The evaluation of feasibility of ambulatory laparoscopic cholecystectomy using intraoperative instillation of bupivacaine: a retrospective observational study.

Purpose: This study aimed to compare outcomes of opioid patients-controlled anesthesia (PCA) and intraoperative local anesthesia in terms of postoperative pain, lab results, patient surveys, and discharge scores to evaluate the feasibility of ambulatory laparoscopic cholecystectomy (LC). Methods: Patients who underwent LC for acute cholecystitis were assigned to the outpatient surgery (OPS) group or inpatient surgery (IPS) group according to the surgeon. In the OPS group, a mixture of bupivacaine and epinephrine was injected into trocar sites and sprayed on the surgical dissection field. Oral opioid and analgesics were given twice a day. In the IPS group, patients received opioid PCA. Numeric rating scale (NRS) for walking, erythrocyte sedimentation rate (ESR), CRP, self-assessed survey on general physical condition and discharge, and discharge score of ambulatory surgery were assessed postoperatively. Results: NRS was significantly lower in the OPS group. There were no significant differences in ESR and CRP between the groups. Self-assessed survey on general conditions and the possibility of discharge were significantly better in the OPS group. The discharge scores at 3, 6, and 9 hours were significantly higher in the OPS group. Conclusion: Intraoperative instillation of bupivacaine at port sites and dissection fields had a better effect on short-term postoperative pain, patient surveys, and discharge criteria of ambulatory surgery than opioid PCA.

The safety and efficacy of percutaneous transhepatic gallbladder drainage in elderly patients with acute cholecystitis before laparoscopic cholecystectomy.

PURPOSE: Laparoscopic cholecystectomy (LC) is the standard management for acute cholecystitis. Percutaneous transhepatic gallbladder drainage (PTGBD) may be an alternative interim strategy before surgery in elderly patients with comorbidities. This study was designed to evaluate the safety and efficacy of PTGBD for elderly patients (>60 years) with acute cholecystitis. METHODS: We reviewed consecutive patients diagnosed with acute cholecystitis between January 2009 and December 2013. Group I included patients who underwent PTGBD, and patients of group II did not undergo PTGBD before LC. RESULTS: All 116 patients (72.7 ± 7.1 years) were analyzed. The preoperative details of group I (n = 39) and group II (n = 77) were not significantly different. There was no significant difference in operative time (P = 0.057) and intraoperative estimated blood loss (P = 0.291). The rate of conversion to open operation of group I was significantly lower than that of group II (12.8% vs. 32.5%, P < 0.050). No significant difference of postoperative morbidity was found between the two groups (25.6% vs. 26.0%, P = 0.969). In addition, perioperative mortality was not significantly different. Preoperative hospital stay of group I was significantly longer than that of group II (10.3 ± 5.7 days vs. 4.4 ± 2.8 days, P < 0.050). However, two groups were not significantly different in total hospital stay (16.3 ± 9.0 days vs. 13.4 ± 6.5 days, P = 0.074). CONCLUSION: PTGBD is a proper preoperative management before LC for elderly patients with acute cholecystitis.

Clinical outcome for laparoscopic cholecystectomy in extremely elderly patients.

PURPOSE: Extremely elderly patients who present with complicated gallstone disease are less likely to undergo definitive treatment. The use of laparoscopic cholecystectomy (LC) in older patients is complicated by comorbid conditions that are concomitant with advanced age and may increase postoperative complications and the frequency of conversion to open surgery. We aimed to evaluate the results of LC in patients (older than 80 years). METHODS: We retrospectively analyzed 302 patients who underwent LC for acute cholecystitis between January 2011 and December 2013. Total patients were divided into three groups: group 1 patients were younger than 65 years, group 2 patients were between 65 and 79 years, and group 3 patients were older than 80 years. Patient characteristics were compared between the different groups. RESULTS: The conversion rate was significantly higher in group 3 compared to that in the other groups. Hematoma in gallbladder fossa and intraoperative bleeding were higher in group 3, the difference was not significant. Wound infection was not different between the three groups. Operating time and postoperative hospital stay were significantly higher in group 3 compared to those in the other groups. There was no reported bile leakage and operative mortality. Preoperative percutaneous transhepatic gallbladder drainage and endoscopic retrograde cholangiopancreatography were performed more frequently in group 3 than in the other groups. CONCLUSION: LC is safe and feasible. It should be the gold-standard approach for extremely elderly patients with acute cholecystitis.

Should subcostal and lateral trocars be used in laparoscopic cholecystectomy? A randomized, prospective study.

BACKGROUND: Three to four trocars are commonly used when performing laparoscopic cholecystectomy (LC). Subcostal and lateral trocars are used for the grasper to retract the gallbladder. These graspers are seldom extracted or exchanged with other instruments. Based on this, it seems that the subcostal and lateral trocars are of minimal importance. The aim of this study was to evaluate the validity and benefits of performing LC without subcostal and lateral trocars (LCWSL). METHODS: From June 2006 to June 2007, 60 patients diagnosed with gallbladder disease were enrolled in this randomized, controlled trial to compare the result of LCWSL to conventional LC (CLC). Operation time, complication, pain scale, cosmetic effect, and hospital cost were compared. RESULTS: There were no differences in operation time and intra- or postoperative morbidity. Total blood loss, pain, duration until resumption of oral diet, and duration of hospital stay were similar. Total cost of LCWSL was cheaper than CLC by $397 USD (P < 0.05), and total incision length was smaller than CLC by 11 mm. CONCLUSIONS: LCWSL seems to be an acceptable procedure, having the same morbidity and better economic and cosmetic outcome, as compared to CLC.

Minimally invasive video-assisted kidney transplantation (MIVAKT).

BACKGROUND: Minimally invasive surgery has been applied to nearly all fields of surgery due to its advantages such as reduced morbidity, a better cosmetic outcome, and early recovery. The recent advances in its technique have allowed us to use modified minimally invasive surgery technique in the field of kidney transplantation. MATERIALS AND METHODS: From January 2004 to March 2006, minimally invasive video-assisted kidney transplantation was carried out in 20 patients. Many clinical variables were compared with the conventional method. The operative procedure began with a 7 to 8 cm skin incision. A laparoscopic balloon dissector was used to create the retroperitoneal space for the placement of the grafted kidney. Vascular anastomosis and ureteroneocystostomy were performed under direct vision and with video-assisted TV monitoring. RESULTS: The average length of the wound was 7.8 cm and it was placed below the belt line. The average operating time was 186 min. Less analgesic was given compared with conventional methods. There was one postoperative complication, a mild lymphocele. All patients showed normalized serum creatinine levels within 4 d. All grafted kidneys showed normal findings on the postoperative ultrasound and renal scans. CONCLUSIONS: Minimally invasive video-assisted kidney transplantation is technically feasible and may offer benefits in terms of better cosmetic outcomes, less pain, and quicker recuperation than conventional kidney transplantation.

The effect of anchoring suture on the anastomotic blood flow in a rat model of human esophagojejunostomy.

PURPOSE: An impairment of anastomotic blood flow (ABF) and the resulting hypoxia readily lead to the complications such as leakage and stricture. We performed an animal study to evaluate the effect of anchoring suture for minimizing the impairment of ABF caused by tensile loading. MATERIALS AND METHODS: An end-to-side jejunojejunostomy was done in 20 rats, and this followed the modeling of a human end-to-side esophagojejunostomy. Laser Doppler flowmetry was checked in three different tensile conditions to evaluate the influence of anchoring suture on the ABF. RESULTS: Before anchoring suture, the mean ABF was 129.06 perfusion unit (PU), 96.99 PU, and 69.04 PU, in the order of tensile stress. After anchoring suture, the mean ABF was 121.68, 103.30, and 87.06 PU (P < 0.01). CONCLUSION: Anchoring suture is a novel method to reduce the impairment of the anastomotic blood flow that is caused by tension.