Pulmonary function after transverse or midline incision in patients with obstructive pulmonary disease

Open pancreaticoduodenectomy: setting the benchmark of time to functional recovery

Purpose

No accepted benchmarks for open pancreaticoduodenectomy (PD) exist. The study assessed the time to functional recovery after open PD and how this could be affected by the magnitude of midline incision (MI).

Materials and methods

Prospective snapshot study during 1 year. Time to functional recovery (TtFR) was assessed for the entire cohort. Further analyses were conducted after excluding patients developing a Clavien-Dindo ≥ 2 morbidity and after stratifying for the relative length of MI.

Results

The overall median TtFR was 7 days (n = 249), 6 days for uncomplicated patients (n = 124). A short MI (SMI, < 60% of xipho-pubic distance, n = 62) was compared to a long MI (LMI, n = 62) in uncomplicated patients. The choice of a SMI was not affected by technical issues and provided a significantly shorter TtFR (5 vs 6 days, p = 0.002) especially for pain control (4 vs. 5 days, p = 0.048) and oral food intake (5 vs. 6 days, p = 0.001).

Conclusion

Functional recovery after open PD with MI is achieved within 1 week from surgery in half of the patients. This should be the appropriate benchmark for comparison with minimally invasive PD. Moreover, PD with a SMI is feasible, safe, and associated with a faster recovery.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00423-021-02333-3.

Decreased Length of Stay After Laparoscopic Diaphragm Repair for Isolated Diaphragm Injury After Penetrating Trauma

BACKGROUND

Isolated diaphragm injury (IDI) occurs in up to 30% of penetrating left thoracoabdominal injuries. Laparoscopic abdominal procedures have demonstrated improved outcome including decreased postoperative pain and length of stay (LOS) compared to open surgery. However, there is a paucity of data on this topic for penetrating IDI. The aim of this study was to examine the prevalence and outcome of laparoscopic diaphragmatic repair versus open diaphragmatic repair (LDR vs ODR) of IDI.

METHODS

The Trauma Quality Improvement Program (2010-2016) was queried for patients with IDI who underwent ODR versus LDR. A bivariate analysis using Pearson chi-square and Mann-Whitney test was performed to determine LOS among the two groups.

RESULTS

From 2039 diaphragm injuries, 368 patients had IDI; 281 patients (76.4%) underwent ODR and 87 (23.6%) underwent LDR. Compared to LDR, the ODR patients were older (median, 31 vs 25 years, P < .001) and had a higher injury severity score (mean, 11.2 vs 9.6, P = .03) but had similar rates of intensive care unit LOS, unplanned return to the operating room, ventilator days, and complications (P > .05). Patients undergoing ODR had a longer LOS (5 vs 4 days, P = .01), compared to LDR. There were no deaths in either group.

CONCLUSIONS

Trauma patients presenting with IDI undergoing ODR had a longer hospital LOS compared to patients undergoing LDR with no difference in complications or mortality. Therefore, we recommend when possible an LDR should be employed to decrease hospital LOS. Further research is needed to examine other benefits of laparoscopy such as postoperative pain, incisional hernia, and wound-related complications.

Delayed Respiratory Distress in a Patient With Chronic Obstructive Pulmonary Disease After Abdominal Surgery

Patients with chronic obstructive pulmonary disease (COPD) are at increased risk for perioperative complications. The frequency of complications depends on the severity of COPD, the type of anesthesia used, the surgical site, and other comorbidities. Patients undergoing upper abdominal surgery have significant changes in lung volumes, likely secondary to changes in diaphragm function and abdominal pain, and these changes increase the risk for complications, including acute respiratory failure, atelectasis, pneumonia and unplanned reintubation. We discuss a patient with COPD who did well for the first 3 days following an open incisional hernia repair. However, on the fourth day he noted significant dyspnea and radiographic studies revealed atelectasis. Over the next week the patient remained symptomatic and dependent on noninvasive ventilation; he eventually had a rapid response to corticosteroids. This case indicates that atelectasis can develop late following a surgical procedure and that multiple factors potentially influence development of this complication.

Laparoscopically assisted repair of an acute traumatic diaphragmatic hernia

A 60-year-old man with chronic obstructive pulmonary disease and a heavy smoker and drinker presented to the emergency department with left-sided thoracoabdominal pain after falling down the stairs. Initial clinical findings were left-sided chest tenderness with no clinical evidence of subcutaneous emphysema. Twenty-four hours later the patient's respiratory distress increased-repeat chest X-ray showed a left gastrothorax indicative of a ruptured left hemi diaphragm. Diagnostic laparoscopy in the supine position via an umbilical port confirmed the presence of the stomach, spleen and splenic flexure of the colon in the left chest. Laparoscopic reduction of the stomach and colon was performed, but a small upper midline incision was required to reduce the spleen without injury. The diaphragmatic tear was repaired by direct open suture. The patient required a brief period of postoperative ventilation via a tracheostomy. The patient remained well at a 3-month follow-up visit.

Up and down or side to side? A systematic review and meta-analysis examining the impact of incision on outcomes after abdominal surgery

BACKGROUND

The aim of this study was to examine whether midline, paramedian, or transverse incisions offer potential advantages for abdominal surgery.

DATA SOURCES

We searched MEDLINE, Embase, Web of Science, and The Cochrane Central Register of Controlled Trials from 1966 to 2009 for randomized controlled trials comparing incision choice.

METHODS

We systematically assessed trials for eligibility and validity and extracted data in duplicate. We pooled data using a random-effects model.

RESULTS

Twenty-four studies were included. Transverse incisions required less narcotics than midline incisions (weighted mean difference = 23.4 mg morphine; 95% confidence interval [CI], 6.9 to 39.9) and resulted in a smaller change in the forced expiratory volume in 1 second on postoperative day 1 (weighted mean difference = -6.94%; 95% CI, -10.74 to -3.13). Midline incisions resulted in higher hernia rates compared with both transverse incisions (relative risk = 1.77; 95% CI, 1.09 to 2.87) and paramedian incisions (relative risk = 3.41; 95% CI, 1.02 to 11.45).

CONCLUSIONS

Both transverse and paramedian incisions are associated with a lower hernia rate than midline incisions and should be considered when exposure is equivalent.

Midline versus transverse incision in major abdominal surgery: a randomized, double-blind equivalence trial (POVATI: ISRCTN60734227)

OBJECTIVE

There are 2 main types of access for patients requiring major open, elective abdominal surgery: the midline or the transverse approach. The aim of this study is to compare both approaches by focusing on postoperative pain, complications, and frequency of incisional hernias.

SUMMARY BACKGROUND DATA

A recent Cochrane review suggested that transverse incisions may be less painful but incisional hernia rates do not differ.

METHODS

Randomized, patient- and observer-blinded, monocentric, equivalence clinical trial. Patients were scheduled for elective primary abdominal incisions. Composite primary end point measured 48 hours after surgery was the total amount of analgesics (piritramide) required in the last 24 hours and pain (Visual Analogue Scale). Secondary end points were early-onset and late complications. This study is registered in the ISRCTN registry and has the ID number ISRCTN60734227.

RESULTS

Two hundred patients (101 midline and 99 transverse) were randomized. Both incision types resulted in similar amounts of required analgesics (95% confidence interval [-0.38; -0.33] was included in the equivalence level). For the Visual Analogue Scale, both the 95% and 90% CI (0-10) were neither within the equivalence levels nor were their differences significant at the 5% level. No relevant differences between midline and transverse incisions were observed for 30-day mortality (2 vs. 2, P = 0.99), mortality after one year (15 vs. 23, P = 0.15), pulmonary complications (13 vs. 17, P = 0.43), median length of hospital stay (11 vs. 12 days, P = 0.08), median time to tolerance of solid food (12 vs. 14 days, P = 0.30), and incisional hernias after one year (13 vs. 8, P = 0.48). More wound infections occurred in the transverse group (15 vs. 5, P = 0.02).

CONCLUSION

The decision about the incision should be driven by surgeon preference with respect to the patient's disease and anatomy.

Risk factors for postoperative pulmonary complications in upper abdominal surgery

BACKGROUND

Pulmonary complications are the most frequent cause of postoperative morbidity and mortality in upper abdominal surgery (UAS). We aimed to examine the influence of possible preoperative, operative and postoperative risk factors on the development of early postoperative pulmonary complications (POPC) after UAS.

METHODS

A prospective study of 60 consecutive patients was conducted who underwent elective UAS in general surgical unit. Each patient's preoperative respiratory status was assessed by an experienced chest physician using clinical examination, chest radiographs, spirometry and blood gas analysis . Anaesthetical risks, surgical indications, operation time, incision type, duration of nasogastric catheter and mobilization time were noted. Forty-eight hours after the operation, pulmonary examinations of the patients were repeated.

RESULTS

Postoperative pulmonary complications were observed in 35 patients (58.3%). The most common complication was pneumonia, followed by pneumonitis, atelectasis, bronchitis, pulmonary emboli and acute respiratory failure. The presence of preoperative respiratory symptoms and the spirometric parameter of forced expiratory volume in 1 s/forced vital capacity were the most valuable risk factors for early prediction of POPC. The sensitivity, specificity and diagnostic efficiency of the presence of preoperative respiratory symptoms in the POPC prediction were 70, 61 and 66%, respectively.

CONCLUSION

We recommend a detailed pulmonary examination and spirometry in patients who will undergo UAS by chest physicians to identify the patients at high risk for POPC, to manage respiratory problems of the patients before surgery and also to help surgeons to take early measures in such patients before a most likely POPC occurrence. Improvement of lung function in those patients at risk for POPC before operation may decrease morbidity in surgical patients.

Optimal Abdominal Incision for Partial Hepatectomy: Increased Late Complications with Mercedes-type Incisions Compared to Extended Right Subcostal Incisions

INTRODUCTION

The optimal abdominal incision for partial hepatectomy has not been established.

METHODS

A prospective hepatobiliary surgery database was retrospective reviewed. Patients with Mercedes and extended right subcostal (ERSC) incisions were identified and compared.

RESULTS

Between December 1991 and September 2001 a total of 1426 patients met the inclusion criteria. Among them, 856 (60%) had a Mercedes incision and 570 (40%) an ERSC incision. The two groups were well matched for demographics and operative variables. Perioperative morbidity and pulmonary complications were similar for the two groups as well. There was no difference in terms of early wound complications, although incisional hernias occurred in 9.8% of patients with a Mercedes incision compared to 4.8% of those with an ERSC incision (P = 0.0001). On multivariate analysis, the incision type, along with gender, body mass index, and age, were significant predictors of incisional hernia.

CONCLUSIONS

An ERSC incision for partial hepatectomy provides adequate, safe access and is associated with fewer long-term wound complications.

Anesthésie et réanimation pour chirurgie réglée de l'anévrisme de l'aorte abdominale

OBJECTIVES

Patient scheduled for infrarenal abdominal aortic aneurysm surgery carries a high risk of cardiac or respiratory comorbidity. To outline the perioperative management for these patients.

METHODS

Review of the literature using MesH Terms "abdominal aortic aneurysm", "anesthesia", "analgesia" "critical care" and/or "surgery" in Medline database.

RESULTS

Cardiac preoperative evaluation and management have recently been reviewed. Intermediate and high-risk patients should undergo non-invasive cardiac testing to decide between a preoperative medical strategy (using betablocker+/-statin and aspirin) and an interventional strategy (coronary angioplasty or cardiac surgery). Perioperative myocardial ischaemia should also be investigated by clinical, electrocardiographic and biologic monitoring such as plasmatic troponin Ic dosage. Specific score could also assess the respiratory failure risk preoperatively. Epidural analgesia decreases this risk. There is no evidence that a pharmacological treatment decreases the incidence of acute renal failure after aortic surgery. Endovascular repair is actually recommended for older, higher-risk patients or patients with a hostile abdomen or other technical factors that may complicate standard open repair.

Outcomes of Patients With Acute Respiratory Failure After Abdominal Surgery Treated With Noninvasive Positive Pressure Ventilation

OBJECTIVES

Little is known about the physiologic and clinical effects of noninvasive positive pressure ventilation (NPPV) in patients who have acute respiratory failure (ARF) after abdominal surgery. We evaluated our clinical experience with the use of NPPV in the treatment of ARF after abdominal surgery.

METHODS

We prospectively evaluated NPPV use during a 2-year period in a medical-surgical ICU of a university hospital. We documented demographic and diagnostic data, gas exchange, and clinical outcomes. We compared patients who were not intubated to those who were intubated after a trial of NPPV.

RESULTS

Of 72 patients with ARF after abdominal surgery who were treated with NPPV, 48 patients avoided intubation (67%). Patients in the intubated and nonintubated groups had similar demographic characteristics, and similar American Society of Anesthesiologists physical status and simplified acute physiology score II scores at admission. The intubated group had a significantly lower Pa(O2)/fraction of inspired oxygen (Fi(O2)) ratio (123 +/- 62 mm Hg vs 194 +/- 76 mm Hg, p < 0.01) and more extended bilateral alveolar infiltrates (67% vs 31%, p < 0.01) than the non-intubated group. Within the first NPPV observation period, the Pa(O2)/Fi(O2) increased (+ 36 +/- 29% [+/- SD], p = 0.04) and the respiratory rate decreased (28.2 +/- 3.4 breaths/min vs 23.1 +/- 3.8 breaths/min, p < 0.01) significantly only in the non-intubated group. The non-intubated group had significantly lower length of ICU stay (17.3 +/- 10.9 days vs 34.1 +/- 28.5 days, p < 0.01) and mortality rate (6% vs 29%, p < 0.01).

CONCLUSION

NPPV may be an alternative to conventional ventilation in selected patients with ARF after abdominal surgery who require ventilatory support.

Estudo prospectivo do derrame pleural pós-cirurgia abdominal e dos fatores de risco associados: avalição por ultra-sonografia

MOTIVAÇÃO: Derrame pleural é alteração pulmonar comumente observada em exames de imagem após cirurgias abdominais eletivas, sem repercussão clínica na maioria dos enfermos, devendo ser individualizada das complicações pulmonares que requerem tratamento. Sua incidência, bem como os indicadores de risco, são desconhecidos em nosso meio. OBJETIVO: Determinar, pela ultra-sonografia, a incidência de derrame pleural pós-operatório (DPPO) em cirurgias abdominais eletivas e averiguar suas possíveis associações com fatores de risco relacionados aos doentes e procedimentos anestésico-cirúrgicos. MATERIAIS E MÉTODOS: Estudaram-se 21 (56,8%) mulheres e 16 (43,2%) homens, entre 29 e 76 anos, submetidos a cirurgias abdominais eletivas. Os exames ecográficos foram realizados no pré-operatório e 48 horas após a cirurgia. Foram estudados os fatores de risco associados ao paciente - idade maior de 60 anos, sexo, obesidade, tabagismo, etilismo e presença de doenças associadas -, e ao procedimento anestésico-cirúrgico - cirurgia para ressecção de câncer, classe ASA > 2, tempo anestésico-cirúrgico, incisão longitudinal e incisão > 15 cm. A litíase biliar (43,2%) e a presença de câncer gastrintestinal (43,2%) foram os principais responsáveis pela indicação cirúrgica. O DPPO foi graduado de pequeno, médio e grande. RESULTADOS: A incidência de DPPO foi de 70,3% (26/37). Dois (5,4%) desses doentes evoluíram com complicações pulmonares graves, um deles vindo a falecer. Idade maior de 60 anos, tabagismo, etilismo, obesidade e presença de doenças associadas não influenciaram o aparecimento de DPPO. Cirurgia para ressecção de câncer, classe ASA > 2, incisão longitudinal e incisão > 15 cm associaram-se de modo significante à presença de DPPO, que ocorreu mesmo na vigência de antibioticoprofilaxia. O tempo de permanência hospitalar foi 2,4 vezes maior nos doentes com DPPO. CONCLUSÃO: A ocorrência de derrame pleural em pós-operatório de cirurgia abdominal eletiva é muito freqüente. A maioria dos DPPO é autolimitada, evoluindo de modo assintomático. A ecografia na constatação do DPPO mostrou-se efetiva e sua utilização merece ser difundida.

Evaluation and management of patients with pulmonary disease before thoracic and cardiovascular surgery

The risks of respiratory complications after thoracic and cardiovascular surgeries are particularly high for patients with chronic pulmonary disease and are associated with prolonged hospital stays and increased mortality. The primary goals of preoperative management are to identify risk factors and institute interventions likely to reduce subsequent postoperative pulmonary complications. Smoking, symptomatic obstructive lung disease, respiratory infection, obesity, and malnutrition are all potentially modifiable risk factors. Chest physiotherapy is indicated in all patients regardless of risk factor profile. Providing a thoughtfully designed, multifaceted course of preoperative care can result in a clinically significant reduction in postoperative morbidity and mortality, particularly if instituted well in advance of surgery.

[Repercussion of postoperative pain, benefits attending to treatment]

Physiological responses to postoperative acute pain may impede organ functions (cardiovascular, pulmonary, coagulation, endocrine, gastrointestinal, central nervous system, etc). Pain alleviation improves patient's comfort, but also may minimise perioperative stress response, physiological responses and postoperative organ dysfunction, assist postoperative nursing and physiotherapy, enhance clinical outcome, and potentially shorten the hospital stay. Potent postoperative analgesia, especially by epidural route, may be associated with reduction in incidence and severity of many perioperative dysfunctions. Peridural analgesia using local anaesthetics is the best technique for decreasing postoperative stress after lower abdominal or lower limb surgery. Analgesia using either epidural or high doses of morphine may improve some cardiac variables such as tachycardia and ischaemia, but does not change the incidence of severe cardiac complications. For patients undergoing vascular or orthopaedic surgery, epidural analgesia can improve clinical outcome by preventing the development of arterial or venous thromboembolic complications. However, in comparative studies, the control groups did not receive adequate prophylactic treatment for thromboembolic complications. Epidural analgesia can hasten the return of gastrointestinal motility and shorten the hospital stay. Postoperative mental dysfunction is decreased using intravenous PCA morphine in the elderly. Epidural analgesia with local anaesthetics improves postoperative respiratory function but, for unknown reasons, these benefits are not associated with a decrease in respiratory complications. On balance, the mode of acute pain relief decreases adverse physiological responses and many intermediate outcome variables; however, there is inconclusive evidence that it affects clinical outcome. Major advances in postoperative recovery can be achieved by early aggressive perioperative care, including potent analgesia, early mobilisation and oral nutrition. As a result, the hospital stay may be shortened.

Abdominal incisions from creation to closure

Many of the techniques involved in creating and closing a surgical incision are based on tradition. Over the last several decades, randomized studies have addressed some of the steps in this process. Animal data and human data often have conflicting results. Randomized trials in human subjects indicate: 1) The incision can be made with one, rather than two, scalpels. 2) There is no advantage to using a laser rather than a scalpel when creating the incision. 3) Subcutaneous Penrose drains carried through the incision increase the infection rate. Closed suction drains in the subcutaneous space are rarely indicated. 4) The surgeon does not need to close peritoneum. 5) Time can be saved by closing the fascia in a continuous rather than interrupted fashion without causing an increase in postoperative wound separation or hernia formation. 6) Closing Camper's fascia after a cesarean delivery reduces the incidence of wound separation. 7) The cosmetic appearance of an incision is not improved by closing skin in a subcuticular rather than interrupted fashion.

[Prevention of respiratory complications after abdominal surgery]

Abdominal surgery, especially upper abdominal surgical procedures are known to adversely affect pulmonary function. Pulmonary complications are the most frequent cause of postoperative morbidity and mortality. This review article aimed to analyse the incidence and risk factors for postoperative pulmonary morbidity and their prevention. The most important means for preoperative assessment is the clinical examination; pulmonary function tests (spirometry) are not reliably predictive for postoperative pulmonary complications. Age, type of surgical procedure, smoking and nutritional state have all been identified as potential predictors for postoperative complications. However, usually there is not enough preoperative time available to obtain beneficial effects of stopping smoking and improvement of nutritional state. In patients with COPD, a preoperative multidisciplinary evaluation including the primary care physician, pulmonologist/intensivist, anesthesiologist and surgeon is required. Consensus as to preoperative physiologic state, therapeutic preparation, and postoperative management is essential. Simple spirometry and arterial blood gas analysis are indicated in patients exhibiting symptoms of obstructive airway disease. There are no values that contra-indicate an essential surgical procedure. Smoking should stop at least 8 weeks preoperatively. Preoperative therapy for elective surgery with antibiotics, beta2-agonist, or anticholinergic bronchodilator aerosols, as well as training in cough and lung expansion techniques should begin at least 24 to 48 hours preoperatively. Postoperative therapy should be continued for 3 to 5 days. Usually, anaesthesia is responsible for early complications, whereas surgical procedures are often associated with delayed morbidity. Laparoscopic procedures are recommended, as postoperative morbidity and hospital stay seem reduced in patients without COPD. Regional anaesthesia is given as having less adverse effects on pulmonary function than general anaesthesia. However, for unknown reasons these benefits are not associated with a decrease in postoperative respiratory complications. Moreover, the quality or the type of postoperative analgesia does not influence postoperative respiratory morbidity. Postoperatively, oxygen administration increases SaO2, but cannot abolish desaturation due to obstructive apnea. The various techniques of physiotherapy (chest physiotherapy, incentive spirometry, continuous positive airway pressure breathing) seem to be equivalent in efficacy; but intermittent positive pressure breathing has no advantages, compared with the other treatments and could even be deleterious. Chest physiotherapy and incentive spirometry are the most practical methods available for decreasing secretion contents of airways, whereas continuous positive airway pressure breathing is efficient on atelectasis. In stage II or III COPD patients, admission in a intensive therapy unit and prolonged mechanical ventilation may be required.

[Prediction of respiratory complications after surgery of the abdominal aorta]

The most frequent type of complication in patients undergoing aortic surgery is respiratory. Preoperative lung function (PFT) and arterial blood gas measurement (ABG) are often carried out to assess the risk more precisely. The aim of the present retrospective study was to determine which value of lung function test could identify patients who developed such complications. "Receiver Operating Characteristic" (ROC) curves and the area beneath the curve for the diagnosis of respiratory complications were calculated for each variable of PFT and ABG. The greatest Youden index for each variable was chosen as indicative pulmonary function criterion of increased risk of pulmonary complications. One hundred and ninety-five patients (age: 65 +/- 10 years) were included. Respiratory complications occurred in 15% of patients. Respiratory complications increased from 12% if the vital capacity (VC) was > or = 77% of the predicted value to 35% if the VC was < 77% (P = 0.002), and from 10% if the FEV1 was > 76% to 34% if the FEV1 was > or = 76% (P = 0.0005). A decreased PaO2 or increased PaCO2 was not correlated with an increased incidence of respiratory complications. Length of stay in ICU or in hospital were increased when VC or FEV1 were low. Frequency of pulmonary complications was 9% in patients without PFT abnormalities, 16% in patients with either diminished VC or FEV1 and 35% in patients with both lowered VC and FEV1. However, all the areas under the ROC curves were < 0.7 and the sensitivity of the different variables was low. It is concluded that routine preoperative PFT and ABG cannot predict respiratory complications after abdominal aortic surgery.

Laparoscopic cholecystectomy produces less postoperative restriction of pulmonary function than open cholecystectomy

This study was undertaken to determine whether laparoscopy produces less postoperative decrease in pulmonary function than does open operation. Ten elective laparoscopic cholecystectomy patients (LC group) were compared to 10 elective open cholecystectomy patients (OC group). Spirometry was performed preoperatively and then postoperatively as soon as each patient was awake and cooperative. The two groups were similar with respect to age, gender, and preexisting medical illness. No patient had underlying cardiopulmonary disease. Postoperatively, forced vital capacity, forced expiratory volume in 1 s, and maximum forced expiratory flow decreased to 56%, 55%, and 43% of preoperative values in the OC group and to 72%, 76%, and 81% of preoperative values in the LC group. These decreases were significantly greater in the OC group as compared to the LC group, P values < or = 0.05. Cholecystectomy had a significant restrictive effect on immediate postoperative pulmonary function. Laparoscopic cholecystectomy produced significantly less restriction.

Pulmonary function after cholecystectomy performed through Kocher's incision, a mini-incision, and laparoscopy

Comparative pulmonary function after cholecystectomy performed through Kocher's incision, a mini-incision, and laparoscopy was evaluated. Forty-five patients were randomly and prospectively divided into three groups of 15 each, depending on the surgical access employed. Forced vital capacity (FVC), forced expiratory volume at 1 second (FEV1), and forced expiratory flow at 25% to 75% (FEF25-75%) were determined 1 to 3 days before and 16 to 24 hours after cholecystectomy. The percent reduction of FVC (p = 0.0170), FEV1 (p = 0.0191), and FEF25-75% (p = 0.0045) was smaller after laparoscopic cholecystectomy than after Kocher's incision cholecystectomy. The percent reduction of FVC (p = 0.0170) was smaller after mini-incision cholecystectomy than after Kocher's incision cholecystectomy. There was no difference in the FEV1 (p = 0.0971) or FEF25-75% (p = 0.2058) between these two groups. FEF25-75% was significantly less impaired in the laparoscopic group than in the mini-incision group (p = 0.0327). No difference between these two groups was found in FVC (p = 0.5755) or FEV1 (p = 0.3952). It is concluded that postoperative pulmonary function is less impaired after laparoscopic cholecystectomy than after either mini-incision or Kocher's incision cholecystectomy.

Open versus laparoscopic cholecystectomy. A comparison of postoperative pulmonary function

Upper abdominal surgery is associated with characteristic changes in pulmonary function which increase the risk of lower lobe atelectasis. Sixteen patients undergoing open cholecystectomy and 20 patients undergoing laparoscopic cholecystectomy were prospectively evaluated by pulmonary function tests (forced vital capacity [FVC], forced expiratory volume [FEV-1], and forced expiratory flow [FEF] 25% to 75%) before operation and on the morning after surgery to determine if the laparoscopic technique lessens the pulmonary risk. Fraction of the baseline pulmonary function was calculated by dividing the postoperative pulmonary function by the preoperative pulmonary function and multiplying by 100%. Postoperative FVC measured 52% of preoperative function for open cholecystectomy and 73% for laparoscopic cholecystectomy (p = 0.002). Postoperative FEV-1 measured 53% of baseline function for open cholecystectomy and 72% for laparoscopic cholecystectomy (p = 0.006). Postoperative FEF 25% to 75% measured 53% for open cholecystectomy and 81% for laparoscopic cholecystectomy (p = 0.07). It is concluded that laparoscopic cholecystectomy offers improved pulmonary function compared to the open technique.

Choice of incision and pain following gallbladder surgery

A prospective randomized trial compared pain in the first 24 h after gallbladder surgery via an upper midline or a transverse incision. Pain was measured by the patients' self-administered consumption of pethidine, degree of postoperative respiratory impairment and a visual analogue pain scale. The upper midline incision group self-administered significantly more pethidine than the transverse incision group (P less than 0.001), but there was no difference between the groups in respiratory function or visual analogue pain scale results 24 h after operation. Length of hospital stay was not different. An upper midline incision is more painful than a transverse incision in the first 24 h following gallbladder surgery.