Efficacy of port-site infiltration with ropivacaine alone versus ropivacaine with fentanyl for postoperative analgesia in patients undergoing laparoscopic procedures

Background and aims: Wound infiltration as a pre-emptive measure to relieve post-operative pain is a common practice following laparoscopic procedures. The addition of adjuvants like opioids to local anesthetics can facilitate the prolongation of postoperative analgesia. Our primary aim was to compare the analgesic efficacy of peri-portal infiltration of Ropivacaine alone versus Ropivacaine with Fentanyl in patients undergoing laparoscopic operations. Methods: The study was conducted on 80 ASA physical status I and II patients, aged 18 to 65 years, undergoing surgical procedures under general anesthesia. Group R was infiltrated with Ropivacaine (0.5%) (18ml+2ml saline) while in Group RF, Ropivacaine(18ml) with Fentanyl 2ml (100礸)] was infiltrated around ports, before wound closure. At the end of the surgery, one of our study drug solutions was infiltrated, to which the patient as well as the assessor were blinded. Postoperative pain was assessed by the VAS (visual analog scale) score. Injection Tramadol 100mg was given as a rescue analgesic if the VAS score was ? 3. Student抯 t-test and Fischer抯 exact test were applied for continuous and categorical variables; Kruskal Wallis and Mann Whitney U test for nonparametric data. The entire statistical analysis was done using STATA 13[ STATA CORP. TEXAS, USA] software. Results: The mean duration of analgesia was significantly longer in group RF, with a requirement of fewer doses of rescue analgesics, compared to group R. Conclusion: The addition of Fentanyl to Ropivacaine for periportal infiltration was found to be superior to Ropivacaine alone in providing effective postoperative analgesia as well as reducing the requirement of rescue analgesics.

A prospective observational study: combined irrigation of bupivacaine at the gallbladder fossa with infiltration at port site for postoperative pain relief after laparoscopic cholecystectomy

Background: Laparoscopic cholecystectomy is a well-established procedure for gallbladder disease. Pain in laparoscopic cholecystectomy is associated with multiple factors: somatic, visceral, and phrenic nerve irritation. Effective analgesic support should, therefore, be a multimodal approach following laparoscopic surgery for better patient compliance.Methods: A prospective, randomized observational study was undertaken at a tertiary research center for a period of two years (2018-2020). 160 patients undergoing laparoscopic cholecystectomy were chosen and randomized using a computer program into 2 groups. No infiltration was given in the control population. The study group was irrigated with a 0.5% bupivacaine solution (20cc in 30 ml normal saline).Results: The bupivacaine group required fewer analgesics in comparison to the control faction, with less pain at 6 hrs. The timing of oral intake and ambulation were comparable in both factions.Conclusions: Combined bupivacaine use led to a considerable decrease in postoperative pain thereby leading to decreased analgesic use.

Controlled Under vision TEchnique (CUTE) of Laparoscopic Port Site Closure

BACKGROUND:Various new challenges have emerged since the introduction of laparoscopic surgery. Port site hernia is one of the serious complication. Various methods have been introduced to reduce it. The aim of this article is to introduce a procedure that is easy, safe and quick to perform and will help in decreasing port site complications after laparoscopic procedure.MATERIAL AND METHOD:We have described here a simple technique for the facial closure after laparoscopic surgery over 100 patients who underwent laparoscopic cholecystectomy repair at VMMC & Safdarjung Hospital, New Delhi.RESULT:This method was used in 100 patients with no intro-operative complication, no port site hernia reported in a follow up period of 1 year.CONCLUSION:This procedure of fascial closure is safe, quick, effective and easy to perform method of facial closure.

Single Dose vs Multiple Dose Prophylactic Antibiotic to Prevent Early Port-Site Infection in Elective Laparoscopic Cholecystectomy

Introduction: Laparoscopic cholecystectomy (LC) is the gold standard treatment of symptomatic cholelithiasis. The need of the hour is to understand the fact that PSI is a totally different subset of infection and antibiotics are not a solution to this problem. The core issue of “prevention” is the principal solution. The study was undertaken to revalidate these well known facts with an effort to bring about a radical reform to this “social” rather than clinical problem. Material and Methods: The study comprised of 60 patients admitted for elective LC. The first thirty patients undergoing elective LC were given single dose (SD) ciprofloxacin (500 mg) within an hour between the induction and making of the first port. While the control group received ciprofloxacin (500mg) post-operatively in the ward from ward nurses (MD). Operation-room anesthetic assistant administered prophylactic antibiotics at induction of anaesthesia to all the patients. Results: Of the 30 cases that received single dose prophylactic antibiotic pre-operatively, 16.67% were males and 83.3% were females. And, of the 30 cases that received multiple dose prophylactic antibiotic pre as well as post-operatively, 10% were males and 90% were females. Analysis showed that there was no statistically significant difference across the groups in regard to the duration of preoperative hospital stay. Of the 30 cases that received single dose prophylactic antibiotic preoperatively, only one patient suffered gross contamination during the surgery. Conclusion: The rate of early PSI after administration of single dose ciprofloxacin (500 mg) intravenously at induction of anesthesia and multiple dose ciprofloxacin (500 mg given thrice or four times) intravenously post-operatively for two or three days in addition to peri-operative dose is comparable in elective laparoscopic cholecystectomy. Furthermore, hospital cost can be reduced with single dose antibiotic regimen. So single dose of ciprofloxacin 500 mg can be used safely in elective cases of laparoscopic cholecystectomy to avoid infection at port site.

Infection in Minimal Access Surgery and Glutaraldehyde

Background: With increasing use of MAS for various surgicalprocedures, the occurrence of port site infection and port sitetuberculosis is seen more often as postoperative complicationin Bangladesh. Most of the cases present as non-healing portsite wounds. The infection has been attributed to impropersterilization of laparoscopy instruments. There is concern aboutthe effectiveness of the high-level disinfection of reusablelaparoscopic instruments by immersion in 2% glutaraldehyde(GTA).Objective: To evaluate the infection and efficacy ofglutaraldehyde in MAS.Materials and Methods: This is a retrospective, observationalstudy carried out during the period of October 2005 to March2016. Study populations were all the patients underwentvarious minimal access surgical procedures by our team duringthis period. Surgeries were performed by Storz standardlaparoscopy set. All instruments were immersed in 2% GTA for15-20 minutes before each use.Results: Among all the patients (3720), 206 had port siteinfection which is 5.53%. Seventeen cases were diagnosed asport site tuberculosis which is about .45%. Most of them werewithin 30-40 years of age groups. Patients presented with portsite cellulitis, abscess and discharging sinus. All tuberculouscases were confirmed by biopsy. Tuberculous patientsresponded to anti-tubercular therapy. Non- specific infectionsresponded to dressing and antibiotics.Conclusion: Port site infection is common but tuberculosis isnot as common as non- specific infection. Both aretroublesome for the patients and surgeons. Proper sterilizationof instruments is the key. Use of 2% GTA is not cent percenteffective against tuberculosis.

Frequency of Port Site Infection in Laparoscopic Cholecystectomies: An Hospital Based Study

Background: Port site infection (PSI), although infrequent, isone of the bothersome complications which undermine thebenefits of minimal invasive surgery. The aim of this study toevaluated the frequency of Port Site infections (PSI) inlaparoscopic cholecystectomies.Materials & Methods: This is a hospital based observationalstudy done on 20 cases with port site infection afterlaparoscopic cholecystectomy in the department of GeneralSurgery, Government Medical College, Pali. Wounds wereassessed clinically a week after surgery and in case infectionhad occurred; once weekly until 4 weeks in the out-patientsclinic. The frequency of port site infection studied in relationextent of infection, duration of surgery, intra-operative findings,site of port that was infected.Results: The mean age of patients was 43.26 years.According to the site of port infection, 19 patients (95%)developed an infection at the epigastric port and one patient(5%) developed an infection at the umbilical port, which was Pvalue was >0.05. The mean duration of surgery was 63.5minutes. The port site infection was present in 18 (90%)patients at 7 days and only 1 (5%) case had port site infectionat 30 days in our study.Conclusion: Laparoscopic cholecystectomy is associated witha low risk of port-site infection which in most the cases is onlysuperficial responding to local measures. Complication canoccur even in the best of hands and it is vital that these arerecognized properly and immediately addressed.

Port site recurrence and unusual diffuse subcutaneous metastases of unexpected early stage ovarian cancer after laparoscopic surgery: a case report / Journal of Rural Medicine

Port site recurrence is a rare but well-documented adverse event peculiar to laparoscopic surgery. We report an unusual outcome of unexpected early stage ovarian cancer in which port site recurrence occurred after laparoscopic surgery and was followed by diffuse subcutaneous metastases. A 31-year-old Japanese woman with a large tumor in her abdomen visited our hospital. Because no intratumoral solid component was detected on diagnostic imaging, the tumor was diagnosed as a benign ovarian tumor and the patient underwent left ovarian laparoscopic cystectomy. Contrary to our expectations, however, the ovarian tumor was a mucinous carcinoma. We performed additional surgery, but the tumor recurred in the umbilical area, and multiple subcutaneous metastases later appeared. The curative effect of chemotherapy and radiation was limited. This atypical metastatic distribution of an extremely small amount of cancer might have been caused by the laparoscopic procedure. Protection against tumor cell dissemination is necessary during all forms of laparoscopic surgery.

Infección de puertos laparoscópicos por Micobacterias Atípicas / Laparoscopic Post-sites Infections by Atypical Mycobacteria

Introducción. Las Micobacterias Atípicas habitan normalmente aguas, suelos y ambientes quirúrgicos pudiendo infectar a personas con inmunidad comprometida o no comprometida afectando a prácticamente cualquier órgano. La especie Mycobactrium Abscessus Complex se describe frecuentemente como agente infeccioso de heridas quirúrgicas en puertos de cirugía laparoscópica siendo su tratamiento complejo y difícil. Materiales y Métodos. Estudio descriptivo de características clínicas, etiológicas y terapéuticas de pacientes con infección de los puertos quirúrgicos laparoscópicos causados por Micobacterias atípicas en cirugías consecutivas. Resultados. Once pacientes operados consecutivamente en el mismo medio y condiciones quirúrgicas desarrollaron infección de los puertos laparoscópicos. La incorrecta desinfección de instrumentos laparoscópicos fue la causa. Todos estos casos se registraron en un lapso de 43 días. El seguimiento fue de entre 10 a 14 meses. Las formas de presentación clínica fueron; fístulas, nódulos y seudotumores, en ese orden. Seis pacientes presentaron síntomas sistémicos como fiebre y sudoración nocturna. Se aislaron Micobacterias de crecimiento rápido caracterizados como M. Abscessus, M. Bolletii, M. Massiliense, especies del Complejo M. Abscessus. Los antibióticos utilizados fueron Claritromicina y Ciprofloxacino guiados por sensibilidad. Conclusiones. Los protocolos de desinfección deben ser estrictos. El tratamiento debe ser precoz y agresivo.

Introduction. Atypical Mycobacteria contaminates water, soil and surgical sets letting them to cause infections in people independent of their immunological status. Mycobacterium Abscessus Complex species frequently cause laparoscopic port sites infections turning about natural outcome in complex and hard to treat issues. Materials and Methods. Consecutive cases of patients affected with laparoscopic port sites infections by Atypical Mycobacterias are described. Etiological, clinical and therapeutic features are exposed. Results. Eleven patients acquired laparoscopic port site infections, all of them were consecutively operated at the same surgical background. Wrong proceedings in disinfection of laparoscopic devices were the causes. All of the surgeries were performed in a 43 days gap. Ten to fourteen months follow up is recorded. Fistulae was the most frequent lesion followed by nodules and pseudo tumors. Systemic symptoms like fever and nocturnal sweating were present in six patients. Rapid growing Mycobacterias were isolated by culture and labeled as M. Abscessus, M. Bolletii and M. Massiliense. Sensibility for antibiotics was tested and it commands therapeutic. Claritromicyn and Ciprofloxacyn were the most used antibiotics. Conclusions. Disinfection procedures there must be carefully controlled. Early and aggressive treatment have to be the rule.

Port-Site Metastasis of Uterine Carcinosarcoma after Laparoscopy

We report a case of port-site metastasis after laparoscopic surgery for early stage uterine carcinosarcoma (UCS) and review the related literature. A 53-year-old woman with suspected uterine malignance underwent a total laparoscopic hysterectomy with bilateral salpingo-oophorectomy, infra-colic omentectomy, and pelvic lymphadenectomy resulting pathologically in a stage IA UCS. Twelve months later she developed a palpable abdominal-wall mass at the trocar site without other synchronous metastases. A mass resection was performed and it was pathologically diagnosed with port-site metastasis of UCS. When performing surgery for UCS, specimens should be carefully removed in case small pieces of the occult disseminated metastatic tissues are trapped between the outer surface of the trocar sleeve and the abdominal wall incisional canal. Despite the low incidence, a laparotomy might be considered rather than laparoscopy to prevent port-site metastasis and more gynecological oncology clinical practices might be relevant to the management of port-site metastasis.

Port-Site Metastases and Chimney Effect of B-Ultrasound-Guided and Laparoscopically-Assisted Hyperthermic Intraperitoneal Perfusion Chemotherapy

PURPOSE: CO₂ leakage along the trocar (chimney effect) has been proposed to be an important factor underlying port-site metastasis after laparoscopic surgery. This study aimed to test this hypothesis by comparing the incidence of port-site metastasis between B-ultrasound-guided and laparoscopically-assisted hyperthermic intraperitoneal perfusion chemotherapy (HIPPC). MATERIALS AND METHODS: Sixty-two patients with malignant ascites induced by gastrointestinal or ovarian cancer were divided into two groups to receive either B-ultrasound-guided or laparoscopically-assisted HIPPC. Clinical efficacy was assessed from the objective remission rate (ORR), the Karnofsky Performance Status (KPS) score, and overall survival. The incidence of port-site metastasis was compared between the two groups. RESULTS: Patients in the B-ultrasound (n=32) and laparoscopy (n=30) groups were comparable in terms of age, sex, primary disease type, volume of ascites, and free cancer cell (FCC)-positive ascites. After HIPPC, there were no significant differences between the B-ultrasound and laparoscopy groups in the KPS score change, ORR, and median survival time. The incidence of port-site metastasis after HIPPC was not significantly different between the B-ultrasound (3 of 32, 9.36%) and laparoscopy (3 of 30, 10%) groups, but significantly different among pancreatic, gastric, ovarian, and colorectal cancer (33.33, 15.79, 10.00, and 0.00%, p<0.001). CONCLUSION: The chimney effect may not be the key reason for port-site metastasis after laparoscopy. Other factors may play a role, including the local microenvironment at the trocar site and the delivery of viable FCCs (from the tumor or malignant ascites) to the trauma site during laparoscopic surgery.

Port Site Chronic Sinuses – A Wisdom of 5 Years and 50 Cases.

Background: Laparoscopic surgery has now become an accepted method of minimal invasion of human anatomy but the dreaded problem of port site complications especially the chronic sinuses has rejuvenated the proponents of open techniques. The scope of laparoscopy widened from diagnostic purposes to resecting large tumors in almost all the systems of the body. As the time progressed, the problems associated with use of long instruments and dexterity of movements started creeping in. The vision, which was analogue, to start with, became 3D digital and with the introduction of robotic arm, the problem of dexterity was addressed to some extent. One thing that persisted right through so much of technical development was the problem of infection and sinuses and the enormity of this issue can be gauged by its evergrowing number. Methods: Although minimal invasive surgery is here to stay for all intent and purposes, we have decided to study 50 cases of chronic port site sinuses treated and followed up for 5 years in various wards of department of surgery in Guru Nanak Dev Hospital, Amritsar. In this study the authors present their experience and rationale regarding various factors like age and sex distribution, site of infection, results of microscopy and culture/sensitivity, treatment given (both surgical and non surgical), response time and prognosis. Results: In the cases where there was discharge culture of the pus yielded skin and soft tissue infections like staphylococcus, streptococcus, pseudomonas, E. coli and klebsiella. Out of 50, 20 cases were treated by appropriate antibiotics after culture sensitivity and quinolones.Conclusion: From the above discussion and flow chart, it can be safely concluded that atypical mycobacteria and some of the anaerobes remain the main offending agents.

Port Site Infection in Laparoscopic Surgeries.

Background/Aims: As the surgeries undertaken by laparoscope are increasing, complications are also increasing. In light of the explosive increase in laparoscopic surgery, there is concern about the effectiveness of sterilizing reusable laparoscopic instruments which might be a potential source of infection if not properly sterilized. Our study explains port site infection, its diagnosis and management with review of literature. Setting and Design: This study was carried out in a tertiary care setting and was an outcome study. Material and Methods: All five patients in the study were operated (April 2008-2010) elsewhere and came to us for management of non healing sinuses. Result: Amongst operated cases of laparoscopic cholecystectomy one healed by irrigation with superoxide, two cases healed with sinus exploration and wound debridement while one case required extensive wound debridement requiring temporary mesh repair of the abdominal wall with removal of the mesh (due to persistence of sinus) six months later following complete healing, no residual hernia. One operated case of laparoscopic incisional hernia repair with laparoscopic Cholecystectomy healed after removal of mesh with sinus exploration. Conclusion: The present study is an attempt to make surgeons aware about the complications which occur due to improper sterilisation of laparoscopic instruments ending into increased morbidity of patients.

Port site tuberculosis: A case report and review of literature.

Sumrnury: A rare case of port site tubercular infection is reported. A young male patient presented, one month after laparoscopic inguinal hernia repair with discharging sinuses at the port sites. Biopsy of the sinus tract showed features of tuberculosis. Excision of sinus tract was done and the patient was started on anti-tubercular therapy, sinuses healed. Probably, the source of tubercular infection was laparoscopic instruments. Proper sterilization of laparoscopic instruments is necessary.

Uso de la Sonda de Foley para el Control del Sangrado de la Pared Abdominal por los Orificios de los Trócares durante la Cirugía Laparoscópica / Use of Foley’s catheter to control abdominal wall bleeding in the trocar insertion place during laparoscopic surgery

INTRODUCCIÓN: Las hemorragias en los puntos de entrada de los trócares son en ocasiones difíciles de cohibir y se asocian con una morbilidad que oscila desde el dolor parietal y el hematoma, hasta el hemoperitoneo masivo. MATERIAL Y MÉTODOS: Realizamos un estudio retrospectivo de nuestra experiencia en el control de las hemorragias en los puntos de entrada de los trócares de laparoscopia mediante compresión con balón de sonda de Foley, en los que la hemostasia mediante electrocoagulación no fue efectiva. RESULTADOS: La técnica fue empleada en 35 pacientes (27 mujeres y 8 varones) con una edad media de 45,37 años (intervalo 24 - 82 años). La mediana de tiempo hasta la retirada de la sonda fue 36 horas (intervalo 24 - 48 horas), sin evidenciarse ningún tipo de complicación hemorrágica, prolongación de la estancia ni reingreso hospitalario. CONCLUSIONES: La compresión con balón de sonda de Foley es un método sencillo y eficaz para el control de las hemorragias a través de los orificios de los trócares de laparoscopia.

BACKGROUND: Abdominal wall bleeding in the port-site insertion place during laparoscopic surgery is sometimes difficult to control and can be associated with morbidity ranging from parietal pain up to haematoma and massive haemoperitoneum. PATIENTS AND METHODS: We perform a retrospective study of our experience in the management of the abdominal wall bleeding port-site using a Foley’s catheter (24F), in those cases when haemostasis with electrocautery was not achieved. RESULTS: This technique was used in 35 patients (27 women and 8 men) with a mean age of 45,37 years (range 24-82 years). The median of time up to the removal of the catheter was 36 hours (range 24-48 hours), without observing bleeding or prolongation of the hospital stay or readmission. CONCLUSIONS: The use of Foley’s catheter is a simple and efficient method for the control of the port-site bleeding during laparoscopic surgery.

Early port-site metastasis during neoadjuvant chemotherapy in advanced stage ovarian cancer: report of two cases / 부인종양

Port-site metastases in gynecological malignancies subsequent to laparoscopy have been reported with an incidence of 1.1-16%. These metastases tend to be disappearing after primary debulking surgery and subsequent primary chemotherapy. Local resection, chemotherapy and/or radiotherapy have been defined in the management of these metastases with enhanced clinical success. However, in extremely rare cases these metastases were also defined very early during neoadjuvant chemotherapy. Herein, we present two ovarian cancer cases which are clinically diagnosed with port site metastasis during neoadjuvant chemotherapy following diagnostic laparoscopy. Although neoadjuvant chemotherapy is sometimes needed in cases of fully advanced ovarian cancers, port-site metastasis may be encountered during neoadjuvant chemotherapy. The possible poor prognosis of these patients, especially those who have ascites, should make us careful in performing diagnostic laparoscopy with preventive measures for port-site metastasis and to start the chemotherapy immediately.

A case of port site implantation of borderline mucinous tumor of ovary after the laparoscopic operation / 대한산부인과학회지

Borderline tumor of ovary is epithelial proliferation without stromal invasion, first reported by Taylor in 1929. Borderline ovarian tumor occurs in younger women and is detects in early stage. Laparosocopy is alternative treatment of younger women for postoperative quality of life because it reduces postoperative adhesion. But it is limited to incomplete staging, tumor cell dissemination and recurrence. We report a case of port site implantation of mucinous borderline tumor after the laparoscopic operation; usually recurrence of borderline tumors were occurred after ten or fifteen years later, this case a direct evidence of cause of metastasis after the laparoscopic operation.

Two cases of small bowel herniation through 5 mm trocar site following removal of drains after gynecologic laparoscopy / 대한산부인과학회지

After laparoscopic surgery, most cases of incisional hernia occur when a trocar greater than 10 mm is used and this rarely occurs when a 5 mm trocar is used. We recently experienced two cases of incisional herniation at a 5 mm port site in connection with withdrawal of the drain after laparoscopic procedure.

Two cases of small bowel herniation through 5 mm trocar site following removal of drains after gynecologic laparoscopy / 대한산부인과학회지

After laparoscopic surgery, most cases of incisional hernia occur when a trocar greater than 10 mm is used and this rarely occurs when a 5 mm trocar is used. We recently experienced two cases of incisional herniation at a 5 mm port site in connection with withdrawal of the drain after laparoscopic procedure.

Incidentally Found Port Site Metastasis followings Laparoscopic Radical Nephrectomy for a Renal Cell Carcinoma / 대한비뇨기과학회지

Herein, a rare case of port site metastasis, following a laparoscopic radical nephrectomy in a 62-years old male patient with a stage pT2N0M0 and Fuhrman grade III renal cell carcinoma, is reported. The patient suffered port site metastasis, with local recurrence. The port site metastasis was incidentally found in the patient during the laparoscopic examination for a laparoscopic mass resection of a local recurrent tumor. The most important appropriate surgical techniques are those where the port site metastasis can be controlled.

A case of port site metastasis of unexpected gallbladder carcinoma after laparoscopic cholecystectomy / 대한내과학회지

Laparoscopic cholecystectomy (LC) is considered as the gold standard operation for the removal of a nonmalignant, diseased gallbladder. With the increasing number of LCs, a number of gallbladder carcinomas have been unexpectedly found either during or following this procedure. The removal of unexpected gallbladder carcinomas by LC can cause also a new complication, port site metastasis (PSM), which is developed by the implantation of tumor cells into the abdominal wall at the port site. We report a rare case of PSM of gallbladder carcinoma which was unsuspected at the time of LC. A 65-year-old man underwent LC at another hospital for calculous cholecystitis. The histologic examination revealed an adenocarcinoma of the gallbladder infiltrating the muscle wall. Despite the surgeon's advice, the patient refused any additional treatment. Ten months after surgery, he visited our hospital because of a painful and palpable subcutaneous mass at the scar of the periumbilical trocar incision. The mass was biopsed and histological examination confirmed metastasis from the gallbladder carcinoma.