Is there a role for drain use in elective laparoscopic cholecystectomy? A controlled randomized trial.

BACKGROUND: Although the issue of drain use in open cholecystectomy has been adequately addressed by prospective randomized trials, there is lack of evidence on the usefulness of drains in elective laparoscopic cholecystectomy, and the surgeons follow their beliefs and bias on this debate. Therefore, a controlled randomized trial was designed to assess the value of drains in elective laparoscopic cholecystectomy. METHODS: During a 5-year period (January 2002 to December 2006), 284 patients were randomized to have a drain placed (group A), whereas 281 patients were randomized not to have a drain (group B) placed in the subhepatic space. End points of this trial were to detect any differences in morbidity, postoperative pain, and hospital stay between the 2 groups. RESULTS: There was no mortality in either group and no statistically significant difference in morbidity or hospital stay between the 2 groups. However, postoperative pain was significantly increased in patients who had a drain placed; median visual analog scale (VAS) score was 5 (range 1 to 8) versus 3 (range 1 to 8), in the non-drained group (P < .0001). Interestingly, in 2 of 3 patients in whom a drain was placed against randomization because of bile leak suspicion, a bile leak occurred. CONCLUSIONS: The routine use of a drain in elective laparoscopic cholecystectomy has nothing to offer; in contrast, it is associated with increased pain. It would be reasonable, however, to leave a drain if there is a worry about an unsolved or potential bile leak, bearing in mind that drain placement, although sometimes providing a false sense of security, does not guarantee either prevention or treatment of postoperative bile collections, bleeding, or bile peritonitis.

Spinal vs general anesthesia for laparoscopic cholecystectomy: interim analysis of a controlled randomized trial.

OBJECTIVE: To compare spinal anesthesia with the gold standard general anesthesia for elective laparoscopic cholecystectomy in healthy patients. DESIGN: Controlled randomized trial. SETTING: University hospital. PATIENTS: One hundred patients with symptomatic gallstone disease and American Society of Anesthesiologists status I or II were randomized to have laparoscopic cholecystectomy under spinal (n = 50) or general (n = 50) anesthesia. METHODS: Intraoperative parameters, postoperative pain, complications, recovery, and patient satisfaction at follow-up were compared between the 2 groups. RESULTS: All the procedures were completed by the allocated method of anesthesia, as there were no conversions from spinal to general anesthesia. Pain was significantly less at 4 hours (P < .001), 8 hours (P < .001), 12 hours (P < .001), and 24 hours (P = .02) after the procedure for the spinal anesthesia group compared with those who received general anesthesia. There was no difference between the 2 groups regarding complications, hospital stay, recovery, or degree of satisfaction at follow-up. CONCLUSIONS: Spinal anesthesia is adequate and safe for laparoscopic cholecystectomy in otherwise healthy patients and offers better postoperative pain control than general anesthesia without limiting recovery.

Laparoscopic ventral hernia repair under spinal anesthesia: a feasibility study.

BACKGROUND: Regional anesthesia has not been used as the sole anesthetic procedure in laparoscopic ventral hernia repair due to the fear of potential adverse effects of the pneumoperitoneum. However, there are recent reports on the feasibility of performing laparoscopic procedures, such as cholecystectomy, in fit patients, under spinal anesthesia alone. The current study aimed to detect the feasibility of performing laparoscopic ventral hernia repair under spinal anesthesia. METHODS: Twenty-five American Society of Anesthesiologists (ASA) I or II patients underwent laparoscopic ventral hernia repair with low-pressure CO2 pneumoperitoneum under spinal anesthesia. In 9 cases the hernia was umbilical/para-umbilical, in 5 cases epigastric, and in 11 cases incisional. Intraoperative incidents, complications, postoperative pain, and recovery in general, as well as patient satisfaction at follow-up examination, were prospectively recorded. RESULTS: All operations were completed laparoscopically and conversion from spinal to general anesthesia was not required in any of the cases. Median pain score at 4 hours postoperatively was .5 (range 0-5), at 8 hours 1.5 (range 0-6), and at 24 hours 1.5 (range 0-4). Most patients were discharged 24 hours after the operation; the median hospital stay was 1 day (range 1-3 days). At 2-weeks follow-up, no late complications were detected and all patients reported being satisfied with the anesthetic procedure. CONCLUSION: Laparoscopic ventral hernia repair with low-pressure CO2 pneumoperitoneum can be successfully and safely performed under spinal anesthesia. Furthermore, it seems that spinal anesthesia is associated with minimal postoperative pain and smooth recovery.

A simplified technique of RFA (radiofrequency assisted) hepatectomy.

A new technique of dividing the hepatic parenchyma in liver resections is presented. Seven liver resections in six patients were carried out, using a modification of the Radiofrequency assisted hepatectomy technique. The transection zone of the liver was coagulated prior to the division of the parenchyma using a transformed cluster cool-tip Radionics electrode. The reported technique resulted in adequate hemostasis of the raw hepatic surface and minimal blood loss. The aforementioned method seems to be quick and safe especially for local hepatic resections or segmentectomies.

Modified radiofrequency-assisted liver resection: a new device.

BACKGROUND: Radiofrequency ablation (RF) is emerging as new therapeutic method for the management of hepatic tumors. So far the RF-assisted hepatectomy has been described using an electrode initially designed for ablation of unresectable tumors. Herein, we describe a new technique for liver resection using a bipolar radiofrequency device. METHOD: Ten patients undergo liver resection using a bipolar radiofrequency device. A minimal zone of desiccation around the tumor is created between pairs of opposing electrodes as a result of a minimum amount of energy released. This coagulated plane can be divided with a scalpel. RESULTS: The liver parenchyma was divided with minimal blood loss. No intensive care unit admission was needed. There was no postoperative biliary leak or any other septic complication. CONCLUSION: The technique is safe and feasible, simplifies liver resection and appears to be associated with minimal morbidity and maximum liver parenchyma preservation.

Laparoscopic appendectomy: differences between male and female patients with suspected acute appendicitis.

BACKGROUND: The role of laparoscopy in the management of patients with suspected acute appendicitis remains controversial. It has been suggested that laparoscopy is useful mainly in young women of reproductive age because of the high incidence of wrong diagnosis in these patients. METHODS: Different management protocols for patients with suspected acute appendicitis were prospectively used in male and female patients; women of reproductive age were treated laparoscopically, while men were randomised to open or laparoscopic appendectomy. RESULTS: From September 2002 to September 2005, 132 patients-54 women and 78 men-with suspected acute appendicitis were treated according to the protocol. The incidence of wrong diagnosis in female patients was high (26% and the conversion rate low (5.5%). In contrast, in the laparoscopic male subgroup, these rates showed a reverse relationship (5.2% and 18.5%, respectively). Morbidity did not differ between female and male patients or between the 2 arms of the male group. Laparoscopic appendectomy took longer to perform without affecting significantly the needs for postoperative analgesia, the duration of hospital stay and the time to return to normal activities when compared with open appendectomy in men. CONCLUSION: Laparoscopic appendectomy is at least as safe as the open procedure in the male population, although it does not appear to offer any obvious advantage over the open procedure. The diagnostic advantage that laparoscopy offers to fertile women makes the procedure attractive for this population.

Timing of laparoscopic cholecystectomy for acute cholecystitis: a prospective non randomized study.

AIM: To study the timing of laparoscopic cholecystectomy for patients with acute cholecystitis. METHODS: Between January 2002 and December 2005, all American Society of Anesthesiologists classification (ASA) I, II and III patients with acute cholecystitis were treated laparoscopically during the urgent (index) admission. The patients were divided into three groups according to the timing of surgery: (1) within the first 3 d, (2) between 4 and 7 d and (3) beyond 7 d from the onset of symptoms. The impact of timing on the conversion rate, morbidity and postoperative hospital stay was studied. RESULTS: One hundred and twenty-nine patients underwent laparoscopic cholecystectomy for acute cholecystitis during the index admission. Thirty six were assigned to group 1, 58 to group 2, and 35 to group 3. The conversion rate and morbidity for the whole cohort of patients were 4.6% and 10.8%, respectively. There was no significant difference in the conversion rate, morbidity and postoperative hospital stay between the three groups. CONCLUSION: Laparoscopic cholecystectomy for acute cholecystitis during the index admission is safe, regardless of the time elapsed from the onset of symptoms. This policy can result in an overall shorter hospitalization.

Multiple small bowel ruptures due to ischemic enteritis: a case report.

A rare case of multiple small bowel ruptures due to ischemic enteritis (ISE) is reported. The patient was admitted to the hospital with acute abdominal pain followed by bloody diarrhoeas. Preoperative colonoscopic findings were similar to those presented in Crohn's disease. Intraoperatively, ischemic lesions and multiple ruptures were localized at the jejunum and the proximal ileum. Histopathological examination of the resected bowel segment established the diagnosis of ISE. Although ISE is not common, concurred multiple ruptures of the small bowel is a rare but actual complication.

One trocar laparoscopic placement of peritoneal shunt for hydrocephalus: A simplified technique.

Peritoneal catheter placement for the treatment of hydrocephalus can nowadays be performed laparoscopically. We report our experience using a single trocar technique, with emphasis to a modification applied especially for the obese patients.

Local posterior perianal block for proctologic surgery.

We present our experience with proctologic operations under local posterior perianal block (LPPB), along with short- and medium-term results of this technique. A total of 72 patients with proctologic disorders consented to operation under LPPB for stapled hemorrhoidectomy, Milligan-Morgan hemorrhoidectomy, subanodermal fistula resection, perianal abscess revision, and anal tumor electrocoagulation. The anesthetic technique, postoperative complications, the pain score, and follow-up were recorded and analyzed retrospectively. Almost all patients were pain-free during surgery. The pain score in visual analog scale (VAS) during the first 24 hours was 1.6 to 3.4 and varied with the type of surgery performed. At follow-up 1-2 weeks later, the patients were satisfied with LPPB (mean level of satisfaction, 8.6 +/- 1.2 on the VAS). Seventy of 72 patients (97.2%) would willingly have surgery again under LPPB if it was required. This study shows that LPPB can be widely and safely applied in proctologic surgery.

Stapled hemorrhoidectomy under local anesthesia: tips and tricks.

Stapled hemorrhoidectomy--a new, evolving technique--is considered to be safe and painless. General and spinal anesthesia are the "gold standard" anesthetic techniques for the procedure. The stapled hemorrhoidectomy under local anesthesia is described. Emphasis is given in few tips and tricks for safe and successful application of the local anesthesia.

Antiangiogenic strategies in hepatocellular carcinoma: current status.

Hepatocellular carcinoma is a leading cause of cancer death worldwide in both adult and pediatric patients. Despite many options, no ideal treatment exists for this highly malignant tumor, and management strategies have varied accordingly. Angiogenesis, the formation of new blood vessels, is an essential component of hepatocellular carcinoma biology. Innovative approaches such as targeting the nontransformed, less resistant, tumor-supporting endothelial cells are currently under investigation in hepatocellular carcinoma. This review will focus on the current knowledge of the pathophysiology of hepatocellular carcinoma angiogenesis, as well as the reported data with angiogenesis inhibitors against hepatocellular carcinoma.

New trends in the management of colonic trauma.

BACKGROUND: The management of colon trauma seems to have swung from the "diversion dogma" to a more liberal use of primary repair. However, there are still debatable issues, regarding the management of destructive injuries of the left colon. METHODS: A review of the current literature on the management of colon trauma was performed using PubMed, with secondary references obtained from key articles. CONCLUSION: There is strong evidence from prospective randomised trials that the vast majority of colonic injuries can be safely managed by primary repair. It seems, however, that there is a limited role for colostomy, particularly in high-risk patients with destructive injuries of the left colon. The final decision should be based on available scientific evidence in combination with personal experience and clinical judgement on the given patient.