Search

Objective: Laparoscopic cholecystectomy stands as the established surgical approach for gallbladder diseases. This study seeks to enhance the management of potential complications by anticipating the likelihood of operative complexity and the risk of requiring conversion to an open procedure. Methods: In this retrospective study, a total of 811 cholecystectomy procedures were undertaken, segregating patients into case and control groups. The case group comprised 24 patients who initiated laparoscopically but ultimately underwent open conversion. Exclusion criteria encompassed direct open procedures, patients below 18 years of age, and cholecystectomies performed concurrently with other surgeries. A control group of 276 patients was chosen, matched for age, gender, and body mass index, to evaluate the influential aspects governing conversion likelihood. Results: The study demonstrated a conversion rate of 3.09%. The preeminent determinant of conversion was the increased gallbladder wall thickness. Factors exerting influence on conversion included a history of endoscopic retrograde cholangiopancreatography, prior abdominal surgery, elevated C-reactive protein, lactate dehydrogenase, and direct bilirubin levels, instances of cholecystitis and cholangitis attacks, dense adhesions between the gallbladder and close organs, gallbladder hydrops, impacted stones, and a Callot dissection time exceeding 90 minutes. The Sugrue scoring system was also observed as a potentially valuable tool for predicting the likelihood of open conversion. Conclusion: The capacity to foresee potential complications proactively empowers optimal preoperative preparations. This approach ensures patients are well-informed about the surgery, potential complications, and the prospect of conversion to an open procedure. Moreover, it enables the possibility of conducting the operation within a more experienced medical center when warranted. [ABSTRACT FROM AUTHOR]

Background: Multiple scores have been created in order to predict difficult cholecystectomy, nonetheless there is not a consensuated standard on which to use. The importance of a predictive score to be able to establish a difficult cholecystectomy would be a relevant instrument in order to better inform the patient, properly call for help when needed, choose the correct staff, and schedule and plan the surgical procedure accordingly. Methods: A diagnostic trial study was performed. All different predictive scores for difficult cholecystectomy were calculated for each patient. The correlation between the preoperative score and cholecystectomies considered as "difficult" were measured estimating the preoperative score's predictive value using a receiver operating characteristics curve in order to predict findings for difficult cholecystectomy. Results: A total of 635 patients between 2014 and 2021 were selected. Selected patients had a mean age of 55.0 (interquartile range: 28.00) and were mostly female (64.25%). Surgical outcomes of patients with difficult cholecystectomy had statistically significant higher rates of subtotal cholecystectomies, drain usage, complications and reinterventions, prolonged surgical times, and longer hospital stay. When analyzing the predictive value on each of the different scores applied, score 4 had the highest performance for predicting difficult cholecystectomy with an area under the curve =0.783 (CI 95% 0.745-0.822). Conclusions: Difficult cholecystectomies are associated with worse surgical outcomes. The standardization and use of predictive scores for difficult cholecystectomy must be implemented in order to improve surgical outcomes as a result of more meticulous planning when scheduling the procedure. [ABSTRACT FROM AUTHOR]

Photoallergic reactions are Type IV hypersensitivity reactions localized to photo-exposed areas, with generalization in severe cases. Diagnosis is based on history, photo-patch testing and clinico-histopathological correlation. A 47-year-old man developed multiple, erythematous plaques over V-area of neck, retroauricular area, extensor aspect of both forearms after oral cefixime postcholecystectomy. He had similar episode of lesser severity two months ago after oral Cefixime. Histopathology showed acanthotic epidermis, foci of spongiosis causing vesiculation with lymphocytes. Upper dermis showed infiltrate of lymphocytes and neutrophils along with perivascular infiltrate. Diagnosis was photoallergic reaction to Cefixime. Lesions completely subsided with oral steroids, hydroxychloroquine, antihistamines, sunscreen and emollients over two months. Cephalosporins have multiple side-effects including hypersensitivity, rash, Steven-Johnson syndrome and toxic epidermal necrolysis. Cephalosporin induced photoallergy is not reported. Hence, cephalosporins should be added to the existing list of systemic drugs causing photoallergic reactions. [ABSTRACT FROM AUTHOR]

Teaching Point: Recognize anatomical bile duct anomalies as a potential etiology of bile leakage post-cholecystectomy, and emphasize the importance of adequate radiological evaluation for correct management. [ABSTRACT FROM AUTHOR]

Background: Bile duct injury rates for laparoscopic cholecystectomy (LC) remain higher than during open cholecystectomy. The "culture of safety" concept is based on demonstrating the critical view of safety (CVS) and/or correctly interpreting intraoperative cholangiography (IOC). However, the CVS may not always be achievable due to difficult anatomy or pathology. Safety may be enhanced if surgeons assess difficulties objectively, recognise instances where a CVS is unachievable and be familiar with recovery strategies.Aims and Methods: A prospective study was conducted to evaluate the achievability of the CVS during all consecutive LC performed over four years. The primary aim was to study the association between the inability to obtain the CVS and an objective measure of operative difficulty. The secondary aim was to identify preoperative and operative predictors indicating the use of alternate strategies to complete the operation safely.Results: The study included 1060 consecutive LC. The median age was 53 years, male to female ratio was 1:2.1 and 54.9% were emergency admissions. CVS was obtained in 84.2%, the majority being difficulty grade I or II (70.7%). Displaying the CVS failed in 167 LC (15.8%): including 55.6% of all difficulty grade IV LC and 92.3% of difficulty grade V. There were no biliary injuries or conversions.Conclusion: All three components of the critical view of safety could not be demonstrated in one out of 6 consecutive laparoscopic cholecystectomies. Preoperative factors and operative difficulty grading can predict cases where the CVS may not be achievable. Adapting instrument selection and alternate dissection strategies would then need to be considered. [ABSTRACT FROM AUTHOR]

Copyright of Medical Journal of Ankara Training & Research Hospital is the property of Medical Journal of Ankara Training & Research Hospital and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Background: Cystic artery pseudoaneurysms are rare. It usually occurs as a complication of laparoscopic cholecystectomy, but can arise uncommonly as a complication of acute cholecystitis. Ruptured cystic artery aneurysms present with haemobilia, intraperitoneal or upper gastrointestinal bleeding. We present an unusual case of cystic artery aneurysm presenting as a massive lower gastrointestinal bleed. Case presentation: A 47-year-old man was admitted with a thoracic abscess and was noted incidentally on CT to have acute cholecystitis. Subsequently the patient then presented with massive fresh PR bleeding. This was found on CT to be the result of a cystic artery pseudoaneurysm with associated gallbladder fistulation to the hepatic flexure, secondary to cholecystitis. The patient was treated with coil embolisation of the cystic artery made a full recovery and was discharged with a view to performing an elective cholecystectomy. Conclusion: Cystic artery pseudoaneurysm is a rare complication of cholecystitis which can present as massive lower gastrointestinal haemorrhage secondary to cholecystocolic fistula. Percutaneous embolization is a safe and effective treatment in the acute phase. [ABSTRACT FROM AUTHOR]

Copyright of Agri: Journal of the Turkish Society of Algology / Türk Algoloji (Ağrı) Derneği'nin Yayın Organıdır is the property of KARE Publishing and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

The article offers information on the abdominal wall pain that is a common condition in gastroenterology clinics that frustrates patients and providers. Topics include examines that prevalence of abdominal wall pain is higher in patients with persistent right upper quadrant pain after cholecystectomy; and reports that right upper quadrant is common location of pain, but patients report pain in the epigastrium or in multiple locations.

Abstract Background Consistent measurement and reporting of outcomes, including adequately defined complications, is important for the evaluation of surgical care and the appraisal of new surgical techniques. The range of complications reported after LC has not been evaluated. This study aimed to identify the range of complications currently reported for laparoscopic cholecystectomy (LC), and the adequacy of their definitions. Methods MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched for prospective studies reporting clinical outcomes of LC, between 2013 and 2016. Results In total 233 studies were included, reporting 967 complications, of which 204 (21%) were defined. One hundred and twenty-two studies (52%) did not provide definitions for any of the complications reported. Conversion to open cholecystectomy was the most commonly reported complication, reported in 135 (58%) studies, followed by bile leak in 89 (38%) and bile duct injury in 75 (32%). Mortality was reported in 89 studies (38%). Conclusion Considerable variation was identified between studies in the choice of measures used to evaluate the complications of LC, and in their definitions. A standardised set of core outcomes of LC should be developed for use in clinical trials and in evaluating the performance of surgical units. [ABSTRACT FROM AUTHOR]

The Erector Spinae Plane Block (ESP) is a novel regional technique for anesthesia or analgesia. Originally the ESP block was described in 2016 in a case report regarding analgesia intervention for a case of thoracic neuropathic pain. Since then, there has been growing interest and research adding experience about the ESP block as regional anesthetic and analgesic technique. Reviewing the literature about this novel technique in databases like PubMed using the key words "erector spinae plane block" returns approximately 56 publications. So far there is no available big series of cases or reviews regarding the ESP block. The literature is limited to case reports or case series. With the present case we are interested in exploring the efficacy of ESP block as a postoperative analgesic method for laparoscopic cholecystectomy. We describe the case of a 76-year-old female patient scheduled for laparoscopic cholecystectomy. Written informed consent was granted (for procedure and publication of photos). We applied a bilateral ultrasound-guided ESP block at T6 level while the patient was awake before general anesthesia induction. The anesthetic solution we used consisted of 12 mL Ropivacaine 0.375% plus 2 mg dexamethasone (on each side). After the successful administration of the block (observation of the solution spread between transverse process and the erector spinae muscles), general anesthesia was induced and the procedure was started. Procedure and recovery was uneventful with the patient experiencing very good analgesia (NRS pain score 0 up to 6 hours after block placement). The patient presented mild pain (NRS score of 2–3) after 6 hours and requested the "on demand" pain medication (1 g paracetamol IV) only 10 hours after the ESP block (NRS pain score of 4–5). The patient experienced no nausea or vomiting, was mobilized easily about 6 hours after the block and was discharged the next day. This relatively simple and safe block dramatically reduced the amount of IV pain medication we usually administer for the specific procedure. The overall result was increased satisfaction of the patient and avoidance of opioid use. [ABSTRACT FROM AUTHOR]

Cystic duct calculus could either be due to the retained stone during the cholecystectomy or recurrence of stone in the actual remnant of the cystic duct and causes common duct obstruction by extrinsic compression - Mirizzi syndrome. We report a rare case of post cholecystectomy Mirizzi's syndrome that developed one year after laparoscopic cholecystectomy and our case reminds usefulness of CT scanning, after already inconclusive ultrasound and invasive diagnostic modality ERCP. Stone removal was achieved successfully by traditional laparotomy after the CT scan. [ABSTRACT FROM AUTHOR]

Background: Gallstones and biliary sludge accounted for 30-55% of acute pancreatitis in the West whereas in other countries the incidence of all cases of pancreatitis amounts up to 68.5%. The risk of subsequent attacks for patients recovering from the first attack of acute biliary pancreatitis is 30-fold higher than general population. Further attacks can be prevented by cholecystectomy. Both immediate and delayed cholecystectomies are used with different degree of success and complication rates. Objectives: To compare the frequencies of complications in early and late cholecystectomy in cases of mild acute biliary pancreatitis. Material & Methods:… Study Design: Randomized control trial. Setting: Surgical unit I Nishtar Medical College/ Hospital Multan. Duration of Study: 2 years from 1-1-2015 to 31-12-3016. Sample Size: Total 172 patients, 86 in each group. Sampling Technique: Nonprobability, consecutive sampling. Results: In this study there were total 172 cases out of which 89 (51.74%) were males and 83 (48.26%) females. The mean age was 42.02± 6.36 years and mean duration of symptoms was 4.08± 2.54 days. Mean duration of surgery was 53.30± 6.30 minutes. There were 47 males in the group undergoing early cholecystectomy and 39 in delayed with p= 0.44. Both groups had maximum cases in age group of 40-50 year with p= 0.39. There was no significant difference in terms of duration of symptoms (p=0.26) in both groups. There was significant difference in terms of prolonged duration of surgery where it was seen in 8 (9.30%) out of 86 cases with early as compared to 2 (2.33%) out of 86 cases with delayed cholecystectomy with p value of 0.05. Prolonged duration of hospital stay was also more seen in early cholecystectomy as compared to delayed one, seen in 10 (11.63) cases in early and 4 (4.65%) cases with delayed surgery in their respective groups with p= 0.09. There was significant difference (p= 0.008) in terms of per operative complication with early surgery where it affected the 18 (20.93%) cases as compared to delayed one with 6 (6.95%) cases. There was again significant difference shown in terms of recurrence of pancreatitis which was seen in 7 (8.14%) of cases with early as compared to 1 (1.16%) with delayed surgery with p= 0.03. Conclusion: Early and late cholecystectomies both are performed in tertiary care hospitals. The late cholecystectomy has shown significantly lower per operative complications, duration of surgery and chances of the recurrent pancreatitis. [ABSTRACT FROM AUTHOR]

Background: Despite being the most commonly performed operations, sometimes cholecystectomy fails to relieve symptoms; this is now a well-recognised clinical entity termed 'post-cholecystectomy syndrome' (PCS). Very few studies from India deal with PCS, and the present study was carried out to find the incidence and risk factors for PCS in patients undergoing elective laparoscopic cholecystectomy (LC). Materials and Methods: The records of 207 patients undergoing elective LC were prospectively maintained for 6 months after surgery. Persistence or appearance of new symptoms after surgery was documented and investigated only when they persisted beyond 30 days of surgery. Results: There were 185 (89.4%) female patients and 22 (10.6%) male patients with a mean age of 44.4 years (age range: 12-79 years). Conversion to open cholecystectomy was done in 18 patients (8.69%), mainly due to adhesions and unclear anatomy. The incidence of symptoms was found to be 13% at 6 months follow-up, showing a reducing trend from 58% in the 1st week after LC; the most common symptom in symptomatic patients was dyspepsia (55.56%). On investigation, a cause for symptoms could be detected in only 0.97%. Conclusion: Symptoms are common after LC, but they settle over time. Very few patients have a detectable cause for symptoms after LC, and it is difficult to predict which patients will become symptomatic after LC; in the present series, previous attacks of cholecystitis and presence of co-morbid conditions were the only consistent risk factors for symptoms after LC. [ABSTRACT FROM AUTHOR]

Premise and Objective: Elective laparoscopic cholecystectomy (LC) has low risk for post-operative infectious complications; still most clinicians use persistent post-operative prophylactic antibiotics out of habit, tradition, or simply as defensive practice due to evolving medicolegal implications of a large number of surgeries being showcased as daycare or next day discharge procedures. This randomised prospective trial was done to test the need for such prophylaxis in cases of elective LC in a rural/semi-urban setting. Materials and Methods: Two hundred and ten successive patients undergoing elective LC were randomised into groups receiving single dose of injection ceftriaxone at the time of induction of anaesthesia, (Group A = 112 cases) and those who in addition to above received injection ceftriaxone twice daily for 2 days postoperatively (Group B = 98 cases). Post-operative infectious complications between two groups were compared for variables such as age, sex, body mass index and bile/stone spillage. Results: There was no significant difference in surgical site infection rates between the groups for variables such as age, sex, body mass index, duration of symptoms, American Society of Anesthesiologists grade, duration of surgery and hospital stay. Intraoperative spillage of stones (9.8% [A]: 5.1% [B]) did not increase infectious complications even in the presence of positive bile culture (Group A, N = 7 vs. Group B, N = 3). An operative time of greater than 60 min was found to be associated with increased surgical site infection (P = 0. 0006). Conclusion: Single dose of ceftriaxone at the time of induction is adequate prophylaxis following elective LC even in the rural/semi-urban Indian setting and routine continued administration of antibiotic should be abandoned as it contributes to adverse reactions, drug resistance and unnecessary financial burden. [ABSTRACT FROM AUTHOR]

Purpose: Intraperitoneal local anesthetic nebulization is a new and novel technique for providing pain relief following laparoscopic cholecystectomy. We compared the analgesic efficacy of intraperitoneal ropivacaine-fentanyl nebulization with ropivacaine nebulization alone for providing pain relief following laparoscopic cholecystectomy Materials and Methods: This prospective, randomized, double-blind, placebo-controlled trial included 75 American Society of Anesthesiologists I/II patients, 18-60 years old, scheduled to undergo laparoscopic cholecystectomy under general anesthesia. Patients were randomly allocated to one of the three groups of 25 patients each to receive intraperitoneal nebulization using normal saline (group I), 30 mg of 0.75% ropivacaine (group II), or 30 mg of 0.75% ropivacaine with 100 μg fentanyl (group III). Visual analogue scale (VAS) scores for pain during rest and movement, shoulder pain, nausea or vomiting, and sedation were recorded for 48 hours postoperatively. Time to providing first rescue analgesia and 48-hour tramadol consumption were also noted.Results: Significantly greater number of patients in the placebo group had overall VAS >30 both at rest and during movement. Greater number of these patients also complained of postoperative shoulder pain and had significantly more tramadol consumption in the postoperative period. Furthermore, patients in the ropivacaine-fentanyl group demanded first dose of rescue analgesic significantly later than the other two groups.Conclusions: Nebulization results in better and uniform dispersion of analgesic drug intraperitoneally. Following laparoscopic cholecystectomy surgeries, ropivacaine nebulization of intraperitoneal cavity, with or without fentanyl, provides highly effective postoperative analgesia, with decreased incidence of shoulder pain. Furthermore, addition of fentanyl to ropivacaine prolongs the duration of analgesia. [ABSTRACT FROM AUTHOR]

Background: Hypothermia is associated with an increased postoperative morbidity and mortality. Forced-air warming systems are the most effective methods for its prevention. When using a mattress, a reduction in the area of diffusion of warm air by crushing due to excess weight cannot be ruled out.Methods: We designed a prospective study to compare the efficacy of a forced-air warming mattress (Bair Hugger® 585) to prevent hypothermia (core temperature (CT°) < 36 °C) in morbidly obese (group MO, body mass index (BMI) ≥ 40 kg/m2) and non-obese patients (group NO, BMI < 30 kg/m2).Results: Twenty-six patients were included in group MO (84% bariatric surgery, 96% laparoscopic procedures) and 32 in group NO (37.5% cholecystectomy, 62.5% laparoscopic procedures). The incidence of hypothermia was not different between the two groups 1 h after induction (H1) and at extubation: 22 vs 19% (not significant (NS)) and 23 vs 19% (NS) for the group MO versus group NO. At H1, the mean CT° was not different: 36.3 ± 0.4 °C vs 36.4 ± 0.5 °C (NS), group MO versus group NO. No patient presented severe hypothermia (CT° < 34.9 °C). Dysfunction of the forced-air warming mattress was observed for eight patients (31%) in group MO but for none in group NO.Conclusion: The forced-air warming mattress is effective in preventing hypothermia in MO patients. However, excess weight is associated with frequent dysfunction of the system, which does not make it a practical system in a context of MO. [ABSTRACT FROM AUTHOR]

Background: Cholecystitis is an inflammation of the gallbladder that most commonly occurs as a result of obstruction of the cystic duct by gallstones. The current standard of treatment for acute cholecystitis is cholecystectomy.Objective: Our goal was to discuss the benefits of and compare early laparoscopic cholecystectomy and delayed laparoscopic cholecystectomy in the treatment of acute cholecystitis.Materials and Methods: A Medline literature search was performed dating from January 1982 to July 2015. We limited the search to human studies written in English and using the keywords "Acute Cholecystitis," early vs. delayed laparoscopic cholecystectomy, surgical management, and surgical complications.Results: There were 225 articles reviewed, of which 25 met criteria for selection. Our recommendations are based on these 25 articles.Conclusion: Early laparoscopic cholecystectomy is preferred over delayed, due to overall better quality of life, lower morbidity rates, and lower hospital cost. Ultimately, management of acute cholecystitis by emergency physicians should be made based on patient's clinical status and available resources in their particular hospital. [ABSTRACT FROM AUTHOR]

Background: Previous studies have focused on the presence of reflux in selected cohorts with pancreaticobiliary maljunction (PBM), but little is known regarding the wider incidence of occult reflux and associated mucosal changes. We aimed to correlate gallbladder mucosal abnormalities with objective evidence of PBM and occult pancreaticobiliary reflux (PBR) in an Australian population undergoing cholecystectomy. Methods: Patients undergoing cholecystectomy between September 2010 and September 2012 were eligible for inclusion. Demographic and pre‐operative clinical data were collated and entered into a pre‐defined database. Operative cholangiograms were routinely performed and the presence of PBM noted. Gallbladder bile samples were analysed for bilirubin (<20 µmol/L), amylase (<100 U/L) and lipase (<70 U/L) levels. Evidence of PBR was correlated with gallbladder mucosal findings. Results: A total of 305 cholecystectomies were performed for biliary colic (73%), choledocholithiasis (9%), cholecystitis (8.4%) and pancreatitis (6.4%). A total of 12.7% had cholangiographic evidence of PBM and 11.9% possessed gallbladder mucosal changes. Overall, 7.7% had increased biliary amylase, which was associated with significantly higher rates of gallbladder intestinal metaplasia (33% versus 8.6%; P = 0.012). Elevated biliary amylase was also higher in patients with prior pancreatitis (P = 0.02) or choledocholithiasis (P < 0.01). The presence of PBM did not predict for the presence of PBR. Conclusion: PBR is associated with an increased frequency of gallbladder mucosal metaplasia, irrespective of the presence of PBM. Objectively identified reflux represents an additional indication for cholecystectomy but the long‐term consequences for extra‐hepatic biliary malignancy remain unknown and warrant further investigation. Methods of objectively identifying PBR pre‐operatively require further investigation. [ABSTRACT FROM AUTHOR]

Background Bile spillage (BS) occurs frequently during laparoscopic cholecystectomy, yet its impact on postoperative outcomes remains unknown. We hypothesized that BS increases the risk of surgical site infections (SSI) after laparoscopic cholecystectomy. Study Design Patients older than 18, who were admitted to an academic hospital for a laparoscopic (or laparoscopic converted to open) cholecystectomy, from May 2010 to March 2017, were prospectively included. Open cholecystectomies were excluded. Patients were assessed clinically during hospitalization and 2 to 4 weeks after discharge. We compared those who had BS during the operation with those who did not. Our primary endpoint was the rate of SSI. Stepwise logistic regression was used to identify independent predictors of SSI. Results Of 1,001 patients, 49.9% underwent laparoscopic cholecystectomy for acute cholecystitis, 20.9% for symptomatic cholelithiasis or biliary colic, 12.8% for gallstone pancreatitis, and 16.4% for other indications. Bile was spilled intraoperatively in 591 patients (59.0%), with hydrops noted in 10.5% and empyema in 14.6% of them. In 202 (20.2%) patients, BS was accompanied by stone spillage. Patients with BS were older (median age of 52 vs 42, p < 0.001) and were more frequently male (44.8% vs 27.8%, p < 0.001). Conversion to open was more likely in operations with BS (13.0% vs 4.4%, p < 0.001). Bile spillage was associated with a higher SSI rate (7.1% vs 2.4%, p = 0.001) and longer hospital stay (median of 3 vs 2 days, p < 0.001). In the multivariable analysis, BS, conversion to open, and American Society of Anesthesiologists (ASA) score > 2 were independent predictors of SSI (odds ratios: 2.29, 2.46, and 2.1 respectively, p < 0.05). Conclusions Bile spillage is associated with SSI, and surgeons should take extra caution to avoid it during laparoscopic cholecystectomy. [ABSTRACT FROM AUTHOR]

Background: Laparoscopy is an acceptable procedure for cholecystitis in pregnancy. Laparoscopic complications during pregnancy can be unique. Uterine perforation is a rare complication during laparoscopy of pregnant women. Acquaintance with this complication can help surgeons and gynecologist to manage these patients properly. We will report a case of uterine perforation during laparoscopy. Case presentation: Our patient was a 24-year pregnant woman with gestational age of 28 weeks. She had nausea and vomiting and right upper quadrant tenderness, she was admitted in surgery ward on January 2017 in an academic hospital in Mashhad and candidate for laparoscopic cholecystectomy with diagnosis of cholecystitis. Her fundal height was 28 centimeters. Laparoscopy was done with Hasson technique and three punctures. During abdominal trocar insertion uterine perforation occurred. Amniotic fluid leaked in the abdomen. Perforation repaired immediately and then cholecystectomy was done. Fetal heart rate was normal. After surgery according to stable vital signs and absence of bleeding and contraction, the patient was transferred to the midwifery department. The patient received one course of betamethasone for fetal lung maturation. Antibiotic therapy initiated. During the hospitalization, the patient was monitored daily for vital signs (fever and tachycardia), uterine contraction, vaginal bleeding and vaginal bleeding. Daily fetal heart monitoring was performed. After close prenatal care cesarean section was done in 38 weeks of pregnancy and a healthy baby was born with appropriate Apgar score. Conclusion: Laparoscopy in pregnant women is usually safe.Pregnancy-specific complications such as uterine injury are not common, but with a series of precautions before and during surgery. These complications can be reduced. Uterine perforation during laparoscopy if properly managed is usually not associated with significant risk. [ABSTRACT FROM AUTHOR]

The incidence of postcholecystectomy syndrome (PCS) at Cipto Mangunkusumo Hospital, Indonesia, was previously found to be 54.29% (2012), which was higher than those reported in other countries. This research was undertaken to identify the risk factors for PCS in developing countries with limited resources and facilities. This was a cross-sectional study of all patients who underwent cholecystectomy in our hospital during 2015. The variables included sex, body mass index, preoperative symptom duration, preoperative flatulence, level of education, preoperative symptoms, preoperative awareness, and preoperative ultrasound. All the data were analyzed through bivariate and multivariate analyses. In total, 112 patients who underwent laparoscopic cholecystectomy were followed. We found the incidence of PCS to be 45.5%. Multivariate logistic regression analysis showed that preoperative flatulence (P ≤ 0.001, OR = 17.152), nonspecific preoperative symptoms (P = 0.012, OR = 3.984), and patients' poor preoperative awareness of PCS (P = 0.003, OR = 5.907) were independent predictive factors for PCS. Statistically significant correlation between patients' awareness and preoperative education (P ≤ 0.001, OR = 69.00) was found. We concluded that preoperative flatulence, nonspecific preoperative symptoms, and poor preoperative awareness increased the incidence of PCS. Besides abdominal ultrasound, other examinations, such as upper GI endoscopy, for nonspecific preoperative symptoms that do not meet the Rome III criteria are recommended to rule out the diagnosis and avoid unnecessary surgeries. Adequate preoperative information and education may reduce the incidence of PCS. [ABSTRACT FROM AUTHOR]

Background: The most desirable treatment of choice of treatment of bile leakage following cholecystectomy is Endoscopic retrograde cholangiopancreatography (ERCP) with placement of a biliary stent or drain. Aim of the study:To study the treatment outcomes in cases with bile leakage following cholecystectomy. Materials and methods:The study was conducted in the department of general surgery of the medical institute. We included 45 patients admitting to the Department of General Surgery with biliary leakage after cholecystectomy or developed biliary leakage after cholecystectomy from January 2017 to June 2017. Patients between the ages of 14 years to 60 years were included in the study. We collected data such as clinical presentations following biliary leak, timing of detection of bile leak post operatively (< 24 hour or > 24 hour), acute or chronic cholecystitis at the time of operation, amount of bile leak, duration of bile leak, postoperative investigation (MRCP, CT abdomen, USG) for bile leak, various modalities of management and its outcome, site of bile leak. Results:In the present study a total of 45 cases were included in the study. The age of the patients ranged between 14 to 60 years with mean age at 42.21 years. No. of male patients was 29 and no. of female patients was 16. No. of cases which underwent open cholecystectomy was 29 and no. of cases which underwent laparoscopic cholecystectomy was 16. The major bile duct injury was seen in 7 patients who underwent open cholecystectomy and 6 patients who underwent laparoscopic cholecystectomy. We observed that conservative treatment with controlled external fistula was performed on 35 patients. Operative treatment was performed on 10 patients. Conclusion: The injury to bile duct during cholecystectomy procedure can be very deliberating to the patients and proper steps should be taken for early diagnosis and treatment to avoid such deliberating condition. In our study, conservative treatment was significantly efficacious. [ABSTRACT FROM AUTHOR]

Aim: To compare the safety of cholecystectomy in early laparoscopic cholecystectomy (ELC) and delayed laparoscopic cholecystectomy (DLC).Methods: We systematically searched PubMed, EMBASE, and Cochrane Library for studies that were published from January 1992 to March 2017. We included studies on patients with mild biliary pancreatitis and that reported the timing of cholecystectomy and the number of complications, readmissions, and conversion to open cholecystectomy. Moreover, we assessed the quality and bias risks of the included studies.Results: After screening 4651 studies, we included 3 randomized clinical trials and 10 retrospective studies. The included studies described 2291 patients, of whom 1141 (49.8%) underwent ELC and 1150 (50.2%) underwent DLC. The reported rate of complications for ELC (6.8%) was lower than that for DLC (13.45%). The reported rate of readmission for ELC was lower than that for DLC. The length of hospital stay was longer with DLC than with ELC. ELC and DLC did not have significantly different rates of conversion to open cholecystectomy and duration of surgery.Conclusion: This meta-analysis provides evidence that ELC is better than DLC in many aspects for acute mild pancreatitis patients undergoing laparoscopic cholecystectomy. ELC associated with few complications and readmissions, as well as a short length of hospital stay. [ABSTRACT FROM AUTHOR]

Background: Surgeons are regularly not involved in the post discharge care of patients after uncomplicated laparoscopic cholecystectomy. The purpose of the current study was to document the symptomatic recovery of patients following laparoscopic cholecystectomy, because this has a bearing on the planning of a postoperative care package. Methods: The study was designed as a postoperative telephone questionnaire survey and was carried out prospectively between June2016 and February2017 in King Abdulaziz Hospital, KSA. Results: The study cohort comprised 51 patients who all completed the study. Postoperatively, only 3% of the patients had postoperative nausea/vomiting lasting ≥2 days. Pain was symptomatic in 12% of patients. Port-site wounds were a source of significant symptoms in 69% of the patients. Postoperative reviews by a nurse and primary-care doctor were necessary in 76% and 34% patients, respectively, with a combined average of 3.1 reviews per patient. Less than 4% of patients believed that they would benefit from a surgeon's review 6 weeks after LC. Median time taken to return to routine preoperative activity after surgery was 21 days (IQR, 16 to 33), which was affected by the degree of activity undertaken, wound-related symptoms persisting for ≥3 weeks, planned follow-up clinic appointment, and discharge as an outpatient. Conclusion: Wound-related symptoms are common after LC, require substantial input from the community health service in their management, and may delay return to preoperative routine. [ABSTRACT FROM AUTHOR]

Background: Iatrogenic bile duct injury (BDI) is a common complication after cholecystectomy. Patients are mainly treated endoscopically, but the optimal treatment method has remained unclear.Aims: The aim was to analyze endoscopic treatment in BDI after cholecystectomy and to explore endoscopic sphincterotomy (ES), with or without stenting, as the primary treatment for an Amsterdam type A bile leak.Methods: All patients referred to Helsinki University Hospital endoscopy unit due to a suspected BDI between the years 2004 and 2014 were included in this retrospective study. To collect the data, all ERC reports were reviewed.Results: Of the 99 BDI patients, 94 (95%) had bile leak of whom 11 had concomitant stricture. Ninety-three percent of all patients were treated endoscopically. Seventy-one patients had native papillae and a leak in the cystic duct or peripheral radicals. They were treated with ES (ES group, n = 50) or with sphincterotomy and stenting (EST group, n = 21). There was no difference between the closure time of the fistula (p = 0.179), in the time of discharge from hospital (p = 0.298), or in the primary healing rate between the ES group and the EST group (45/50 vs 19/21 patients, p = 0.951).Conclusion: After the right patient selection, the success rate of endoscopic treatment can approach 100% for Amsterdam type A bile leak. ES is an effective and cost-effective single procedure with success rate similar to EST. It may be considered as a first-line therapy for the management of Amsterdam type A leaks. [ABSTRACT FROM AUTHOR]

Cholecystolithiasis and its complications remain to be one of the leading burdens in general surgery which require surgical intervention in majority of cases. In Saudi Arabia, this pathology has huge impact on its health system and society. In current management of acute and chronic cholecystitis as a result of cholecystolithisis, laparoscopic cholecystectomy has become a procedure of choice. The aim of this cross-sectional study was to estimate the incidence of cholecystitis as the complication of cholecystolithiasis in central rural area of Saudi Arabia with relatively large population and analyze current management outcome in selected group of patients, who underwent laparoscopic cholecystectomy procedure. Multiple criteria including demographics, results of investigations and surgical outcome were analyzed and compared. The incidence of acute cholecystitis in this study was 4.4/100,000 of population per year with prevalence of 24% and female to male ratio 11.9:1. The results demonstrated satisfactory surgical outcomes with low complications rate and cost effectiveness. [ABSTRACT FROM AUTHOR]

Laparoscopic cholecystectomy (LC) is preferred in the treatment of symptomatic cholecystolithiasis. Gallstone spillage is not uncommon, and there have been reports of associated complications. We report a case of a free intraperitoneal gallstone, left inadvertently during LC, which developed an inflammatory phlegmon with abscess containing gallstone, causing extraluminal compression on the distal ileum, resulting in small bowel obstruction. This complication in particular is almost unheard of. The patient underwent laparoscopic drainage of abscess and retrieval of gallstone, which relieved the obstruction. Clinicians, therefore, need to keep an open mind in the workup for bowel obstruction. During LC, gallstone spillage should be prevented and retrieved whenever possible to minimize early and late complications associated with it. [ABSTRACT FROM AUTHOR]

Introduction and Background: Infection of the incised skin or soft tissue is a common but potentially avoidable complication of surgical procedures. Some bacterial contamination of surgical site infection is inevitable, from patients own flora or from the environment. Pre operative risk score based on presence of co-morbidities has been devised by American Society of Anaesthesiologists (ASA). Post operative wound infection has an enormous impact on patient's quality of life and contributes substantially to the financial cost of patient care. Objective: To find out the prevalence of wound infection, its correlation with ASA score, duration of procedure and positive bile culture and also to find out the type of organisms commonly found in the bile aspirated from gall bladder in patients subjected to cholecystectomy in a tertiary care hospital in Kashmir. Materials and Methods: After an institutional approval, the study was conducted by the Department of Pharmacology; Government Medical College Srinagar in collaboration with the Department of Surgery, SMHS Hospital (Associated hospital of Government Medical College, Srinagar). Patients with USG diagnosed cholelithiasis attending the surgical OPD of the SMHS hospital, planned for elective cholecystectomy were enlisted and those with no known drug allergy were eligible. Results: Out of 200 patients studied, the number of females was twice the number of males with the mean age of study population being 41.4± 9.4 years.66% of patients belonged to ASA score 1 and rest to ASA score 2.The prevalence of post operative wound infection amongst the study population was 18.5% with a higher rate amongst those belonging to ASA score 2 as compared to those belonging to score 1. Amongst the study population, 99% showed negative bile culture, in 0.5% aspiration was not done and only 9.5% of patients showed the growth of one or the other organisms that included Klebsiella and E. Coli (31.5% each), Pseudomonas and Non haemolytic streptococcus (10.5% each) and Citrobacter(16%). As such no co relation was found to exist between positive bile culture and duration of surgery with the subsequent development of post operative wound infection. Conclusion: The overall prevalence of wound infection amongst the study group was 18.5% with a higher rate amongst those belonging to ASA score 2 as compared to those belonging to score 1 with statistically no significant association between the positive bile culture and duration of surgery with the development of postoperative wound infection. [ABSTRACT FROM AUTHOR]

Background and Study Aims: The risk of infectious complications due to peritoneal contamination is a major concern and inhibits the widespread use of transrectal NOTES. A standardized rectal washout with a reversible colon occlusion device in situ has previously shown potential in reducing peritoneal contamination. The aim of this study was to compare the peritoneal contamination rate and inflammatory reaction for transrectal cholecystectomy after ideal rectal preparation (trCCE) and standard laparoscopic cholecystectomy (lapCCE) in a porcine survival experiment.Methods: Twenty pigs were randomized to trCCE (n = 10) or lapCCE (n = 10). Before trCCE, rectal washout was performed with saline solution. A colon occlusion device was then inserted and a second washout with povidone-iodine was performed. The perioperative course and the inflammatory reaction (leukocytes, C-reactive protein) were compared. At necropsy, 14 days after surgery the abdominal cavity was screened for infectious complications and peritoneal swabs were obtained for comparison of peritoneal contamination.Results: Peritoneal contamination was lower after trCCE than after lapCCE (0/10 vs. 6/10; p = 0.003). No infectious complications were found at necropsy in either group and postoperative complications did not differ (p = 1.0). Immediately after the procedure, leukocytes were higher after lapCCE (17.0 ± 2.7 vs. 14.6 ± 2.3; p = 0.047). Leukocytes and C-reactive protein showed no difference in the further postoperative course. Intraoperative complications and total operation time (trCCE 114 ± 32 vs. 111 ± 27 min; p = 0.921) did not differ, but wound closure took longer for trCCE (31.5 ± 19 vs. 13 ± 5 min; p = 0.002).Conclusions: After standardized rectal washout with a colon occlusion device in situ, trCCE was associated without peritoneal contamination and without access-related infectious complications. Based on the findings of this study, a randomized controlled clinical study comparing clinical outcomes of trCCE with lapCCE should be conducted. [ABSTRACT FROM AUTHOR]

Introduction: preemptive analgesia is a treatment that prevents the establishment of changes, so-called sensitive processing of the aphasic signals which increase post-operative pain. It is a treatment that prevents the creation of central hypersensitivity caused by dissection or inflamed tissue injury Preemptive analgesia prevents or reduces the "pathological" pain that differs from physiological pain in some characteristics: it is too extensive in intensity and expansion can be triggered by low intensity stimuli (hyperalgesia) or even typical painless sensations recognized as painful (allodynia). Aim: to compare the effectiveness of pre applied diclofenac in reducing post operative pain following laparoscopic cholecystectomy and to prove how adequate preemptive analgesia, diclofenac reduces the use of pain reliever (analgesic) in the postoperative period. Within the study we also examined the characteristics and qualities of the effect of applied analgesic depending on the following factors: age, body mass index and the presence of comorbidity in patients at the Public Hospital Travnik in Travnik. Materials and methods: this prospective study included 90 patients who underwent laparoscopic cholecystectomy The study was realized by dividing the patients into 3 groups: Group I included 30 patients, who received pre operatively diclofenac in the amount of 1 mg/kg intramuscular; Group II consisting of 30 patients who received diclofenac in the amount of lmg/kg in a form of suppositories and Group III consisted of 30 patients who were not given diclofenac. The study included the total of 90 patients. Results: the research showed that patients' age and weight did not have any influence on subjective pain assessment either in the overall sample or in individual groups. There was statistically significant difference in the estimation of pain intensity after 15, 20, 30, 45 and 60 minutes and 2, 3 and 6 hours after the surgery There was a difference among the individual groups regarding the pain occurrence after 15, 30, 45 and 60 minutes, and 2, 3 and 6 hours after the surgery among the control and other two groups, but not between Group I (diclofenac intramuscularly) and Group II (diclofenac suppository). Conclusion: preemptive analgesia administered intramuscularly or in the form of suppositories, significantly reduced the intensity of pain postoperatively but we could not confirm significant difference in the manner of analgesia administration (intramuscular injection or suppository). [ABSTRACT FROM AUTHOR]

Introduction: Cholecystectomies are most common surgical specimens sent in pathology laboratories. Most common histologically identified lesion of gallbladder is chronic cholecystitis which on most occasions is associated with cholelithiasis. It is most common indication for cholecystectomy and also associated with gallbladder carcinomas. Aim: The aim of the present was to study the morphological spectrum of gallstone disease and correlation of cholelithiasis with benign and malignant lesions. Materials and Methods: A retrospective study was carried out from January 2012 to June 2016. A total of 1693 specimens were assessed for size of gallbladder, serosa, wall thickness, mucosa, presence/absence of stones, their number, and type along with any mass lesions. Microscopic features assessed included inflammation, cholesterolosis, granulomas, metaplasia, calcification, dysplasia, benign and malignant neoplasms. Results: Maximum numbers of cases were between 31 to 40 years with female preponderance. Chronic cholecystitis was the most common lesion seen in 1170 (69.1%) cases. Associated calculi was present in 1625 cases, mixed and cholesterol type accounting for 1050 (64.6%) and 382 (23.51%) respectively based on morphological appearance. Amongst 439 cases showing metaplasia, antral type metaplasia was most common followed by intestinal metaplasia. Most frequent stromal change was cholesterolosis. Dysplasia was seen in 15 (0.88%) cases and malignancy in 16 cases. Conclusion: Incidental detection of gallbladder malignancy on microscopic examination is the most significant information for the surgeon as well as for the patient and this fact emphasises the importance of subjecting each gallbladder specimen for histopathological examination. [ABSTRACT FROM AUTHOR]

Objective:Further research is needed to understand how pain frequency, localization of pain and the patient’s conviction of the cause of pain effects long-term outcome after gallstone surgery. Materials and methods:A cohort study was conducted based on patients evaluated with SF-36 along with three single-items focusing on gallstone specific symptoms. The physical component summary (PCS) and bodily pain (BP) of SF-36 were used as main outcome measures. To assess the improvement from the procedure, the differences between the preoperative and postoperative ratings were tested with univariate and multivariate logistic regression analysis. The ratings on the single-items regarding pain frequency, pain localization and patient’s conviction of the cause of pain were used as predictors. In the multivariate analysis, adjustment was made for age, gender and approach. The study was approved by the Swedish Ethics Committee, Dnr 2015/115. Results:The study group was based on 4021 patients who responded to the questionnaire SF-36 and the three gallstone specific items preoperatively. A total of 2216 (55.1%) patients also responded postoperatively. In multivariate logistic regression analysis the frequency of the pain attacks and the patient’s conviction of the origin of pain significantly predicted postoperative pain as well as PCS of SF-36 (allp < .05). Conclusions:The preoperative frequency of pain attacks and the patient’s conviction of the cause of pain can predict the outcome regarding PCS and the subscale BP of SF-36 with significantly better ratings in patients with a pain frequency exceeding once per month and in patients convinced of having pain related to gallstones. [ABSTRACT FROM AUTHOR]

Operations of varying duration cause the release of a number of inflammatory mediators, in particular cytokines which lead to proteasome and acute-phase reactions. The purpose of this novel human study, was to characterize inflammatory response in children undergoing laparoscopic cholecystectomy, by analyzing changes in selected inflammatory mediators: C-reactive protein concentration and circulating 20S proteasome activity following surgical injury and to correlate them with the duration of the surgical procedure. Plasma C-reactive protein concentration (CRP) was determined by standard biochemical laboratory procedures. Proteasome activity in the plasma of children was assessed using Suc-Leu-Leu-Val-Tyr-AMC peptide substrate. Statistically significant increase in the plasma proteasome activity and C-reactive protein concentration, was noted (p < .05) in children after laparoscopic cholecystectomy. We found the correlation between the 20S proteasome activity and the length of the procedure. In children undergoing longer lasting laparoscopic cholecystectomy the proteasome activity was much higher than in patients having shorter surgical procedure. The CRP concentration and 20S proteasome activity significantly increase after surgery, but only 20S proteasome activity correlate with the length of the surgery. This may confirm that CRP is only an indicator of pathological state, while the function of the proteasomes is more complex because of their participation in the processes of repair and wound healing, and in the removal of damaged proteins. [ABSTRACT FROM PUBLISHER]

Background Previous studies have reported that same-day laparoscopic cholecystectomy for acute cholecystitis is superior to delayed elective cholecystectomy. Although this practice is ideal, it requires significant hospital resources, particularly for an underprivileged inner-city population at a large, municipal hospital. We sought to evaluate the implementation of same-day laparoscopic cholecystectomy in a large, municipal hospital and assess the possible benefits of decreasing preoperative length of stay (LOS), particularly its effect on operative time and length of stay in patients with acute cholecystitis. Materials and Methods This was a retrospective chart review of patients treated for symptomatic gallstone disease between September 2012 and November 2013. Medical records were reviewed, and relevant data points were collected. Univariate and multivariate regressions were performed to assess the correlation between time to operation (<36 h [no delay] or >36 h [delay]) and the main outcomes (operative time and total length of stay). Inclusion criteria were patients age ≥18 y who underwent same-admission cholecystectomy and had a diagnosis of cholecystitis on pathology. Eighty-eight patients met all inclusion criteria. Results The mean (standard deviation) preoperative LOS was 76.2 (±48.6) h, the mean operative time was 2.3 (±1.1) h, and the mean postoperative LOS was 60.3 (±60.1) h. The average total LOS was 136 (±79.8) h. Operative times and postoperative LOS were similar for patients in the delay and no delay groups. Patients with >36 h wait before surgery had a total length of stay twice as long as patients with <36 h wait (152 versus 83.3 h; P = 0.0005). These findings remained significant when adjusted for age, sex, radiologic findings, number of preoperative tests, and pathology. Conclusions Increased preoperative LOS is not associated with a significant increase in operative time. However, it was associated with significantly increased length of stay. Further analysis is needed to explore the potential cost savings of decreasing preoperative LOS. [ABSTRACT FROM AUTHOR]

Background The aim of the study was to assess the rate of 30-d hospital readmissions after ambulatory laparoscopic cholecystectomy. Materials and methods The 2009 to 2011 State Ambulatory Surgery and Services and State Inpatient Databases from California, Florida, and New York were analyzed to evaluate the incidence of 30-d readmissions after laparoscopic cholecystectomy performed in outpatient settings. Hospital transfers and the principal diagnoses of hospital readmission were analyzed as secondary outcomes. Multilevel generalized mixed linear regression analyses with fixed and random effects were used to evaluate variables associated with increased likelihood of readmissions. Results A total of 230,745 encounters for ambulatory laparoscopic cholecystectomies performed in 890 ambulatory facilities between 2009 and 2011 in the three states were analyzed. The rate of 30-d readmission was 20.2 per 1000 discharges. The rate of direct transfers from the ambulatory surgery center to an acute care hospital was 0.6 per 1000 discharges. The most common diagnoses of readmission were surgical complications, postoperative pain, infection, and nausea or vomiting. After adjusting for comorbidities, increasing age, male sex, non-Hispanic white race/ethnicity, any nonprivate insurance type, diagnosis of acute cholecystitis, use of intraoperative cholangiography, and having the procedure performed on a weekend were significantly associated with increased odds of 30-d readmissions. Conclusions This large-state data analysis reveals that the unplanned admission and readmission rates after laparoscopic cholecystectomy are very low. Some causes of readmission (e.g., pain, nausea, and vomiting) are modifiable by the intervention of surgeons and anesthesia providers. [ABSTRACT FROM AUTHOR]

Background: Gallstone disease is common, and it is asymptomatic, patients may need an operative. Laparoscopic cholecystectomy becomes the choice for symptomatic gallstone disease intervention; open surgery was replaced by Laparoscopic cholecystectomy in the cholecystolithiasis treatment, open surgery has different complications. Laparoscopic cholecystectomy has several advantages over open surgery, but it has several complications also. Aim: To investigate the prevalence and risk factors of postoperative complications of open and lab cholecystectomy in AL-Madinahcitizen. Method: This retrospective cross-section study included 205 patients from king Fahad hospital in Al-Madinah AL-Munwwarah. A questionnaire was conducted on the participant by interview to investigate different variables. Results: The percent of a female was 73.7%, and percent of a male was 26.3%, the bleeding complication represented 19.5%, infection was 3.9%, biliary leakage was 3.9%, and wound infection was 1.5%. The mean duration of recovery was 3.56 days while the mean duration for returning back to work was 12.37 days. Lap operation had less duration for recovery than an open operation. Conclusion: Bleeding was the most common complication among patients, lap group patients experienced complications less than the open group. Male gender, age, obesity, the emergency of operation, diabetes mellitus, hypertension, thyroid and heart disease were not risked factors for complications. [ABSTRACT FROM AUTHOR]

Background and Aims: Sevoflurane is an excellent but expensive anesthetic agent for laparoscopic cholecystectomy. To decrease sevoflurane consumption during surgery adjuvants like dexmedetomidine may be used. Dexmedetomidine is a recently introduced drug which alleviates the stress response of surgery, produces sedation and analgesia. We aimed to evaluate sevoflurane sparing effect of dexmedetomidine in patients undergoing laparoscopic cholecystectomy under entropy-guided general anesthesia (GA). Material and Methods: In this prospective randomized control study, 100 American Society of Anesthesiologists physical status I-II adult surgical patients scheduled to undergo laparoscopic cholecystectomy were enrolled. Patients were randomly divided into two groups (n = 50). In dexmedetomidine group, patients received intravenous (IV) dexmedetomidine 0.5 μg/kg over 10 min before induction followed by 0.5 μg/kg/h infusion while in control group, patients received the same volume of normal saline. Results: Sevoflurane consumption was 41% lower in dexmedetomidine group as compared to control group (7.1 [1.6] vs. 12.1 [1.9] ml, P<0.001). A 40% reduction was observed in induction dose of propofol (83.0 [19.1] vs. 127.6 [24.8] mg, P <0.001). Mean Riker sedation-agitation score, visual analog score for pain and Aldrete's score were significantly lower in dexmedetomidine group as compared to control group. None of the patients experienced any significant side effects. Conclusion: A 41% reduction in sevoflurane consumption was observed in patients receiving IV dexmedetomidine as an adjuvant in patients undergoing laparoscopic cholecystectomy under GA. [ABSTRACT FROM AUTHOR]

Purpose: Robotic LaparoEndoscopic Single-Site Surgery Cholecystectomy has been performed for 5 years using a dedicated platform (da Vinci® Single-Site®) with the da Vinci® Surgical System (Intuitive Surgical Inc., Sunnyvale, CA, USA). While short-term feasibility has been described, long-term assessment of this method is currently outstanding. The aim of this study was to assess long-term parietal complications of this technique.Methods: In this retrospective study, patients operated between 2011 and 2013 were evaluated. Parietal incision was assessed with ultrasonography and patients screened for residual pain from scar tissue. Demographic and perioperative data were also collected.Results: We evaluated 48 patients [38 female, 79.2%; median age 49 years (range: 24-81 years)]; mean BMI 25.9 kg/m2 [±SD 4.1 kg/m2]. After a median follow-up of 39 months (range: 25-46 months), six incisional hernias (two patients had a positive echography but a negative clinical examination) were found (12.5%, 95% CI 7.5-30.2), and two patients had a surgical repair. The overall rate of incisional hernia was 16.7% (95% CI 7.5-30.2). Residual pain was observed in 5 of 48 patients.Conclusion: This preliminary study suggests that a clinically significant rate of incisional hernias can occur after R-LESS-C. Larger studies comparing R-LESS-C to alternative methods with long-term follow-up are necessary. [ABSTRACT FROM AUTHOR]

Background: Post-laparoscopic shoulder pain (PLSP) frequently follows a laparoscopic cholecystectomy. A proposed mechanism for PLSP is the irritation or injury of the phrenic nerve by the CO2 pneumoperitoneum during laparoscopic surgery. Here, we investigated whether a phrenic nerve block (PNB), performed under ultrasound guidance, could reduce the incidence and severity of PLSP after laparoscopic cholecystectomy.Method: Sixty patients were randomized into two groups, with one group receiving PNB with 4 ml (30 mg) of 0.75% ropivacaine (group P, n = 28) and a control group (group C, n = 32). The existence and severity of PLSP were assessed for 2 days postoperatively. A pulmonary function test (PFT) and diaphragmatic excursion test were performed pre- and postoperatively.Results: With ultrasound guidance, all PNBs were performed successfully in group P. In group P, the overall incidence and severity of PLSP decreased significantly. There were no significant differences in incisional pain, visceral pain, and analgesic requirements between the groups. Right-side diaphragmatic excursion decreased significantly in group P at 1 h postoperatively. The PFT results and respiratory discomfort assessed by a modified Borg's scale were not different significantly between the groups.Conclusion: Based on these findings, ultrasound-guided PNB can prevent or reduce the PLSP without clinically significant respiratory discomfort. [ABSTRACT FROM AUTHOR]

Hemobilia is caused by the abnormal connection between a blood vessel and the bile duct, which is usually iatrogenic and caused by hepatobiliary procedures. The classic triad of hemobilia includes biliary colic, obstructive jaundice, and gastrointestinal bleeding. We present the case of an 80-year-old man who had laparoscopic cholecystectomy complicated by hemobilia. He had an unusual presentation of hemobilia in the form of transient vasovagal episodes in addition to abdominal pain and hematochezia. [ABSTRACT FROM AUTHOR]

Background: Pneumoperitoneum during laparoscopic cholecystectomy (LC) can cause hypercapnia, hypoxemia, hemodynamic changes and shoulder pain. General anesthesia (GA) enables the control of intraoperative pain and ventilation. The need for GA has been questioned by studies suggesting that neuraxial anesthesia (NA) is adequate for LC.Study Objective: To quantify the prevalence of intraoperative pain and to verify whether evidence on the maintenance of ventilation, circulation and surgical anesthesia during NA compared with GA is consistent.Design: Systematic review with meta-analyses.Setting: Anesthesia for laparoscopic cholecystectomy.Patients: We searched Medline, Cochrane and EBSCO databases up to 2016 for randomized controlled trials that compared LC in the two groups under study, neuraxial (subarachnoid or epidural) and general anesthesia.Measurements: The primary outcome was the prevalence of intraoperative pain referred to the shoulder in the NA group. Hemodynamic and respiratory outcomes and adverse effects in both groups were also collected.Main Results: Eleven comparative studies were considered eligible. The pooled prevalence of shoulder pain was 25%. Intraoperative hypotension and bradycardia occurred more frequently in patients who received NA, with a risk ratio of 4.61 (95% confidence interval [CI] 1.70-12.48, p=0.003) and 6.67 (95% CI 2.02-21.96, p=0.002), respectively. Postoperative nausea and vomiting was more prevalent in patients who submitted to GA. The prevalence of postoperative urinary retention did not differ between the techniques. Postoperative headache was more prevalent in patients who received NA, while the postoperative pain intensity was lower in this group. Performing meta-analyses on hypertension, hypercapnia and hypoxemia was not possible.Conclusions: NA as sole anesthetic technique, although feasible for LC, was associated with intraoperative pain referred to the shoulder, required anesthetic conversion in 3.4% of the cases and did not demonstrate evidence of respiratory benefits for patients with normal pulmonary function. [ABSTRACT FROM AUTHOR]

Background Acute cholecystitis is a common condition. Recent studies have shown an association between creation of an acute surgical unit ( ASU) and improved outcomes. This study aimed to evaluate the outcomes of a subspecialty based approach to the management of acute cholecystitis as an alternative to the traditional 'generalist' general surgery approach or the ASU model. Method A 6-year retrospective analysis of outcomes in patients admitted under a dedicated upper gastrointestinal service for acute cholecystitis undergoing emergency laparoscopic cholecystectomy. Results Seven hundred emergency laparoscopic cholecystectomies were performed over this time. A total of 486 patients were available for analysis. The median time to operation was 2 days and median length of operation was 80 min. A total of 86.9% were performed during daylight hours. Eight cases were converted to open surgery (1.6%). Intra-operative cholangiography was performed in 408 patients. The major complication rate was 8.2%, including retained common bile duct stones (2.3%), sepsis (0.2%), post-operative bleeding (0.4%), readmission (0.6%), bile leak (2.1%), AMI (0.4%), unscheduled return to theatre (0.6%) and pneumonia (0.8%). There were no mortalities and no common bile duct injuries. Conclusion Over a time period that encompasses the current publications on the ASU model, a subspecialty model of care has shown consistent results that exceed established benchmarks. Subspecialty management of complex elective pathologies has become the norm in general surgery and this study generates the hypothesis that subspecialty management of patients with complex emergency pathologies should be considered a valid alternative to ASU. Access block to emergency theatres delays treatment and prolongs hospital stay. [ABSTRACT FROM AUTHOR]

This prospective, observational study explored the need for pain-related unscheduled contact with healthcare services after outpatient surgery. We hypothesised that 10% of outpatients would have pain-related unscheduled contact with healthcare services, and that the incidence would differ depending on the type of surgical procedure. In total, 905 patients who had undergone one of five common outpatient surgical procedures (knee or shoulder arthroscopy, surgical correction of hallux valgus, laparoscopic cholecystectomy or laparoscopic gynaecological procedures) completed an electronic questionnaire one week and eight weeks after surgery. Data from 732 patients (81%) were available for analysis. Within the first eight weeks after surgery, 150 patients (20.5%) had made unscheduled contact with healthcare professionals, in 247 cases due to pain that was most frequent in the first postoperative week. Risk factors were female sex, unemployment and laparoscopic cholecystectomy. The most frequent healthcare contact was with the general practitioner (46.4%), and the most frequent outcome was further information and guidance (41.2%). We have demonstrated that a minority of patients still needed to make contact with health services after outpatient surgery, most often due to inadequate pain management. This finding should be considered when planning postoperative monitoring and care, and developing postoperative patient education. [ABSTRACT FROM AUTHOR]

Background: We previously reported outcome after transvaginal cholecystectomy (TVC) from two cohort studies and a randomized controlled trial. We now present a pooled analysis of postoperative pain scores.Design: Single-center data of postoperative pain after TVC from a level II hospital between October 2007 and June 2012.Methods: Female patients, above 18 years with symptomatic cholecystolithiasis, received either TVC or conventional laparoscopic cholecystectomy (CLC). Follow up 4 days. The primary outcome of the study was pain after surgery. Pain was measured via a visual rating scale. Descriptive statistics include age, body mass index (BMI), ASA grade, surgical times, number of trocars, complications and hospital stay as well as pain medication. Pain data were assessed against histologic findings.Results: The combined register included 316 patients. Of these, 7 patients were excluded from analysis due to conversion to open surgery, complications and denial of follow-up. There were 141 patients in the TVC and 168 in the CLC group. There was no difference in age, ASA grade, surgical times, complications or hospital stay. BMI was significantly different with an average BMI of 27.1 in the TVC and 28.7 in the CLC group (p = 0.027). The numbers of trocars were significantly different as expected. There was no difference in postoperative pain medication. Pain scores were significantly different on day two to four. Multivariate testing revealed no dependence between postoperative pain and histologic findings.Conclusion: On smaller patient numbers, we were previously unable to demonstrate a consistently, significant difference for postoperative pain in our cohort and randomized studies. The pooled analysis suggests that there is an advantage with less postoperative pain after transvaginal compared to standard laparoscopic cholecystectomy. [ABSTRACT FROM AUTHOR]

Objective: To describe the experience of treating empyema gall bladder with laparoscopic cholecystectomy. Study Design: Descriptive observational study. Place and Duration of Study: The study was carried out at Combined Military Hospital (CMH) Peshawar, from Feb 2012 till May 2014 for a period of twenty eight months. Material and Methods: Twenty eight patients were enrolled in the study who fulfilled the criteria for empyema and were willing for laparoscopic cholecystectomy, chances of conversion to open cholecystectomy and risk of complications involved. We defined the operative difficulty levels according to the intra-operative findings. Level 1-adherent omentum, level 2--oedematous gall bladder wall, level 3--necrotic gall bladder wall, level 4--adherent gut and level 5 -- adherent Hartmann's pouch and oedematous Calot's triangle having no defined planes. The results were noted in terms of time taken for the operation and complications of the operative procedure. Results: Twenty eight patients of empyema gall bladder underwent laparoscopic cholecystectomy. Mean age was 46.2 ± 7.1 years. Average duration of symptoms was 4.1 ± 2.3 days. Two patients had level-I operative difficulty, 6 patients had level-II difficulty, 9 patients had level-3 difficulty, 2 patients had level-IV difficulty and 9 patients had level-V difficulty. In 21(75%) patients total cholecystectomy was performed, anterior partial cholecystectomy was done in 2 patients (7.1%) and 5 patients (17.9%) were converted to open cholecystectomy. One patient (3.5%) had Stresburgh Bismuth type D injury and was managed by open exploration and T-tube placement. No mortality was encountered in the study group. Conclusion: The technique of laparoscopic cholecystectomy can be used effectively for treating empyema gall bladder specifically in American Society of Anaesthesiologists (ASA) I & II patients. Further randomized controlled trials can elaborate its efficacy. This will not only prove to be cost effective but it will also add to the comfort of the patient. [ABSTRACT FROM AUTHOR]

Objective: To study the effects of laparoscope cholecystectomy on serum levels of superoxide dismutase (SOD) and malondialdehyde (MDA) and liver functions of patients with acute suppurative cholecystitis and its curative effects. M础ods: 92 patients with acute suppurative cholecystitis who were treated in our hospital from September 2014 to September 2016 were selected and randomly divided into the observation group (n=46) and the control group (n=46). The patients in the control group were treated with the conventional cholecystectomy, while the patients in the observation group were treated with laparoscope cholecystectomy. Then the blood loss, the operation time, postoperative drainage volume, the exhaust time and hospitalization, the serum levels of alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bilirubin (TBIL), superoxide dismutase (SOD) and malondialdehyde (MDA) and the complications were observed and compared between the two groups before and after the operation. Results: The blood loss and postoperative drainage volume in the observation group were lower than those of the control group, and the the operation time, postoperative exhaust time, defecation time and hospitalization were shorter than those of the control group (P<0.05); After the operation, the serum levels of alanine aminotransferase (ALT), aspartate aminotransferase (AST) and total bilirubin (TBIL) in the observation group were lower than those of the control group (P<0.05); After the operation, the serum levels of SOD in the observation group was higher than that of the control group, while the MDA was lower (P<0.05); The incidence of postoperative complications in the observation group was lower than that of the control group (P<0.05). Conclusion: Laparoscope cholecystectomy has obvious clinical effects on the treatment of acute suppurative cholecystitis, with less damage to liver functions and lower incidence of postoperative complications, which is worthy of clinical application. [ABSTRACT FROM AUTHOR]