Anaesthetic considerations for laparoscopic cholecystectomy

Preoperative versus intraoperative antiemetic strategies in patients undergoing laparoscopic cholecystectomy: A randomised double-blind study

BACKGROUND

Previous studies have determined ondansetron's efficacy in preventing and treating postoperative nausea and vomiting (PONV). However, evidence regarding the timing of drug administration in relation to the surgical procedure remains vague.

OBJECTIVE

To compare the preoperative and intraoperative administration of ondansetron on the incidence of PONV.

DESIGN

Single-centred, randomised, double-blind trial. Patients were recruited between November 2018 and April 2021. Follow-up for PONV and retching was up to 24 h.

SETTING

Aretaieio University Hospital, Greece.

PATIENTS

A total of 121 patients undergoing elective laparoscopic cholecystectomy gave written consent.

INTERVENTIONS

Patients were randomly allocated to the preoperative or the intraoperative group. The preoperative group received 4 mg of ondansetron dissolved in 100 ml of 0.9% saline 1 hour before induction of anaesthesia and 100 ml of 0.9% saline 30 min before end of surgery. The intraoperative group received 100 ml of 0.9% saline 1 h before induction of anaesthesia and 4 mg of ondansetron dissolved in 100 ml of 0.9% saline 30 min before end of surgery.

MAIN OUTCOME MEASURES

The primary outcome was the incidence of nausea and/or vomiting combined at 24 h.

RESULTS

No difference was found between the two groups regarding either the incidence of nausea and vomiting at 24 h (1.7% for the preoperative group versus 5.3% for the intraoperative group, P  = 0.31) or the incidence of nausea, vomiting and retching combined (5.3% for the preoperative group versus 10.5% for the intraoperative group, P  = 0.30). There was no difference between the groups in the pain intensity at rest or with coughing in the post anaesthesia care unit, at 4, 8 and 24 h postoperatively ( P  = 0.961, 0.929, 0.748 and 0.883 at rest, and 0.974, 0.220, 0.235 and 0.317 with coughing, respectively).

CONCLUSION

Under the current study design, we found no difference in the incidence of PONV between the administration of ondansetron 1 h before induction of anaesthesia and the intraoperative administration of ondansetron 30 min before the end of surgery.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03023306.

Intraoperative fluid therapy for video-assisted ovariohysterectomy in dogs

Background

Intraoperative fluids are still poorly studied in veterinary medicine. In humans the dosage is associated with significant differences in postoperative outcomes.

Objectives

The aim of this study is to verify the influence of three different fluid therapy rates in dogs undergoing video-assisted ovariohysterectomy.

Methods

Twenty-four female dogs were distributed into three groups: G5, G10, and G20. Each group was given 5, 10, and 20 mL·kg⁻¹·h⁻¹ of Lactate Ringer, respectively. This study evaluated the following parameters: central venous pressure, arterial blood pressure, heart rate, respiratory rate, temperature, acid-base balance, and serum lactate levels. Additionally, this study evaluated the following urinary variables: urea, creatinine, protein to creatinine ratio, urine output, and urine specific gravity. The dogs were evaluated up to 26 h after the procedure.

Results

All animals presented respiratory acidosis during the intraoperative period. The G5 group evidenced intraoperative oliguria (0.80 ± 0.38 mL·kg⁻¹·h⁻¹), differing from the G20 group (2.17 ± 0.52 mL·kg⁻¹·h⁻¹) (p = 0.001). Serum lactate was different between groups during extubation (p = 0.036), with higher values being recorded in the G5 group (2.19 ± 1.65 mmol/L). Animals from the G20 group presented more severe hypothermia at the end of the procedure (35.93 ± 0.61°C) (p = 0.032). Only the members of the G20 group presented mean potassium values below the reference for the species. Anion gap values were lower in the G20 group when compared to the G5 and G10 groups (p = 0.017).

Conclusions

The use of lactated Ringer's solution at the rate of 10 mL·kg⁻¹·h⁻¹ seems to be beneficial in the elective laparoscopic procedures over the 5 or 20 mL·kg⁻¹·h⁻¹ rates of infusion.

Anaesthesia for Robotic-Assisted Radical Prostatectomy: Considerations for Laparoscopy in the Trendelenburg Position

Two cases of anaesthetic complications after robotic-assisted laparoscopic radical prostatectomy using the da Vinci Remote-Controlled Surgical System are presented. Case 1 describes a patient with post-extubation respiratory distress requiring reintubation and subsequent ventilation in an intensive care unit. This was attributed to laryngeal oedema, which was most likely due to the reduction in venous outflow from the head caused by the pneumoperitoneum and prolonged, extreme Trendelenburg position. Case 2 describes a patient with mild brachial plexus neurapraxia, which was most likely due to compression by shoulder braces (to prevent cephalad sliding) during the exaggerated head-down tilt. For this procedure, the authors recommend limiting the duration and extent of head-down tilt as much as possible, avoiding excessive intravenous fluids and careful positioning of the patient with avoidance of shoulder braces whenever possible.

The Effects of Positive End-Expiratory Pressure at Different Levels on Postoperative Respiration Parameters in Patients Undergoing Laparoscopic Cholecystectomy

Purpose/Aim of the study: We investigated the effects of different positive end-expiratory pressure (PEEP) levels on postoperative respiration parameters in patients undergoing laparoscopic cholecystectomy.

MATERIALS AND METHODS

One hundred and five consecutive patients were randomly divided to three groups (n = 35, for each group). Group I did not receive PEEP whereas group II received PEEP as 5 cmH₂O and group III received PEEP as 8 cm H₂O. Measurements with spirometer were taken 1 hour before the operation (T₁) and, 1 (T₂), 6 (T₃), and 24 hours (T₄) after extubation by an anesthetist. Forced expiratory volume (FEV₁), forced vital capacity (FVC), and peak expiratory flow (PEF) were recorded.

RESULTS

Group I had higher FVC values measured at T₂ time point compared with other groups (p < 0.05, for both groups). There was a statistically significant difference between group I and group III in terms of the FVC values measured at T₃ and T₄ time points (p = 0.05 and p < 0.05, retrospectively). A statistical difference was found between group I and group II in terms of FEV₁ measured at T₂ time point (p < 0.05). Group I had higher FEV₁ values measured at T₃ and T₄ time points compared to group III (p = 0.05, P<0.05; respectively). Group III had lower PEF values measured at T₄ time point compared to group I and II (p < 0.05).

CONCLUSIONS

We concluded that PEEP with 5 or 8 cmH₂O has negative effects on lung function tests measured with spirometer during postoperative 1^st, 6^th, and 24^th hours in patients underwent elective laparoscopic cholecystectomy.

Low vs Standard Pressures in Gynecologic Laparoscopy: a Systematic Review

BACKGROUND

The optimal intraperitoneal pressure during laparoscopy is not known. Recent literature found benefits of using lower pressures, but the safety of doing abdominal surgery with low peritoneal pressures needs to be assessed. This systematic review compares low with standard pneumoperitoneum during gynecologic laparoscopy.

DATABASE

We searched Medline, Embase, and the Cochrane Library for randomized controlled trials comparing intraperitoneal pressures during gynecologic laparoscopy. Two authors reviewed references and extracted data from included trials. Risk ratios, mean differences, and standard mean differences were calculated and pooled using RevMan5. Of 2251 studies identified, three were included in the systematic review, for a total of 238 patients. We found a statistically significant but modest diminution in postoperative pain of 0.38 standardized unit based on an original 10-point scale (95% confidence interval [CI], -0.67 to -0.08) during the immediate postoperative period when using low intraperitoneal pressure of 8 mm Hg compared with ≥ 12 mm Hg and of 0.50 (95% CI, -0.80 to -0.21) 24 hours after the surgery. Lower pressures were associated with worse visualization of the surgical field (risk ratio, 10.31; 95% CI, 1.29-82.38). We found no difference between groups over blood loss, duration of surgery, hospital length of stay, or the need for increased pressure.

CONCLUSION

Low intraperitoneal pressures during gynecologic laparoscopy cannot be recommended on the behalf of this review because improvement in pain scores is minimal and visualization of the surgical field is affected. The safety of this intervention as well as cost-effectiveness considerations need to be further studied.

The comparative evaluation of intravenous with intramuscular clonidine for suppression of hemodynamic changes in laparoscopic cholecystectomy

Background:

Clonidine diminishes stress response by reducing circulating catecholamines and hence increases perioperative circulatory stability in patients undergoing laparoscopic surgeries. The aim of this study was to compare intravenous (IV) clonidine (2 μg/kg) with intramuscular (IM) clonidine (2 μg/kg) for attenuation of stress response in laproscopic surgeries.

Methods:

Eighty adult patients classified as ASA physical status I or II, aged between 20 and 60 years undergoing elective cholecystectomy under general anesthesia were enrolled for a prospective, randomized, and double-blind controlled trial. They received either IV clonidine (2 μg/kg) 15 min prior to the scheduled surgery (Group I) or IM clonidine (2 μg/kg) 60-90 min prior to the scheduled surgery (Group II). Hemodynamic variables (Heart rate, systolic (SBP), diastolic (DBP), mean arterial pressure (MAP)), SpO₂ and EtCO₂ were recorded at specific times - baseline, prior to induction, 1 min after intubation, before CO₂, insufflation, after CO₂ insufflation at 1,5,10,20,30,45,60 min, after release of CO₂, at 1 and 10 minutes after extubation. Secondary outcomes included evaluation of adverse effect profile of the two groups.

Results:

No significant difference was observed in the HR throughout the intraoperative period in between the two groups (P>0.05). There was statistically significant difference in SBP between the two groups starting from 1 minute after induction till 1 min after extubation (P<0.05) but not in DBP except at 1 minute after intubation (P=0.042). Significant difference in MAP was noted at 1 minute after intubation (P=0.004) and then from 5 minutes after CO₂ insufflation to 1 minute after extubation (P<0.05). Incidence of adverse effects were higher in group II (P=0.02) especially incidence of hypertension requiring treatment (0.006).

Conclusion:

We conclude that under the conditions of this study, hemodynamic parameters (SBP, DBP and MAP) were better maintained in the IV as compared to the IM route that had significantly higher incidence of hypertension requiring treatment.

Current and future practices in surgical retraction

Retraction of tissues and anatomical structures is an essential component of all forms of surgery. The means by which operative access is gained through retraction are many and diverse. In this article, the various forms of retraction methods currently available are reviewed, with special reference to hand held, self-retaining and compliant techniques. The special challenges posed by laparoscopic surgery are considered and future developments in new retraction techniques are anticipated.

Venous gas embolism: An unusual complication of laparoscopic cholecystectomy

Venous gas embolism (VGE) is a rare but potentially lethal complication of many forms of surgery, especially posterior fossa neurosurgery where the incidence is reported to be up to 80% - it can also occur in laparoscopic surgery. It usually occurs early in the procedure during insufflation of the abdomen. Rapid entry or large volumes of gas entering the venous circulation initiate a predictable chain of pathophysiological events which may continue to cardiovascular collapse. Arterial hypoxaemia, hypercapnia, decreased end-tidal CO₂, arrhythmias, myocardial ischaemia and elevated central venous and pulmonary arterial pressures can occur. The management of VGE relies on a high index of suspicion and close liaison between anaesthetist, surgeon and theatre staff. The authors present a case of venous gas embolism (VGE) during laparoscopic cholecystectomy (LC) which presented without many of the usual clinical features and was diagnosed by auscultation of a millwheel murmur.

A very common case become rare: Anesthetic considerations of lepromatous leprosy

Leprosy or Hansen's disease is very uncommon in developed countries. More than 80% of the world's cases occurs and still reported from developing countries. But nowadays due to increase in international affairs, medical tourism, globalization and immigration, there is increasing possibility to find patients anywhere, which require anesthesia for surgical interventions. Leprosy is a chronic infectious disease caused by Mycobacterium leprae and involves mainly skin, peripheral nervous system, upper respiratory tract, eyes and testes. Anesthetic consideration is focused mainly on complications related to leprosy like cardiac or respiratory dysautonomia, autonomic dysfunctions and side effects which are related to drug therapy and are challenging. There can be drug-related hepatitis and renal insufficiency in these patients. We report the anesthetic management of a patient with lepromatous leprosy who had undergone laparoscopic radical nephrectomy for renal cell carcinoma under general anesthesia.

Surgical emphysema as a cause of severe hypercapnia during laparoscopic surgery

Surgical emphysema is a well-recognised complication of laparoscopic surgery, but its impact on end-tidal carbon dioxide levels and carbon dioxide elimination is seldom reported and may not be fully appreciated by anaesthetists. Four cases are presented where extensive surgical emphysema occurred during laparoscopic surgery. The visual display of the anaesthetic record using the software program Monitor showed substantial rises in end-tidal carbon dioxide levels and allowed calculation of the carbon dioxide elimination, which increased two- to three-fold above normal levels. Having a visual record of carbon dioxide changes facilitated the recognition of surgical emphysema in three out of the four cases. Strategies such as estimating and tracking changes in carbon dioxide elimination from the minute ventilation and end-tidal carbon dioxide levels may assist in early identification, and palpating for surgical emphysema is recommended during laparoscopy if other causes of increased carbon dioxide levels are excluded.

Effects of epidural-and-general anesthesia combined versus general anesthesia alone on femoral venous flow during laparoscopic cholecystectomy

BACKGROUND AND OBJECTIVE

The pneumoperitoneum has been shown to decrease femoral blood flow, resulting in venous stasis. We analyzed the effects of the pneumoperitoneum and epidural analgesia on femoral vein diameter and the peak flow rate of femoral vein during laparoscopic cholecystectomy.

PATIENTS AND METHODS

Forty patients were randomly allocated to receive either combined epidural analgesia (EA) and general anesthesia (GA) (group EA/GA) or GA alone (group GA). Laparoscopic cholecystectomy was the standard operation for the selected patients. Then, 10 mL of 1% lidocaine in group EA/GA or physiologic serum in group GA was injected via epidural catheter. Peak flow rates (PFRs) of femoral vein cross-sectional areas (CSAs) were measured from the right femoral vein at three different times: after induction of anesthesia, during the pneumoperitoneum, and after abdominal deflation, but prior to reversal of anesthesia.

RESULTS

The two groups were similar in age, sex, body mass index, and duration of operation. The CSA slightly increased after the induction of anesthesia, compared with the previous measurements, although there was no statistical significance between them for both groups (P > 0.05). The PFR decreased, whereas the CSA increased during the pneumoperitoneum in each group. The PFR values after basal measurements were significantly higher in the EA/GA than in the GA group (P < 0.05). Group EA/GA had significantly lower heart-rate and blood-pressure levels during surgery than those in group GA (P < 0.05).

CONCLUSIONS

Abdominal insufflation during laparoscopic cholecystectomy results in dilation and decreased flow in the common femoral vein. Epidural analgesia added to the GA partially compensated for the reduction in femoral PFR.

Post-operative recovery profile after laparoscopic cholecystectomy: a prospective, observational study of a multimodal anaesthetic regime

BACKGROUND

Laparoscopic cholecystectomy is now often an ambulatory procedure, but dependent on short-term post-operative complaints of pain and post-operative nausea and vomiting (PONV). The efficacy of post-anaesthesia care units (PACUs) is therefore important to facilitate return to normal functions. We investigated the feasibility and efficacy of a standardized, evidence-based anaesthesia/analgesic regime to identify residual problems in the early post-operative phase.

METHODS

One hundred and thirty-four consecutive patients admitted for elective laparoscopic cholecystectomy at Hvidovre University Hospital between 15 March and 30 September 2005 were included in the study. The standardized, evidence-based regime consisted of total intravenous (i.v.) anaesthesia (propofol-remifentanil), well-defined fluid therapy, dexamethasone, ketorolac, ondansetron, sufentanil and incisional bupivacaine intra-operatively, and in the PACU on demand (prn) administration of sufentanil, morphine, paracetamol, ondansetron, droperidol, oral fluids and oxygen (if SpO(2) < 93%) with PACU discharge using a modified Aldrete score.

RESULTS

Protocol violations were moderate and occurred unsystematically, 8% had medical violations and 10% did not receive the pre-planned fluid amount. Severe PONV was seen in 2%. Thirteen per cent experienced severe pain, and the presence of any pain and/or PONV were predictors of an extended PACU stay. Mean oxygen demand was 46 min (range, 0-300 min), which influenced time to discharge (mean, 88 min). There were on average 2.7 treatment interventions (range, 0-11) before discharge.

CONCLUSION

An evidence-based, multimodal approach to the anaesthetic/analgesic management in laparoscopic cholecystectomy is feasible and advantageous in the early post-operative phase. Pain and PONV are predictors of a complicated recovery profile and deserve further attention. Transient oxygen desaturations postpone discharge from the PACU, but the clinical significance of this fact is questionable.

Comparison of cardiopulmonary responses during sedation with epidural and local anesthesia for laparoscopic-assisted jejunostomy feeding tube placement with cardiopulmonary responses during general anesthesia for laparoscopic-assisted or open surgical jejunostomy feeding tube placement in healthy dogs

OBJECTIVE

To evaluate the use of laparoscopic-assisted jejunostomy feeding tube (J-tube) placement in healthy dogs under sedation with epidural and local anesthesia and compare cardiopulmonary responses during this epidural anesthetic protocol with cardiopulmonary responses during general anesthesia for laparoscopic-assisted or open surgical J-tube placement.

ANIMALS

15 healthy mixed-breed dogs.

PROCEDURES

Dogs were randomly assigned to receive open surgical J-tube placement under general anesthesia (n = 5 dogs; group 1), laparoscopic-assisted J-tube placement under general anesthesia (5; group 2), or laparoscopic-assisted J-tube placement under sedation with epidural and local anesthesia (5; group 3). Cardiopulmonary responses were measured at baseline (time 0), every 5 minutes during the procedure (times 5 to 30 minutes), and after the procedure (after desufflation [groups 2 and 3] or at the start of abdominal closure [group 1]). Stroke volume, cardiac index, and O(2) delivery were calculated.

RESULTS

All group 3 dogs tolerated laparoscopic-assisted J-tube placement under sedation with epidural and local anesthesia. Comparison of cardiovascular parameters revealed a significantly higher cardiac index, mean arterial pressure, and O(2) delivery in group 3 dogs, compared with group 1 and 2 dogs. Minimal differences in hemodynamic parameters were found between groups undergoing laparoscopic-assisted and open surgical J-tube placement under general anesthesia (ie, groups 1 and 2); these differences were not considered to be clinically important in healthy research dogs.

CONCLUSIONS AND CLINICAL RELEVANCE

Sedation with epidural and local anesthesia provided satisfactory conditions for laparoscopic-assisted J-tube placement in healthy dogs; this anesthetic protocol caused less cardiopulmonary depression than general anesthesia and may represent a better choice for J-tube placement in critically ill patients.

Habitual exercise program protects murine intestinal, skeletal, and cardiac muscles against aging

Aging and aerobic exercise are two conditions known to interfere with health and quality of life, most likely by inducing oxidative stress to the organism. We studied the effects of aging on the morphological and functional properties of skeletal, cardiac, and intestinal muscles and their corresponding oxidative status in C57BL/6 mice and investigated whether a lifelong moderate exercise program would exert a protective effect against some deleterious effects of aging. As expected, aged animals presented a significant reduction of physical performance, accompanied by a decrease of gastrocnemius cross-sectional area and cardiac hypertrophy. However, most interesting was that aging dramatically interfered with the intestinal structure, causing a significant thickening of the ileum muscular layer. Senescent intestinal myocytes displayed many mitochondria with disorganized cristae and the presence of cytosolic lamellar corpuscles. Lipid peroxidation of ileum and gastrocnemius muscle, but not of the heart, increased in aged mice, thus suggesting enhanced oxidative stress. With exception of the intestinal muscle responsiveness, animals submitted to a daily session of 60 min, 5 days/wk, at 13 up to 21 m/min of moderate running in treadmill during animal life span exhibited a reversion of all the observed aging effects on intestinal, skeletal, and heart muscles. The introduction of this lifelong exercise protocol prevented the enhancement of lipid peroxidation and sarcopenia and also preserved cellular and ultracellular structures of the ileum. This is the first time that the protective effect of a lifelong regular aerobic physical activity against the deleterious effects of aging on intestinal muscle was demonstrated.

Laparoscopic appendectomy in the elderly

BACKGROUND

Evidence suggests that laparoscopic appendectomy (LA) has advantages over open appendectomy (OA) in the treatment of appendicitis. It remains, however, unclear whether LA is indicated in the elderly patient population.

METHODS

Patients with primary International Classification of Diseases, revision 9, procedure codes for LA (n=32406 patients) and OA (n=112884 patients) were selected from the 1998, 1999, and 2000 Nationwide Inpatient Samples. The end points that were under investigation were the length of hospital stay, the rate of routine discharge, and in-hospital morbidity and mortality rates. Multiple linear and logistic regression analyses were performed to assess the risk-adjusted association between the surgery type and the patient outcomes. Stratified analyses were performed according to age (65 years and older; less than 65 years old) and to the presence of appendiceal perforation or abscess.

RESULTS

After risk adjustment, patients who underwent LA had a significantly shorter mean length of stay (LA, 2.45 days; OA, 3.71 days; P <. 0001), higher rate of routine discharge (odds ratio, 2.80; P <.0001), lower overall complication rate (odds ratio, 0.92; P=.03), and mortality rate (odds ratio, 0.23; P=.001) compared with OA patients. Similar benefits of LA were found in the strata of patients who were less than 65 years old, in elderly patients, and in patients with appendiceal perforation or abscess.

CONCLUSION

LA has statistically significant advantages over OA with respect to the length of hospital stay, the rate of routine discharge, and postoperative morbidity and mortality rates for patients who are less than 65 years old, in elderly patients, and in patients with appendiceal abscess or perforation.