Nitrous oxide in isufflation does not increase the incidence of gas embolism during laparoscopic cholecystectomy: detection by transoesaphageal echocardiograply

In a prospective randomized clinical trial, 24 patients with ASA score I or II were scheduled for laparoscopic cholecystectomy. They were divided into two equal groups, where either carbon dioxide [CO2] or nitrous oxide [N2O] was used for pneumoperitoneum. Standard general anesthesia was used in all cases. Transesophageal echocardiography [TEE] probe was introduced to monitor gas embolism [GE] events. The procedure was divided into four operative stages [T1 = insufflation, T2 = dissection of cystic duct and artery, T3 = gallbladder bed dissection and T4 = extraction and desufflation]. For each stage, the number and score [from 1-3] of gas embolism episodes were recorded. In addition, heart rate [HR], mean arterial blood pressure [MAP], saturation of oxygen [SaO2] and end-tidal CO2 [ET CO2] were recorded immediately after induction [baseline], during insufflation and every ten minutes of the procedure. The study concluded that during laparoscopic cholecystectomy, insufflating gas does not increase the incidence of GE events compared with CO2. On the contrary, N2O exhibits slightly less GE events in some of the operative stages. The stage of insufflation predisposes to more GE events than the rest of the operation. Most of the GE events are associated with some rate of gas flow into the peritoneal cavity, whatever the type of gas is. Therefore, more cautions must be taken into consideration whenever there is active gas flow into the peritoneal cavity for the risk of GE

Common bile duct clearance of stones by surgery, endoscopy and laparoscopy [comparative study]

In this study, 70 cases of choledocholithiasis were managed randomly by either conventional surgical techniques, endoscopic techniques or laparoscopic techniques. Most of these patients were presented with calcular obstructive jaundice [54.3%]; however other presentations were also encountered as colic, cholangitis or accidental discovery in 14.3%, 10% and 21.5%, respectively. Group I [surgery] included 30 patients who were treated by open choledocholithotomy and T tube insertion, the mean operative time was 90 [60-180] min. Group II [endoscopy] included 30 cases treated by endoscopic sphincterotomy and basket extraction in 46%, balloon in 26.6%, combined maneuver in 16.6% and mechanical lithotripsy in 13.3%. Group III [laparoscopy] included ten cases treated by laparoscopic approaches in the form of trans- cystic approaches in two cases, trans-choledochotomy approaches in three cases, choledochoscopic techniques in two cases and converted to open techniques with failure of the attempt in three cases. The study showed that open surgery permits direct manual palpation and instrumentation of bile ducts using a variety of instruments. However, it has its drawbacks in long maneuver time, invasiveness, increased mortality and morbidity, long hospital stay and delayed return to work. On the contrary, endoscopic management of choledocholithiasis has the advantage of minimally invasive maneuver, could be done as outpatient clinic, less procedure time, less hospital stay, very low or no mortality and morbidity, rapid return of the patients to work