital, in-hospital complication rate, 30-day complication rate, 90-day complication rate, readmission rate, quality of life, blood loss, pain, rate of moderate/severe post-anaesthesia care unit (PACU) complications, and delirium. Participants are managed in an ERAS setup in both arms of the trial.

DISCUSSION

We report on the design and objectives of a novel experimental feasibility study investigating whether blinding of the surgical technique in cystectomy patients is possible. This information is essential for the design of future blinded trials comparing ORC to RARC. There is a continued need to compare RARC and ORC in terms of both efficacy, safety, and oncological outcomes. Estimated end of study is March 2021.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT03977831. Registered on the 6th of June 2019.

[Evidence-based medicine of gallstone disease regarding development of national clinical guidelines]

OBJECTIVE

To study the Cochrane evidence base of systematic reviews and meta-analyses regarding development of national guidelines for surgical treatment of gallstone disease and its complications.

MATERIAL AND METHODS

We analyzed the original database involving 35 systematic reviews and meta-analyses of Cochrane Library devoted to gallstone disease and its complications. Methodology of electronic and manual searching of trials was used for identification and screening of information for the period until October 2021.

RESULTS

There were 430 randomized controlled trials from different countries estimated in 35 systematic reviews of Cochrane Library. At the same time, Russian-language researches are not included in the world's evidence database of biliary tract surgery. Expert groups couldn't perform meta-analysis and limited to systematic-review in 6 (17%) publications because of insufficient statistical power or primary researches. Need for further research of this issue was determined after assessment of 26 (74%) meta-analyses.

CONCLUSION

We have to convey foreign experience as subbase of national clinical guidelines taking into account deficiency of scientific trials with high level of evidence in our country. Need for further evidence trials, considering the peculiarities of surgical care in the Russian Federation, is determined by unsolved issues of treatment of gallstone disease and its complications.

Comparative outcomes of needlescopic, single-incision laparoscopic, standard laparoscopic, mini-laparotomy, and open cholecystectomy: A systematic review and network meta-analysis of 96 randomized controlled trials with 11,083 patients

BACKGROUND

Most randomized trials on minimally invasive cholecystectomy have been conducted with standard (3/4-port) laparoscopic or open cholecystectomy serving as the control group. However, there exists a dearth of head-to-head trials that directly compare different minimally invasive techniques for cholecystectomy (eg, single-incision laparoscopic cholecystectomy versus needlescopic cholecystectomy). Hence, it remains largely unknown how the different minimally invasive cholecystectomy techniques fare up against one another.

METHODS

To minimize selection and confounding biases, only randomized controlled trials were considered for inclusion. Perioperative outcomes were compared using frequentist network meta-analyses. The interpretation of the results was driven by treatment effects and surface under the cumulative ranking curve values. A sensitivity analysis was also undertaken focusing on a subgroup of randomized controlled trials, which recruited patients with only uncomplicated cholecystitis.

RESULTS

Ninety-six eligible randomized controlled trials comprising 11,083 patients were identified. Risk of intra-abdominal infection or abscess, bile duct injury, bile leak, and open conversion did not differ significantly between minimally invasive techniques. Needlescopic cholecystectomy was associated with the lowest rates of wound infection (surface under the cumulative ranking curve value = 0.977) with an odds ratio of 0.095 (95% confidence interval: 0.023-0.39), 0.32 (95% confidence interval: 0.11-0.98), 0.33 (95% confidence interval: 0.11-0.99), 0.36 (95% confidence interval: 0.14-0.98) compared to open cholecystectomy, single-incision laparoscopic cholecystectomy, mini-laparotomy, and standard laparoscopic cholecystectomy, respectively. Mini-laparotomy was associated with the shortest operative time (surface under the cumulative ranking curve value = 0.981) by a mean difference of 22.20 (95% confidence interval: 13.79-30.62), 12.17 (95% confidence interval: 1.80-22.54), 9.07 (95% confidence interval: 1.59-16.54), and 8.36 (95% confidence interval: -1.79 to 18.52) minutes when compared to single-incision laparoscopic cholecystectomy, needlescopic cholecystectomy, standard laparoscopic cholecystectomy, and open cholecystectomy, respectively. Needlescopic cholecystectomy appeared to be associated with the shortest hospitalization (surface under the cumulative ranking curve value = 0.717) and lowest postoperative pain (surface under the cumulative ranking curve value = 0.928).

CONCLUSION

Perioperative outcomes differed across minimally invasive techniques and, in some instances, afforded superior outcomes compared to standard laparoscopic cholecystectomy. These findings suggest that there may be equipoise for exploring further the utility of novel minimally invasive techniques and potentially incorporating them into the general surgery training curriculum.

Difficult laparoscopic cholecystectomy and preoperative predictive factors

Laparoscopic cholecystectomy (LC) is the standard technique for treatment of gallbladder disease. In case of acute cholecystitis we can identify preoperative factors associated with an increased risk of conversion and intraoperative complications. The aim of our study was to detect preoperative laboratory and radiological findings predictive of difficult LC with potential advantages for both the surgeons and patients in terms of options for management. We designed a retrospective case-control study to compare preoperative predictive factors of difficult LC in patients treated in emergency setting between January 2015 and December 2019. We included in the difficult LC group the surgeries with operative time > 2 h, need for conversion to open, significant bleeding and/or use of synthetic hemostats, vascular and/or biliary injuries and additional operative procedures. We collected 86 patients with inclusion criteria and difficult LC. In the control group, we selected 86 patients with inclusion criteria, but with no operative signs of difficult LC. The analysis of the collected data showed that there was a statistically significant association between WBC count and fibrinogen level and difficult LC. No association were seen with ALP, ALT and bilirubin values. Regarding radiological findings significant differences were noted among the two groups for irregular or absent wall, pericholecystic fluid, fat hyperdensity, thickening of wall > 4 mm and hydrops. The preoperative identification of difficult laparoscopic cholecystectomy provides an important advantage not only for the surgeon who has to perform the surgery, but also for the organization of the operating block and technical resources. In patients with clinical and laboratory parameters of acute cholecystitis, therefore, it would be advisable to carry out a preoperative abdominal CT scan with evaluation of features that can be easily assessed also by the surgeon.

[Randomized trials and progress in surgery]

It is very difficult to find certain surgical field in which surgeon's decision is absolutely evidence-based. The objective of evidence-based medicine (and surgery) is offering the best treatment for each patient that should encourage conducting the randomized trials (RT) as the highest level of evidence. The results of RTs often contradict the existing clinical experience, and experience per se does not always confirm the significance of the results obtained. One cannot make any conclusions based on RT data. Treatment strategy for a particular patient remains unclear. The authors have analyzed the results of large-scale RTs devoted to laparoscopic cholecystectomy, rectal surgery, lung cancer surgery, postoperative care, treatment of pulmonary emphysema. It was shown that RT data as the highest level of evidence are not always true for surgery. In most clinical situations, the decision is not based on RT results. The desire of surgeons to master a new technique is often more significant than patient care, while clinical experience and the laws of the market are more important than science. There is no doubt that knowledge of RT results are essential in training period, but this means quite a bit for a particular patient. The best decision can be made during discussion and conversation with colleagues, where an experience of each specialist will have the same value as the best evidence.

Mini-cholecystectomy versus laparoscopic cholecystectomy: a retrospective multicentric study among patients operated in some Eastern Libyan hospitals

Objectives

This study was conducted to analyze the difference between Mini-Cholecystectomy (MC) and Laparoscopic Cholecystectomy (LC) in terms of feasibility and postoperative outcomes to determine if MC could be accepted as a good alternative procedure to LC.

Material and Methods

A retrospective comparative study of 206 consecutively operated patients of chronic cholecystitis (138 LC and 68 MC), in Al-Jalaa, Ajdabiya and Almrg Teaching hospitals between January 2014 and December 2015 was performed. All cases within the two groups were balanced for age, sex, co-morbidities, ultrasound and intraoperative findings. Exclusion criteria were acute cholecystitis, preoperative jaundice, liver cirrhosis, suspicion of malignancy, previous upper abdominal surgery and pregnancy.

Results

Mean age of the patients in the study was around 37 years. Female patients represented 88.84%. Intraoperative complications occurred in about 2% of the patients with bleeding in three cases (one in MC, two in LC) and injury to the bile ducts occurred in one case who underwent LC. Operative duration was longer in LC (mean values 64 minutes for LC and 45 minutes for MC). Rate of conversion to classical cholecystectomy in LC was 5% while it was 0% in MC. Only one case of wound infection was registered in the LC group. Postoperative hospital stay was insignificantly longer for LC versus MC (1.97 days for MC and 2.63 days for LC).

Conclusion

Mini-cholecystectomy is a feasible technique, which can be considered as a good alternative method for gallbladder removal for surgeons who have no experience with laparoscopic techniques and in peripheral hospitals where LC is not available.

Bile Duct Injuries during Laparoscopic Cholecystectomy: Management and Outcome

The aim of this study is to analyze our experience with the management of bile duct injuries (BDIs) following laparoscopic cholecystectomy (LC). From 1996 to 2004, 21 patients with BDI after LC were treated in our department. The BDIs were graded according to the classification of Strasberg. Ten patients had minor BDI. Minor injuries were classified as A in six and D in four patients. In three patients, endoscopic retrograde cholangiopancreatography sphincterotomy and stent placement was adequate treatment. Six patients required laparotomy and bile duct ligation or suturing, and one patient underwent laparoscopy with additional ligation of a duct of Luschka. Eleven patients had major BDIs. These injuries were classified as E1 in two, E2 in three, E3 in four, and E4 in two patients. Among the patients with a major BDI, Roux- en-Y hepaticojejunostomy was performed. After a median follow-up of 69.45 months, no evidence of biliary disease has been detected among our patients. BDIs should be managed in a specialist unit where surgeons skilled to perform such repairs should undertake definitive treatment. Roux- en-Y hepaticojejunostomy is the procedure of choice in the management of major BDIs as it is accompanied by satisfactory results.

Feasibility study for a randomized clinical trial of bupivacaine, lidocaine with adrenaline, or placebo wound infiltration to reduce postoperative pain after laparoscopic cholecystectomy

Background

Short‐term pain relief can be achieved by local anaesthetic infiltration of port sites at the end of laparoscopic surgery. This study aimed to assess feasibility of performing an RCT to evaluate short‐term postoperative analgesia after laparoscopic surgery in Nigeria using two local anaesthetics for port‐site infiltration versus saline placebo.

Methods

This was a placebo‐controlled, patient‐ and outcome assessor‐blinded, external feasibility RCT. Patients undergoing elective laparoscopic cholecystectomy for symptomatic ultrasound‐proven gallstones were randomized into three groups: lidocaine with adrenaline (epinephrine), bupivacaine or saline control. The feasibility of recruitment, compliance with randomized treatment allocation, and completion of pain and nausea outcome measures were evaluated. Pain was assessed at 2, 6, 12 and 24 h after surgery using a 0–10‐point numerical rating scale (NRS) and a four‐point verbal rating scale. Nausea was assessed using NRS at the same time points. Clinical outcomes were assessed only in patients who received the correct randomized treatment allocation.

Results

Of 79 patients screened for eligibility, 69 were consented and randomized (23 per group). Overall, compliance with randomized treatment allocation was achieved in 64 patients (93 per cent). All pain and nausea assessments were completed in these 64 patients. On the NRS, most patients had moderate to severe pain at 2 h (39 of 64, 61 per cent), which gradually reduced. Only six patients (9 per cent) had moderate to severe pain at 24 h.

Conclusion

Recruitment, compliance with the randomized allocation, and completion of pain outcome measures were satisfactory. This study demonstrates the feasibility of conducting a surgical RCT in a resource‐limited setting. Registration number: ISRCTN 17667918 (https://www.isrctn.com).

Which Cholecystectomy do Medical Students Prefer?

Introduction:

This study was undertaken to identify which minimally invasive technique medical students prefer for cholecystectomy and what factors determine their decision.

Methods:

Brazilian medical students watched a video reviewing the advantages and disadvantages of six different surgical approaches to cholecystectomy: open surgery, conventional laparoscopy, mini-laparoscopy (MINI), single-incision laparoscopic surgery, natural-orifice transluminal endoscopic surgery, and robotic surgery. Respondents then answered questions about hypothetical situations in which the participants would be submitted to elective cholecystectomy.

Results:

One hundred eleven medical students completed the survey, 60 females (54%) and 51 males (46%). Most students were 19–26 years old. When asked whether they would consider an open cholecystectomy if minimally invasive surgery (MIS) techniques were available, only 9% answered yes. Senior medical students were the least willing to consider open surgery (P = .036). When asked if they would prefer conventional laparoscopy, MINI, or robotic surgery for their cholecystectomy, 85% of the women and 63% of the men chose MINI (P = .025). When asked if they would consider a single-incision laparoscopic surgery or natural-orifice transluminal endoscopic surgery approach, 94 respondents (84%) answered no. When asked to rank which factors they consider the most important when choosing a surgical technique, they ranked safety of the procedure first (58%) and surgeon experience second (30%).

Conclusion:

When Brazilian medical students were asked to select a surgical approach for cholecystectomy, most chose MINI. The preference for MINI was strongest amongst female medical students. Both female and male medical students ranked safety as the most important factor.

The Feasibility of Laparoscopic Surgery in Gynecologic Oncology for Obese and Morbidly Obese Patients

Background

Surgical interventions are the mainstay of treatment for many gynecological cancers. Although minimally invasive surgery offers many potential advantages, performing laparoscopic pelvic surgery in obese patients remains challenging. To overcome this, many centers have shifted their practice to robotic surgery; however, the high costs associated with robotic surgery are concerning and limit its use.

Objective

This study aimed to examine the feasibility of performing laparoscopic gynecologic oncology procedures in obese and morbidly obese patients.

Materials and Methods

This retrospective study evaluated patients who underwent laparoscopic surgeries by a gynecologic oncologist from January 2012 to June 2016 at a designated gynecologic oncology center. Patients were categorized as nonobese (body mass index [BMI] < 30 kg/m2), obese (BMI 30–39.9 kg/m2), and morbidly obese (BMI ≥ 40 kg/m2). Intra and postoperative complications and outcomes were recorded. Group differences were computed with Kruskal-Wallis nonparametric test (continuous) or Fisher exact test (categorical).

Results

Of 497 patients, 288 were nonobese (58%), 162 obese (33%), and 47 morbidly obese (9%). Complex surgical procedures were performed in 57.4% of obese patients and 55.3% of morbidly obese patients. Although morbidly obese and obese patients had longer operative times (mean of 181 and 166 minutes vs 144 minutes,P= 0.014), conversion from laparoscopy to laparotomy occurred in 9.05% of all patients, with no group differences. Low intraoperative (9%–11%) and severe postoperative (2.41%) complication rates were observed overall, with no group differences. There was no statistically significant difference in the rate of emergency room visits 30 days postoperation between the 3 BMI groups (P= 0.6108). Average length of postoperative stay was statistically significant (P= 0.0003) but was low overall (1–2 days). Hospital readmission rates were low, with the lowest rate among morbidly obese patients (2.13%).

Conclusions

Our data suggest that laparoscopic gynecologic-oncology procedures for obese patients are feasible and safe.

Evaluation of the impact of preoperative education in ambulatory laparoscopic cholecystectomy. A prospective, double-blind randomized trial

INTRODUCTION

Outpatient laparoscopic cholecystectomy is a safe procedure and provides a better use of health resources and perceived satisfaction without affecting quality of care. Preoperative education has shown less postoperative stress, pain and nausea in some interventions. The principal objective of this study is to assess the impact of preoperative education on postoperative pain in patients undergoing ambulatory laparoscopic cholecystectomy. Secondary objectives were: to evaluate presence of nausea, morbidity, hospital admissions, readmissions rate, quality of life and satisfaction.

METHODS

Prospective, randomized, and double blind study. Between April 2014 and May 2016, 62 patients underwent outpatient laparoscopic cholecystectomy.

INCLUSION CRITERIA

ASA I-II, age 18-75, outpatient surgery criteria, abdominal ultrasonography with cholelithiasis. Patient randomization in two groups, group A: intensified preoperative education and group B: control.

RESULTS

Sixty-two patients included, 44 women (71%), 18 men (29%), mean age 46,8 years (20-69). Mean BMI 27,5. Outpatient rate 92%. Five cases required admission, two due to nausea. Pain scores obtained using a VAS was at 24-hour, 2,9 in group A and 2,7 in group B. There were no severe complications or readmissions. Results of satisfaction and quality of life scores were similar for both groups.

CONCLUSIONS

We did not find differences due to intensive preoperative education. However, we think that a correct information protocol should be integrated into the patient's preoperative preparation. Registered in ISRCTN number ISRCTN83787412.

Pancreatic resection in the era of laparoscopy: State of Art. A systematic review

BACKGROUND

Innovation in surgical devices and improvement in laparoscopic skills have gradually led to achieve more challenging surgical procedures. Among these demanding interventions is the pancreatic surgery that is seen as intraoperatively risky and with high postoperative morbi-mortality rate. In order to understand the complexity of laparoscopic pancreatic surgery, we performed a systematic review of literature.

DATA SOURCE

A systematic review of literature was performed regarding laparoscopic pancreatic resection.

RESULTS

Laparoscopic approach in pancreas resections has been extensively reported as safe and feasible regarding pancreaticoduodenectomy, distal pancreatectomy and pancreatic enucleation. Compared to open approach, no benefit in morbi-mortality has been demonstrated (except for laparoscopic distal pancreatectomy) and no controlled randomized trials have been reported.

CONCLUSIONS

Laparoscopic approach is not workable in all patients and patient selection is not standardized. Additionally, most optimistic reports considering laparoscopic approach are produced by tertiary centres. Currently, two tasks should be accomplished 1°) standardization of the laparoscopic pancreatic procedures 2°) comparative trials to assess endpoint benefits of laparoscopic pancreatic resection compared with open procedures.

Difficult Laparoscopic Cholecystectomy and Trainees: Predictors and Results in an Academic Teaching Hospital

Laparoscopic cholecystectomy (LC) is one of the first laparoscopic procedures performed by surgical trainees. This study aims to determine preoperative and/or intraoperative predictors of difficult LC and to compare complications of LC performed by trainees with that performed by trained surgeons. A cohort of 180 consecutive patients with cholelithiasis who underwent LC was analyzed. We used univariate and binary logistic regression analyses to predict factors associated with difficult LC. We compared the rate of complications of LCs performed by trainees and that performed by trained surgeons using Pearson's chi-square test. Patients with impacted stone in the neck of the gallbladder (GB) (OR, 5.0; 95% CI, 1.59-15.77), with adhesions in the Triangle of Calot (OR, 2.9; 95% CI, 1.27-6.83), or with GB rupture (OR, 3.4; 95% CI, 1.02-11.41) were more likely to experience difficult LC. There was no difference between trainees and trained surgeons in the rate of cystic artery injury (p = .144) or GB rupture (p = .097). However, operative time of LCs performed by trained surgeons was significantly shorter (median, 45 min; IQR, 30-70 min) compared with the surgical trainees' operative time (60 min; IQR, 50-90 min). Surgical trainees can perform difficult LC safely under supervision with no increase in complications albeit with mild increase in operative time.

Postoperative shoulder pain after laparoscopic hysterectomy with deep neuromuscular blockade and low-pressure pneumoperitoneum: A randomised controlled trial

BACKGROUND

Postoperative shoulder pain remains a significant problem after laparoscopy. Pneumoperitoneum with insufflation of carbon dioxide (CO2) is thought to be the most important cause. Reduction of pneumoperitoneum pressure may, however, compromise surgical visualisation. Recent studies indicate that the use of deep neuromuscular blockade (NMB) improves surgical conditions during a low-pressure pneumoperitoneum (8 mmHg).

OBJECTIVE

The aim of this study was to investigate whether low-pressure pneumoperitoneum (8 mmHg) and deep NMB (posttetanic count 0 to 1) compared with standard-pressure pneumoperitoneum (12 mmHg) and moderate NMB (single bolus of rocuronium 0.3 mg kg with spontaneous recovery) would reduce the incidence of shoulder pain and improve recovery after laparoscopic hysterectomy.

DESIGN

A randomised, controlled, double-blinded study.

SETTING

Private hospital in Denmark.

PARTICIPANTS

Ninety-nine patients.

INTERVENTIONS

Randomisation to either deep NMB and 8 mmHg pneumoperitoneum (Group 8-Deep) or moderate NMB and 12 mmHg pneumoperitoneum (Group 12-Mod). Pain was assessed on a visual analogue scale (VAS) for 14 postoperative days.

MAIN OUTCOME MEASURES

The primary endpoint was the incidence of shoulder pain during 14 postoperative days. Secondary endpoints included area under curve VAS scores for shoulder, abdominal, incisional and overall pain during 4 and 14 postoperative days; opioid consumption; incidence of nausea and vomiting; antiemetic consumption; time to recovery of activities of daily living; length of hospital stay; and duration of surgery.

RESULTS

Shoulder pain occurred in 14 of 49 patients (28.6%) in Group 8-Deep compared with 30 of 50 (60%) patients in Group 12-Mod. Absolute risk reduction was 0.31 (95% confidence interval 0.12 to 0.48; P = 0.002). There were no differences in any secondary endpoints including area under the curve for VAS scores.

CONCLUSION

Deep NMB and low-pressure pneumoperitoneum (8 mmHg) reduced the incidence of shoulder pain after laparoscopic hysterectomy in comparison to moderate NMB and standard-pressure pneumoperitoneum (12 mmHg).

TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT01722097.

Is mini-laparoscopic cholecystectomy any better than the gold standard?: A comparative study

BACKGROUND:

Mini-laparoscopic cholecystectomy (MLC) has widened the horizons of modern laparoscopic surgery. Standard four port laparoscopic cholecystectomy (SLC), which has long been established as the “Gold Standard” for gall bladder diseases, is under reconsideration following the advent of further minimally-invasive procedures including MLC. Our study aims to provide a comparison between MLC and SLC and assesses whether MLC has any added benefits.

MATERIALS AND METHODS:

Patients with symptomatic gall bladder disease undergoing MLC or SLC during the 2.5-month period were included in the study. Thirty-two patients underwent MLC while SLC was performed on 40 patients by the same surgeon. Data was collected prospectively and analysed retrospectively using a predesigned questionnaire.

RESULTS:

In our study, both the groups had similar age, body mass index (BMI) and gender distribution. No cases of MLC required insertion of additional ports. The mean operative time for MLC was 38.2 min (33-61 min), which is longer than SLC; but it was not statistically significant. There was no significant difference in mean operative blood loss, postoperative pain, analgesia requirement and mobilization. Patients who underwent MLC were able to return to normal activity earlier than patients undergoing SLC (P < 0.01).

CONCLUSION:

Our experience suggests that MLC can safely be used as an alternative to SLC. Compared to SLC, it has the added benefit of an early return to work along with excellent cosmetic results. Further large scale trials are required to prove any additional benefit of MLC.

Inflammatory response to surgical trauma in patients with minilaparotomy cholecystectomy versus laparoscopic cholecystectomy: a randomised multicentre study

OBJECTIVE

The aim of the study was to evaluate the inflammatory response to surgical trauma in minilaparotomy cholecystectomy (MC) compared to laparoscopic cholecystectomy (LC). Assessment of inflammatory response to surgical trauma in MC has not been addressed properly. Therefore, we investigated five interleukins (IL) and C-reactive protein (CRP) in MC versus LC group in a prospective randomised trial.

METHODS

Initially, 106 patients with non-complicated symptomatic gallstone disease were randomised into MC (n = 56) or LC (n = 50) groups. Plasma levels of five interleukins (IL-1β, IL-1ra, IL-6, IL-8, IL-10) and hs-CRP were measured at three time points; before operation (PRE), immediately after operation (POP1) and six hours after operation (POP2). The primary end-point of the study was to compare the plasma levels of five interleukins and CRP in LC versus MC group.

RESULTS

The demographic variables and the surgical data were similar in the study groups. The patients in the MC group had higher elevation of the CRP mean values post-operatively (p = 0.01). However, the patients in the MC group had higher elevation of the IL-1ra mean values post-operatively, the mean pre-/post-operative IL-1ra values being 299/614 pg/ml in the MC group versus 379/439 pg/ml in the LC group (p = 0.003). There was no statistical significance in IL-6 mean values between the MC and LC groups pre- and post-operatively (POP1). However, the patients in the MC group had higher IL-6 mean values six hours post-operatively (POP2), the mean IL-6 values being 27.6 pg/ml in the MC group versus 14.8 pg/ml in the LC group (p = 0.037). In addition, the patients in the MC group had higher elevation of the IL-6 mean values post-operatively, the mean pre-/post-operative IL-6 values being 4.1/27.6 pg/ml in the MC group versus 3.8/14.8 pg/ml in the LC group (p = 0.04). There was no statistical significance in IL-8, IL-10, and IL-1β mean values between the MC and LC groups pre- and post-operatively.

CONCLUSION

Our results suggest that the inflammatory response in MC versus LC groups was similar based on the IL-8, IL-10, and IL-1β values. A new finding with possible clinical relevance in the present work is higher relative elevation of the IL-1ra and IL-6 mean values post-operatively in the MC group.

Day case laparoscopic cholecystectomy in patients with high BMI: Experience from a UK centre

INTRODUCTION

Symptomatic gall stones may require laparoscopic cholecystectomy (LC), which is one of the most commonly performed general surgical operations in the western world. Patients with a high body mass index (BMI) are at increased risk of having gall stones, and are often considered at high risk of surgical complications due to their increased BMI. We believe that day case surgery could nevertheless have significant benefits in terms of potential cost savings and patient satisfaction in this population. We therefore compared the outcomes of day case patients undergoing LC stratified by BMI, with a specific focus on the safety and success of the procedure in obese and morbidly obese groups.

METHODS

We reviewed a database of day case procedures performed between January 2004 and December 2012, including all patients with symptomatic gall stone disease who underwent LC. The patients were divided in four BMI groups: less than 25 kg/m(2), 25-29 kg/m(2), 30-39 kg/m(2) and 40 kg/m(2) or above.

RESULTS

The overall success rate for day case surgery was 78%. There were no significant differences in rates of intra-abdominal collection or readmission with increasing BMI. However, increasing BMI was associated with a significant increase in the rate of wound infection.

CONCLUSIONS

LC in patients with a high BMI is safe and can be performed effectively as a day case procedure.

[Not Available]

OBJECTIVES

Database review to analyse age and sex differences in complication and conversion rates and influence on return to normal daily activities and work after laparoscopic cholecystectomy (LC).

METHODS

658 patients had a laparoscopic cholecystectomy for proven gallstones between 9/4/2001 and 15/2/2006 under the care of one surgeon (F. H.) at Benenden hospital, Kent, UK.

RESULTS

We had a 65.5% response rate with 431 replies at a mean follow up of 22.4 months (2.3-52.8). There was a male to female ratio of 5:23 with a mean age of 54.2 years (22-83). Using linear regression we found no significant correlation with operative time and variables of age and sex (df = 2, 251, R (2) = 0.03, F = 0.574, p < 0.564). No significant correlation with number of complications and age or sex (df = 2, 334, R (2) = 0.004, F = 1.615, p < 0.200). Age (Exp(B) = 1.040, p < 0.51) and sex (Exp(B) = 0.863, p < 0.855) had no effect on conversion. No difference was found in relation to age and sex with return to normal daily activities (df = 2, 307, F = 0.904, p < 0.406). Age was a non-significant predictor of return to work (Beta = 0.040, p < 0.572) however men return to work significantly sooner (Beta = 0.191, p < 0.007).

CONCLUSIONS

Operative time, number of complications, conversion to open and return to normal daily activities may not be affected by age or sex of patients. Hospital stay may be longer in older patients. Men appear to return to work sooner. Further analysis with validated questionnaires are required.

Early hospital readmission after laparoscopic cholecystectomy

INTRODUCTION

Laparoscopic cholecystectomy (LC) now has become the golden standard in the treatment of symptomatic gallstone cholecystitis.

AIM

This retrospective analysis was conducted to clarify the reasons of early return to the hospital after discharge following a procedure like LC that has been frequently performed in daily surgical practice.

MATERIALS AND METHODS

This study covers 586 patients, who were called to follow-ups and thus evaluated, of 676 patients who had had LCs at Meram Medical School's General Surgery Clinic between January 2010 and May 2011.

FINDINGS

The rate of representation to the hospital during the early phase following LC was found to be 2.4% in our study. It was observed that 71% of returning patients had presented to the hospital with complaints of abdominal pain.

DISCUSSION

We believe that the rate of 2.4% early return to the hospital in our series is a bit high when all the complications are taken into consideration. This retrospective analysis, however, has shown that this rate can further be decreased by taking simple measures.

Waterlow score as a surrogate marker for predicting adverse outcome in acute pancreatitis

Introduction Introduced originally to stratify risk for developing decubitus ulcers, the Waterlow scoring system is recorded routinely for surgical admissions. It is a composite score, reflecting patients' general condition and co-morbidities. The aim of this study was to investigate whether the Waterlow score can be used as an independent surrogate marker to predict severity and adverse outcome in acute pancreatitis. Methods In this retrospective analysis, a consecutive cohort was studied of 250 patients presenting with acute pancreatitis, all of whom had their Waterlow score calculated on admission. Primary outcome measures were length of hospital stay and mortality. Secondary outcome measures included rate of intensive care unit (ICU) admission and development of complications such as peripancreatic free fluid, pancreatic necrosis and pseudocyst formation. Correlation of the Waterlow score with some known markers of disease severity and outcomes was also analysed. Results The Waterlow score correlated strongly with the most commonly used marker of disease severity, the Glasgow score (analysis of variance, p=0.0012). Inpatient mortality, rate of ICU admission and length of hospital stay increased with a higher Waterlow score (Mann-Whitney U test, p=0.0007, p=0.049 and p=0.0002 respectively). There was, however, no significant association between the Waterlow score and the incidence of three known complications of pancreatitis: presence of peripancreatic fluid, pancreatic pseudocyst formation and pancreatic necrosis. Receiver operating characteristic curve analysis demonstrated good predictive power of the Waterlow score for mortality (area under the curve [AUC]: 0.73), ICU admission (AUC: 0.65) and length of stay >7 days (AUC: 0.64). This is comparable with the predictive power of the Glasgow score and C-reactive protein. Conclusions The Waterlow score for patients admitted with acute pancreatitis could provide a useful tool in prospective assessment of disease severity, help clinicians with appropriate resource management and inform patients.

New minimally invasive approaches for cholecystectomy: Review of literature

Laparoscopic cholecystectomy is the most commonly performed abdominal intervention in Western countries. In an attempt to reduce the invasiveness of the procedure, surgeons have developed single-incision laparoscopic cholecystectomy (SILC), minilaparoscopic cholecystectomy (MLC) and natural orifice transluminal endoscopic surgery (NOTES). The aim of this review was to determine the role of these new minimally invasive approaches for elective laparoscopic cholecystectomy in the treatment of gallstone related disease. Current literature remains insufficient for the correct assessment of emerging techniques for laparoscopic cholecystectomy. None of these procedures has demonstrated clear benefits over conventional laparoscopic cholecystectomy. SILC cannot be currently recommended as it can be associated with an increased risk of bile duct injury and incisional hernia incidence. NOTES cholecystectomy is still experimental, although hybrid transvaginal cholecystectomy is gaining popularity in clinical practice. As it is standardized and almost identical to the standard laparoscopic technique, MLC could lead to limited benefits without exposing patients to increased postoperative complications, being therefore adoptable for routine elective cholecystectomy. Technical challenges of SILC and NOTES cholecystectomy could be addressed with the evolution of new surgical tools that need to catch up with the innovative minds of surgeons. Regardless the place of these approaches in the future, robotization may be necessary to impose them as standard treatment.

Public perception of "scarless" laparoendoscopic single-site surgery in gynecology

Objective

To investigate the public perception of laparoendoscopic single-site surgery (LESS) according to the age group.

Methods

An anonymous questionnaire about the desire for cosmesis and the preference for LESS in treatment of benign gynecologic diseases was provided to healthy volunteers (n=102). The survey participants were divided into two age groups (young women ≤40 years and middle-aged women >40 years). The desire for cosmesis was assessed using a validated scale, Body Image Scale.

Results

All of the participants completed the questionnaire. The Body Image Scale scores were not different between the two age groups (11.5±3.5 vs. 11.8±4.0, P=0.656). The most common fear of surgery was the risk of complications in both age groups (69% in the young age group and 65% in the middle-aged group). Unless the operative risk increased, most of the participants (61% to 67%) in both age groups preferred LESS. Their choice was influenced by reduced scarring (43% to 61%), more safety (20% to 39%), reduced postoperative pain (8% to 10%), and new technology (4% to 6%).

Conclusion

Based on these results, there was no difference in the desire for cosmesis and perception of LESS according to the age. Therefore, physicians should discuss and consider LESS even in middle-aged women.

Laparoscopic cholecystectomy versus minilaparotomy in cholelithiasis: systematic review and meta-analysis

Introduction

A introdução da técnica laparoscópica em 1985 foi um fator importante na colecistectomia por representar técnica menos invasiva, resultado estético melhor e menor risco cirúrgico comparado ao procedimento laparotômico.

Aim

To compare laparoscopic and minilaparotomy cholecystectomy in the treatment of cholelithiasis.

Methods

A systematic review of randomized clinical trials, which included studies from four databases (Medline, Embase, Cochrane and Lilacs) was performed. The keywords used were "Cholecystectomy", "Cholecystectomy, Laparoscopic" and "Laparotomy". The methodological quality of primary studies was assessed by the Grade system.

Results

Ten randomized controlled trials were included, totaling 2043 patients, 1020 in Laparoscopy group and 1023 in Minilaparotomy group. Laparoscopic cholecystectomy dispensed shorter length of hospital stay (p<0.00001) and return to work activities (p<0.00001) compared to minilaparotomy, and the minilaparotomy shorter operative time (p<0.00001) compared to laparoscopy. Laparoscopy decrease the risk of postoperative pain (NNT=7) and infectious complications (NNT=50). There was no statistical difference between the two groups regarding conversion (p=0,06) and surgical reinterventions (p=0,27), gall bladder's perforation (p=0,98), incidence of common bile duct injury (p=1.00), surgical site infection (p=0,52) and paralytic ileus (p=0,22).

Conclusion

In cholelithiasis, laparoscopic cholecystectomy is associated with a lower incidence of postoperative pain and infectious complications, as well as shorter length of hospital stay and time to return to work activities compared to minilaparotomy cholecystectomy.

Efficacy of laparoscopic subtotal gastrectomy with D2 lymphadenectomy for locally advanced gastric cancer: the protocol of the KLASS-02 multicenter randomized controlled clinical trial

Background

Despite the well-described benefits of laparoscopic surgery such as lower operative blood loss and enhanced postoperative recovery in gastric cancer surgery, the application of laparoscopic surgery in patients with locally advanced gastric cancer (AGC) remains elusive owing to a lack of clinical evidence. Recently, the Korean Laparoscopic Surgical Society Group launched a new multicenter randomized clinical trial (RCT) to compare laparoscopic and open D2 lymphadenectomy for patients with locally AGC. Here, we introduce the protocol of this clinical trial.

Methods/design

This trial is an investigator-initiated, randomized, controlled, parallel group, non-inferiority trial. Gastric cancer patients diagnosed with primary tumors that have invaded into the muscle propria and not into an adjacent organ (cT2–cT4a) in preoperative studies are recruited. Another criterion for recruitment is no lymph node metastasis or limited perigastric lymph node (including lymph nodes around the left gastric artery) metastasis. A total 1,050 patients in both groups are required to statistically show non-inferiority of the laparoscopic approach with respect to the primary end-point, relapse-free survival of 3 years. Secondary outcomes include postoperative morbidity and mortality, postoperative recovery, quality of life, and overall survival. Surgeons who are validated through peer-review of their surgery videos can participate in this clinical trial.

Discussion

This clinical trial was designed to maintain the principles of a surgical clinical trial with internal validity for participating surgeons. Through the KLASS-02 RCT, we hope to show the efficacy of laparoscopic D2 lymphadenectomy in AGC patients compared with the open procedure.

Trial registration

ClinicalTrial.gov, NCT01456598.

Laparoscopic cholecystectomy: consensus conference-based guidelines

INTRODUCTION

Laparoscopic cholecystectomy (LC) is the gold standard technique for gallbladder diseases in both acute and elective surgery. Nevertheless, reports from national surveys still seem to represent some doubts regarding its diffusion. There is neither a wide consensus on its indications nor on its possible related morbidity. On the other hand, more than 25 years have passed since the introduction of LC, and we have all witnessed the exponential growth of knowledge, skill and technology that has followed it. In 1995, the EAES published its consensus statement on laparoscopic cholecystectomy in which seven main questions were answered, according to the available evidence. During the following 20 years, there have been several additional guidelines on LC, mainly focused on some particular aspect, such as emergency or concomitant biliary tract surgery.

METHODS

In 2012, several Italian surgical societies decided to revisit the clinical recommendations for the role of laparoscopy in the treatment of gallbladder diseases in adults, to update and supplement the existing guidelines with recommendations that reflect what is known and what constitutes good practice concerning LC.

SAGES expert Delphi consensus: critical factors for safe surgical practice in laparoscopic cholecystectomy

BACKGROUND

Although it has been 25 years since the introduction of laparoscopy to cholecystectomy, outcomes remain largely unchanged, with rates of bile duct injury higher in the modern age than in the era of open surgery. The SAGES Safe Cholecystectomy Task Force (SCTF) initiative seeks to encourage a culture of safety in laparoscopic cholecystectomy (LC) and reduce biliary injury. An expert consensus study was conducted to identify interventions thought to be most effective in pursuit of this goal.

METHODS

An initial list of items for safer practice in LC was identified by the SCTF through a nominal group technique (NGT) process. These were put forward to 407 SAGES committee members in two-stage electronically distributed Delphi surveys. Consensus was achieved if at least 80 % of respondents ranked an item as 4 or 5 on a Likert scale of importance (1-5). Additionally, respondents ranked five top areas of importance for the following domains: training, assessment, and research.

RESULTS

Thirty-nine initial items were identified through NGT. Response rates for each Delphi round were 40.2 and 34 %, respectively. Final consensus was achieved on 15 items, the majority of which related to non-technical factors in LC. Key domains for training, assessment, and research were identified. Critical view of safety was deemed most important for overall safety, as well as training and assessment of LC. Intraoperative cholangiography was identified as an additional priority area for future research.

CONCLUSIONS

Consensus items to progress surgical practice, training, assessment, and research have been identified, to promote safe practice and improve patient outcomes in LC.

Male gender impact on the outcome of laparoscopic cholecystectomy

BACKGROUND AND OBJECTIVES

Our aim was to assess the impact of male gender on the outcomes of laparoscopic cholecystectomy by eliminating associated risk factors for conversion.

METHODS

A quantitative comparative study was set up on the background of our null hypothesis that male gender has no impact on the outcomes of laparoscopic cholecystectomy. We performed a retrospective study of 241 patients and recorded the duration of surgery, length of postoperative hospital stay, conversion rate, and procedure-specific complications. Risk factors for conversion were excluded. Inferential statistics were applied, and a 2-sided P value of < .05 was considered the cutoff point to indicate the amount of evidence against the null hypothesis. We used SPSS for Windows, version 12 (IBM, Armonk, New York). Parametric data were analyzed with the independent-samples t test, and nonparametric data were analyzed with the χ(2) test.

RESULTS

A total of 175 women (72.6%) and 66 men (27.4%) underwent laparoscopic cholecystectomy. The mean age was 51.4 ± 14.8 years for women and 55 ± 12.7 years for men (P = .08). Women had a higher body mass index (28.4 ± 4.5) than men (26.8 ± 3.5) (P < .005). There were no statistically significant differences in the conversion rate and perioperative morbidity rate. The conversion rate was 2.9% for women and 7.5% for men (P = .142); the morbidity rate was 10.2% and 12.1%, respectively (P = .66). The mean duration of surgery was longer in men, at 67.9 ± 27.8 minutes, than in women, at 56.5 ± 23.98 minutes (P < .002). Both genders had an equal length of postoperative hospital stay, with 1.9 ± 1.8 days for men and 1.9 ± 2.1 days for women (P = .8).

CONCLUSIONS

Male gender has no impact on the outcomes of laparoscopic cholecystectomy. Gender affects the duration of surgery. Larger-scale studies may disclose the factors responsible for variations in the operative time.

The role of the posterior parietal cortex in stereopsis and hand-eye coordination during motor task behaviours

The field of 'Neuroergonomics' has the potential to improve safety in high-risk operative environments through a better appreciation of the way in which the brain responds during human-tool interactions. This is especially relevant to minimally invasive surgery (MIS). Amongst the many challenges imposed on the surgeon by traditional MIS (laparoscopy), arguably the greatest is the loss of depth perception. Robotic MIS platforms, on the other hand, provide the surgeon with a magnified three-dimensional view of the environment, and as a result may offload a degree of the cognitive burden. The posterior parietal cortex (PPC) plays an integral role in human depth perception. Therefore, it can be hypothesized that differences in PPC activation between monoscopic and stereoscopic vision may be observed. In order to investigate this hypothesis, the current study explores disparities in PPC responses between monoscopic and stereoscopic visual perception to better de-couple the burden imposed by laparoscopy and robotic surgery on the operator's brain. Fourteen participants conducted tasks of depth perception and hand-eye coordination under both monoscopic and stereoscopic visual feedback. Cortical haemodynamic responses were monitored throughout using optical functional neuroimaging. Overall, recruitment of the bilateral superior parietal lobule was observed during both depth perception and hand-eye coordination tasks. This occurred contrary to our hypothesis, regardless of the mode of visual feedback. Operator technical performance was significantly different in two- and three-dimensional visual displays. These differences in technical performance do not appear to be explained by significant differences in parietal lobe processing.

A prospective, randomized multicenter study comparing conventional laparoscopic cholecystectomy versus minilaparotomy cholecystectomy with ultrasonic dissection as day surgery procedure--1-year outcome

OBJECTIVE

The long-term outcome between laparoscopic cholecystectomy (LC) and minilaparotomy cholecystectomy (MC) with ultrasonic dissection (UsD) technique has not been compared in randomized trials. Therefore, we investigated the outcome after conventional LC and MC with UsD in 78 patients (ClinicalTrials.gov Identifier: NCT0172340).

MATERIAL AND METHODS

Initially 88 patients with non-complicated symptomatic gallstone disease were randomized into MC (n = 44) or LC (n = 44) over a period of 2 years (2010-2012) and 78 of them (89%) were reached for a follow-up interview at 12 months after the surgery.

RESULTS

Baseline parameters were similar in the two groups, and 1/44 MCs and 2/44 LCs were converted to open laparotomy. The prevalence of chronic post-surgical pain (CPSP) one year after the procedure was quite similar in the two groups: 3/36 (8%) in the MC group and 2/42 (5%) in the LC group (p = 0.502). Residual abdominal symptoms were common, but the proportion was similar in both groups (28% in MC and 33% in LC group, p = 0.665). Both groups were very satisfied with the cosmetic outcome (numeric rating scale, p = 0.470). The Quality of life (QoL) improved 34/36 (94%) in the MC group and 33/42 (79%) in the LC group (p = 0.046) and all patients in both groups were satisfied with the operation overall.

CONCLUSION

Day-case MC and LC patients have a quite similar one-year outcome with no significant difference regarding residual abdominal symptoms, cosmetic satisfaction, QoL or CPSP.

Evaluation of the health-related quality of life for patients following laparoscopic cholecystectomy

PURPOSE

Laparoscopic cholecystectomy (LC) has become the standard procedure, and contributes to a shorter hospital stay. However, there have been no reports regarding when the patients can be discharged in terms of their health-related quality of life (HRQOL).

METHODS

The HRQOL was evaluated by using the SF-8 health survey (SF-8) 24-hour version in 127 consecutive patients treated from May 2007 to December 2008. The HRQOL and a visual analogue scale (VAS) score were assessed on the day before surgery and on postoperative day (POD) 1, POD2 and POD7.

RESULTS

All scores of the eight domains on POD1 were significantly decreased compared to the preoperative score (P < 0.05), and seven scores were still decreased on POD2, with the mental health (MH) domain showing an improvement. On POD7, the general health score improved to the preoperative level. The physical component summary 8 (PCS-8) was suppressed for all 7 days after LC. The mental health component summary 8 (MCS-8) was improved to the preoperative level on POD2, despite the significant suppression observed on POD1 (P < 0.05). The VAS score was higher in the low PCS-8 (PCS-8 < 42.4) and low MCS-8 (MCS-8 < 40.6) patients than in the high PCS-8 and high MCS-8 patients.

CONCLUSION

The HRQOL score demonstrated the improvement of the MCS-8 on POD2, which might suggest that a discharge of LC patients is appropriate on POD2 in terms of the patients' point of view.

Peritoneal adhesions after laparoscopic gastrointestinal surgery

Although laparoscopy has the potential to reduce peritoneal trauma and post-operative peritoneal adhesion formation, only one randomized controlled trial and a few comparative retrospective clinical studies have addressed this issue. Laparoscopy reduces de novo adhesion formation but has no efficacy in reducing adhesion reformation after adhesiolysis. Moreover, several studies have suggested that the reduction of de novo post-operative adhesions does not seem to have a significant clinical impact. Experimental data in animal models have suggested that CO₂ pneumoperitoneum can cause acute peritoneal inflammation during laparoscopy depending on the insufflation pressure and the surgery duration. Broad peritoneal cavity protection by the insufflation of a low-temperature humidified gas mixture of CO₂, N₂O and O₂ seems to represent the best approach for reducing peritoneal inflammation due to pneumoperitoneum. However, these experimental data have not had a significant impact on the modification of laparoscopic instrumentation. In contrast, surgeons should train themselves to perform laparoscopy quickly, and they should complete their learning curves before testing chemical anti-adhesive agents and anti-adhesion barriers. Chemical anti-adhesive agents have the potential to exert broad peritoneal cavity protection against adhesion formation, but when these agents are used alone, the concentrations needed to prevent adhesions are too high and could cause major post-operative side effects. Anti-adhesion barriers have been used mainly in open surgery, but some clinical data from laparoscopic surgeries are already available. Sprays, gels, and fluid barriers are easier to apply in laparoscopic surgery than solid barriers. Results have been encouraging with solid barriers, spray barriers, and gel barriers, but they have been ambiguous with fluid barriers. Moreover, when barriers have been used alone, the maximum protection against adhesion formation has been no greater than 60%. A recent small, randomized clinical trial suggested that the combination of broad peritoneal cavity protection with local application of a barrier could be almost 100% effective in preventing post-operative adhesion formation. Future studies should confirm the efficacy of this global strategy in preventing adhesion formation after laparoscopy by focusing on clinical end points, such as reduced incidences of bowel obstruction and abdominal pain and increased fertility.

Mini-invasive surgery for colorectal cancer

Laparoscopic techniques have been extensively used for the surgical management of colorectal cancer during the last two decades. Accumulating data have demonstrated that laparoscopic colectomy is associated with better short-term outcomes and equivalent oncologic outcomes when compared with open surgery. However, some controversies regarding the oncologic quality of mini-invasive surgery for rectal cancer exist. Meanwhile, some progresses in colorectal surgery, such as robotic technology, single-incision laparoscopic surgery, natural orifice specimen extraction, and natural orifice transluminal endoscopic surgery, have been made in recent years. In this article, we review the published data and mainly focus on the current status and latest advances of mini-invasive surgery for colorectal cancer.

Laparoscopy in the era of enhanced recovery

Laparoscopy is one of the cornerstones in the surgical revolution and transformed outcome and recovery for various surgical procedures. Even if these changes were widely accepted for basic interventions, like appendectomies and cholecystectomies, laparoscopy still remains challenged for more advanced operations in many aspects. Despite these discussion, there is an overwhelming acceptance in the surgical community that laparoscopy did transform the recovery for several abdominal procedures. The importance of improved peri-operative patient management and its influence on outcome started to become a focus of attention 20 years ago and is now increasingly spreading, as shown by the incoming volume of data on this topic. The enhanced recovery after surgery (ERAS) concept incorporates simple measures of general management, and requires multidisciplinary collaboration from hospital staff as well as the patient and the relatives. Several studies have demonstrated a significant decrease in postoperative complication rate, length of hospital stay and reduced overall cost. The key elements of success are fluid restriction, a functioning epidural and preoperative carbohydrate intake. With the expansion of laparoscopic techniques, ERAS increasingly incorporates laparoscopic patients, especially in colorectal surgery. However, the precise impact of laparoscopy on ERAS is still not clearly defined. Increasing evidence suggests that laparoscopy itself is an additional ERAS item that should be considered as routine where feasible in order to obtain the best surgical outcomes.

Trends in cholecystectomy rates in a defined population during and after the period of transition from open to laparoscopic surgery

OBJECTIVE

To evaluate cholecystectomy rates in a Norwegian county during the transition time from open to laparoscopic surgery, with focus on the incident rate of laparoscopic operations, sex differences, age at operation, and indications for cholecystectomy.

MATERIAL AND METHODS

All 2615 patients living in North Trondelag County and operated with cholecystectomy for benign biliary disease between 1990 and 2011 were identified. Poisson regression was used to analyze factors associated with cholecystectomy incidence rate ratios (IRRs).

RESULTS

The proportion of completed laparoscopic cholecystectomies was 8% in 1992, 50% in 1994, 94% in 2003 and 99% in 2011. The incidence of cholecystectomy increased from 6.2 per 10 000 person-years in 1990-1992, 8.0 in 1993-1997, to 10.0 in 1998-2003 and remained at this level with a rate of 10.7 during 2004-2011. Adjusting for age at each year of surgery the IRR for females compared with males was 2.3(2.1-2.5) p < 0.001. The median age at operation was 60.2 years (13-90) in males, 50.1 years (12-93) in females p < 0.001. The median age diminished by 5 years in both males and females. A conversion from laparoscopic to open surgery decreased significantly by calendar year of surgery, increased with age of the patient, and was less often in surgery for gallstone colic than for other indications.

CONCLUSIONS

During the introduction of laparoscopic surgery, the rates of cholecystectomy increased and remained stable at a higher level during the later years of the study. The rate of completed laparoscopic operations increased from 8% in 1992 to 99% in 2011.

Single-port versus multiport laparoscopic cholecystectomy: a prospective randomized clinical trial

PURPOSE

We report the outcomes of a randomized clinical trial of single-port laparoscopic cholecystectomy (SPLC) and multiport laparoscopic cholecystectomy (MPLC).

METHODS

Fifty-four patients (27 in each group) were randomized. A visual analog scale was used with a 10-point scale for an objective assessment of incisional pain and incisional cosmesis on postoperative days 1, 3, and 14.

RESULTS

The mean operating time was significantly longer in the SPLC. The mean cosmesis scores on postoperative days 3 (9.7 vs. 8.9, P = 0.01) and 14 (9.9 vs. 9.2, P<0.01) were significantly greater in the SPLC group than in the MPLC group. The group's mean visual analog scale scores for incisional pain, and their requirements for analgesics, did not differ significantly.

CONCLUSIONS

Although SPLC takes longer than MPLC, experienced laparoscopic surgeons can perform SPLC safely with results comparable with those for MPLC. SPLC is superior to MPLC in terms of short-term cosmetic outcomes.

[Minimally invasive surgical therapy of acute cholecystitis]

Acute cholecystitis is the most common complication of cholecystolithiasis. It develops in about 10 % of symptomatic patients and gangrenous cholecystitis, gallbladder perforation, gallbladder empyema, or abscesses are typical complications. Cholecystectomy is the most relevant therapy to achieve pain reduction, to prevent the progression of inflammation or local complications and to minimize the risk of recurrence. Surgical therapy can be supported by medical and interventional treatment modalities depending on the severity of the disease. The present review summarizes the surgical aspects in acute cholecystitis with a focus on laparoscopic cholecystectomy which is the gold standard of therapy.