Two-port technique for laparoscopic cholecystectomy using a microendoscope

Effects of elevated artificial pneumoperitoneum pressure on invasive blood pressure and levels of blood gases

BACKGROUND AND OBJECTIVE

to evaluate the clinical, hemodynamic, gas analysis and metabolic repercussions of high transient pressures of pneumoperitoneum for a short period of time to ensure greater security for introduction of the first trocar.

METHODS

sixty-seven patients undergoing laparoscopic procedures were studied and randomly distributed in P12 group: n=30 (intraperitoneal pressure [IPP] 12mmHg) and P20 group: n=37 (IPP of 20mmHg). Mean arterial pressure (MAP) was evaluated by catheterization of the radial artery; and through gas analysis, pH, partial pressure of oxygen (PaO2), partial pressure of CO2 (PaCO2), bicarbonate (HCO3) and alkalinity (BE) were evaluated. These parameters were measured in both groups at time zero before pneumoperitoneum (TP0); at time 1 (TP1) when IPP reaches 12mmHg in both groups; at time 2 (TP2) after five min with IPP=12mmHg in P12 and after 5min with IPP=20mmHg at P20; and at time 3 (TP3) after 10min with IPP=12mmHg in P12 and with return of IPP from 20 to 12mmHg, starting 10min after TP1 in P20. Different values from those considered normal for all parameters assessed, or the appearance of atypical organic phenomena, were considered as clinical changes.

RESULTS

there were statistically significant differences in P20 group in MAP, pH, HCO3 and BE, but within normal limits. No clinical and pathological changes were observed.

CONCLUSIONS

high and transient intra-abdominal pressure causes changes in MAP, pH, HCO3 and BE, but without any clinical impact on the patient.

Effects of elevated artificial pneumoperitoneum pressure on invasive blood pressure and levels of blood gases

BACKGROUND AND OBJECTIVE

to evaluate the clinical, hemodynamic, gas analysis and metabolic repercussions of high transient pressures of pneumoperitoneum for a short period of time to ensure greater security for introduction of the first trocar.

METHODS

sixty-seven patients undergoing laparoscopic procedures were studied and randomly distributed in P12 group: n=30 (intraperitoneal pressure [IPP] 12mmHg) and P20 group: n=37 (IPP of 20mmHg). Mean arterial pressure (MAP) was evaluated by catheterization of the radial artery; and through gas analysis, pH, partial pressure of oxygen (PaO2), partial pressure of CO2 (PaCO2), bicarbonate (HCO3) and alkalinity (BE) were evaluated. These parameters were measured in both groups at time zero before pneumoperitoneum (TP0); at time 1 (TP1) when IPP reaches 12mmHg in both groups; at time 2 (TP2) after five min with IPP=12mmHg in P12 and after 5min with IPP=20mmHg at P20; and at time 3 (TP3) after 10min with IPP=12mmHg in P12 and with return of IPP from 20 to 12mmHg, starting 10min after TP1 in P20. Different values from those considered normal for all parameters assessed, or the appearance of atypical organic phenomena, were considered as clinical changes.

RESULTS

there were statistically significant differences in P20 group in MAP, pH, HCO3 and BE, but within normal limits. No clinical and pathological changes were observed.

CONCLUSIONS

high and transient intra-abdominal pressure causes changes in MAP, pH, HCO3 and BE, but without any clinical impact on the patient.

Single-port laparoscopic surgery

Laparoscopic surgery performed through a single-incision is gaining popularity. The demand from the public for even less invasive procedures will motivate surgeons, industry, and academic centers to explore the possibilities and refine the technology. Although the idea seems quite attractive, there are several technological obstacles that are yet to be conquered by improved technology or additional training. The question of safety has yet to be answered and will require well-designed randomized control trials. Opponents to the approach argue that the size of the single incision (see Table 1) is frequently larger than all the standard laparoscopy incisions combined. On the other hand, proponents remember a similar argument from traditional open surgeons during the initial development of laparoscopy. That argument was quickly discredited when the immediate benefits oflaparoscopy were compared with patients undergoing surgery with small laparotomy incisions. During the development of a new technique, the learning curve exposes patients to risk and society to expense. LESS pioneers appear to have reached a level of comfort with technology and techniques that paves the way for scientific scrutiny. Perhaps, the surgical community will capitalize on this situation with randomized, controlled studies and sound evidence to support or refute the benefits of LESS. If we do not seize this opportunity, patient demand and industry's dual edge message of financial success versus fear of losing referrals will lead to a scenario similar to the development of laparoscopic cholecystectomy in the 1990s. Regardless of its future, the surgical community will still benefit from a renewed excitement as surgeons aim to continually reduce the amount of pain and trauma our patients must endure. In addition, technological advances on instrumentation will benefit the field of laparoscopy and improve patient care.

Three-port microlaparoscopic cholecystectomy in 159 patients

BACKGROUND

Laparoscopic cholecystectomy has undergone many refinements including reductions in port size and number. This study attempts to determine whether further reduction in port size from that previously reported by us can reduce postoperative pain without compromising the efficacy of the surgery.

METHODS

In this study, 159 patients underwent laparoscopic cholecystectomy with three ports: one 5-mm umbilical port, one 3-mm subxiphoid port, and one 3-mm port in the right subcostal position. Data were collected prospectively for each patient on the duration of analgesic use, quantity of analgesic tablets consumed, postoperative pain, most painful incision, and days of recovery required before return to activity and work. These measures were compared with those collected from a group of 100 patients who had undergone laparoscopic cholecystectomy with three 5-mm ports in a previous study.

RESULTS

Patients in the current study group required analgesics for a longer duration (4 vs 2.9 days; p = 0.001), used more analgesic tablets (10.7 vs 8.1; p = 0.007), and reported greater postoperative discomfort (5 vs 4.1; p = 0.016) as compared with all in the 5-mm port group. The 3-mm port group needed more days for recovery before leaving the house (2.9 vs 2.7; p = 0.504), but they returned to work earlier (5.1 vs 5.9; p = 0.065) than the group that had undergone cholecystectomy with three 5-mm ports, although there was not a significant difference between the groups. Operative time increased from 18.5 to 20.9 min (p = 0.054) in the group with two 3-mm ports. Five patients (3.1%) in the current group required enlargement of a port to complete the procedure, as compared with none in the comparison group. There was one complication (0.6%), as compared with two complications (2.0%) in the previous group.

CONCLUSIONS

This study did not demonstrate a reduction in postoperative pain or a consistent improvement in recovery when the port size was reduced at the subcostal and subxiphoid positions. It did, however, show that ports could safely be reduced in size without a negative impact on the surgeon's ability to perform a cholecystectomy. Reducing port size can be a tool in the surgeon's armamentarium for use in the attempt to optimize cosmetic results.