Intraperitoneal normal saline and bupivacaine infusion for reduction of postoperative pain after laparoscopic cholecystectomy.

After laparoscopic cholecystectomy, CO2 remains within the peritoneal cavity, commonly causing pain. This prospective randomized study was performed to determine the efficacy of intraperitoneal normal saline and bupivacaine infusion on postoperative pain after laparoscopic cholecystectomy. Three hundred patients were randomly assigned to one of six groups of 50 patients each. Group A patients served as controls. In group B patients, normal saline was infused under the right hemidiaphragm and suctioned after the pneumoperitoneum was deflated. After suction, a subhepatic closed drain was left for 24 h. In group C patients, bupivacaine 1.5 mg/kg in solution 2.5 mg/ml, minus 15 ml of this solution, which was infiltrated in the trocar wounds, was infused under the right hemidiaphragm at the end of the cholecystectomy. In group D patients, bupivacaine was given as in group C, but a subhepatic drain was left for 24 h. In group E patients, normal saline was used as in group B plus bupivacaine as in group C. Group F patients were treated as in group E, but a subhepatic drain was left for 24 h. In all groups, 15 ml of a 2.5 mg/ml bupivacaine solution was infiltrated in the trocar wounds. Postoperatively, analgesic medication usage, nausea, vomiting, and pain scores were recorded at 2, 6, 12, 24, 36, 48, and 72 h. Postoperative pain was reduced significantly in the patients of the treatment groups vs. the controls. Between treatment groups, patients in groups B, E, and F had the best results, while those in groups C and D had significantly greater pain than those in groups B, E, and F. It is concluded that postoperative pain after laparoscopic cholecystectomy can be significantly reduced by intraperitoneal normal saline infusion subdiaphragmatically and after its postdeflation suction, bupivacaine infusion in the same area, or without bupivacaine in case a subhepatic drainage has been needed.

Laparoscopic cholecystectomy using ultrasonically activated coagulating shears.

Ultrasonic energy has recently been used for surgical cutting and coagulating. A prospective randomized study was undertaken to determine the effectiveness of ultrasonic energy versus monopolar electrosurgery in human laparoscopic cholecystectomy. Two hundred patients were enrolled and randomized into two groups of 100 patients each. Group A patients underwent laparoscopic cholecystectomy with monopolar electrocautery. Group B patients underwent laparoscopic cholecystectomy with ultrasonically activated shears. In 18 cases of this group, the cystic artery was coagulated and cut without clips. Subhepatic closed drainage was left for 24 h in patients who were candidates for oozing of blood or leakage of bile. The median operating time was 45 min in group A and 37 min in group B. Subhepatic drainage was left in 37 patients of group A and 26 of group B. The median blood loss was 14 ml in group A and 2 ml in group B, while 3 patients of group A and none of group B had bile leakage from the bed of the gallbladder for 1, 1, and 6 days, respectively. Postoperative ultrasound examination showed a minor subhepatic fluid collection in 5 patients of group A and in 1 patient of group B. All these collections were treated without drainage. The length of hospital stay was 1.9 +/- 0.5 days in group A and 1.4 +/- 0.2 days in group B. Postoperative pain scores, nausea, and vomiting were equivalent in both groups. It is concluded that ultrasonically activated coagulating shears are safer, easier to use, faster, and less prone to intraoperative complications and postoperative morbidity than monopolar electrocautery in laparoscopic cholecystectomy.

Intraperitoneal normal saline infusion for postoperative pain after laparoscopic cholecystectomy.

After laparoscopic surgery carbon dioxide remains within the peritoneal cavity for a few days, commonly causing pain. This prospective randomized study was performed to determine the efficacy of intraperitoneal infusion of normal saline on postoperative pain after laparoscopic cholecystectomy. Altogether 300 patients were randomly assigned to one of five groups of 60 patients each. Group A: control group, no peritoneal infusion, no subhepatic drain. Group B: no peritoneal infusion but a subhepatic closed brain was left for 24 hours. Group C: normal saline 25 to 30 ml/kg body weight at a temperature of 37 degrees C was infused under the right hemidiaphragm and left in the peritoneal cavity. Group D: normal saline in a room temperature was infused under the right hemidiaphragm and suctioned after the pneumoperitoneum was deflated. Group E: normal saline was infused and suctioned as in group D, but a subhepatic closed drain was left for 24 hours. Postoperatively, analgesic medication usage, nausea, vomiting, and pain scores were determined at 2, 6, 12, 24, 48, and 72 hours (during hospitalization and at home). Postoperative pain was reduced significantly (p < 0.001) in the patients of groups C, D, and E versus controls, whereas no difference was observed between groups A and B. Among groups C < D and E, group E (p < 0.01) had the best results followed by group D and then group C. Intraperitoneal normal saline offered a detectable benefit to patients undergoing laparoscopic cholecystectomy. The beneficial effect was better when the fluid was suctioned after deflation of the pneumoperitoneum and even better when a subhepatic closed drain continued fluid suction during the first postoperative hours.

Cholecystectomy and hernioplasty during the same laparoscopic procedure.

Cholelithiasis and inguinal or femoral hernia usually coexist in the same patient. The simultaneous laparoscopic approach to these diseases benefits the patients, who avoid two separate admissions to the hospital, two operations, and twice the cost, recuperation, and potential morbidity and mortality. The authors describe a technique that facilitates cholecystectomy and hernioplasty during the same laparoscopic approach, thus avoiding the use of two separate procedures. The results of this procedure in the first six patients were excellent.

Modified Nissen fundoplication in the treatment of gastroesophageal reflux disease.

Twenty-five consecutive patients underwent a primary modified Nissen fundoplication for gastroesophageal reflux disease. According to this procedure, an increase of the diameter of the gastric wrap to a comfortable passage of the surgeon's index finger between oesophagus and gastric wrap was obtained, while the length of the gastric wrap was 1.0 cm. The fixation of the wrap on the anterior wall of the oesophagus was done at the level of the mucosal cardia 1.0 cm above the gastroesophageal junction strengthened by four mesh pledgets. Two more stitches between the seromuscular layer of the gastric fundus and the oesophageal musculature were placed to prevent reduction of created oesophagogastric intussusception. The results of this modified Nissen procedure are excellent during the early postoperative follow-up period, ranging from 10 to 45 months and averaging 26 months.

Short-term antibiotic prophylaxis in elective colorectal surgery.

In the last 2 years, 50 patients who underwent elective colorectal surgery were prospectively studied about antibiotic prophylaxis. Two groups of 25 patients each were randomly selected. Both received: (a) a colic preparation: hypactic drugs and two enemas during the day before surgery and (b) metronidazole 0.5 g plus neomycin 1 g per 8 h orally for 1 day before surgery. Every group also received: group A, metronidazole 0.5 g plus amikacin 500 mg i.v. 2 h before surgery and the same doses per 8 or 12 h, respectively, for 2 days postoperatively; group B, ornidazole 1 g by intravenous infusion plus ceftriaxone 2 g i.v. 2 h before surgery and the same doses of the drugs per 24 h for 2 days postoperatively. Wound infection occurred in 1 case of group A versus 2 cases of group B (p greater than 0.25). Ornidazole plus ceftriaxone prophylactic antibiotic therapy is therefore as effective as a classic therapy (metronidazole plus amikacin) and constitutes an alternative choice for patients undergoing elective colorectal surgery, because the simple manner of its administration (once per 24 h) is resulting in cost saving due to gained nursing time.

Prevention of peritoneal adhesions in rats with trimetazidine.

The effect of trimetazidine (an antianginal drug that acts as a scavenger of oxygen radicals) in the prevention of peritoneal adhesions induced by complete vascular obstruction of an ileal segment for 30 minutes followed by reperfusion was investigated in rats. Group A (n = 20) acted as controls. Group B (n = 20) received trimetazidine intravenously in a dose of 2.5 mg/kg 30 minutes before the induction of ischaemia. Group C (n = 20) received the same dose of trimetazidine for 5 days before the experiment, twice a day intraperitoneally, and also intravenously 30 minutes before the induction of ischaemia. Group D (n = 20) received the same dose of trimetazidine intravenously immediately after reperfusion had started. Ten days later adhesions had developed in 90% of the animals of group A, 40% of those in group B (p less than 0.001), 5% of those in group C (p less than 0.001), and 60% of those in group D (p less than 0.05). The severity of adhesions was significantly less in the treated groups than in the control animals. Release of creatine phosphokinase during ischaemia and reperfusion significantly increase in groups A, B, and D. These results suggest that trimetazidine reduces the incidence and severity of peritoneal adhesion formation induced by ileal ischaemia and reperfusion, treatment before induction of ischaemia gave better results than treatment given afterwards.

The role of oxygen-derived free radicals in peritoneal adhesion formation induced by ileal ischaemia/reperfusion.

The effectiveness of superoxide dismutase (SOD), catalase (CAT), dimethyl sulphoxide (DMSO) and allopurinol in prevention of peritoneal adhesion formation induced by complete vascular obstruction and reperfusion of an ileal segment was investigated in rats. The ischaemic period was 30 min. Group A (n = 20) were controls, group B (n = 15) received SOD 15,000 U/kg i.v. and group C (n = 17) the same dose of CAT immediately before induction of ischaemia. In group D (n = 20) DMSO 20 mg/kg was given i.v. 5 min before ischaemia, and group E (n = 20) received allopurinol orally 50 mg/kg daily for 2 days and also 2 hours before ischaemia. Ten days later adhesions had developed in 80% of group A, 40% of group B, 47% of group C and 45% of groups D and E (p less than 0.05). The severity of the adhesions was significantly less in the pretreated groups than in the controls. Oxygen-derived free radicals may be pathogenetically important for such adhesion formation. Xanthine oxidase is the principal source of oxygen radicals after a 30-min period of complete regional intestinal ischaemia.