Effects of laparoscopic cholecystectomy on lung function: A systematic review

Laparoscopic repair of bile duct injuries: Feasibility and outcomes

INTRODUCTION

Bile duct injuries (BDI) following laparoscopic cholecystectomy occurs in approximately 0.6% of the cases, often being more severe and complex. Roux-en-Y hepaticojejunostomy (RYHJ) is considered the optimal therapeutic option, with success rates ranging from 75% to 98%. Several series have demonstrated the advancements of the laparoscopic approach for resolving this condition. The objective of this study is to describe our experience in the laparoscopic repair of BDI.

METHODS

A retrospective, descriptive study was conducted, including patients who underwent laparoscopic repair after BDI. Demographic, clinical, surgical, and postoperative variables were analysed using descriptive statistical analyses.

RESULTS

Eight patients with BDI underwent laparoscopic repair (out of 81 surgically repaired patients). Women comprised 75% of the sample. A complete laparoscopic repair was achieved in 75% (6) of cases. The mean age was 40.8 ± 16.61 years (range 19-65). Injuries at or above the confluence (Strasberg-Bismuth ≥ E3) occurred in 25% of cases (2). Primary repair was performed in two cases. Half of the cases underwent a Hepp-Couinaud laterolateral RYHJ, while three patients received a terminolateral RYHJ, and one underwent a bi-terminolateral RYH. The mean operative time was 260 min (range 120-360). Overall morbidity was 37.5% (3 cases): two minor complications (bile leak grade A and drainage-related bleeding) and one major complication (bile leak grade C). No mortality was recorded. The maximum follow-up period reached 26 months (range 6-26).

CONCLUSIONS

Our study demonstrates the feasibility of laparoscopic RYHJ in a selected group of patients, offering the benefits of a minimally invasive approach.

Early Postoperative Fever and Atelectasis in Patients Undergoing Upper Abdominal Surgery

BACKGROUND

Atelectasis is a common complication after upper abdominal surgery and considered as a cause of early postoperative fever (EPF) within 48 hours after surgery. However, the pathophysiologic mechanism of how atelectasis causes fever remains unclear.

STUDY DESIGN

Data for adult patients who underwent elective major upper abdominal surgery under general anesthesia at Seoul National University Hospital between January and December of 2021 were retrospectively analyzed. The primary outcome was the association between fever and atelectasis within 2 days after surgery.

RESULTS

Of 1,624 patients, 810 patients (49.9%) developed EPF. The incidence of atelectasis was similar between the fever group and the no-fever group (51.6% vs 53.9%, p = 0.348). Multivariate analysis showed no significant association between atelectasis and EPF. Culture tests (21.7% vs 8.8%, p < 0.001) and prolonged use of antibiotics (25.9% vs 13.9%, p < 0.001) were more frequent in the fever group compared to the no-fever group. However, the frequency of bacterial growth on culture tests and postoperative pulmonary complications within 7 days were similar between the two groups.

CONCLUSIONS

EPF after major upper abdominal surgery was not associated with radiologically detected atelectasis. EPF also was not associated with the increased risk of postoperative pulmonary complications, bacterial growth on culture studies, or prolonged length of hospital stay.

Effects of Dexmedetomidine on Immunomodulation and Pain Control in Videolaparoscopic Cholecystectomies: A Randomized, Two-Arm, Double-Blinded, Placebo-Controlled Trial

Aim: Digital and robotic technology applications in laparoscopic surgery have revolutionized routine cholecystectomy. Insufflation of the peritoneal space is vital for its safety but comes at the cost of aseptic ischemia-reperfusion-induced intraabdominal organ compromise before the return of physiologic functions. Dexmedetomidine in general anesthesia promotes controlling the response to trauma by altering the neuroinflammatory reflex. This strategy may improve clinical outcomes in the postoperative period by reducing postoperative narcotic use and lowering the risk of subsequent addiction. In this study, the authors aimed to evaluate dexmedetomidine’s therapeutic and immunomodulatory potential on perioperative organ function. Methods: Fifty-two patients were randomized 1:1: group A—sevoflurane and dexmedetomidine (dexmedetomidine infusion [1 µg/kg loading, 0.2–0.5 µg/kg/h maintenance dose]), and group B—sevoflurane with saline 0.9% infusion as a placebo control. Three blood samples were collected: preoperatively (T0 h), 4–6 h after surgery (T4–6 h), and 24 h postoperatively (T24 h). The primary outcome was the level analysis of inflammatory and endocrine medications. Secondary outcome measures were the time to return to normal preoperative hemodynamic parameters, spontaneous ventilation, and postoperative narcotic requirements to control surgical pain. Results: A reduction of Interleukin 6 was found at 4–6 h after surgery in group A with a mean of 54.76 (27.15–82.37; CI 95%) vs. 97.43 (53.63–141.22); p = 0.0425) in group B patients. Systolic and diastolic blood pressure and heart rate were lower in group A patients, who also had a statistically significantly lower opioid consumption in the first postoperative hour when compared to group B patients (p < 0.0001). We noticed a similar return to spontaneous ventilation pattern in both groups. Conclusions: Dexmedetomidine decreased interleukin-6 4–6 h after surgery, likely by providing a sympatholytic effect. It provides good perioperative analgesia without respiratory depression. Implementing dexmedetomidine during laparoscopic cholecystectomy has a good safety profile and may lower healthcare expenditure due to faster postoperative recovery.

Low tidal volume ventilation for patients undergoing laparoscopic surgery: a secondary analysis of a randomised clinical trial

BACKGROUND

We recently reported the results for a large randomized controlled trial of low tidal volume ventilation (LTVV) versus conventional tidal volume (CTVV) during major surgery when positive end expiratory pressure (PEEP) was equal between groups. We found no difference in postoperative pulmonary complications (PPCs) in patients who received LTVV. However, in the subgroup of patients undergoing laparoscopic surgery, LTVV was associated with a numerically lower rate of PPCs after surgery. We aimed to further assess the relationship between LTVV versus CTVV during laparoscopic surgery.

METHODS

We conducted a post-hoc analysis of this pre-specified subgroup. All patients received volume-controlled ventilation with an applied PEEP of 5 cmH₂O and either LTVV (6 mL/kg predicted body weight [PBW]) or CTVV (10 mL/kg PBW). The primary outcome was the incidence of a composite of PPCs within seven days.

RESULTS

Three hundred twenty-eight patients (27.2%) underwent laparoscopic surgeries, with 158 (48.2%) randomised to LTVV. Fifty two of 157 patients (33.1%) assigned to LTVV and 72 of 169 (42.6%) assigned to conventional tidal volume developed PPCs within 7 days (unadjusted absolute difference, - 9.48 [95% CI, - 19.86 to 1.05]; p = 0.076). After adjusting for pre-specified confounders, the LTVV group had a lower incidence of the primary outcome than patients receiving CTVV (adjusted absolute difference, - 10.36 [95% CI, - 20.52 to - 0.20]; p = 0.046).

CONCLUSION

In this post-hoc analysis of a large, randomised trial of LTVV we found that during laparoscopic surgeries, LTVV was associated with a significantly reduced PPCs compared to CTVV when PEEP was applied equally between both groups.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry no: 12614000790640.

Robotic Revision of Hepaticojejunostomy for Benign Biliary Stricture

Surgical revision of biliary enteric anastomoses (BEA) can be a challenging undertaking and a robotic platform may provide advantages that address many of the technical obstacles. We present our technical approach and outcomes for patients undergoing robotic revision of BEA for benign strictures. A retrospective review was performed for robot-assisted benign BEA revision at our institution. Operative details, perioperative metrics, and outcomes are reported. Four patients underwent anastomotic revision following previously failed non-operative management. There were no intraoperative complications, mean length of stay was 4-days, and all patients experienced resolution of presenting clinical signs and symptoms. No patients required reoperation and there was no mortality. Postoperative outcomes were consistent with findings reported for other interventional modalities. Based on our experience we conclude robotic intervention in this context is safe and improves the technical feasibility of this complex procedure.

New techniques of regional anaesthesia for renal laparoscopic surgeries

Renal procedures are performed within the realm of urology, general and transplant surgery. The implementation of new operating techniques imposes on anaesthetists the need to adapt their methods, aiming to improve the patient's perioperative comfort and safety. Laparoscopy is gaining increasing interest as a less invasive procedure; however clinical research shows that pain after the procedure is underestimated and therefore poorly controlled. Multimodal analgesia is very promising, though, as it allows better pain control, expedites discharge and enhances recovery. This is achieved through a combination of general and regional anaesthesia with administration of adjuvant drugs intraoperatively, resulting in reduced opioid requirements in the recovery room with diminished side effects of pain treatment. Good communication between the surgeon and the anaesthetist is the key to effective anaesthesia and analgesia.

The effect of ultrasound-guided transversus abdominis plane block on pulmonary function in patients undergoing laparoscopic cholecystectomy: a prospective randomized study

BACKGROUND

Transversus abdominis plane block (TAPB) is commonly used for postoperative pain control after laparoscopic cholecystectomy. However, few studies have analyzed its effect on pulmonary function. The goal of this study was to elucidate the effect of ultrasound-guided bilateral TAPB on pulmonary function preservation and analgesia after laparoscopic cholecystectomy.

METHODS

We enrolled 58 patients who underwent laparoscopic cholecystectomy. Among them, 53 were randomized to group T (n = 27) and group C (n = 26). Group T and group C received ultrasound-guided bilateral TAPB with 40 ml of 0.375% ropivacaine and 40 ml of 0.9% normal saline, respectively. Visual analog scale (VAS) scores, patient-controlled analgesia (PCA) consumption, forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1), FEV1/FVC, peak expiratory flow rate (PEF), and modified Borg scale scores were measured until 24 h post-surgery.

RESULTS

The VAS scores were significantly lower in group T than in group C at 1 and 8 h after the surgery. PCA consumption was significantly lower in group T than in group C at all postoperative time points. FEV1, PEF, and FEV1/FVC were more preserved in group T than in group C at 1 h. Group T had significantly lower modified Borg scale scores than did group C at 1 and 8 h.

CONCLUSION

Ultrasound-guided TAPB is effective in pulmonary function preservation and pain control after laparoscopic cholecystectomy. Therefore, it could be a great option for multimodal analgesia, preservation of pulmonary function, prevention of pulmonary complications including atelectasis, and promotion of postoperative recovery after laparoscopic cholecystectomy.

CLINICAL REGISTRATION

This study was enrolled in the Clinical Research Information Service (Clinical Research Information Service, KCT0004435, Hwa Yong Shin, 2019-08-19).

Perioperative Pulmonary Atelectasis: Part II. Clinical Implications

The development of pulmonary atelectasis is common in the surgical patient. Pulmonary atelectasis can cause various degrees of gas exchange and respiratory mechanics impairment during and after surgery. In its most serious presentations, lung collapse could contribute to postoperative respiratory insufficiency, pneumonia, and worse overall clinical outcomes. A specific risk assessment is critical to allow clinicians to optimally choose the anesthetic technique, prepare appropriate monitoring, adapt the perioperative plan, and ensure the patient's safety. Bedside diagnosis and management have benefited from recent imaging advancements such as lung ultrasound and electrical impedance tomography, and monitoring such as esophageal manometry. Therapeutic management includes a broad range of interventions aimed at promoting lung recruitment. During general anesthesia, these strategies have consistently demonstrated their effectiveness in improving intraoperative oxygenation and respiratory compliance. Yet these same intraoperative strategies may fail to affect additional postoperative pulmonary outcomes. Specific attention to the postoperative period may be key for such outcome impact of lung expansion. Interventions such as noninvasive positive pressure ventilatory support may be beneficial in specific patients at high risk for pulmonary atelectasis (e.g., obese) or those with clinical presentations consistent with lung collapse (e.g., postoperative hypoxemia after abdominal and cardiothoracic surgeries). Preoperative interventions may open new opportunities to minimize perioperative lung collapse and prevent pulmonary complications. Knowledge of pathophysiologic mechanisms of atelectasis and their consequences in the healthy and diseased lung should provide the basis for current practice and help to stratify and match the intensity of selected interventions to clinical conditions.

Outcomes of inpatient cholecystectomy among adults with cystic fibrosis in the United States

BACKGROUND

Symptomatic biliary and gallbladder disorders are common in adults with cystic fibrosis (CF) and the prevalence may rise with increasing CF transmembrane conductance regulator modulator use. Cholecystectomy may be considered, but the outcomes of cholecystectomy are not well described among modern patients with CF.

AIM

To determine the risk profile of inpatient cholecystectomy in patients with CF.

METHODS

The Nationwide Inpatient Sample was queried from 2002 until 2014 to investigate outcomes of cholecystectomy among hospitalized adults with CF compared to controls without CF. A propensity weighted sample was selected that closely matched patient demographics, patient’s individual comorbidities, and hospital characteristics. The propensity weighted sample was used to compare outcomes among patients who underwent laparoscopic cholecystectomy. Hospital outcomes of open and laparoscopic cholecystectomy were compared among adults with CF.

RESULTS

A total of 1239 inpatient cholecystectomies were performed in patients with CF, of which 78.6% were performed laparoscopically. Mortality was < 0.81%, similar to those without CF (P = 0.719). In the propensity weighted analysis of laparoscopic cholecystectomy, there was no difference in mortality, or pulmonary or surgical complications between patients with CF and controls. After adjusting for significant covariates among patients with CF, open cholecystectomy was independently associated with a 4.8 d longer length of stay (P = 0.018) and an $18449 increase in hospital costs (P = 0.005) compared to laparoscopic cholecystectomy.

CONCLUSION

Patients with CF have a very low mortality after cholecystectomy that is similar to the general population. Among patients with CF, laparoscopic approach reduces resource utilization and minimizes post-operative complications.

Incidence, Patient-Related Risk Factors, and Outcomes of Postoperative Pneumonia after Cholecystectomy: A Population-Based Cohort Study

Background

Cholecystectomy is one of the most common surgical procedures performed worldwide. The objective of this large, population-based cohort study is to explore the risk factors of pneumonia after cholecystectomy in Taiwan.

Methods

From the Taiwanese National Health Insurance Research Database, we selected all patients who underwent cholecystectomy by using ICD-9-codes, from January 1, 1998, to December 31, 2016. The patients were separated into two groups based on the presence or absence of postoperative pneumonia. Basic information, comorbidities, and postoperative complications were evaluated using a t-test or chi-square test. There were 6056 patients in the pneumonia group and 24224 patients in the control group. These two groups were shown in a ratio of 1 : 4 and were matched by age and sex. The log-rank test was used to examine differences in postoperative mortality between patients with and without pneumonia. Preoperative risk factors were analyzed using logistic regression analysis, after adjusting for age and sex.

Results

The final dataset included 282184 cholecystectomy patients. Of these patients, 6056 (2.15%) had postoperative new-onset pneumonia. The patient-related risk factors for pneumonia after cholecystectomy in the order of relevance were chronic obstructive pulmonary disease, congestive heart failure, cerebrovascular disease, diabetes mellitus, surgical type, hemodialysis, coronary artery disease, and liver cirrhosis. Compared to patients without postcholecystectomy pneumonia, those with postcholecystectomy pneumonia had higher rates of mortality (within first month, 1.72% vs. 2.28%, P < 0.005) and admission to intensive care unit (15.02% vs. 41.80%, P < 0.0001) and longer hospital stays (10.71 vs. 18.55 days, P < 0.0001).

Conclusion

Our results show that postcholecystectomy associated with pneumonia had higher rates of morbidity and mortality in this clinical population. Early identification and possible management of risk factors for pneumonia could improve outcomes of cholecystectomy and lower the risk for patient comorbidities after surgery.

Effect of Various Modes of Mechanical Ventilation in Laparoscopic Cholecystectomies on Optic Nerve Sheath Diameter and Cognitive Functions

Aim: In this study, we aim at investigating the effects of volume-controlled ventilation (VCV) and pressure-controlled ventilation (PCV) modes on changes in the optic nerve diameter and cognitive functions in laparoscopic cholecystectomy operations. Materials and Methods: Sixty patients who underwent laparoscopic cholecystectomy were randomly divided into two groups based on the mode of mechanical ventilation provided: Group P; PCV, Group V; VCV. Optic nerve sheath diameter was measured when the patient was awake (T0), in the 10th minute after induction (T1), in the 10th minute after the initiation of gas insufflation (T2), when maximum gas pressure was reached in the reverse-Trendelenburg position (T3), and pre-extubation (T4). Partial oxygen saturation (PaO₂), PCO₂, end-tidal carbon dioxide (ETCO₂), and peak airway pressure (pPEAK) were also recorded. A Mini-Mental State Examination (MMSE) was conducted on patients preoperatively and in the postoperative third month. Results: Between the groups, a statistically significant difference was found in Group P compared with Group V in terms of optic nerve diameter at measurement times T1 (P < .05). In the intragroup comparison, a significant difference was found in the initial values in all measurements except for measurement times T0 and T4 in both Group P and Group V (P < .05). pPEAK values were identified to be statistically significantly lower in Group P than Group V at all measurement times (P < .05). No difference was identified in the MMSE scores in the intergroup and intragroup comparisons. Conclusion: Laparoscopic cholecystectomy increases the optic nerve diameter due to the mechanical and systemic effects of the operation, and the PCV mode can be preferred. Clinical Trial Number: NCT04413903.

Perioperative and midterm outcomes of emergent robotic repair of incarcerated ventral and incisional hernia

The literature surrounding emergent robotic ventral hernia repair (RVHR) is scarce. We aimed to present the results of 6 years of experience of RVHR in the emergency setting. Data were retrospectively analyzed from patients who underwent RVHR in an emergent setting between 2013 and 2019. Complications were assessed with the Clavien-Dindo (CD) and Comprehensive Complication Index (CCI^®) scoring systems. Kaplan-Meier's time-to-event analysis was performed to calculate freedom-of-recurrence. Out of 589 patients who underwent RVHR, 34 patients were included. Median APACHE-II scores were 6.5. The average skin-to-skin time was 139 min. 7/34(20.5%) patients experienced minor complications (CD-grades I-II) and 4/34 (11.7%) patients experienced major complications (CD-grades III-IV). CCI^® scores ranged from 0-42.4. Only one (2.9%) patient experienced hernia recurrence. The mean postoperative follow-up was 20.5 (range 1.6-56.3) months. Emergent RVHR showed promising results in terms of midterm outcomes and overall feasibility. RVHR appears to be effective in emergency settings, however, further multicenter studies with long-term follow-up are needed.

Respiratory function following major emergency abdominal surgery

The purpose of this study was to evaluate the timewise postoperative respiratory function measured by spirometry and peak flow during the first postoperative week after major emergency abdominal surgery. Patients were tested daily with forced expiratory volume (FEV) and peak flow (PEF) from postoperative day (POD) 1 through to POD7. FEV1, FEV6, FEV1/FEV6 ratio and PEF were analysed by unadjusted linear regression with 95% confidence interval (CI) on mean values for each postoperative day. A total of 35 consecutive patients were included in the study. The FEV at 1 second was 51% of predicted at POD1, which increased to 67% at POD7 (p = 0.005), whereas FEV6 was 55% of predicted at POD1, which increased to 70% at POD7 (p = .008). Respiratory function was not significantly correlated to synchronous pain scores. In conclusion, respiratory function following major emergency abdominal surgery was reduced throughout the first postoperative week irrespective of pain scores.

Internal Carotid Artery Blood Flow Response to Anesthesia, Pneumoperitoneum, and Head-up Tilt during Laparoscopic Cholecystectomy

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Background

Little is known about how implementation of pneumoperitoneum and head-up tilt position contributes to general anesthesia-induced decrease in cerebral blood flow in humans. We investigated this question in patients undergoing laparoscopic cholecystectomy, hypothesizing that cardiorespiratory changes during this procedure would reduce cerebral perfusion.

Methods

In a nonrandomized, observational study of 16 patients (American Society of Anesthesiologists physical status I or II) undergoing laparoscopic cholecystectomy, internal carotid artery blood velocity was measured by Doppler ultrasound at four time points: awake, after anesthesia induction, after induction of pneumoperitoneum, and after head-up tilt. Vessel diameter was obtained each time, and internal carotid artery blood flow, the main outcome variable, was calculated. The authors recorded pulse contour estimated mean arterial blood pressure (MAP), heart rate (HR), stroke volume (SV) index, cardiac index, end-tidal carbon dioxide (ETco2), bispectral index, and ventilator settings. Results are medians (95% CI).

Results

Internal carotid artery blood flow decreased upon anesthesia induction from 350 ml/min (273 to 410) to 213 ml/min (175 to 249; −37%, P &lt; 0.001), and tended to decrease further with pneumoperitoneum (178 ml/min [127 to 208], −15%, P = 0.026). Tilt induced no further change (171 ml/min [134 to 205]). ETco2 and bispectral index were unchanged after induction. MAP decreased with anesthesia, from 102 (91 to 108) to 72 (65 to 76) mmHg, and then remained unchanged (Pneumoperitoneum: 70 [63 to 75]; Tilt: 74 [66 to 78]). Cardiac index decreased with anesthesia and with pneumoperitoneum (overall from 3.2 [2.7 to 3.5] to 2.3 [1.9 to 2.5] l · min−1 · m−2); tilt induced no further change (2.1 [1.8 to 2.3]). Multiple regression analysis attributed the fall in internal carotid artery blood flow to reduced cardiac index (both HR and SV index contributing) and MAP (P &lt; 0.001). Vessel diameter also declined (P &lt; 0.01).

Conclusions

During laparoscopic cholecystectomy, internal carotid artery blood flow declined with anesthesia and with pneumoperitoneum, in close association with reductions in cardiac index and MAP. Head-up tilt caused no further reduction. Cardiac output independently affects human cerebral blood flow.

Effects of Different Levels of Intra-Abdominal Pressure on the Postoperative Hepatic Function of Patients Undergoing Laparoscopic Cholecystectomy: A Systematic Review and Meta-Analysis

OBJECTIVE

The aim of this meta-analysis is to compare the differences in postoperative markers of the hepatic function under different intra-abdominal pressures in laparoscopic cholecystectomy (LC).

METHODS

Several databases were searched for control studies, and then the weighted data were pooled with random-effect models.

RESULTS

A total of 11 studies involving 865 patients were included. The meta-analysis reveals that the level of the aspartate aminotransferase and alanine transaminase of the low-pressure group has a lower postoperative increase than the moderate-pressure group (P<0.001). The level of the aspartate aminotransferase and alanine transaminase of the moderate-pressure group has a lower postoperative increase than the high-pressure group (P<0.001). Totally, the effect of lower pressure LC on postoperative hepatic functions is less significant than that of the higher one. Potential subgroup analysis does not modify these results.

CONCLUSIONS

The recommended pressure in LC is suggested to be lower so as to result in a better surgical safety, especially for special populations.

Effect of Intrapleural Meperidine on Post-Operative Pain after Open Cholecystectomy

BACKGROUND

Post-operative pain after open cholecystectomy can result in increased oxygen consumption, atelectasis, pneumonia, decreased vital capacity, and increased morbidity and mortality. The aim of this study was to compare the analgesic effects of intrapleural meperidine and intravenous morphine in controlling post-cholecystectomy pain.

MATERIALS AND METHODS

In a double-blinded randomized clinical trial, 72 patients who were candidate for elective open cholecystectomy, were divided randomly into two groups based on accidental randomized numbers. Anesthesia technique was precisely the same for all patients. At the end of surgery, 50 mg of meperidine (diluted in 20 cc normal saline) was injected intrapleurally for meperidine group patients; whereas, 0.1 mg/kg intravenous morphine was injected intravenously in control group. Onset of pain and total dose of rescue analgesic were measured.

RESULTS

In order to obtain a Numerical Rating Scale (NRS) <3, the difference in morphine consumption up to 12 hours in two groups (4.4 ±1.7 mg in meperidine group & 5±2 mg in control group) was not statistically different. However, the first request for analgesia in meperidine group was delayed significantly longer than the control group (146.6 ±6.8 minutes in meperidine group & 40 ±1.8 minutes in control group).

CONCLUSION

A single injection of intrapleural meperidine can delay the first request for analgesia in open cholecystectomy compared to intravenous morphine.

The Effect of Exaggerated Lithotomy Position on Shoulder Pain after Laparoscopic Cholecystectomy

BACKGROUND

The exaggerated lithotomy position with the expertise of nurses can be successful solution for the patients who have the postoperative shoulder pain after laparoscopic cholecystectomy.

AIMS

This study aimed to determine the effect of applying an exaggerated lithotomy positions to patients who had laparoscopic cholecystectomy to relieve shoulder pain. The study was conducted on nonrandomized groups and made as a semiexperimental study with a pretest/post-test control group design. Design, Settings, and Subjects/Participants: The study was conducted on 102 patients who had elective laparoscopic cholecystectomy and agreed to participate in this study after they met the inclusion-exclusion criteria in the general surgery clinic of a training and research hospital in Istanbul between December 12, 2012, and June 30, 2013.

METHODS

The pain levels (10 minutes before and after positioning) and peripheral oxygen saturation (SPO₂) levels (1 minute, 5 minutes, and 10 minutes before and after positioning-total 6 times) of the patients were measured using a visual analog scale and pulse oximetry, respectively. The pain levels and the analgesic (pethidine hydrochloride and diclofenac sodium) usage of the patients in both the experimental and the control group were compared.

RESULTS

The exaggerated lithotomy position appreciably lowered the shoulder pain of the patients in the experimental group (t = 12.663; p = .000 < .001). It also increased peripheral saturation levels of the patients more rapidly compared with those in the control group receiving analgesics (t = 17.693; p = .000 < .005). In addition, it decreased the need to use additional analgesics and opioids (t = 2.14; p = .037).

CONCLUSIONS

In this study the exaggerated lithotomy position was found to be fast and effective for relieving shoulder pain after laparoscopic cholecystectomy, decreased the need to use additional analgesics and opioids, and, in conjunction with pain control, also contributed to improvements in respiratory functions.

Pulmonary function evaluation in type 2 diabetes mellitus patients submitted to metabolic surgery

Abstract Introduction: Diabetes Mellitus (DM) is a multifactorial metabolic disorder. As considered a public health problem needing additional treatment options. Objective: This prospective study aimed at evaluating pulmonary function through spirometry, before and after metabolic surgery without gastric resection in type 2 DM patients. Methods: Sample was composed by 17 type 2 DM females. They were analyzed in pre (24 hours before surgical procedure), immediate post-operative period POST1 (24 hours after surgical procedure) and in the late postoperative period POST2 (two years after surgical procedure). Besides statistical analysis, it was evaluated the following spirometric parameters: forced vital capacity (FVC), forced expiratory volume in the first second (FEV1) and the FEV1 / FVC ratio (%). Results: Spirometric parameters showed a value increase when compared PRE and POS2 values, except for FVC and FEV1, which was not statistically significant. Conclusion: Type 2 DM women submitted to metabolic surgery without gastric resection showed spirometric value increased after two-year surgical procedure, when compared to preoperative period values. It is important additional studies about pulmonary function, diabetic patients and metabolic surgery without gastric resection.

Effects of Laparoscopic and Conventional Methods on Lung Functions in Colorectal Surgery

Background

We aimed to compare the lung functions, complication rates, and durations of the hospital and intensive care unit stays of patients who had undergone laparoscopic colorectal resection and open colorectal resection.

Material/Methods

In this study, data were collected prospectively and then evaluated retrospectively. The study was carried out between January 2015 and November 2016 in 2 university hospitals. Pulmonary function tests (PFT) and chest radiography were performed in all patients preoperatively. In the postoperative period, PFT was performed in all patients but chest radiography was obtained only in patients for whom it was clinically indicated.

Results

There were no significant differences between the 2 groups regarding their preoperative PFT parameters (p>0.05 for all variables). When compared to their preoperative PFT results, FEV1 and FVC values were determined to be significantly reduced on the 5^th postoperative day (p≤0.05) in both groups. When the postoperative 5^th day PFT results of the Laparoscopy (LG) and Open group (OG) were compared, there were no significant differences (for all variables p>0.05). Consolidation developed in 11 patients, all of whom were in the OG, but this result was not associated with surgical procedure (p=0.080). The median duration of the postoperative intensive care stay was 1 day in the LG, whereas it was 2 days in the OG (p<0.001).

Conclusions

In terms of pulmonary functions, both laparoscopic surgery and open surgery procedure have the same results. However, in terms of hospital stay and pulmonary infections, laparoscopy is more reliable.

Robotic-assisted Roux-en-Y hepaticojejunostomy after bile duct injury

BACKGROUND

The Da Vinci Robotic Surgical System has positioned itself as a tool that improves the ergonomics of the surgeon, facilitating dissection in confined spaces and enhancing the surgeon's skills. The technical aspects for successful bile duct repair are well-vascularized ducts, tension-free anastomosis, and complete drainage of hepatic segments, and all are achievable with robotic-assisted approach.

METHODS

This was a retrospective study of our prospectively collected database of patients with iatrogenic bile duct injury who underwent robotic-assisted Roux-en-Y hepaticojejunostomy. Pre-, intra-, and short-term postoperative data were analyzed.

RESULTS

A total of 30 consecutive patients were included. The median age was 46.5 years and 76.7% were female. Neo-confluences with section of hepatic segment IV were performed in 7 patients (those classified as Strasberg E4). In the remaining 23, a Hepp-Couinaud anastomosis was built. There were no intraoperative complications, the median estimated blood loss was 100 mL, and the median operative time was 245 min. No conversion was needed. The median length of stay was 6 days and the median length of follow-up was 8 months. The overall morbidity rate was 23.3%. Two patients presented hepaticojejunostomy leak. No mortality was registered.

CONCLUSION

Robotic surgery is feasible and can be safely performed, with acceptable short-term results, in bile duct injury repair providing the advantages of minimally invasive surgery. Further studies with larger number of cases and longer follow-up are needed to establish the role of robotic assisted approaches in the reconstruction of BDI.

Laparoscopic cholecystectomy under spinal-epidural anesthesia vs. general anaesthesia: a prospective randomised study

Purpose

Laparoscopic cholecystectomy (LC) is usually performed under the general anesthesia (GA). Aim of the study is to investigate the availability, safety and side effects of combined spinal/epidural anesthesia (CSEA) and comparison it with GA for LC.

Methods

Forty-nine patients who have a LC plan were included into the study. The patients were randomly divided into GA (n = 25) and CSEA (n = 24) groups. Intraoperative and postoperative adverse events, postoperative pain levels were compared between groups.

Results

Anesthesia procedures and surgeries for all patients were successfully completed. After the organization of pneumoperitoneum in CSEA group, 3 patients suffered from shoulder pain (12.5%) and 4 patients suffered from abdominal discomfort (16.6%). All these complaints were recovered with IV fentanyl administration. Only 1 patient developed hypotension which is recovered with fluid replacement and no need to use vasopressor treatment. Postoperative shoulder pain was significantly less observed in CSEA group (25% vs. 60%). Incidence of postoperative nausea and vomiting (PONV) was less observed in CSEA group but not statistically significant (4.2% vs. 20%). In the group of CSEA, 3 patients suffered from urinary retention (12.5%) and 2 patients suffered from spinal headache (8.3%). All postoperative pain parameters except 6th hour, were less observed in CSEA group, less VAS scores and less need to analgesic treatment in CSEA group comparing with GA group.

Conclusion

CSEA can be used safely for laparoscopic cholecystectomies. Less postoperative surgical field pain, shoulder pain and PONV are the advantages of CSEA compared to GA.