Cases Of Laparoscopic Cholecystectomy Research Articles

Factors contributing to prolonged operative time for laparoscopic cholecystectomy performed by trainee surgeons: a retrospective single-center study.

Laparoscopic cholecystectomy for a benign disease is often the initial endoscopic surgery performed by trainee surgeons. However, a lack of surgical experience is associated with prolonged operative times, which may increase the risk of postoperative complications and poor outcomes. This study aimed to identify the factors associated with prolonged operative times for laparoscopic cholecystectomy performed by inexperienced surgeons. This retrospective single-center study was conducted between January 2018 and December 2023. We performed a multivariate analysis to identify the factors associated with prolonged operative time by analyzing elective cases of laparoscopic cholecystectomy performed by surgeons with limited experience. The study included 323 patients, subjected to a median operative time of 89min. Multivariate analysis identified that patient characteristics such as male sex, increased body mass index, and a history of conservative treatment for cholecystitis, as well as operating surgeon's post-graduation years (< 4years), and an attending surgeon without endoscopic surgical skill certification from the Japan Society of Endoscopic Surgery, were independent risk factors for a prolonged operative time. Our findings suggest that endoscopic surgical skill-certified attending surgeons have excellent coaching skills and mitigate the operative time for elective cholecystectomy.

CVS: An Effective Strategy to Prevent Bile Duct Injury

Background: Bile duct injuries have been substantially increased after the introduction of laparoscopic cholecystectomy (LC). These are accompanied by major morbidity and mortality. Studies have shown varying degrees of success in the reduction of bile duct injury (BDI) using the Critical View of Safety (CVS) technique. The aim of this study was to see the efficacy of the CVS technique as the sole method of dissection in laparoscopic cholecystectomy. Methods: 1647 cases of LC were done between January 2012 and January 2022 for a period of 10 years in two hospitals. All were operated by the CVS dissection technique and none by the infundibular technique. Cases included acute cholecystitis, chronic cholecystitis, gangrenous cholecystitis, empyema, and Gallbladder (GB) polyp. Results: The average operating time was 42 minutes and the range was 13 to 80 minutes. In 92% of cases, all 3 criteria of CVS were achieved. In the remaining 8% cases were either converted to open or operated by a division of GB or subtotal cholecystectomy was done. There was only one case of cystic duct stump leak requiring drainage and common bile duct stenting. Conclusion: The excellent outcome of our study suggests that the CVS method will be the gold standard technique in the dissection of the gallbladder in LC. Further dissemination of the technique is necessary to improve safety in LC.

Acute cholecystitis, obesity, and steatohepatitis constitute the lethal triad for bile duct injury (BDI) during laparoscopic cholecystectomy.

The most feared complication during laparoscopic cholecystectomy remains a bile duct injury (BDI). Accurately risk-stratifying patients for a BDI remains difficult and imprecise. This study evaluated if the lethal triad of acute cholecystitis, obesity, and steatohepatitis is a prognostic measure for BDI. A retrospective review of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) registry was performed. All laparoscopic cholecystectomy cases within the main NSQIP database for 2012-2019 were queried. Two study cohorts were constructed. One with the lethal triad of acute cholecystitis, BMI ≥ 30, and steatohepatitis. The other cohort did not have the full triad present. Multivariate analysis was performed via logistic regression modeling with calculation of odds ratios (OR) to identify independent factors for BDI. An uncontrolled and controlled propensity score match analysis was performed. A total of 387,501 cases were analyzed. 36,887 cases contained the lethal triad, the remaining 350,614 cases did not have the full triad. 860 BDIs were identified resulting in an overall incidence rate 0.22%. There were 541 BDIs within the lethal triad group with 319 BDIs in the other cohort and an incidence rate of 1.49% vs 0.09% (P < 0.001). Multivariate analysis identified the lethal triad as an independent risk factor for a BDI by over 15-fold (OR 16.35, 95%CI 14.28-18.78, P < 0.0001) on the uncontrolled analysis. For the controlled propensity score match there were 29,803 equivalent pairs identified between the cohorts. The BDI incidence rate remained significantly higher with lethal triad cases at 1.65% vs 0.04% (P < 0.001). The lethal triad was an even more significant independent risk factor for BDI on the controlled analysis (OR 40.13, 95%CI 7.05-356.59, P < 0.0001). The lethal triad of acute cholecystitis, obesity, and steatohepatitis significantly increases the risk of a BDI. This prognostic measure can help better counsel patients and potentially alter management.

A novel comparison of erector spinae plane block and paravertebral block in laparoscopic cholecystectomy.

Erector spinae plane block is an updated method than paravertebral block, possessing a lower risk of complications. This study aimed to compare erector spinae plane and paravertebral blocks to safely reach the most efficacious analgesia procedure in laparoscopic cholecystectomy cases. The study included 90 cases, aged 18-70 years, classified as American Society of Anesthesiologists I-II, who underwent an laparoscopic cholecystectomy procedure. They were randomly separated into three groups, namely, Control, erector spinae plane, and paravertebral block. No block procedure was applied to Control, and a patient-controlled analgesia device was prepared containing tramadol at a 10 mg bolus dose and a 10-min locked period. The pain scores were recorded with a visual analog scale for 24 h postoperatively. The visual analog scale values at 1, 5, 10, 20, and 60 min at rest and 60 min coughing were found to be significantly higher in Control than in paravertebral block. A significant difference was revealed between Control vs. paravertebral block and paravertebral block vs. erector spinae plane in terms of total tramadol consumption (p=0.006). Total tramadol consumption in the first postoperative 24 h was significantly reduced in the paravertebral block compared with the Control and erector spinae plane groups. Sonography-guided-paravertebral block provides sufficient postoperative analgesia in laparoscopic cholecystectomy surgery. Erector spinae plane seems to attenuate total tramadol consumption.

OGBN P34 Telemedicine clinics are a safe and feasible alternative to preoperative face-to-face assessments for day case laparoscopic cholecystectomy surgery: a retrospective cohort study

Abstract Background The telemedicine clinic for follow ups after minor surgical procedures in general surgery is now ubiquitously considered a standard of care. However, this method of consultation is not the mainstay for preoperative assessment and counselling of patients for common surgical procedures such as laparoscopic cholecystectomy. The aim of this study was to assess the safety of assessing and counselling patients in the telemedicine clinic without a physical encounter for laparoscopic cholecystectomy. Methods We conducted a retrospective analysis of patients who were booked for laparoscopic cholecystectomy for benign gallbladder disease via general surgery telemedicine clinics from March 2020 to November 2021. The primary outcome was the cancellation rate on the day of surgery. The secondary outcomes were complication and readmission rates. Statistical analysis was done using JASP 0.16.2 software. Results We identified 206 cases booked for laparoscopic cholecystectomy from telemedicine clinics. 6.8% of patients had surgery cancelled on the day of surgery. Only one such cancellation was deemed avoidable as it may have been prevented by a face-to-face assessment. Severe postoperative adverse events (equal or higher than grade 3) were observed in 1% of patients. 30-day readmission rate was 11%. Conclusions Our series showed that it is feasible to assess and counsel patients for laparoscopic cholecystectomy remotely with a minimal cancellation rate on the day of operation. Further work is needed to understand the effect of remote consultations on patient satisfaction, environmental impact, and healthcare economics to support its routine use in general surgery.

388 “Day Case Laparoscopic Cholecystectomy – Are We Getting It Right?”

Abstract Introduction About 66,660 cholecystectomies are performed in the UK annually, of which majority are laparoscopic, costing NHS about £ 111 million. As per GIRFT, 80% eligible patients should have cholecystectomy within 8 days of hospital admission. Cholecystectomy quality improvement collaborative was established nationwide to support surgical teams and improve patient outcomes. At our hospital, we have established a twice weekly HOT LAP CHOLE list to manage these patients. Aim To analyze outcomes after day case laparoscopic cholecystectomy. Method Records of 100 patients over 3 months undergoing elective or emergency cholecystectomy were retrospectively analyzed. Data collection included demographics, diagnosis, length of stay (LOS), complications, conversion rate, and re-admission rate. Results Among 100 cases (26 males, 74 females, with an age range of 22 – 89), 80 were elective and 20 were emergency. All emergency cases were operated on within 8 days of hospital admission. 73 were successfully performed as day cases (69 elective, 4 emergency), making the elective day-case rate 86%. LOS ranged from 1 to 34 days, and the reason of stay was mainly post-op pain/vomiting or drain left intraoperatively. 3 cases were converted to open (2 electives, 1 emergency). The re-admission rate was 6% (4 electives, 2 emergencies), mainly because of post-operative pain. 9 patients had complications (3 - bleeding, 5 - bile leak, 1 - wound infection). Conclusions The successful day-case rate meets the recommendation by the British Association of Day Case Surgery (&amp;gt; = 60%). And our HOT LAP CHOLE list has effectively improved the management of emergency cholecystectomy. However, post-op pain control should be optimized.

1211 Review of the Factors Leading to an Unplanned Inpatient Stay Following a Day Case Laparoscopic Cholecystectomy in a Tertiary Centre

Abstract Aim To review the factors responsible for an unplanned Inpatient Stay (IPS) following a day case Laparoscopic Cholecystectomy (LC). To develop strategies preventing unnecessary hospital stays after Day Case LC. Method We retrospectively collected data on all the LC performed in a Tertiary Centre over 3 months (January – March 2022). Results 162 patients underwent LC during this period; 135 (83.3%) patients were planned day cases out of which 68/135 (50.37%) had an IPS and 67/135 (49.62%) were same-day discharges (SDD). 27/162 (16.66%) patients had emergency LC. 54% n = 37 LC performed in the afternoon had IPS compared to 14% n = 10 among the SDD [p&amp;lt;0.0001]. 47% n = 32 In-patient LC performed by non-consultant grade compared to 32% n = 22 among the SDD. 7% n = 5 IP due to social issues, 10% n = 7 no documented IP causes identified and 4% n = 3 had booking error, booked as Inpatient despite the patient having SDD. Other identified causes were drain Insertion (9% n = 6), longer operations (n = 1; mean operation time 92 min IP vs 82 min SDD) and late recovery (9% n = 6). Conclusions The rate of an unplanned overnight stay was found to be significantly high (50.37%, n = 135). Several human factors such as errors in the booking proforma, late-afternoon lists, and no clear discharge planning in the post-op notes were among the few factors which could easily be improved. A review of these factors is deemed necessary not only for improving patient outcomes &amp; quality of care but equally for reducing healthcare costs.

ThTP5.1 Laparoscopic cholecystectomy on index admission – are we following AUGIS guidelines?

Abstract Background Laparoscopic cholecystectomy is the gold standard in management of acute cholecystitis, biliary colic and gallstone induced pancreatitis. AUGIS has produced guidelines recommending optimal timing during index presentation for surgery. Aim To identify if our local acute surgical unit was following AUGIS guideline recommendations and performing laparoscopic cholecystectomy on index admission for recurrent/ongoing biliary colic, mild gallstone pancreatitis and for acute cholecystitis within 72 hours of onset of symptoms. Methods Prospective review of surgical patients admitted to DGH in Northern Ireland with acute cholecystitis, biliary colic and gallstone pancreatitis over six-month period between April and September 2021. Results 103 patients were admitted during 6 months with gallstone disease. Of these, only 20 underwent inpatient lap cholecystectomy during their admission. 21 patients were deemed unfit for surgery and 3 declined surgery. 10 patients with acute cholecystitis had surgery; only 4 had symptom onset within 72 hours as recommended. Conclusion This unit was not following AUGIS recommendations on the timing of laparoscopic cholecystectomy for patients presenting with gallstone disease. During this data collection a pathway was started for day case laparoscopic cholecystectomy at a satellite site to help expedite patients who were unable to have their operation as inpatient.

FTP6.13 Do prophylactic antibiotics on general anaesthetic induction improve surgical site and intra-abdominal infection post emergency laparoscopic cholecystectomy?

Abstract Background The role of prophylactic antibiotics in reducing surgical site infection (SSI) and intra-abdominal infection rates in emergency laparoscopic cholecystectomy remains controversial. New antimicrobial Trust guidelines at our unit introduced in May 2022 stated that all emergency “hot” laparoscopic cholecystectomies should receive single dose of IV antibiotics on general anaesthetic induction. We aim to assess whether SSI and intra-abdominal infection rates have improved since introducing these new guidelines. Methods Retrospective study comparing SSI and intra-abdominal infection rates within 30 days of all emergency laparoscopic cholecystectomy cases between February and April 2022 (before new guidelines), to those between August to October 2022 (post new guidelines). Results Total of 56 emergency “hot” laparoscopic cholecystectomy cases prior to, and 44 cases after introduction of new guidelines. 91% cases received IV antibiotics on induction post new guidelines, compared to 35% prior to new guidelines (P=0.038). Proportion of patients who continued with antibiotics post-surgery between 2 cohorts was not statistically significant (P=0.69). There was no statistically significant improvement in overall SSI rates post introduction of new guidelines (P=0.61). Skin closure method (P=0.044) and operating time (P=0.031) were statistically significant in contributing to SSI. There was further no statistically significant difference in rate of intra-abdominal infection post introduction of new guidelines (P=0.83). Conclusion Prophylactic antibiotics at induction do not appear to improve either SSI or intra-abdominal infection rates post emergency lap cholecystectomy cases. Further evaluation is needed over a longer study period, however, in order to ascertain whether these guidelines should be altered for future practise.

Evaluating the Impact of Surgical Occurrence of Bile Duct Injuries in Laparoscopic Cholecystectomy- A Retrospective Observational study

Background: Laparoscopic cholecystectomy (LC) is the gold standard for treating gallstone disease, offering numerous benefits over traditional open cholecystectomy. However, bile duct injuries (BDIs) are a significant complication, contributing to substantial morbidity and mortality. This study aims to evaluate the incidence, causes, risk factors, treatments, and outcomes of BDIs in laparoscopic cholecystectomy in Bangladesh. Material &amp; Methods: This retrospective observational study was conducted at the Department of Hepatobiliary, Pancreatic and Liver Transplant Surgery, Bangabandhu Sheikh Mujib Medical University, Al-Manar Hospital Limited, and Abeer General Hospital, Dhaka, Bangladesh. During this period, a total of 1255 complete hospital records of laparoscopic cholecystectomy conducted over the last 5 years at the study hospital were selected for the study following inclusion and exclusion criteria. Results: Out of laparoscopic cholecystectomy cases, 20 (1.64%) patients experienced BDIs. The most common cause of BDI was clipping or transection of the duct (33.33%), followed by mistaken anatomy (22.22%) and ischemic injury due to clip (18.52%). Acute cholecystitis was the most prevalent risk factor (37.04%). Standard laparoscopic cholecystectomy was performed in 83.33% of BDI cases, with the remaining 16.67% undergoing single-incision laparoscopic cholecystectomy. The majority of patients (74.07%) had no complications after BDI treatment, while 18.52% experienced minor complications, 5.56% had major complications, and 1.85% resulted in mortality. Conclusion: This study highlights the importance of meticulous surgical technique, early recognition, and appropriate management of bile duct injuries in laparoscopic cholecystectomy. By continually refining our understanding of the factors contributing to BDIs and implementing evidence-based strategies to prevent and manage this complication, we can optimize patient outcomes and ensure the highest standards of care in laparoscopic cholecystectomy.

Pre-Emptive Analgesia by Intraperitoneal Instillation of Lignocaine in Laparoscopic Cholecystectomy

Objective: To compare the effects of preemptive intraperitoneal instillation of local anesthetic (lignocaine) with conventional instillation after the removal of gall bladder in elective laparoscopic cholecystectomy. Study Design: Quasi-experimental study. Place and Duration of study: General Surgical ward, Combined Military Hospital, Rawalpindi Pakistan, from Jan to Apr 2018. Methodology: Patients fulfilling the inclusion criteria were randomly assorted into two groups. Group A received intraperitoneal lignocaine at the conventional timing where was in Group B local anesthetic was instilled preemptively at the time of insertion of trocar. Post operatively pain was measure on visual analogue scale at 3,6 and 12 hours. Results: Total of 184 patients were followed up post-operatively. Mean age of patients in Group A was 44.5±13.57 years and in Group B was 46.2±13.9 years. Mean post-operative pain on visual analogue scale score for Group A was 2.53±0.73 and that for Group B was 2.0±0.66 with p-value&lt;0.01.Conclusion: The use of preemptive instillation of local anesthetic intraperitoneal was found better as compared to conventional timing of instillation in reducing the post-operative pain in elective and uncomplicated cases of laparoscopic cholecystectomy.

Incidence and reasons for conversion of laparoscopic cholecystectomy to open cholecystectomy

Introduction: Cholelithiasis is one of the most common problems affecting the gastrointestinal tract. The objective of the study was to find the incidence of cases converted to open cholecystectomy from laparoscopic cholecystectomy and find the association with other intra-operative and preoperative findings. Methods: This is a prospective observational study. One hundred elective laparoscopic cholecystectomy cases in the institution of the study were the study sample. Pre-operative and intra-operative findings were noted. Conversion in surgery from laparoscopic cholecystectomy to open cholecystectomy was also recorded and the association was tested through Fisher’s exact test. Results: The rate of conversion from laparoscopic cholecystectomy to open cholecystectomy was 5%. which was significantly related to sex, time duration of the surgery, bleeding, and anatomical difficulties. Conclusions: The conversion rate is only 5% which was significantly associated with sex, time duration of surgery, intraoperative bleeding, and anatomical difficulties.

Machine Learning Analysis of Postlaparoscopy Hernias and “I'm Leaving You to Close” Strategy

IntroductionContributing factors to postlaparoscopy hernia are unknown. We hypothesized that postlaparoscopy incisional hernias are increased when the index surgery was performed in teaching hospitals. Laparoscopic cholecystectomy was chosen as the archetype for open umbilical access. Materials and methodsMaryland and Florida SID/SASD databases (2016-2019) wereused to track 1-year hernia incidence in both inpatient and outpatient settings, which was then linked to Hospital Compare, Distressed Communities Index (DCI), and ACGME. Postoperative umbilical/incisional hernia following laparoscopic cholecystectomy was identified using CPT and ICD-10. Propensity matching and eight machine learning modes were utilized including logistic regression, neural network, gradient boosting machine, random forest, gradient boosted trees, classification and regression trees, k nearest neighbors and support vector machines. ResultsPostoperative hernia incidence was 0.2% (total = 286; 261 incisional and 25 umbilical) in 117,570 laparoscopic cholecystectomy cases. Days to presentation (mean ± SD) were incisional 141 ± 92 and umbilical 66 ± 74. Logistic regression performed best (AUC 0.75 (95% ci 0.67-0.82) and accuracy 0.68 (95% ci 0.60-0.75) using 10-fold cross validation) in propensity matched groups (1:1; n = 279). Postoperative malnutrition (OR 3.5), hospital DCI of comfortable, mid-tier, at risk or distressed (OR 2.2 to 3.5), LOS >1 d (OR 2.2), postop asthma (OR 2.1), hospital mortality below national average (OR 2.0) and emergency admission (OR 1.7) were associated with increased hernias. A decreased incidence was associated with patient location of small metropolitan areas with <1 million residents (OR 0.5) and Charlson Comorbidity Index-Severe (OR 0.5). Teaching hospitals were not associated with postoperative hernia after laparoscopic cholecystectomy. ConclusionsDifferent patient factors as well as underlying hospital factors are associated with postlaparoscopy hernias. Performance of laparoscopic cholecystectomy at teaching hospitals is not associated with increased postoperative hernias.

Development of a cross-artificial intelligence system for identifying intraoperative anatomical landmarks and surgical phases during laparoscopic cholecystectomy.

Attention to anatomical landmarks in the appropriate surgical phase is important to prevent bile duct injury (BDI) during laparoscopic cholecystectomy (LC). Therefore, we created a cross-AI system that works with two different AI algorithms simultaneously, landmark detection and phase recognition. We assessed whether landmark detection was activated in the appropriate phase by phase recognition during LC and the potential contribution of the cross-AI system in preventing BDI through a clinical feasibility study (J-SUMMIT-C-02). A prototype was designed to display landmarks during the preparation phase and Calot's triangle dissection. A prospective clinical feasibility study using the cross-AI system was performed in 20 LC cases. The primary endpoint of this study was the appropriateness of the detection timing of landmarks, which was assessed by an external evaluation committee (EEC). The secondary endpoint was the correctness of landmark detection and the contribution of cross-AI in preventing BDI, which were assessed based on the annotation and 4-point rubric questionnaire. Cross-AI-detected landmarks in 92% of the phases where the EEC considered landmarks necessary. In the questionnaire, each landmark detected by AI had high accuracy, especially the landmarks of the common bile duct and cystic duct, which were assessed at 3.78 and 3.67, respectively. In addition, the contribution to preventing BDI was relatively high at 3.65. The cross-AI system provided landmark detection at appropriate situations. The surgeons who previewed the model suggested that the landmark information provided by the cross-AI system may be effective in preventing BDI. Therefore, it is suggested that our system could help prevent BDI in practice. Trial registration University Hospital Medical Information Network Research Center Clinical Trial Registration System (UMIN000045731).

Psychological and sociodemographic factors for delayed patient discharge after daycare laparoscopic cholecystectomy.

Objective: To estimate the psychological and sociodemographic correlates of delayed discharge of patients undergoing Elective Laparoscopic Cholecystectomy. Study Design: Retrospective Cross-sectional Descriptive study. Setting: Department of Surgery, Fauji Foundation Hospital. Period: July 2019 and June 2022. Material &amp; Methods: The study comprised reviewing medical records of 160 patients who underwent daycare cholecystectomy. It was noticed from patients’ medical records that patients were carefully selected for daycare surgery. Patients with comorbidities, previous upper intra-abdominal surgery, ultrasound findings of thickened gallbladder wall &gt; 5mm were not offered day care surgery. For data collection a Performa was designed based on literature review. To assess psychological state, we applied Hospital anxiety and depression scale in Urdu. Descriptive statistics were calculated for the sociodemographic variables, mean and standard deviation was found for continuous variables and frequency percentages for categorical variables. Results: One hundred and thirty-one 131 (81.8 percent) of the 160 cholecystectomies could be sent home within 24 hours, whereas 29 (18 percent) required a lengthier hospital stay. One hundred and thirty-one 131 (81.8 percent) of the 160 cholecystectomies could be sent home within 24 hours, whereas 29 (18 percent) required a lengthier hospital stay. In LS group, the postoperative stay range was 2 –19. Observation of postoperative fever (n = 3), surgery-related causes postoperative pain (n= 6), delayed oral diet = 1, retained abdominal drain = 4, and postoperative complications (n= 3). Bowel injury (n = 2) and septicemia (n = 1) were serious postoperative consequences resulting in more prolonged hospital stay. PONV (n = 2), medical causes (n = 3), and patient preference (n = 7) were among the reasons for the prolonged hospital stay. Conclusion: While our study has a few limitations; it is a retrospective review with nonrandomized patient selection and a smaller sample size, we have established safety of day case laparoscopic cholecystectomy in select group of patients. Patients’ personal satisfaction was the most common reason for their overnight admission after day case LC which was because of number of sociodemographic factors.

Laparoscopic cholecystectomy for double gallbladder

Gallbladder duplication is a rare abnormality of the biliary system. When a pathology develops in a doubled gallbladder, there can be difficulties in diagnosis and surgical treatment. Apart from the ultrasound investigation, other imaging methods are of great importance for more accurate diagnostics: computed tomography, magnetic resonance tomography, magnetic resonance cholangiopancreatography and endoscopic ultrasonography. The article presents a literature review and demonstrates our own clinical case of laparoscopic cholecystectomy in the patient with gallbladder duplication.

Implications of routine cholangiography during laparoscopic cholecystectomy on postoperative testing: Review of more than 2,300 cases in a community-based practice

BackgroundWe hypothesized that routine cholangiography during laparoscopic cholecystectomy may increase use of postoperative imaging and invasive testing. MethodsA retrospective review was performed of laparoscopic cholecystectomy cases at 6 community hospitals from 2017 through 2020. For surgeons performing routine vs selective cholangiography, we compared primary outcomes of operative time, 30-day complications, and postoperative imaging or procedures. ResultsIn total, 2359 laparoscopic cholecystectomy procedures were performed. Eighteen surgeons performed routine cholangiography (1125 cases), and 13 performed selective (1234 cases). Mean operative time was longer in the routine group (125.3 vs 98.7 min, P < .001). Between groups, 30-day complications were similar. Two common bile duct injuries were identified in the routine group. Postoperatively, the routine group underwent 2.5 times more imaging and invasive testing (P < .001). ConclusionsIn community hospitals, laparoscopic cholecystectomy can be performed safely by surgeons using cholangiography routinely or selectively. Routine cholangiography resulted in more postoperative imaging and invasive testing.

Shiv-mix for perioperative hemodynamic stability and analgesia: A new paradigm for limited resource centres

Dear editor, A very interesting article has been published in your esteemed journal titled “Effect of pre-emptive intravenous paracetamol, magnesium sulfate, and lignocaine on hemodynamic variables during perioperative period in pre-eclampsia patients scheduled for lower segment cesarean section under general anesthesia: A prospective randomized study” by Kothari et al., (December 2022|Vol 13|Issue 12). Research is not complete unless it reaches to its potential audience. We, firstly, would like to congratulate the authors and the journal for publishing their research on such a very important topic. Authors have described their findings in a clear and scientific manner. Randomized and double-blinded studies provide inferences which are considered more authentic. Authors in this study used envelop method for allocating patient in the two groups; the intervention and the control. Findings of this study will definitely help readers and practitioners in providing safe and stable anesthesia to their patients. In this prospective randomized study, authors concluded that combination of paracetamol, magnesium sulfate, and lignocaine is effective in attenuating hemodynamic responses to laryngoscopy and intubation. They also found better hemodynamic stability during intraoperative and post-operative period in pre-eclampsia patients scheduled for lower segment cesarean section under general anesthesia. Finally, they opined that when paracetamol, magnesium sulfate, and lignocaine are given together effective and prolonged post-operative analgesia can be obtained. Authors discussed efficacy and safety of various medications (Lignocaine, fentanyl, esmolol, and magnesium sulfate) comparing with placebo and different combinations used to attenuate laryngoscopy and intubation response. However, in last paragraph of introduction and in discussion, authors wrote that they could not find any single study using all three drugs (intravenous paracetamol, magnesium sulfate, and lignocaine) simultaneously for attenuation of hemodynamic changes during laryngoscopy and intubation. We would like to draw your kind attention published work that have utilized the same combination with similar effects and this study support the conclusions of those studies. We do agree that these were nor RCTs but case series. Two related articles are discussed here. Khan and Singh in their narrative review described efficacy, safety, and patient satisfaction of various combinations of paracetamol, tramadol, magnesium sulfate, and lignocaine (Shiv-mix 1, 2, and 3). Authors found the described opioid free anesthesia (OFA) regimen (Shiv-mix) very effective in attenuating laryngoscopic and intubation response. In their case series, they also found stable intraoperative hemodynamics and absence of some commonly seen post-operative complications such as PONV and shivering. In another case series by Ansari et al., using similar OFA describing ten cases of laparoscopic cholecystectomy, the authors found that OFA using Shiv-Mix (A combination of paracetamol, tramadol, magnesium sulfate, and lignocaine) infusion preoperatively was a safe, opioid‑sparing, and feasible option that provide good perioperative analgesia, stable hemodynamics, and an uneventful recovery profile. We again support the findings of the study by Kothari et al. We hope that this discussion will help researchers and practitioners to provide effective and safe perioperative course of their patients and opening new horizons for multimodal analgesia.

Incidence of difficult laparoscopic cholecystectomy at a tertiary care hospital in eastern Nepal

Background: Laparoscopic cholecystectomy (LC) is the gold standard modality for the treatment of gall bladder diseases. Sometimes LC needs to be converted to open due to intraoperative complications. A few factors like age, body weight, comorbidities, ASA score, and surgeons’ experience will warn about the possible complications and need for conversion to open. Prior prediction of the difficulties will warn the surgeon to prepare accordingly. The patient’s family will also be counseled regarding it. Objectives: To identify the possible factors for predicting difficult LC. Methods: This was a descriptive cross-sectional study conducted in the general and laparoscopic surgery department at Nobel Medical College Teaching Hospital, Biratnagar, Nepal. Simple random sampling technique was utilised in this retrospective analysis. Data were taken from 2021 May to 2022 May after institutional ethical clearance. Descriptive statistics were assessed done using SPSS v.26. Results: A total of 230 cases were included and analysed in the study. The incidence of difficult LC was 17.8%. An overall conversion rate of LC to open cholecystectomy in difficult LC was seen in 1.3% of the cases. Intraoperative complications were not seen in 87.8% of the patients. The mean duration of hospital stay in difficult LC cases was five days. Conclusion: Predicting difficult LC will not only warn surgeons to be prepared for the possible difficulties but will also help in counseling patients’ families regarding the intraoperative complications and the possible need for the conversion to open.

The clinical impact of COVID-19 on endoscopic surgery in Japan: Analysis of data from the National Clinical Database.

This study aimed to evaluate the impact of the coronavirus disease (COVID-19) pandemic on elective endoscopic surgeries in Japan using the National Clinical Database. We retrospectively analyzed the clinicopathological factors and surgical outcomes of laparoscopic cholecystectomy (LC), laparoscopic distal gastrectomy (LDG), and laparoscopic low anterior resection (LLAR) and compared the monthly numbers of each procedure performed in 2020 with those in 2018 and 2019. The degree of infection in prefectures was classified into low and high groups. In 2020, the number of LCs (except for acute cholecystitis) was 76 079 (93.0% of that in 2019), the number of LDGs was 14 271 (85.9% of that in 2019), and the number of LLARs was 19 570 (88.1% of that in 2019). Although the number of robot-assisted LDG and LLAR cases increased in 2020, the growth rate was mild compared with that in 2019. There was little difference in the number of cases in the degree of infection in the prefectures. The numbers of LC, LDG, and LLAR cases decreased from May to June and recovered gradually. In late 2020, the proportion of T4 and N2 cases of gastric cancer and the number of T4 cases of rectal cancer increased compared with those in 2019. There was little difference between the proportions of postoperative complications and mortality in the three procedures between 2019 and 2020. The number of endoscopic surgeries decreased in 2020 as a result of the COVID-19 pandemic. However, the procedures were performed safely in Japan.