Gasless laparoscopic cholecystectomy: comparison of postoperative recovery with conventional technique

Global scientific production on gasless laparoscopy: a bibliometric analysis

Objectives

To characterize the bibliometric characteristics of the global scientific production of original research on gasless laparoscopy in the Web of Science Core Collection (WoSCC) platform.

Materials and methods

A bibliometric study of original articles published up to the year 2023 was carried out. Articles were included following the selection criteria in the Rayyan web application, indexed in the Scopus database. The bibliometric analysis was performed using the Bibliometrix program in the R programming language and VOSviewer. The bibliometric characteristics evaluated were articles, journals, citations, publications, ten most mentioned articles, journals with the highest number of publications, authors and institutional affiliations; and cooccurrence of terms.

Results

A total of 223 publications were included, with the highest number of articles being published in the years 1999 and 2014. The publication with the most citations was found to be a randomized trial by Galizia G in 2001 with 132 citations. We identified 846 authors involved in the production of articles on gasless laparoscopy, with Nakamura H being the most productive author with 15 articles between the years 2007 and 2020, followed by Takeda A and Imoto S, all three affiliated with "Gifu Prefectural Tajimi Hospital". The country with the highest production was Japan with 64 publications, followed by China and Italy with 46 and 18 publications, respectively. In the top 10 journals with the highest number of publications, "Surgical Endoscopy-Ultrasound and Interventional Techniques" is in first place with 20 articles published on gasless laparoscopy; in addition, most of these are located in Q1 and Q2. Regarding the terms or keywords, it was found that the initial studies had terms related to the disadvantages of pneumoperitoneum and later focused on more specific topics of the application of gasless laparoscopy.

Conclusions

Production on gasless laparoscopy has stagnated, with the topics of interest currently being its application in new, less invasive techniques. The most productive countries are found in the Asian and European continents, with little information collected in Latin America. This fact makes it necessary to increase the production of studies to promote this technique and its possible advantages.

Cost-effectiveness of gasless laparoscopy as a means to increase provision of minimally invasive surgery for abdominal conditions in rural North-East India

Laparoscopic surgery, a minimally invasive technique to treat abdominal conditions, has been shown to produce equivalent safety and efficacy with quicker return to normal function compared to open surgery. As such, it is widely accepted as a cost-effective alternative to open surgery for many abdominal conditions. However, access to laparoscopic surgery in rural North-East India is limited, in part due to limited equipment, unreliable supplies of CO₂ gas, lack of surgical expertise and a shortage of anaesthetists. We evaluate the cost-effectiveness of gasless laparoscopy as a means to increase provision of minimally invasive surgery (MIS) for abdominal conditions in rural North-East India. A decision tree model was developed to compare costs, evaluated from a patient perspective, and health outcomes, disability adjusted life years (DALYs), associated with gasless laparoscopy, conventional laparoscopy or open abdominal surgery in rural North-East India. Results indicate that MIS (performed by conventional or gasless laparoscopy) is less costly and produces better outcomes, fewer DALYs, than open surgery. These results were consistent even when gasless laparoscopy was analysed using least favourable data from the literature. Scaling up provision of MIS through increased access to gasless laparoscopy would reduce the cost burden to patients and increase DALYs averted. Based on a sample of 12 facilities in the North-East region, if scale up was achieved so that all essential surgeries amenable to laparoscopic surgery were performed as such (using conventional or gasless laparoscopy), 64% of DALYS related to these surgeries could be averted, equating to an additional 454.8 DALYs averted in these facilities alone. The results indicate that gasless laparoscopy is likely to be a cost-effective alternative to open surgery for abdominal conditions in rural North-East India and provides a possible bridge to the adoption of full laparoscopic services.

Clinical effectiveness of gasless laparoscopic surgery for abdominal conditions: systematic review and meta-analysis

BACKGROUND

In high-income countries, laparoscopic surgery is the preferred approach for many abdominal conditions. Conventional laparoscopy is a complex intervention that is challenging to adopt and implement in low resource settings. This systematic review and meta-analysis evaluate the clinical effectiveness of gasless laparoscopy compared to conventional laparoscopy with CO2 pneumoperitoneum and open surgery for general surgery and gynaecological procedures.

METHODS

A search of the MEDLINE, EMBASE, Global Health, AJOL databases and Cochrane Library was performed from inception to January 2021. All randomised (RCTs) and comparative cohort (non-RCTs) studies comparing gasless laparoscopy with open surgery or conventional laparoscopy were included. The primary outcomes were mortality, conversion rates and intraoperative complications.

SECONDARY OUTCOMES

operative times and length of stay. The inverse variance random-effects model was used to synthesise data.

RESULTS

63 studies were included: 41 RCTs and 22 non-RCTs (3,620 patients). No procedure-related deaths were reported in the studies. For gasless vs conventional laparoscopy there was no difference in intraoperative complications for general RR 1.04 [CI 0.45-2.40] or gynaecological surgery RR 0.66 [0.14-3.13]. In the gasless laparoscopy group, the conversion rates for gynaecological surgery were high RR 11.72 [CI 2.26-60.87] when compared to conventional laparoscopy. For gasless vs open surgery, the operative times were longer for gasless surgery in general surgery RCT group MD (mean difference) 10 [CI 0.64, 19.36], but significantly shorter in the gynaecology RCT group MD - 18.74 [CI - 29.23, - 8.26]. For gasless laparoscopy vs open surgery non-RCT, the length of stay was shorter for gasless laparoscopy in general surgery MD - 3.94 [CI - 5.93, - 1.95] and gynaecology MD - 1.75 [CI - 2.64, - 0.86]. Overall GRADE assessment for RCTs and Non-RCTs was very low.

CONCLUSION

Gasless laparoscopy has advantages for selective general and gynaecological procedures and may have a vital role to play in low resource settings.

Use of intraoperative mild hyperventilation to decrease the incidence of postoperative shoulder pain after laparoscopic gastric sleeve surgery: A prospective randomised controlled study

BACKGROUND AND AIMS

Post-laparoscopic shoulder pain (PLSP) is a common problem. It is a referred type of pain resulting from irritation of phrenic nerve endings. Multiple manoeuvres were used to decrease its incidence with varying success rates. In this study, we tested the use of mild intraoperative hyperventilation to reduce PLSP in patients undergoing laparoscopic sleeve gastrectomy surgery (LSG).

METHODS

Consenting American Society of Anesthesiologists-I and II patients undergoing LSG under general anaesthesia were randomly assigned to two groups. Group A (53 patients) received intraoperative mild hyperventilation with target end-tidal carbon dioxide (ETCO2) of 30-32 mmHg. Group B (51 patients) received conventional ventilation (ETCO2 of 35-40 mmHg). Incidence and severity of PLSP, cumulative analgesic requirements and incidence of nausea and vomiting were recorded at 12 and 24 hours postoperatively and then followed up after discharge over the phone at 48 hours, 1 week, 1 month and 3 months. Statistical significance of differences between the two groups was defined at P < 0.05.

RESULTS

Incidence of PLSP was comparable between the two groups in the first 24 hours. The intervention group had a significantly lower incidence of PLSP throughout the remaining assessment points (56.6% vs. 80.4%, 30.2% vs. 78.4%, 15.1% vs. 70.6%, 3.8% vs. 35.3% at 36 hours, 48 hours, 1 week and 1 month, respectively, P < 0.05). The average PLSP pain score was significantly lower in the mild hyperventilation group at all assessment time points. Nausea and vomiting were non-significantly lower in the mild hyperventilation group.

CONCLUSION

Mild intraoperative hyperventilation could be beneficial in reducing the incidence and severity of PLSP after LSG surgery.

Comparison of a new gasless method and the conventional CO2 pneumoperitoneum method in laparoendoscopic single-site cholecystectomy: a prospective randomized clinical trial

To avoid CO₂ pneumoperitoneum-associated cardiopulmonary side-effects during conventional laparoscopic surgeries, we have developed a gasless laparoscopic operation field formation (LOFF) device for laparoendoscopic single-site surgery. The aim of this study is to analyze the safety and efficacy of the LOFF device for laparoendoscopic single-site cholecystectomy and to verify its advantage of avoiding CO₂ pneumoperitoneum-associated complications. In this prospective, randomized, observer-blinded clinical trial, eligible participants were randomized in a 1:1 ratio to undergo either conventional CO₂ pneumoperitoneum assisted laparoendoscopic single-site cholecystectomy (LESS) or the new gasless LOFF device assisted laparoendoscopic single-site cholecystectomy (LOFF-LESS). Outcomes including intra-operative respiratory and hemodynamic parameters, operation time, conversion rate, complication rate, et al were compared between the two groups. A total of 100 patients were randomized to the LESS group [n = 50; mean (SD) age, 49.5 (13.9) years; 24 (48.0%) women] and the LOFF-LESS group [n = 50, mean (SD) age, 47.4 (13.3) years; 27 (54.0%) women]. Compared with the LOFF-LESS group, the LESS group witnessed significant fluctuations in intra-operative respiratory and hemodynamic parameters. The tracheal extubation time of the LESS group was significantly longer (P = 0.001). The gasless LOFF device is safe and feasible for simple laparoscopic cholecystectomy and has a predominance of avoiding CO₂ pneumoperitoneum-associated cardiopulmonary side-effects. Trial registration number: ChiCTR2000033702.

Evaluation of Gasless Laparoscopy as a Tool for Minimal Access Surgery in Low-to Middle-Income Countries: A Phase II Noninferiority Randomized Controlled Study

Background

Minimal access surgery is not available to most people in rural areas of low-to middle-income countries. This leads to an increase in morbidity and economic loss to the poor and marginalized. Gasless laparoscopic (GAL) procedures are possible in rural areas because they can be performed under spinal anesthesia. In most cases, it does not require the logistics of providing gases for pneumoperitoneum and general anesthesia. The current study compares GAL with conventional laparoscopic (COL) operations for general surgical procedures.

Methods

A single-center, nonblinded randomized controlled trial was conducted to evaluate noninferiority of GAL vs COL at a teaching hospital in New Delhi, India. Patients were allocated into 3 groups and underwent minimal access surgery (cholecystectomies and appendectomies). The procedures were performed by 2 surgeons choosing randomly between GAL and COL. The data were collected by postgraduates and analyzed by a biostatistician.

Results

One hundred patients who met the inclusion criteria were allocated into 2 groups. No significant difference was observed in the mean operating time between the GAL group (52.9 minutes) and the COL group (55 minutes) (p = 0.3). Intraoperative vital signs were better in the GAL group (p < 0.05). The postoperative pain score was slightly higher in the GAL group (p = 0.01); however, it did not require additional analgesics.

Conclusions

No significant differences were found between the 2 groups. GAL can be considered as noninferior compared with COL and has the potential to be adopted in low-resource settings.

A Novel Strategy of Laparoscopic Insufflation Rate Improving Shoulder Pain: Prospective Randomized Study

BACKGROUND

Laparoscopic surgery is the main trend method in a variety of surgical fields. Post-operative shoulder pain remains a bothersome issue although many surgical techniques have been applied to minimize it. A simple novel approach to reduce shoulder pain without adverse effects during and after laparoscopic surgery is desired.

METHODS

This prospective randomized controlled study was conducted to enroll a total of 140 patients to evaluate the efficacy of low flow rate (1 L/min) for induction followed by high flow rate (10 L/min) for maintaining 12 mmHg pneumoperitoneum (group A, n = 70) during laparoscopic cholecystectomy (LC), compared to the continuous high flow rate group (group B, n = 70) in postoperative shoulder pain and other clinical features. The 10-visual analog scale (VAS) was applied for the severity of shoulder pain and scores were obtained at 1, 6, 12, 24, and 48 h after LC.

RESULTS

There was no obvious difference in baseline characteristics as well as operative time, occurrence of bradycardia, or hospital stay between groups. The incidence of shoulder pain was not significantly different (group A 45.7% vs group B 48.6%, p = 0.866). However, the patients in group A with shoulder pain reported significantly less pain scores (p < 0.001) at 12 and 24 h after surgery, compared with those in group B.

CONCLUSIONS

Applying the strategy of low flow rate to induce pneumoperitoneum followed by high flow rate to maintain the pressure provides advantages to reduce the severity of shoulder pain for patients who underwent LC and then experienced shoulder pain.

Role of Routine Subhepatic Abdominal Drain Placement following Uncomplicated Laparoscopic Cholecystectomy: A Prospective Randomised Study

INTRODUCTION

Routine abdominal drainage after laparoscopy cholecystectomy is an issue of considerable debate. Reason for draining is to detect early bile/blood leak and allow CO₂ insufflate during laparoscopy to escape via drain site thereby decreased shoulder tip pain and post-operative nausea and vomiting. But some studies show no difference in post-operative nausea /vomiting/pain between drain and no drain group.

AIM

To assess the role of drains following uncomplicated laparoscopic cholecystectomy.

MATERIALS AND METHODS

This prospective randomized study was conducted in the Department of General Surgery, Government Medical College and Rajindra Hospital, Patiala. Hundred patients of symptomatic gallstones satisfying the selection and exclusion criteria, undergoing uncomplicated laparoscopic cholecystectomy were included in this study, 50 cases with drains in right subhepatic space (Group I) and 50 cases without drains (Group II). Both groups were compared in terms of post-operative shoulder pain, analgesic requirement, nausea and vomiting, hospital stay and analgesic requirement in patient with drains and without drains. SPSS version 16.0 (Chi-Square Test and Fisher-Exact Test) were used for statistical analysis.

RESULTS

In this study, average operative time in both the groups was same (p-value 0.977). There was more incidence of nausea /vomiting in no drain group than in drain group. Shoulder tip pain was lower in drain group in first 12 hours post-operative. However, after 12 hours, drain group had higher shoulder tip pain than no drain group. Analgesic requirement was higher in no drain group upto 12 hours after which it was higher in drain group (statistically not significant). In terms of hospital stay patients in drain group had a longer stay in hospital as compared to no drain group (2.96 vs 2.26; p <0.001 statistically significant).

CONCLUSION

Use of drains in uncomplicated laparoscopic cholecystectomy is not advantageous; its role in reducing post-operative nausea/vomiting is insignificant. It increases post-operative shoulder tip pain and hospital stay. Therefore, routine use of drains cannot be justified as it increases morbidity without significant advantage.

Ondansetron combined with ST36 (Zusanli) acupuncture point injection for postoperative vomiting

BACKGROUND

Ondansetron, sometimes combined with acustimulation at PC6 (Neiguan), is commonly used for preventing postoperative nausea and vomiting, but PC6 is not the only point that can be used for this purpose.

OBJECTIVES

To evaluate the combined effects of ondansetron and ST36 (Zusanli) acupuncture point injection on postoperative vomiting (POV) after laparoscopic surgery.

METHODS

A randomised, patient and assessor-blinded, placebo-controlled clinical study was conducted. One hundred and sixty patients undergoing laparoscopic surgery were randomly assigned to one of four groups: (1) group P (placebo-control): intravenous normal saline+bilateral non-acupuncture point injection of vitamin B1 (n=40); (2) group O (ondansetron): intravenous ondansetron+bilateral ST36 sham injection (n=40); (3) group A (acupuncture point injection): intravenous normal saline+bilateral acupuncture point injection at ST36 of vitamin B1 (n=40); (4) group C (combination): intravenous ondansetron+bilateral acupuncture point injection at ST36 of vitamin B1 (n=40). Interventions were made on arrival at the postanaesthesia care unit. The primary outcome was the incidence of POV within 24 h after the operation. Secondary outcomes included severity of vomiting, incidence of rescue treatment, patients' satisfaction and the first anal exsufflation time 24 h after the operation.

RESULTS

The incidence of POV within 24 h postoperative period in each group was P 33%; O 11%, A 9% and C 6%. Outcomes for all intervention groups were significantly better than that for placebo (p<0.01). For the three interventions compared with placebo, the numbers needed to treat (NNTs) were O, NNT=5; A, NNT=5 and C, NNT=4. The secondary outcomes also demonstrated greater benefits of the combined regimen, with improvement seen in all the measures.

CONCLUSIONS

Ondansetron, acupuncture, and ondansetron and acupuncture combined are effective prophylaxis for POV.

Comparison of tubal sterilization procedures performed by keyless abdominal rope-lifting surgery and conventional CO2 laparoscopy: a case controlled clinical study

Objective. To evaluate the safety and efficacy of Keyless Abdominal Rope-Lifting Surgery (KARS), for tubal sterilization procedures in comparison with the conventional CO₂ laparoscopy. Material and Methods. During a one-year period, 71 women underwent tubal ligation surgery. Conventional laparoscopy (N = 38) and KARS (N = 33) were used for tubal sterilization. In KARS, an abdominal access pathway through a single intra-abdominal incision was used to place transabdominal sutures that elevated the abdominal wall, and the operations were performed through the intraumbilical entry without the use of trocars. In CO₂ laparoscopy, following the creation of the CO₂ pneumoperitoneum a 10 mm trocar and two 5 mm trocars were introduced into the abdominal cavity. Tubal sterilizations were performed following the creation of the abdominal access pathways in both groups. The groups were compared with each other. Results. All operations could be performed by KARS without conversion to CO₂ laparoscopy or laparotomy. The mean operative time of the two groups was not significantly different (P > 0.05). Intra- and postoperative findings including complications, bleeding, and hospital stay time did not differ between groups (P > 0.05). Conclusion. KARS for tubal sterilization seems safe and effective in terms of cosmesis, postoperative pain, and early hospital discharge.

Abdominal lift for laparoscopic cholecystectomy

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded until February 2013.

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

For abdominal wall lift with pneumoperitoneum versus pneumoperitoneum, a total of 130 participants (all with low anaesthetic risk) scheduled for elective laparoscopic cholecystectomy were randomised in five trials to abdominal wall lift with pneumoperitoneum (n = 53) versus pneumoperitoneum only (n = 52). One trial which included 25 people did not state the number of participants in each group. All five trials had a high risk of bias. There was no mortality or conversion to open cholecystectomy in any of the participants in the trials that reported these outcomes. There was no significant difference in the rate of serious adverse events between the two groups (two trials; 2/29 events (0.069 events per person) versus 2/29 events (0.069 events per person); rate ratio 1.00; 95% CI 0.17 to 5.77). None of the trials reported quality of life, the proportion of people discharged as day-patient laparoscopic cholecystectomies, or pain between four and eight hours after the operation. There was no significant difference in the operating time between the two groups (four trials; 53 participants versus 54 participants; 13.39 minutes longer (95% CI 2.73 less to 29.51 minutes longer) in the abdominal wall lift with pneumoperitoneum group and 100 minutes in the pneumoperitoneum group).For abdominal wall lift versus pneumoperitoneum, a total of 774 participants (the majority with low anaesthetic risk) scheduled for elective laparoscopic cholecystectomy were randomised in 18 trials to abdominal wall lift without pneumoperitoneum (n = 332) versus pneumoperitoneum (n = 358). One trial which included 84 people did not state the number in each group. All the trials had a high risk of bias. There was no mortality in any of the trials that reported this outcome. There was no significant difference in the proportion of participants with serious adverse events (six trials; 5/172 (weighted proportion 2.4%) versus 2/171 (1.2%); RR 2.01; 95% CI 0.52 to 7.80). There was no significant difference in the rate of serious adverse events between the two groups (three trials; 5/99 events (weighted number of events per person = 0.346 events) versus 2/99 events (0.020 events per person); rate ratio 1.73; 95% CI 0.35 to 8.61). None of the trials reported quality of life or pain between four and eight hours after the operation. There was no significant difference in the proportion of people who underwent conversion to open cholecystectomy (11 trials; 5/225 (weighted proportion 2.3%) versus 7/235 (3.0%); RR 0.76; 95% CI 0.26 to 2.21). The operating time was significantly longer in the abdominal wall lift group than in the pneumoperitoneum group (16 trials; 6.87 minutes longer (95% CI 4.74 minutes to 9.00 minutes longer) in the abdominal wall lift group versus 75 minutes in the pneumoperitoneum group). There was no significant difference in the proportion of people discharged as laparoscopic cholecystectomy day-patients (two trials; 15/31 (weighted proportion 48.5%) versus 9/31 (29%); RR 1.67; 95% CI 0.85 to 3.26).

AUTHORS' CONCLUSIONS

Abdominal wall lift with or without pneumoperitoneum does not seem to offer an advantage over pneumoperitoneum in any of the patient-oriented outcomes for laparoscopic cholecystectomy in people with low anaesthetic risk. Hence it cannot be recommended routinely. The safety of abdominal wall lift is yet to be established. More research on the topic is needed because of the risk of bias in the included trials and because of the risk of type I and type II random errors due to the few participants included in the trials. Future trials should include people at higher anaesthetic risk. Furthermore, such trials should include blinded assessment of outcomes.

Acute renal failure following laparoscopic cholecystectomy

A 67-year-old man underwent a laparoscopic cholecystectomy, which was complicated by an empyematous gallbladder. Postoperatively, he was found to have acute renal failure (evidenced by abdominal distension and pain, anuria and vomiting). This was thought to be secondary to pneumoperitoneum, an essential part of the laparoscopic procedure.

Management of benign ovarian cysts by a novel, gasless, single-incision laparoscopic technique: keyless abdominal rope-lifting surgery (KARS)

BACKGROUND

To find the most efficacious method to minimize the side effects and maximize the advantages of laparoscopic surgery, this study aimed to define and document a gasless, single-incision abdominal access technique for the management of benign ovarian cysts.

METHODS

During a 1½ year period, 55 women underwent surgery for a benign ovarian cyst. Conventional carbon dioxide (CO(2)) laparoscopy was used for 33 of the women, and 22 of the women underwent a novel, gasless, single-incision laparoscopic surgery. An abdominal access pathway through a single intraabdominal incision was used to place transabdominal sutures that elevated the abdominal wall, and the operations were performed through the intra-umbilical entry without the use of trocars. Thus, the new technique was called keyless abdominal rope-lifting surgery (KARS). Two operative groups were compared to assess the feasibility of the new technique.

RESULTS

All the operations could be performed by KARS without conversion to CO(2) laparoscopy or laparotomy. However, for two patients in the conventional laparoscopy group, minilaparotomy had to be performed for tissue retrieval. Although the two techniques had many similar results, the total operative times and the abdominal access times in the KARS group were significantly longer than in the conventional laparoscopy group (p < 0.05). Simple oral analgesics were adequate for postoperative pain relief in both groups.

CONCLUSIONS

The KARS technique is a gasless, single-incision laparoscopic procedure that can be performed safely and effectively in terms of cosmesis, postoperative pain, and fertility preservation for the management of benign adnexal pathologies.

Abdominal lift for laparoscopic cholecystectomy

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Multiple-, but not single-, dose of parecoxib reduces shoulder pain after gynecologic laparoscopy

BACKGROUND

The aim of this study was to investigate effect of single- and multiple-dose of parecoxib on shoulder pain after gynecologic laparoscopy.

METHODS

126 patients requiring elective gynecologic laparoscopy were randomly allocated to three groups. Group M (multiple-dose): receiving parecoxib 40mg at 30min before the end of surgery, at 8 and 20hr after surgery, respectively; Group S (single-dose): receiving parecoxib 40mg at 30min before the end of surgery and normal saline at the corresponding time points; Group C (control): receiving normal saline at the same three time points. The shoulder pain was evaluated, both at rest and with motion, at postoperative 6, 24 and 48hr. The impact of shoulder pain on patients' recovery (activity, mood, walking and sleep) was also evaluated. Meanwhile, rescue analgesics and complications were recorded.

RESULTS

The overall incidence of shoulder pain in group M (37.5%) was lower than that in group C (61.9%) (difference=-24.4%; 95% CI: 3.4~45.4%; P=0.023). Whereas, single-dose regimen (61.0%) showed no significant reduction (difference with control=-0.9%; 95% CI: -21.9~20.0%; P=0.931). Moreover, multiple-dose regimen reduced the maximal intensity of shoulder pain and the impact for activity and mood in comparison to the control. Multiple-dose of parecoxib decreased the consumption of rescue analgesics. The complications were similar among all groups and no severe complications were observed.

CONCLUSIONS

Multiple-, but not single-, dose of parecoxib may attenuate the incidence and intensity of shoulder pain and thereby improve patients' quality of recovery following gynecologic laparoscopy.

Evaluation of post operative shoulder tip pain in low pressure versus standard pressure pneumoperitoneum during laparoscopic cholecystectomy

INTRODUCTION

Insufflation of carbon dioxide during laparoscopic cholecystectomy leads to postoperative shoulder tip pain. The origin of shoulder pain is commonly assumed to be due to overstretching of the diaphragmatic muscle fibres owing to a high carbon dioxide pressure.

AIMS

To study the frequency and intensity of post operative shoulder tip pain in laparoscopic cholecystectomy and compare low and standard pressure pneumoperitoneum during laparoscopic cholecystectomy with respect to post operative shoulder tip pain.

METHODS

Patients admitted in the department of surgery for elective cholecystectomy were enrolled in the study. The patients were randomly allocated to two groups (group A and group B). In group A (n = 50), low pressure pneumoperitoneum (8 mm Hg) and in group B (n = 50), standard pressure pneumoperitoneum (14 mm Hg) was generated during laparoscopic cholecystectomy. Postoperative shoulder tip pain was assessed at 4, 8 and 24 h after operation by the Visual Analogue Scale of Pain.

RESULTS

14 patients (28%) in group B complained of post operative shoulder tip pain as compared to only 5 patients (10%) in group A. The mean intensity of post operative shoulder tip pain assessed by visual analogue scoring scale at 4, 8 and 24 h was less in group A as compared to group B, although statistical significance was seen only at 4 h. Analgesic requirements and the mean length of post operative stay in the hospital were also less in group A as compared to group B.

CONCLUSION

Low pressure laparoscopic cholecystectomy (LPLC) significantly decreases the frequency and intensity of postoperative shoulder tip pain. LPLC decreases the demand for postoperative analgesics, decreases postoperative hospital stay and hence improves the quality of life in the early stage of postoperative rehabilitation.

The effect of perioperative esmolol infusion on the postoperative nausea, vomiting and pain after laparoscopic appendectomy

BACKGROUND

Perioperative opioid administration results in postoperative nausea and vomiting (PONV) and acute opioid tolerance that manifests in increased postoperative pain. Esmolol is an ultra short acting cardioselective β1-adrenergic receptor antagonist, and it has been successfully used for perioperative sympatholysis and it reduces the opioid requirement during total intravenous anesthesia. We tested the hypothesis that perioperative esmolol administration results in decreased PONV and postoperative pain.

METHODS

Sixty patients undergoing laparoscopic appendectomy were randomly assigned to two groups (Group E and Group C). The Group E patients were administered 5-10 µg/kg/min esmolol with remifentanil that was titrated to the autonomic response. The Group C patients received normal saline that was of the same volume as the esmolol in Group E, and the remifentanil was also titrated to the vital sign. Before intubation and extubation, the Group E patients were administered 1.0 mg/kg esmolol, and the Group C patients were administered normal saline of the same volume. The incidence and severity of PONV, the pain score, the rescue antiemetics and the rescue analgesics were assessed 30 min, 6 h and 24 h after surgery. The mean arterial pressure and heart rate under anesthesia were also recorded.

RESULTS

PONV and postoperative pain were significantly increased in Group C. These patients needed more antiemetics and analgesics in the first 24 postoperative hours. The mean arterial pressure and heart rate were significantly higher in Group C at the time of intubation and extubation.

CONCLUSIONS

Perioperative esmolol administration contributes to the significant decrease in PONV and postoperative pain, and so this facilitates earlier discharge.

Abdominal lift for laparoscopic cholecystectomy

BACKGROUND

Laparoscopic cholecystectomy is the main method of treatment of symptomatic gallstones. Several cardiopulmonary changes (decreased cardiac output, pulmonary compliance, and increased peak airway pressure) occur during pneumoperitoneum. These changes may not be tolerated in individuals with poor cardiopulmonary reserve.

OBJECTIVES

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

SEARCH STRATEGY

We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, The Cochrane Central Register of Controlled Trials in The Cochrane Library, MEDLINE, EMBASE, and Science Citation IndexExpanded until January 2007.

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

We calculated the relative risk (RR), weighted mean difference (WMD) or standardised mean difference (SMD) with 95% confidence intervals (CI) based on intention-to-treat analysis with both the fixed-effect and the random-effects model using RevMan Analysis.

MAIN RESULTS

Abdominal wall lift with pneumoperitoneum versus pneumoperitoneum. A total of 156 participants (all with low anaesthetic risk) who underwent elective laparoscopic cholecystectomy were randomised in six trials to abdominal wall lift with pneumoperitoneum (n = 65) versus pneumoperitoneum only (n = 66). One trial which included 25 patients did not state the number of patients in each group. All six trials were of high risk of bias. The cardiopulmonary changes were less in abdominal wall lift than pneumoperitoneum. There was no difference in the morbidity and pain between the groups. Abdominal wall lift versus pneumoperitoneum. A total of 550 participants (the majority with low anaesthetic risk) who underwent elective laparoscopic cholecystectomy were randomised in fourteen trials to abdominal wall lift without pneumoperitoneum (n = 268) versus pneumoperitoneum (n = 282). Two of these fourteen trials were of low risk of bias. The cardiopulmonary changes were less in abdominal wall lift than with pneumoperitoneum. There was no difference in the morbidity and pain between the groups. The operating time was prolonged in abdominal wall lift compared with pneumoperitoneum (WMD 7.74, 95% CI 1.37 to 14.12).

AUTHORS' CONCLUSIONS

(1) Abdominal wall lift seems safe and decreases the cardiopulmonary changes associated with laparoscopic cholecystectomy.(2) Abdominal wall lift does not seem to offer advantage over pneumoperitoneum in any of the patient-oriented outcomes for laparoscopic cholecystectomy in patients with low anaesthetic risk and may increase costs by increasing the operating time. Hence it cannot be recommended routinely. More research on the topic is needed.

Routine abdominal drainage for uncomplicated laparoscopic cholecystectomy

BACKGROUND

Laparoscopic cholecystectomy is the main method of treatment of symptomatic gallstones. Drains are used after laparoscopic cholecystectomy to prevent abdominal collections. However, drain use may increase infective complications and delay discharge.

OBJECTIVES

The aim is to assess the benefits and harms of routine abdominal drainage in uncomplicated laparoscopic cholecystectomy.

SEARCH STRATEGY

We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded until March 2007.

SELECTION CRITERIA

We included all randomised clinical trials comparing drainage with no drainage after uncomplicated laparoscopic cholecystectomy. Randomised clinical trials comparing one type of drain with another were also reviewed.

DATA COLLECTION AND ANALYSIS

We collected the data on the characteristics, methodological quality, mortality, abdominal collections, pain, nausea, vomiting, and hospital stay from each trial. We analysed the data with both the fixed-effect and the random-effects models using RevMan Analysis. For each outcome we calculated the odds ratio (OR) with 95% confidence intervals (CI) based on intention-to-treat analysis.

MAIN RESULTS

We analysed six trials involving 741 patients randomised to drain (361) versus no drain (380). The only patient with abdominal collections requiring intervention belonged to the drain group. Wound infection was significantly higher in those with a drain (OR 5.86, 95% CI 1.05 to 32.70). Drainage was associated with nausea, but this was not statistically significant. Hospital stay was longer in the drain group and the number of patients discharged at the day of operation was significantly reduced in the no drain group (OR 2.45, 95% CI 0.00 to 0.57, 1 trial). We also reviewed one trial with 41 patients randomised to suction drain (22) versus closed passive drain (19). This trial suggests that suction drains carried less pain than passive drains.

AUTHORS' CONCLUSIONS

Drain use after elective laparoscopic cholecystectomy increases wound infection rates and delays hospital discharge. We could not find evidence to support the use of drain after laparoscopic cholecystectomy.

Routine abdominal drainage for uncomplicated laparoscopic cholecystectomy

BACKGROUND

Laparoscopic cholecystectomy is the main method of treatment of symptomatic gallstones. Drains are used after laparoscopic cholecystectomy to prevent abdominal collections. However, drain use may increase infective complications and delay discharge.

OBJECTIVES

The aim is to assess the benefits and harms of routine abdominal drainage in uncomplicated laparoscopic cholecystectomy.

SEARCH STRATEGY

We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded until March 2007.

SELECTION CRITERIA

We included all randomised clinical trials comparing drainage with no drainage after laparoscopic cholecystectomy. Randomised clinical trials comparing one type of drain with another were also reviewed.

DATA COLLECTION AND ANALYSIS

We collected the data on the characteristics, methodological quality, mortality, abdominal collections, pain, nausea, vomiting, and hospital stay from each trial. We analysed the data with both the fixed-effect and the random-effects models using RevMan Analysis. For each outcome we calculated the odds ratio (OR) with 95% confidence intervals (CI) based on intention-to-treat analysis.

MAIN RESULTS

We analysed five trials involving 591 patients randomised to drain (281) versus no drain (310). We also reviewed one trial with 41 patients randomised to suction drain (22) versus closed passive drain (19). The only trial that reported on abdominal collections requiring intervention reported no abdominal collections requiring intervention in either group. Wound infection tended to be higher in those with a drain (OR 15.38, 95% CI 0.86 to 275.74). Drainage was associated with lower shoulder, abdominal pain, and nausea, but this was not statistically significant. Hospital stay was longer in the drain group.

AUTHORS' CONCLUSIONS

Drain use after elective laparoscopic cholecystectomy reduces early post-operative pain, but increases wound infection rates and delays hospital discharge. We could not find evidence to support the use of drain after laparoscopic cholecystectomy.

Postoperative pain treatment for ambulatory surgery

One of the most significant changes in surgical practice during the last two decades has been the growth of ambulatory surgery. Adequate postoperative analgesia is a prerequisite for successful ambulatory surgery. Recent studies have shown that large numbers of patients suffer from moderate to severe pain during the first 24-48 hr. The success of fast-tracking depends to a considerable extent on effective postoperative pain management routines and the cost saving of outpatient surgery may be negated by unanticipated hospital admission for poorly treated pain. Depending on the intensity of postoperative pain current management includes the use of analgesics such as paracetamol, NSAIDs including coxibs and tramadol as single drugs or in combination as part of balanced (multimodal) analgesia. However, in the ambulatory setting many patients suffer from pain at home in spite of multimodal analgesic regimens. Sending patients home with perineural, incisional, and intra-articular catheters is a new and evolving area of postoperative pain management. Current evidence suggests that these techniques are effective, feasible and safe in the home environment if appropriate patient selection routines and organization for follow-up are in place.

A procedure-specific systematic review and consensus recommendations for postoperative analgesia following laparoscopic cholecystectomy

BACKGROUND

Laparoscopic cholecystectomy has advantages over the open procedure for postoperative pain. However, a systematic review of postoperative pain management in this procedure has not been conducted.

METHODS

A systematic review was conducted according to the guidelines of the Cochrane Collaboration. Randomized studies examining the effect of medical or surgical interventions on linear pain scores in patients undergoing laparoscopic cholecystectomy were included. Qualitative and quantitative analyses were performed. Recommendations for patient care were derived from review of these data, evidence from other relevant procedures, and clinical practice observations collated by the Delphi method among the authors.

RESULTS

Sixty-nine randomized trials were included and 77 reports were excluded. Recommendations are provided for preoperative analgesia, anesthetic and operative techniques, and intraoperative and postoperative analgesia.

CONCLUSIONS

A step-up approach to the management of postoperative pain following laparoscopic cholecystectomy is recommended. This approach has been designed to provide adequate analgesia while minimizing exposure to adverse events.

Vacuum-assisted abdominal wall lift for minimal-access surgery: a porcine model study

Carbon dioxide pneumoperitoneum, although used universally in laparoscopy, has several well-documented complications and disadvantages. The authors describe a simple method of creating vacuum between a rigid shell and the abdominal wall in a porcine model to create adequate operative space for minimal-access surgery, which does not requires carbon dioxide, does not raise intraabdominal pressure, and is safe, cost effective, and feasible. The proposed device and method could be useful wherever basic laparoscopic equipment and a vacuum pump are available, including many parts of the developing world. The study was carried out with three groups using individual porcine models for each study. Group 1 was studied for feasibility of abdominal wall lift, adequacy of intraabdominal space, optimal vacuum levels, and safety and efficacy of the procedure. Group 2 was subjected to laparoscopic cholecystectomy and salpingectomy. Group 3 was studied for 2 days and 8 days after the animals were subjected to prolonged, high-level vacuum and monitored every 24 h to establish long-term effects. In all three groups the safety and efficacy of the proposed method were established, as well as the absence of physiological or histological alterations.

Abdominal wall lift versus positive-pressure capnoperitoneum for laparoscopic cholecystectomy: randomized controlled trial

OBJECTIVE

To compare intraoperative cardiac function, postoperative cognitive recovery, and surgical performance of laparoscopic cholecystectomy with abdominal wall lift (AWL) versus positive-pressure capnoperitoneum (PPCpn).

SUMMARY BACKGROUND DATA

AWL has been proposed as an alternative approach to PPCpn to avoid adverse cardio-respiratory changes. However, the workspace obtained with the AWL is less optimal than PPCpn and previous studies documenting delayed postoperative recovery of consciousness following PPCpn have not assessed mental alertness despite its importance.

METHODS

Forty operations were randomized into AWL and PPCpn. A standard anesthetic protocol was followed. Cardiac indices were measured with an esophageal Doppler machine. An auditory vigilance test was used to measure alertness level following extubation. All operations were videotaped and human reliability assessment techniques were used to identify surgical errors.

RESULTS

There was a significant reduction in cardiac output during the first 20 minutes following CO2 insufflation in the PPCpn group, whereas in the AWL group it did not exhibit any significant change. Patients in AWL arm had better vigilance scores at 90 and 180 minutes following extubation compared with the PPn group (P < 0.05). Significantly more surgical errors were observed during surgery with AWL than with PPCpn (7.1 +/- 1.1; versus 2.9 +/- 0.4; P = 0.001).

CONCLUSIONS

The AWL approach avoids fall in cardiac output associated with PPCpn during laparoscopic surgery and is associated with a more rapid recovery of postoperative cognitive function compared with PPCpn. However, AWL increases the level of difficulty in the execution of the operation.

Randomized comparison between different insufflation pressures for laparoscopic cholecystectomy

Laparoscopy using carbon dioxide insufflation induces adverse effects in both the cardiovascular and the respiratory function. The use of low pressure pneumoperitoneum has been shown to reduce adverse hemodynamic effects. However, its effect on tissue trauma and postoperative pain and recovery remains controversial. The aim of this study was to compare tissue trauma, postoperative pain, and recovery in two groups of patients undergoing laparoscopic cholecystectomy, one at insufflation pressure of 8 (LC8) and the other at 15 mm Hg (LC15). Forty patients were randomized, 20 in each group. The characteristics of the patients were similar in the two groups. The procedure was completed in all patients in the LC15 group, but in 2 patients in the LC8 group the pressure was increased to 15 mm Hg to complete the operation. There were no significant differences in postoperative pain scores, analgesic consumption, and the incidence of nausea, vomiting, and shoulder pain between the two groups. C-reactive protein concentrations and white blood cell count rose significantly after surgery, but the increase was similar in the two groups. The median duration of surgery was similar, 23 minutes (range 15-65) in the LC8 group and 25 minutes (range 15-80) in the LC15 group. Using our technique of laparoscopic cholecystectomy, there were no advantages to tissue damage, postoperative pain, and recovery when a low pressure pneumoperitoneum was used.

Effect of drainage on postoperative nausea, vomiting, and pain after laparoscopic cholecystectomy

BACKGROUND

Laparoscopic cholecystectomy is associated with a high incidence of postoperative pain, nausea, and vomiting. Pneumoperitoneum created during the operation and residual gas after the operation are two of the factors in postoperative pain and nausea. We studied the effects of a subdiaphragmatic gas drain, which is intended to decrease the residual gas, on postoperative pain, nausea, and vomiting after laparoscopic cholecystectomy.

PATIENTS AND METHODS

Seventy patients were randomized into two demographically and clinically comparable groups: drainage and control. Postoperative pain, nausea, and vomiting were measured by verbal grading and visual analog scale 2-72 h postoperatively. Analgesic and antiemetic use and incidence of retching, vomiting and other complaints were also recorded.

RESULTS

Subdiaphragmatic drain effectively reduced the incidence and amount of subdiaphragmatic gas bubble. The incidence and severity of nausea was lower in the drainage group at 72 h. Although severity of pain was lower at 8 and 12 h in the drainage group, the difference was not significant. There was also no difference between the groups in regard to analgesic and antiemetic use.

CONCLUSIONS

Subdiaphragmatic drain offers only minor, if any, benefit on postoperative pain, nausea, and vomiting after laparoscopic cholecystectomy, and this effect is probably clinically irrelevant.

Systemic response in patients undergoing laparoscopic cholecystectomy using gasless or carbon dioxide pneumoperitoneum: a randomized study

In general, laparoscopic cholecystectomy produces a surgical stress response very similar to which occurs after open cholecystectomy. The question is whether the pneumoperitoneum constitutes a significant pathophysiologic trauma, which might be followed by profound changes in the stress response. We conducted a prospective, randomized trial involving 50 consecutive patients scheduled for laparoscopic cholecystectomy, who had a body mass index equal to or less than 30 kg/m(2) with no acute cholecystitis, pancreatitis, or liver or renal disease. These patients were randomized to undergo either the gasless (GLC, n = 24) or the carbon dioxide pneumoperitoneum (CLC, n = 26) procedure. Perioperative assessment of cortisol, insulin, glucose, and C-reactive protein levels was the main determinant of outcome. During the operative procedure, significantly higher levels of serum cortisol and insulin were found in the CLC group than in the GLC group (P < 0.05). No difference in glucose levels was observed between the two groups. The inflammatory response was moderate in both groups. However, on postoperative day 1 the median C-reactive protein level was significantly higher in the GLC group than that in the CLC group (P < 0.05). Carbon dioxide and the positive intra-abdominal pressure during conventional laparoscopy may contribute to the activation of the surgical stress response.

Gastric air tonometry during laparoscopic cholecystectomy: a comparison of two PaCO2 levels

PURPOSE

Pneumoperitoneum can cause disturbances in acid-base balance and splanchnic perfusion. We studied the effect of ventilation on acid-base balance and gastric mucosal tonometric values in patients undergoing laparoscopic cholecystectomy.

METHODS

Twenty-four patients (ASA I-II) were randomly allocated into two groups. In the fixed ventilation group, ventilation was constant allowing free increase in PCO2, while in the constant CO2 group end-tidal PCO2 was fixed with ventilatory adjustment. Intraabdominal pressure was limited to 12 mmHg. Arterial acid-base balance, automated air tonometric variables and gastric mucosal to arterial PCO2 gap were determined frequently from anesthesia induction until three hours postoperatively.

RESULTS

During pneumoperitoneum, in the fixed ventilation group arterial PCO2 changed from 5.0 +/- 0.2 to 6.6 +/- 0.4 kPa and pH from 7.43 +/- 0.03 to 7.33 +/- 0.04, tonometric PCO2 from 5.1 +/- 0.5 to 6.9 +/- 0.4 and pH from 7.44 +/- 0.04 to 7.33 +/- 0.04. In the constant CO2 group these variables remained at control levels (P < 0.01 between groups). The PCO2 gap remained unchanged without any differences between the groups. In the recovery room all measured variables were within normal range in both groups.

CONCLUSION

Despite inter-group differences in arterial and tonometric PCO2 and pH values during CO2 pneumoperitoneum, the patients did not develop splanchnic hypoperfusion detectable by air tonometric method, as indicated by normal PCO2 gap in both groups throughout the study.

Pain after laparoscopic cholecystectomy

BACKGROUND

Although laparoscopic cholecystectomy (LC) results in less pain than open chole-cystectomy, it is not a pain-free procedure. Many methods of analgesia for pain after laparoscopy have been evaluated.

METHODS

Forty-two randomized controlled trials assessing interventions to reduce pain after LC are reviewed, as are the mechanisms and nature of pain after this procedure.

RESULTS

Non-steroidal anti-inflammatory drugs, wound local anaesthetic, intraperitoneal local anaesthetic, intraperitoneal saline, a gas drain, heated gas, low-pressure gas and nitrous oxide pneumo-peritoneum have been shown to reduce pain after LC. The clinical significance of this pain reduction is questionable.

CONCLUSION

Pain after LC is multifactorial. Although many methods of analgesia produce short-term benefit, this does not equate with earlier discharge or improved postoperative function. However, single trials evaluating low-pressure insufflation, heated gas and multimodal analgesia suggest that clinically relevant benefits can be achieved.

Respiratory mechanics during laparoscopic cholecystectomy: the effects of the abdominal wall lift

The abdominal wall lift (AWL) has been proposed for laparoscopic cholecystectomy to reduce hemodynamic effects caused by carbon dioxide (CO2) and high intraabdominal pressures (IAP). Data concerning effects of AWL on respiratory mechanics are scant. We therefore used a noninvasive method to evaluate whether the AWL could offset these effects. The PETCO2, airflow, and airway pressure were continuously measured in nine patients undergoing laparoscopic cholecystectomy using an AWL with minimal CO2 insufflation. We used a least-squares method to calculate maximal airway pressure (Pmax), elastance (Ers), and resistances (Rrs) of the respiratory system. After CO2 insufflation, the initiation of AWL resulted in a significantly decreased IAP (from 13 to 6 mm Hg; P < 0.001) and Rrs (from 20.6 to 17.8 cm H2O.L(-1).s(-1); P = 0.029), whereas Ers was partly modified (34.0 to 33.3 cm H2O/L; not significantly different). With AWL, we hypothesized that the diaphragm remained flat and stiff, outweighing the beneficial effect of the decrease of IAP on Ers. PETCO2 significantly increased after AWL and at the end of the procedure. We conclude that AWL partly reverses the impairment of the respiratory mechanics induced by CO2 insufflation during laparoscopic surgery.

IMPLICATIONS

The abdominal wall lift (AWL), acting on the abdominal chest wall, had some benefits during laparoscopic surgery by limiting CO2 peritoneal insufflation and several side effects, such as hemodynamics. We examined the consequences of this technique on respiratory mechanics in nine patients undergoing laparoscopic cholecystectomy. Our findings suggest that the AWL decreases intraabdominal pressure and respiratory resistances without a significant effect on respiratory elastance.

A randomized, prospective comparison of pain after gasless laparoscopy and traditional laparoscopy

STUDY OBJECTIVE

To compare pain after laparoscopic tubal ligation by gasless laparoscopy versus carbon dioxide (CO2) pneumoperitoneum.

DESIGN

Prospective, randomized, single-blind comparison (Canadian Task Force classification I).

SETTING

Private obstetric-gynecology hospital associated with a university resident teaching program.

PATIENTS

Women age 21 to 42.

INTERVENTION

Single-puncture laparoscopic tubal ligation was performed with a silicone elastomer band. Gasless laparoscopy was performed with a Laprolift and traditional laparoscopy with CO2 pneumoperitoneum. Postoperative pain in the shoulder and periumbilical and lower pelvic regions was measured by visual analog scale on the day of surgery and postoperative days 1, 2, 3, 7, and 14.

MEASUREMENTS AND MAIN RESULTS

Of the 67 patients, 54 provided visual analog scales for analysis, 30 in the gasless group and 24 in the traditional group. No statistical difference was seen in scores for shoulder, periumbilical, and pelvic pain between techniques.

CONCLUSION

Patients undergoing gasless laparoscopy and traditional laparoscopy experience similar postoperative pain.

Effects of esmolol on haemodynamic response to CO2 pneumoperitoneum for laparoscopic surgery

BACKGROUND

Carbon dioxide (CO2) pneumoperitoneum for laparoscopic surgery increases arterial pressures, systemic vascular resistance and heart rate and decreases urine output.

METHODS

In this double-blind randomized study esmolol, an ultrashort-acting beta1-adrenoceptor antagonist was compared with physiological saline (control) in 28 patients undergoing laparoscopic surgery in standardized 1 MAC isoflurane anaesthesia. Alfentanil infusion was used to prevent the increase of mean arterial pressure more than 25% from baseline.

RESULTS

Esmolol effectively prevented the pressor response to induction and maintenance of CO2 pneumoperitoneum. Significantly (P<0.001) less alfentanil was needed in the esmolol group than in the control group. Urine output was higher (P<0.05) and plasma renin activity (P<0.01) and urine N-acetyl-beta-D-glucosaminidase levels lower in the esmolol group when compared with the control group.

CONCLUSIONS

Esmolol blunts the pressor response to induction and maintenance of pneumoperitoneum and may protect against renal ischaemia during pneumoperitoneum.

A comparison of gasless mechanical and conventional carbon dioxide pneumoperitoneum methods for laparoscopic cholecystectomy

Carbon dioxide (CO2) insufflation with increased intraabdominal pressure (IAP) has adverse hemodynamic, pulmonary, and renal effects. To avoid these problems, an abdominal wall lift method with a retractor was used to provide the surgical view without CO2 insufflation. Twenty-six patients undergoing elective laparoscopic cholecystectomy were randomly allocated to either the gasless, retractor group, or conventional CO2 pneumoperitoneum group (CPP). Hemodynamic data, ventilatory variables, urine output, urine oxygen tension, and blood samples for determining stress hormones were collected throughout the perioperative period. Patients in the retractor group had lower mean arterial pressure, heart rate, and central venous pressure (P < 0.001). They also had higher pulmonary dynamic compliance and needed a lower minute volume of ventilation to achieve normocarbia (P < 0.001). Urine output and oxygen tension in urine were higher (P < 0.05) with the retractor method than with CPP. Increase in plasma renin activity (P < 0.05) and decrease in core temperature (P < 0.001) were smaller with the gasless method than with CPP. The gasless method for laparoscopic cholecystectomy might be beneficial, especially in patients with compromised cardiorespiratory or renal function.

IMPLICATIONS

Totally gasless laparoscopic cholecystectomy was compared with conventional pressure pneumoperitoneum with CO2 insufflation. The gasless method resulted in more stable hemodynamics and pulmonary function, as well as higher urine, output than conventional pressure pneumoperitoneum. No changes in renal oxygenation was seen with the gasless method, compared with conventional pressure pneumoperitoneum.