[Danger of monopolar current in laparoscopic gallbladder surgery]

Comparative evaluation of three laparoscopic cholecystectomy techniques in rabbit's model

PURPOSE

The aim of this randomized study was to compare the complications and perioperative outcome of three different techniques of laparoscopic cholecystectomy (LC). Changes in the liver function test after LC techniques were investigated. Also, we compared the degree of postoperative adhesions and histopathological changes of the liver bed.

METHODS

Thirty rabbits were divided into three groups: group A) Fundus-first technique by Hook dissecting instrument and Roeder Slipknot applied for cystic duct (CD) ligation; group B) conventional technique by Maryland dissecting forceps and electrothermal bipolar vessel sealing (EBVS) for CD seal; group C) conventional technique by EBVS for gallbladder (GB) dissection and CD seal.

RESULTS

Group A presented a longer GB dissection time than groups B and C. GB perforation and bleeding from tissues adjacent to GB were similar among tested groups. Gamma-glutamyl transferase and alkaline phosphatase levels increased (p ≤ 0.05) on day 3 postoperatively in group A. By the 15th postoperative day, the enzymes returned to the preoperative values. Transient elevation of hepatic transaminases occurred after LC in all groups. Group A had a higher adherence score than groups B and C and was associated with the least predictable technique.

CONCLUSIONS

LC can be performed using different techniques, although the use of EBVS is highly recommended.

Thermal Processes in Bile Ducts During Laparoscopic Cholecystectomy with Monopolar Instruments. Experimental Study Using Real-Time Intraluminal and Surface Thermography

Introduction. A significant rate of complications during laparoscopic cholecystectomy (LC) occurs due to thermal injury caused by monopolar electrosurgery (MES) equipment. Most of them manifest weeks and months after surgery with the common bile duct (CBD) and large duodenal papilla strictures, some in the early postoperative period with bile leaks. Objective. To study thermal processes occurring in the lumen and on the surface of the bile ducts during monopolar coagulation in a porcine model of LC. Methods. The temperature of the bile ducts was measured using instrumentation consisted of biliary stent with temperature sensors, which was inserted in the porcine CBD, signal amplifier, and current sense transformer. Surface temperature was measured with a scientific grade thermal camera. Cholecystectomy was performed using a standard "critical view of safety" (CVS) approach with 5 mm monopolar laparoscopic instruments. Results. Application of MES caused significant tissue heating. Lateral thermal spread and the rate of tissue heating depended on the duration of energy application and the initial tissue temperature. In 5 out of 6 experiments, the intraluminal temperature rose up to the critical threshold, and the exposure time ranged from 54 to 560 seconds. A sensor positioned at the papilla site was heated in all the experiments but still below the cell damage inducing threshold. The analysis of thermographic charts revealed the presence of the "current channeling" effect and the pedicle effect. Conclusion. There is a possibility of a direct and delayed thermal injury to the bile ducts during LC.

Reduce Adverse Effects of Laparoscopic Cholecystectomy with Pulse Width Modulated LED Light (625 nm, 76 Hz, 23% Duty Cycle)

OBJECTIVE

Reducing adverse effects in laparoscopic cholecystectomy (LCE) is important to avoid complications. After removal, the porta hepatis and gallbladder bed of liver were treated with pulse width modulated (PWM) red LED light with parameters λ = 625 ± 5 nm, full width at half maximum 17 nm, 76 Hz, duty cycle 23%, 15-30 mW/cm², and 0.9-1.8 J/cm². The changes of eight blood parameters were studied: red blood cell, hemoglobin, white blood cell, erythrocyte sedimentation rate (ESR), bilirubin, aspartate transaminase (AST), alanine transaminase (ALT), and amylase.

BACKGROUND DATA

Other current methods of reducing undesirable effects of LCE significantly affect surgery and are not commonly used in practice.

MATERIALS AND METHODS

Before LCE, 263 patients were randomized into the control and test groups. Patients in the test group were treated with light radiated for 2 min during the surgery on the bed of the removed gallbladder and porta hepatis. Blood samples were taken before surgery and on the third day after surgery, studied, and compared by nonparametric statistical methods.

RESULTS

The test group revealed significant reduction in postsurgery gain of levels of ALT, AST, and ESR compared with the control group.

CONCLUSIONS

Treatment of the removed gallbladder bed and porta hepatis by red LED PWM radiation during LCE significantly reduces the adverse effects of surgery while increasing its time insignificantly and does not affect the surgical best practices deployed.

Effect of carbon dioxide pneumoperitoneum on liver function following laparoscopic cholecystectomy

BACKGROUND

It has been noted that following a laparoscopic cholecystectomy (LC), liver function parameters were disturbed. The causes of this disturbance are still controversial.

PATIENTS AND METHODS

The serum levels of eight parameters of liver function were measured both before and 24 hours after surgery in 142 consecutive patients who underwent LC, 23 patients who underwent open cholecystectomy (OC), and in 25 patients who underwent a conventional hernial repair. The same anesthetic protocol was applied to all patients in the various groups and in the case of LC; the intra-abdominal pressure was maintained at 12 mmHg of CO2.

RESULTS

Twenty-four (24) hours after surgery, there was a statistically significant change of all the eight parameters studied, except alkaline phosphatase in patients who underwent LC, whereas there were only 3 patients from the OC group who had changes of alanine aminotransferase and aspartite aminotransferase and 2 patients who had raised levels of direct bilirubin, and no changes were observed among those who had conventional hernial repair. We found that 83% of the patients showed more than a 100% increase in at least one parameter, 43% showed an increase in two or more parameters, and 23% showed an increase in three or more parameters. We also observed a significant drop of total proteins and albumin levels in all patients who had LC.

CONCLUSIONS

It appears that the pneumoperitoneum plays a major role in these changes. Although these changes of liver function were of no clinical relevance in healthy patients, the safety of the procedure must nonetheless be assessed in those with underlying liver diseases.

Changes in the level of serum liver enzymes after laparoscopic surgery

AIM: The purpose of this study was to investigate the effect of laparoscopic surgery on liver function in humans and the possible mechanisms behind such effect.

METHODS: Blood samples from 286 patients who underwent laparoscopic cholecystectomy (LC) and 40 patients who underwent open cholecystectomy (OC) were tested for liver function by measuring the level of serum alanine aminotrasferase (ALT) and aspartate aminotrasferase (AST) before and after the operations. The same tests were also applied to 18 laparoscopic colorectal cancer resection (LCR) patients and 23 open colorectal cancer resection (OCR) patients to determine whether CO₂ pneumoperitoneum could alter the serum liver enzymes.

RESULTS: The level of serum ALT and AST increased significantly during the first 48 h post operations in both LC and LCR patients. However, no significant change of the serum liver enzymes was detected in both OC and OCR patients. As a result, there was statistically significant difference in change of both ALT and AST levels between LC and OC patients and LCR and OCR patients, respectively. By the 7^th day post operation, the level of both enzymes returned to normal values in LC, OC and OCR patients except LCR patients whose enzymes remained at a higher level.

CONCLUSION: Transient elevation of hepatic transaminases occurred after laparoscopic surgery. The major causative factor seemed to be the CO₂ pneumoperitoneum. In most of the laparoscopic surgery patients, the transient elevation of serum liver enzymes showed no apparent clinical implications. However, if preoperative liver function was very poor, laparoscopic surgery may not be the best choice for the treatment of patients with certain abdominal diseases.