Assessment of Port-Specific Pain After Gynecological Laparoscopy: A Prospective Cohort Clinical Trial

Best Evidence for Each Surgical Step in Minimally Invasive Right Hemicolectomy: A Systematic Review

Objective

The aim of this study was to systematically review the literature for each surgical step of the minimally invasive right hemicolectomy (MIRH) for non-locally advanced colon cancer, to define the most optimal procedure with the highest level of evidence.

Background

High variability exists in the way MIRH is performed between surgeons and hospitals, which could affect patients' postoperative and oncological outcomes.

Methods

A systematic search using PubMed was performed to first identify systematic reviews and meta-analyses, and if there were none then landmark papers and consensus statements were systematically searched for each key step of MIRH. Systematic reviews were assessed using the AMSTAR-2 tool, and selection was based on highest quality followed by year of publication.

Results

Low (less than 12 mmHg) intra-abdominal pressure (IAP) gives higher mean quality of recovery compared to standard IAP. Complete mesocolic excision (CME) is associated with lowest recurrence and highest 5-year overall survival rates, without worsening short-term outcomes. Routine D3 versus D2 lymphadenectomy showed higher LN yield, but more vascular injuries, and no difference in overall and disease-free survival. Intracorporeal anastomosis is associated with better intra- and postoperative outcomes. The Pfannenstiel incision gives the lowest chance of incisional hernias compared to all other extraction sites.

Conclusion

According to the best available evidence, the most optimal MIRH for colon cancer without clinically involved D3 nodes entails at least low IAP, CME with D2 lymphadenectomy, an intracorporeal anastomosis and specimen extraction through a Pfannenstiel incision.

Unilateral Right-Sided Ultrasound-Guided Erector Spinae Plane Block for Post-Laparoscopic Cholecystectomy Analgesia: A Randomized Control Trial

Background

Post-laparoscopic cholecystectomy (LC) pain control is still an issue postoperatively.

Objectives

We investigated the effectiveness of the unilateral right-side ultrasound-guided erector spinae plane block (ESPB) on post-LC pain intensity and opioid consumption.

Methods

This is a parallel-arm randomized control trial on 62 adult patients with an American Society of Anesthesiologists (ASA) physical status ≤ 2 who underwent LC. The patients were randomized into 2 groups (the block group [BG] and the control group [CG]; n = 31 per group). BG received a single-shot right-sided T7 ESPB with 20 mL of 0.2% ropivacaine at arrival time in the post-anesthesia care unit (PACU). CG) received no regional anesthesia. Both groups received patient-controlled intravenous fentanyl and rescue meperidine for analgesia. The primary outcome was the pain intensity determined using a Numerical Rating Scale (NRS) in the first 24 hours after surgery. Secondary outcomes included total fentanyl and meperidine consumption within 24 hours.

Results

Median pain scores were significantly higher in CG at rest and with coughing up to 12 hours after surgery compared with BG. Pain scores were higher in CG with a cough at 24 hours compared with BG (median 1 [interquartile range (IQR) 1, 2] vs. 1 [1, 0]; P = 0.0005). Total fentanyl consumption and meperidine consumption within 24 hours were significantly lower in BG compared with CG (median 60 µg [IQR 60, 90] vs 250 µg [90, 300]; P < 0.0001 and median 20 µg [IQR 10, 20] vs 25 [20, 25]; P = 0.002, respectively).

Conclusions

A single-shot, right-sided, unilateral ESPB decreases post-LC opioid consumption and pain.

Does size matter? Opioid use after laparoscopy for apical pelvic organ prolapse using an 8mm versus 10-12mm accessory port

STUDY OBJECTIVE

To determine if a change in lateral accessory port (LAP) size from 10-12mm to 8mm among women undergoing laparoscopic native tissue pelvic organ prolapse (POP) surgery was effective at reducing opioid use after surgery.

DESIGN

Prospective cohort of women taking part in a POP surgical registry.

SETTING

Tertiary academic hospital in Calgary, Canada.

PATIENTS

Women undergoing laparoscopic uterosacral ligament apical suspensions for stage ≥2 POP with either uterine preservation or concomitant hysterectomy. 92 women were included during a 15-month study period from June 2020 to September 2021.

INTERVENTIONS

Laparoscopic apical suspension using either a 10-12mm or 8mm LAP, with the change occurring at the mid-point of the study period. Fascial defects from 10-12mm ports were closed with a fascial closure device. Perioperative care and technique were otherwise unchanged.

MEASUREMENTS AND MAIN RESULTS

Post-operative opioid use was measured by mean morphine equivalent daily dose (MEDD), accounting for all oral and intravenous opioids used in the first 24-hours post-surgery. 50 cases (54.3%) used a 10-12mm LAP, 42 cases (45.7%) used an 8mm LAP. Mean MEDD after surgery with a 10-12mm LAP was significantly higher than with an 8mm LAP (35.3 (95% CI 24.9-45.6) vs. 13.6 (95% CI 8.0-19.2), p<0.001). Proportion of women who did not require opioids post-operatively was higher in the 8mm group (45.2%, n=19) than the 10-12mm group (18.0%, n=9) (cOR 3.76, 95% CI 1.47-9.66). Similarly, the proportion of women who did not fill an opioid prescription after discharge was higher in the 8mm group (35.7%, n=15) than the 10-12mm group (16.0%, n=8) (cOR 2.92, 95% CI 1.09-7.81). These results remained statistically significant after adjustment for age, body mass index, race/ethnicity, length of procedure, and concomitant procedures performed.

CONCLUSION

Compared to 10-12mm port, use of an 8mm LAP during laparoscopic native-tissue apical POP surgery is associated with decreased opioid use in the first 24 hours after surgery.

Efficacy and Safety of a Surgeon-Performed Laparoscopic-Guided, 4-point Transversus Abdominis Plane Block: A retrospective review

We performed a retrospective chart review from October 2017 to March 2019 to demonstrate the safety and efficacy of a surgeon-performed, laparoscopically guided, transversus abdominis plane (TAP) blocks for robot-assisted gynecologic procedures. A total of 116 patients who underwent robot-assisted gynecologic surgery, at 1 academic hospital, with administration of a 4-point TAP block were included. A 4-point TAP block was performed under laparoscopic visualization, by the same surgeon, after induction of anesthesia and immediately after placement of the laparoscope. Liposomal bupivacaine (20 mL) and 0.5% bupivacaine (20 mL) mixed with saline were used as the injectant. All information from the surgical admission and the postoperative follow-up were reviewed. Data were presented in our descriptive study. A total of 116 patients were included with a mean age of 40.6 years (19-80 years) and a mean body mass index of 30.6 kg/m² (17.2-53.3 kg/m²). Of the patients, 70.7% were discharged to home on the day of surgery. Of the 29.3% of patients who were admitted, 20.6% were admitted because of pain control. Those who were admitted for pain control comprised 6.0% of the total of all study participants. There were no adverse events in our cohort and no readmissions because of pain control. A surgeon-performed TAP block, under laparoscopic visualization, is a safe and efficacious intervention to reduce postoperative pain and may add to a multimodal approach for enhanced recovery protocols.

Does Erector Spinae Plane Block Have a Visceral Analgesic Effect?: A Randomized Controlled Trial

The visceral analgesic efficacy of erector spinae plane block (ESPB) is still a matter of debate. This study attempted to investigate the visceral analgesic efficacy of ESPB in clinical setting. After randomized, we performed ultrasound-guided bilateral rectus sheath block (RSB), which was aimed to prevent postoperative somatic pain on all patients who underwent laparoscopic cholecystectomy (LC). Ultrasound-guided bilateral ESPB at T7 level was performed only to the intervention group to provide the visceral analgesic block. The intraoperative requirement for remifentanil (P = 0.021) and the cumulative fentanyl consumption at postoperative 24-hours was significantly lower in the ESPB group (206.5 ± 82.8 μg vs.283.7 ± 102.4 μg, respectively; P = 0.004) compared to non-ESPB group. The ESPB group consistently showed lower accumulated analgesic consumption compared with those in the non-ESPB group at all observed time-points (all P < 0.05) after 2 hours and the degree of the accumulated analgesic consumption reduction was greater (P = 0.04) during the 24-hour postoperative period. Pain severity was lower in the ESPB group at 6-hours postoperatively. The significantly reduced opioid consumption in ESPB group may imply that while preliminary and in need of confirmation, ESPB has potential visceral analgesic effect. Therefore, performing ESPB solely may be feasible in inducing both somatic and visceral analgesia.

A Prospective, Observational Trial Assessing the Efficacy of Abdominal Compression in Reducing Laparoscopic-Induced Shoulder Pain

INTRODUCTION

Postoperative shoulder pain is a condition associated with laparoscopic surgery and presumably attributed to residual carbon dioxide (CO₂) in the abdomen. The intent of the current prospective, observational study was to assess the efficacy of abdominal compression in mitigating this painful complication.

METHODS

We recruited 30 patients who were treated with laparoscopic surgery for the management of gynecologic disease. All study participants underwent abdominal compression to evacuate the CO₂ associated with their pneumoperitoneum. Postoperatively, the subjects' pain intensity was measured via the visual analogue scale at 12, 24, and 48 hours.

RESULTS

The patients' mean postoperative visual analogue scale pain scores were the highest during the initial 12 hours (1.93), and thereafter, steadily declined at 24 hours (0.73) and 48 hours (0.70) ( P = .045). Furthermore, toxicity was reasonable, with only 20% of subjects who reported grade ≤2 nausea and vomiting.

CONCLUSION

Abdominal compression is a relatively safe procedure that appears to sufficently evacuate residual CO₂, thereby reducing the severity of laparoscopic surgery induced shoulder pain.