Lactate metabolism during laparoscopic cholecystectomy: comparison between CO2 pneumoperitoneum and abdominal wall retraction.

Recent reports have implicated CO2 pneumoperitoneum for laparoscopic surgery in the occurrence of postoperative mesenteric ischemia. With this kind of surgery, the increase in blood lactate levels has been attributed to anaerobic metabolism, probably due to tissue ischemia induced by high intraabdominal pressure (IAP). The aim of this study was to evaluate the metabolic repercussion of CO2 pneumoperitoneum during laparoscopic cholecystectomy (LC). This was a prospective randomized study of CO2 pneumoperitoneum (PP group, n = 19) versus abdominal wall retraction (AWR group, n = 15). Demographic data were collected preoperatively. Four-trocar LC was performed with either a CO2 pneumoperitoneum (IAP of 12 mmHg) or abdominal wall retraction (abdominal wall pressure 6-10 kp). Intraoperative and postoperative blood samples were collected and lactate levels determined by enzymatic analysis. Repeated measures analysis of variance (MANOVA) was used for statistical analysis. Significance was evaluated at p < 0.05. The groups were shown to be homogeneous. Lactate concentration, expressed as mean (SD), went from 25.4 (14.4) mg/dl at baseline to 18.9 (13.6) mg/dl 4 hours after surgery in the PP group and from 19.4 (6.1) mg/dl at baseline to 17.8 (14.7) mg/dl in the AWR group. No significant differences were found between groups intraoperatively (p = 0.116) or postoperatively (p = 0.99). Our study did not show significant differences in blood lactate levels during LC with CO2 pneumoperitoneum compared to the same procedure with abdominal wall retraction.

Gasless laparoscopic cholecystectomy is not more time-consuming.

BACKGROUND: Although abdominal wall retraction is said to be advantageous in laparoscopic cholecystectomy (LC), many surgeons have found that, when this option is chosen, more time is needed to prepare for and carry out the surgical procedure. Our aim was to determine the time required for surgical preparation and operation in patients undergoing LC with carbon dioxide (CO2) pneumoperitoneum (CO2 PP) vs abdominal wall retraction (AWR). METHODS: We performed a prospective randomized study of a CO2 PP LC group (n = 19) vs an AWR LC group (n = 15). Demographic data were collected preoperatively. LC was performed with either CO2 PP (12 mmHg) or AWR (6-10 kps). Two phases were considered: (a) time employed to create the surgical field (phase 1) and (b) operating time (phase 2). The chi-square test was used to compare the medians of the two groups. RESULTS: The two groups were homogeneous. Phase 1 required 35 min in the CO2 PP group vs 25 min in the AWR group (p = 0.24). Phase 2 required 60 min in both groups (p = 0.76). CONCLUSION: We found no statistically significant difference between the PP CO2 and AWR groups in either time spent to create the surgical field or actual operating time.

Formación del cirujano en cirugía laparoscópica / Laparoscopic training for surgeons

La cirugía laparoscópica es una nueva vía de abordaje quirúrgico que posee una serie de características diferenciales con la cirugía convencional: creación de una cavidad real mediante la introducción de gas y el impacto de éste sobre los órganos intraabdominales, utilización de material sofisticado (óptica, cámara, etc.) y modificación de los sentidos del cirujano en cuanto a su interrelación con la intervención. Se incrementa el detalle y se magnifica el campo, pero se pierde la tercera dimensión. El tacto se modifica de forma sustancial por el tipo de instrumentos, con la pérdida de la sensibilidad estereognóstica (reconocimiento de objetos por el tacto). A la vez, el movimiento manual para la realización de cualquier maniobra quirúrgica es totalmente diferente al de la cirugía convencional. Todo ello significa que la cirugía laparoscópica debe ser aprendida y, por tanto, enseñada de forma diferente a la convencional. La formación del cirujano en cirugía laparoscópica debe realizarse desde los ámbitos teórico, práctico y clínico. Esto incluye el conocimiento del aparataje y de la fisiopatología, el desarrollo de las habilidades en técnicas de disección y sutura en el simulador y el animal de experimentación y, finalmente, en el quirófano, en un inicio como ayudantes para progresar hasta la realización completa de la intervención. Este planteamiento es aplicable tanto a cirujanos formados como a residentes en formación. Los hospitales y servicios de cirugía con responsabilidad en la formación de especialistas deben garantizar la adecuada enseñanza de la cirugía laparoscópica a los nuevos cirujanos para que ésta sea una técnica habitual y no la técnica excepcional (AU)

Non-absorbable prosthetic meshes: which is the best option in the repair of abdominal wall defects?

The mechanical properties and macroscopic behaviour of non-absorbable materials have been widely studied. Nevertheless, biological tissue response to contact with these prostheses is not well-known. Our purpose was to compare the microscopic behaviour of two non-absorbable materials. Polypropylene and mersilene meshes were implanted on 36 female Wistar rats each (PPL and ME groups) . Six animals per group were sequentially sacrificed at 1, 2, 3, 5, 10 and 15 weeks. Global cell density and number of polymorphonuclear leukocytes, giant cells, fibroblasts and histiocytes were compared for every studied phase. The polypropylene group showed higher cell density and polymorphonuclear response in the initial phases, while scores for giant cells were higher in the mersilene group. Fibrohistiocytic reaction was increased in the polypropylene group. Polypropylene tends to provoke higher acute inflammatory reaction and connective tissue formation than mersilene. The latter induces higher foreign body reaction.

[Intestinal pneumatosis]. / Neumatosis intestinal.

Intestinal pneumatosis is an infrequent disease of difficult clinical and radiologic diagnosis. It may be accompanied by pneumoperitoneum in up to 30% of the cases leading to differential diagnosis with pictures of visceral perforation. We herein present 4 cases of intestinal pneumatosis in whom pneumoperitoneum was associated in 3 patients. Diagnosis was intraoperative in 2 patients submitted to emergency surgery because of an associated acute gastrointestinal event (intestinal volvulus and acute cholecystitis). The other 2 cases were diagnosed by computerized tomography and colonoscopy, respectively, and given their satisfactory clinical evolution they received conservative treatment. The course of the disease was favorable in all the patients with the radiologic signs of pneumatosis disappearing.

Risks of the minimal access approach for laparoscopic surgery: multivariate analysis of morbidity related to umbilical trocar insertion.

The objective of this study was to determine the morbidity associated with trocar and needle insertion for laparoscopic surgery and to identify risk factors for complications. Data from a prospectively collected database of all laparoscopic operations performed at a major teaching hospital over a 4-year period were analyzed. In 203 patients closed laparoscopy (Veress needle plus blind trocar insertion) was used to establish the pneumoperitoneum. Open laparoscopy with a Hasson's trocar was performed in 200 patients. A total of 1206 operative trocars were inserted (mean +/- SD 2.99 +/- 0.4). Sixty-nine percutaneous punctures for cholangiography or liver biopsy were carried out. Of the 403 patients undergoing laparoscopic surgery, 20 (3%) had developed complications specifically related to the access to the abdominal cavity after a minimum follow-up of 3 months, abdominal wall hematoma being the most frequent (n = 8, 2.0%), followed by umbilical hernias (n = 6, 1.5%) and umbilical wound infection (n = 5; 1.2%). The rate of penetrating injuries was 0.2% (n = 1). Of 20 complications, 15 (75%) were related to the umbilical insertion site. Female sex and closed laparoscopy were associated with umbilical morbidity by univariate analysis. In a multivariate analysis, closed laparoscopy was the only factor associated with these complications (odds ratio = 6.0; p = 0.04). Age, gender, obesity, diabetes mellitus, previous abdominal surgery, and the specific procedure had no influence. In conclusion, gaining access to the peritoneal cavity for laparoscopic surgery may cause severe complications, most of which are related to the umbilical trocar. Although closed laparoscopy can be safely used, open laparoscopy is associated with a lower morbidity rate; therefore its utilization is recommended.

[Excision of esophageal leiomyoma using videothoracoscopy]. / Extirpación de leiomioma esofágico mediante videotoracoscopia.

We report the case of a 57 years old male patient presenting with pyrosis and dysphagia. A mid-third esophageal leiomyoma was diagnosed. The tumour was resected through a right video-thoracoscopic approach and simultaneous intraoperative esophagoscopy was performed. The postoperative course was uneventful and six months after surgery neither relapsing symptoms nor radiologic pathological findings were observed. We consider that symptomatic leiomyoma is a good indication for video-assisted thoracoscopic enucleation. The possible postoperative complications (esophageal fistula, esophageal pseudodiverticulum) may be minimized by means of an adequate surgical technique.

[Laparoscopic surgery in the treatment of complicated gastroesophageal reflux]. / Cirugía laparoscópica en el tratamiento del reflujo gastroesofágico complicado.

Laparoscopic antireflux surgery has quickly developed since Bernard Dallemagne carried out the first laparoscopic fundoplication in 1991. However, only preliminary results from institutional series are available. The authors review the indications for laparoscopic antireflux surgery. In addition, technical aspects of several reported laparoscopic antireflux procedures are evaluated. Data from institutional series show that morbidity and mortality rates after laparoscopic antireflux surgery are similar to those reported for open surgery, with a perioperative morbidity rate ranging between 4% and 26% and a mortality rate under 0.6%. Endoscopic dilation for postoperative dysphagia is required in 7%-11% of the cases. In summary, preliminary data show that laparoscopic antireflux surgery may play a predominant role in the treatment of complicated gastroesophageal reflux. Meanwhile, controlled trials with open surgery and medical therapy should be done before the laparoscopic approach is generalized.

Experimentally contaminated reabsorbable meshes: their evolution in abdominal wall defects.

Contamination by septic materials may represent an important handicap in evaluating the tolerance of reabsorbable prostheses, increasing the possible onset of abdominal fistulae. This is also the case when these materials are used in the treatment of abdominal wall defects. Nevertheless, reabsorbable meshes exist that allow visceroprosthetic contact without risk, thus making it possible to use them in spite of the presence of infection. We have performed this experimental study with the aim of evaluating the behaviour and evolution of polyglycolic acid reabsorbable meshes contaminated by septic materials in the treatment of abdominal wall defects. For this purpose, 40 Wistar rats were operated and distributed into two series of 20 animals each. Massive mesh contamination by fecaloid material did not jeopardise the fact that prostheses were well tolerated in experimental animals throughout the reabsorption process, without increasing the incidence of infection.

[Acute cholecystitis and laparoscopic cholecystectomy. Comparison with non-complicated cholelithiasis]. / Colecistitis aguda y colecistectomia laparoscópica. Comparación con la colelitiasis no complicada.

Laparoscopic cholecystectomy has become the treatment of choice for symptomatic cholelithiasis. However, the indication of the laparoscopic approach for acute inflammation of the gallbladder in unclear and further analysis of the results is required. The aim of our study was to compare the results of laparoscopic cholecystectomy after uncomplicated cholelithiasis and after acute cholecystitis. Data from 201 patients who underwent laparoscopic cholecystectomy were collected prospectively. Uncomplicated cholelithiasis was present in 149 patients and 52 individuals had acute cholecystitis. No differences in age, sex distribution or associated diseases were observed between groups. The mean operative time was significantly higher in patients with acute cholecystitis. However, no difference was observed regarding conversion rate (7.3%-7.6%) and morbidity rate (8.7%-9.6%). No mortality has occurred in any group. The average hospital stay after laparoscopic cholecystectomy was greater when acute cholecystitis was present (2.6 days-4.9 days; p < 0.01). But in this case hospitalization was shorter than after elective conversion (8 days; p < 0.001 and p < 0.05). We conclude that patients with acute cholecystitis can undergo laparoscopic cholecystectomy safely, with low morbidity and mortality rates and reduced hospital stay.

[Laparoscopic cholecystectomy: 3 years of experience at a university hospital]. / Colecistectomía laparoscópica: tres años de experiencia en un Hospital Universitario.

We analyse the first 174 patients treated with laparoscopic cholecystectomy (LC) and their follow-up results. Average age was 57 years. Intraoperative cholangiography was not done in anyone. Conversion rate into other forms of intervention was 6.3%. The rate of common bile duct injury has been null. Total morbidity was 6.3%. Two cases of pulmonary embolism and two biliary leakages stand out in the postoperative morbidity. There was no death. After a follow-up period of up to 36 months, only 1 case of residual choledocholithiasis was registered, and it was cured with endoscopy. In this series morbid-mortality figures are low. LC is a safe procedure in the treatment of cholelithiasis, even in older patients.

[Colangiocarcinoma on a choledochal cyst]. / Colangiocarcinoma sobre quiste de colédoco.

Patients with choledochal cysts have an increased incidence of biliary tract carcinoma. We report a case of adenocarcinoma arising in a type I choledochal cyst which was surgically treated by resection and biliodigestive anastomosis (hepaticojejunostomy).