Elective Laparoscopic Cholecystectomy Research Articles

Rare Case Reports on Ectopic Liver Tissue: Incidence, Surgical Management, and Outcomes

Introduction and importance: Ectopic liver tissue is a rare finding, often discovered incidentally during procedures like cholecystectomy. Understanding its clinical implications, including potential malignancy and complications, is crucial for effective management and improving patient outcomes. Case presentation: A 45-year-old female presented with six months of biliary colic, worsened by fatty meals. Preoperative ultrasound revealed a gallbladder with microcalculi. During elective laparoscopic cholecystectomy, a brownish tissue fragment resembling hepatic parenchyma was found on the gallbladder fundus and removed. Histopathology confirmed ectopic liver tissue with mild steatosis and no malignancy. Clinical discussion: Ectopic liver tissue, with a prevalence of 0.47%, typically attaches to the gallbladder but can also be found in other abdominal and thoracic locations. It may be linked to congenital malformations and has a risk of degeneration into malignancy due to its incomplete vascular and ductal system. Diagnosis is usually incidental during surgery, and en-bloc removal is advised to prevent complications and potential neoplastic transformation. Identifying its vascular supply before dissection is crucial to avoid severe bleeding. Conclusion: Ectopic liver tissue, despite its rarity, requires careful management due to its potential for malignancy and complications. Timely detection and en-bloc removal are vital to prevent adverse outcomes and ensure optimal patient care.

Adapting general anaesthesia for a patient with class III obesity and obstructive sleep apnoea undergoing day case laparoscopic cholecystectomy: A case report.

This report describes the anaesthesia provided for a class III obese patient with obstructive sleep apnoea, undergoing an elective laparoscopic cholecystectomy. Several adaptations were required to provide safe anaesthesia. A McGrath video laryngoscopy was utilised for intubation. The patient was positioned in the ramped position, thereby increasing time to desaturation on induction of anaesthesia. Pressure controlled ventilation - volume guaranteed mode was selected for ventilation to provide consistent tidal volumes. An increased level of positive end-expiratory pressure was utilised to minimise atelectasis. Drug doses were carefully considered and calculated with the aid of The Society for Obesity and Bariatric Anaesthesia dose calculator. The airway management adaptations provided an unobstructed view for intubation. Peak airway pressures during surgery remained within safe limits and no atelectasis was evident postoperatively. Pain was kept under control and desaturation was avoided during postanaesthetic care. The patient was discharged home later that evening.

Efficacy of Laparoscopic-Assisted Subcostal Transversus Abdominis Plane (TAP) Block: A Double-Blind, Randomized Controlled Trial

Objective: To analyze efficacy of laparoscopic administered Transversus Abdominis Plane (TAP) block on pain scores and opioid consumption in the first 24 hours in patients undergoing laparoscopic cholecystectomy. Study design and setting: The randomized, double-blinded trial was conducted in surgical unit, Shalamar Medical & Dental College Lahore from September 2019 to March 2020. Methodology: 100 patients of either gender scheduled for elective laparoscopic cholecystectomy were included using consecutive probability sampling method. After informed consent, patients were randomized into Intervention TAP GroupA and Control Group-B. Intervention TAP Group-A received laparoscopic aided TAP block with 20ml 0.5% Ropivacaine in subcostal region while Control Group-B received 20ml saline solution which was used as placebo. Both groups received paracetamol 1gm intravenous eight-hourly and Ketorolac 30mg intravenous 12-hourly. Nalbuphine 5mg intravenous was administered as “rescue analgesic” in patients having pain score of four or above. Postoperative pain scores at rest and on coughing were documented using numerical rating scores (VAS) at 2, 4, 6, 12, and 24 hours. Results: There was a significant difference (p-value=0.038, 0.000, 0.025, 0.000, 0.000) in pain scores over the first 24 hours postoperatively in laparoscopically assisted Intervention TAP Group-A. The total nalbuphine consumption was significantly reduced in Intervention TAP Group-A as compared to Control Group-B. Conclusions: Laparoscopic administered TAP block significantly reduced postoperative pain and total opioid consumption following laparoscopic cholecystectomy

A Clinical Prospective Randomised Comparative Study Of Ultrasound Guided Bilateral Subcostal Transversus Abdominis Plane Block And Port Site Infiltration With Bupivacaine For Post-Operative Analgesia In Patients Undergoing Laparoscopic Cholecystectomy.

Background: Post-operative pain management is critical in laparoscopic cholecystectomy to enhance patient recovery and satisfaction. This study compares the efficacy of ultrasound-guided bilateral subcostal transversus abdominis plane (TAP) block and port site infiltration with bupivacaine for post-operative analgesia. Methods: In this prospective, randomized, comparative study, 60(30/30) patients undergoing elective laparoscopic cholecystectomy were randomly assigned to one of two groups: Group A received an ultrasound-guided bilateral subcostal TAP block with 0.25% bupivacaine (20 ml on each side), while Group B received port site infiltration with 0.25% bupivacaine (5 ml per port). The primary outcome was the duration of post-operative analgesia, assessed by the time to first rescue analgesic request. Secondary outcomes included total analgesic consumption in the first 24 hours post-operatively, pain intensity measured by the Visual Analog Scale (VAS) at 1, 4, 8, 12, and 24 hours, and any complications related to the procedures. Results: The TAP block group (Group A) demonstrated a significantly longer duration of analgesia compared to the port site infiltration group (Group B) (p < 0.05). Group A also exhibited lower total analgesic consumption and lower VAS scores at all time points. No significant complications were observed in either group. Conclusion: Ultrasound-guided bilateral subcostal TAP block with bupivacaine provides superior post-operative analgesia compared to port site infiltration in patients undergoing laparoscopic cholecystectomy, with a longer duration of pain relief and reduced analgesic requirements. This technique should be considered a viable option for enhancing post-operative recovery in these patients.

Pre-Operative Evaluation of Risk Factors for Difficult Laparoscopic Cholecystectomy

Cholelithiasis or the gallstone disease is the most common biliary pathology. 10-15% population of western world is estimated to be affected by gallstone disease, of which majority remains asymptomatic (>80%) and 1-2 % of these asymptomatic patients will develop symptoms needing surgery per year. In this prospective study, 77 patients years undergoing elective Laparoscopic Cholecystectomy (LC) and meeting all inclusion criteria in Department of General Surgery, Nepal Medical College and Teaching Hospital over period of 1 year. History, detailed clinical examination and laboratory investigations were performed as per the working proforma. Operative time and conversion to open cholecystectomy were recorded. The association between clinical, laboratory and sonographic factors with difficult laparoscopy were obtained. Data analysis was done using SPSS-17 version. Out of 77 patients, 63 were females. Body mass index (BMI) above 30 representing obese population were 33.2% with p value 0.0004. Also, 41.5% patients had history of acute cholecystitis while 12.9% patients had previous history of abdominal surgery and 70.1% patients had history of recurrent abdominal pain. Total of 19.4% patients had increased leucocyte count. On ultrasonography thickened GB wall of >3 mm was seen in 42.8%, distended GB was seen in 41.5%, stone size of >1 cm was seen in 70.1% patients and multiple stones were seen in 84.4%. Similarly, duration of surgery was >90 mins in 31.1% and 7.04% patients underwent conversion to open cholecystectomy both of which were considered difficult laparoscopy. Our study reveled that clinical factors like age, BMI, history of acute cholecystitis, previous history of recurrent abdominal pain and past history of abdominal surgery had significant association in prediction of difficult LC.

Indocyanine green in laparoscopic cholecystectomy: utility and correlation with a preoperative risk score

BackgroundThis study aims to compare the visualization of the cystic duct-common bile duct junction with indocyanine green (ICG) among 3 groups of patients divided according to the difficulty of elective laparoscopic cholecystectomy. MethodsConducted at a single center, this non-randomized, prospective, observational study encompassed 168 patients who underwent elective laparoscopic cholecystectomy and were assessed with a preoperative risk score to predict difficult cholecystectomies, including clinical factors and radiological findings. Three groups were identified: low, moderate, and high risk. A dose of 0.25 mg of IV ICG was administered during anesthesia induction and the different objectives were evaluated. ResultsThe visualization of the cystic duct-common bile duct junction was achieved in 28 (100%), 113 (91.1%), and 10 (63%) patients in the low, moderate, and high-risk groups, respectively. The high-risk group had longer total operative time, higher conversion, more complications and longer hospital stay. In the surgeon’s subjective assessment, ICG was considered useful in 36% of the low-risk group, 58% in the moderate-risk group, and 69% in the high-risk group. Additionally, there were no cases where ICG modified the surgeon’s surgical approach in the low-risk group, compared to 11% in the moderate-risk group and 25% in the high-risk group (p < 0.01). ConclusionsThe results of this study confirm that in the case of difficult cholecystectomies, the visualization of the cystic duct-common bile duct junction is achieved in 63% of cases and prompts a modification of the surgical procedure in one out of four patients.

The effect of lung-recruitment maneuver on postoperative shoulder pain in patients undergoing laparoscopic cholecystectomy: a randomized controlled trial.

Lung-recruitment maneuvers (LRM) have been shown to reduce postoperative pain after laparoscopic surgery. This study aimed to investigate the association of LRM with the incidence of shoulder pain after laparoscopic cholecystectomy. A randomized controlled study was conducted with 110 patients undergoing elective laparoscopic cholecystectomy from July 2022 to March 2023. Participants were randomized to receive either routine exsufflation or LRM at pneumoperitoneum release. The postoperative shoulder pain and abdominal pain were assessed at 1, 4, 6, 12, and 24h after surgery using a numeric rating scale. Analgesic consumption and postoperative nausea or vomiting (PONV) were evaluated during the first 24h after surgery. The incidence of shoulder pain during the first 24h after surgery was significantly lower in the LRM group compared to the control group (26.9 vs. 59.3%; P = 0.001). The median [interquartile range] score of worst shoulder pain was significantly lower compared to the control group (3 [2-3] vs 4 [3-5.5]; P = 0.003). Participants in the LRM group showed reduced abdominal pain at rest at 4 and 24h after surgery, and experienced significantly lower intensities of abdominal pain during mobilization at all time points over 24h after surgery. There were no significant differences in opioid consumption or the incidence of PONV between the groups. LRM reduces both the incidence and intensity of shoulder pain during 24h after laparoscopic cholecystectomy. Additionally, LRM was associated with reduced intensity of abdominal pain during mobilization over the study period.

WP8.9 - Laparoscopic Cholecystectomy Performed by a Surgical Care Practitioner: Review of Outcomes

Abstract Introduction Surgical Care Practitioners (SCPs) are non-medical workers involved in various aspects of management of surgical patients. The role includes assisting and performing surgical procedures. Over 60,000 laparoscopic cholecystectomies (LC) are performed annually in the UK. With ever increasing pressure on waiting lists, it is important to look at fully utilising the skills of our entire workforce. We report what we believe is the first published series of LC performed by an SCP. Materials and Methods A retrospective review of a prospectively collected database was performed. Primary outcome was any complication requiring intervention. Secondary outcomes were minor complications, operative time, length of stay, conversion and readmission. Results 170 patients were operated on. Indications were biliary colic in 127 (74.7%), cholecystitis 30 (17.6%) and pancreatitis in 13(7.6%). Mean operating time was 65 minutes (Range 35-152). 53 operations were assisted by a consultant, 110 by a senior SAS grade and 7 by a CT2. 139 (81.7%) patients were discharged on the day of surgery. 24 (14.1%) stayed one night in hospital. There were no major complications. Four patients required readmission. Two with pain and 2 with port site infections. There were no conversions or transfusions required. Conclusion There is a paucity of published data on surgical outcomes of procedures performed by SCPs. With a structured, supervised approach SCPs could be trained to take on more complex procedures and further strengthen the surgical workforce. This study demonstrates that elective LC can be safely performed by an appropriately trained and supervised SCP.

Cutaneous sensory block area of the laparoscopic-assisted transversus abdominis plane block.

Different approaches and techniques are used to apply a transversus abdominis plane block (TAP), but their characteristics are poorly described. Precise injection of local anaesthetic is considered crucial to achieving the desired block effect. Laparoscopic-assisted TAP (L-TAP) is a blind technique and potentially less reliable than ultrasound (US)-guided techniques. This study assessed the cutaneous sensory block area (CSBA) after an L-TAP adopting a subcostal dual block approach. Thirty elective laparoscopic cholecystectomy patients received bilateral L-TAPs. The CSBA was mapped 150 min. after block application using cold sensation and a sterile marker, photo-documented and transferred to a transparency sheet from which the area was calculated. The median CSBA of the subcostal bilateral dual L-TAP was 161 cm2 (interquartile range: 131-217 cm2; range: 67-408 cm2). In all patients, the CSBA mainly covered the skin over the epigastrium, whereas 23% also had an infraumbilical component. In none of the patients did the CSBA cover the abdominal wall laterally to a vertical line through the anterior superior iliac spine. The subcostal bilateral dual L-TAP produces a heterogeneous non-dermatomal CSBA of varying size and distribution across the medial epigastric abdominal wall, similar to the CSBA described in the existing literature on US-guided subcostal TAP. The authors have no sources of funding to declare for this manuscript. Not relevant.

EP289 - Laparoscopic Management of Cholecystocoloic Fistula as a Day Surgery Case – A Case Report

Abstract Introduction Cholecystocoloic fistula (CF) is a rare sequelae of biliary stone disease with a 2% prevalence, previously it was considered a contraindication for laparoscopic management. Preoperative diagnosis can be very challenging, the pathognomonic triad of Pneumobilia, chronic diarrhoea, and vitamin K malabsorption should raise a high index of suspicion but is not always present, furthermore, preoperative imaging (EUS, ERCP, and Barium enema) help in the diagnosis, however, those are not routine practice in investigating typical biliary colic presentation. Case presentation We report a Cholecystocoloic fistula diagnosed intraoperatively and successfully managed with a laparoscopic approach. A 63-year-old male with a background of hemiplegia and aphasia followed a surgical treatment for intracranial haemorrhage 12 years ago. He presented with recurrent attacks of acute calculus cholecystitis investigated by US and CT scans, and both have failed to detect CF. During his previous admission, he was managed conservatively and added to the elective laparoscopic cholecystectomy list. His surgery was challenging, Intraoperative findings revealed a gallbladder adherent to the surrounding omentum and transverse colon, with a fistulous communication of the gallbladder fundus to the transverse colon, the fistula was divided, and the colonic opening was sutured. The surgery was uneventful and he was discharged home after 18 hours with no postoperative complications. Conclusion A high index of suspicion should be raised for Cholecystocoloic fistula diagnosis intraoperatively, especially with a history of long-term recurrent cholecystitis even in the absence of usual presentation and imaging. Moreover, a laparoscopic approach is possible and successful in experienced hands.

Assessment of the effectiveness of a polypropylene onlay mesh in the prevention of laparoscopic trocar-site incisional herniain high-risk patients. A randomized clinical trial.

Trocar site incisional hernia (TSIH) is a common complication of laparoscopic surgery. In the scientific literature there are few descriptions of methods or tools for its prevention. The aim of this report was to assess the effectiveness and safety of a prophylactic measure designed to lower rates of TSIH. A multicenter randomized double-blinded clinical trial was performed in high-risk patients (diabetes mellitus and/or age ≥ 70years and/or BMI ≥ 30kg/m2 and/or extended incision for specimen retrieval) who underwent either elective or emergency laparoscopic cholecystectomy. Patients were assigned to prophylactic onlay polypropylene mesh fixation (intervention) or to standard trocar closure (control). The main aim was to analyze the efficacy of the intervention, taking occurrence of TSIH as the primary outcome. Clinical and radiological follow up lasted at least one year after surgery. Secondary endpoints were technique-related complications (surgical site occurrences). One hundred and forty-three patients were randomized and finally 116 were analyzed (64 in the intervention arm and 52 in the control arm). Groups were homogeneous. Mean [SD] age, 65 [18] years; 86 (60.6%) were women. The cumulative TSIH incidence was lower in the intervention group although the differences did not reach statistical significance, assessed either radiologically (16 [25.4%] vs 17 [31.5%], p = 0.538) or clinically (9 [16.1%] vs 9 [20], p = 0.613). No differences in surgical site infection, hematoma or seroma were detected. Mean follow-up was 670days (range 223-1294). Our results show that, when properly assessed, the overall TSIH incidence is extremely high. Although polypropylene onlay mesh placement is safe, it does not appear to be effective in reducing the TSIH incidence rate. Radiological evaluation may be more accurate. ClinicalTrials.org NCT03495557. Date of registration: April 12, 2018.

Comparison of Intravenous Ondansetron and Dexamethasone for Preventing Propofol-Induced Pain During Laparoscopic Cholecystectomy: A Double-Blind, Randomized Study.

Background Propofol is the most common induction agent used in current anesthesia practice. Patients receiving propofol injections commonly experience varying degrees of pain, creating an unpleasant anesthesia experience. Methods Seventy-two patients, aged between 18 and 70, scheduled for elective laparoscopic cholecystectomy under general anesthesia were randomized into two groups. Group D received 8 mg of dexamethasone, and Group O received 8 mg of ondansetron intravenously before induction. After five seconds, mid-arm venous occlusion was applied for one minute using a tourniquet. Propofol (0.5 mg/kg) was administered intravenously over five seconds, and patients rated the injection pain over the next 15 seconds. The primary outcome was pain intensity using the Verbal Rating Scale during propofol injection. Secondary outcomes included intraoperative hemodynamic changes and postoperative nausea and vomiting (PONV). Normally distributed variables were compared using the Student's t-test, non-normally distributed variables using the Mann-Whitney U-test, and qualitative data using the chi-square or Fisher's exact test. Statistical significance for the study was set at p < 0.05. Results In Group D, 30 out of 36 patients (83.3%) experienced no pain, while four patients (11.1%) reported mild pain, two patients (5.6%) reported moderate pain, and no patients (0.0%) reported severe pain. In contrast, in Group O, only 15 out of 36 patients (41.6%) experienced no pain, with 12 patients (33.3%) experiencing mild pain, seven patients (19.4%) experiencing moderate pain, and two patients (5.6%) experiencing severe pain. Overall, six out of 36 patients in Group D (16.7%) experienced some level of pain, compared to 21 out of 36 patients in Group O (58.3%), a statistically significant difference (p < 0.05). Regarding postoperative nausea, 16 out of 36 patients in Group Dexamethasone (44.44%) experienced nausea, whereas 23 out of 36 patients in Group Ondansetron (63.88%) reported this symptom, with the difference being statistically significant (p = 0.0372). Additionally, postoperative vomiting occurred in nine out of 36 patients in Group Dexamethasone (25%), compared to 18 out of 36 patients in Group Ondansetron (50%), with this difference also reaching statistical significance (p= 0.026). Conclusions Intravenous dexamethasone before propofol administration reduces injection pain and PONV in laparoscopic cholecystectomy more effectively as compared to ondansetron.

Surgical Skill Decay as a Result of the COVID-19 Pandemic.

This study aimed to objectively evaluate the impact of the gap in surgical practice caused by COVID-19 on surgical skill decay. This retrospective cohort study enrolled 148 cases of adult patients who were qualified for elective or urgent laparoscopic cholecystectomy. This study compared the period of nine months before the pandemic outbreak and nine months after the end of the pandemic. We analyzed the duration of surgery, the number of intraoperative adverse events (IAEs), postoperative complications (PCs), and differences between the surgeries performed by residents and those performed by specialists. The number of IAEs did not differ significantly between groups (after COVID-19 (AC) and before COVID-19 (BC)). A difficult gallbladder (DGB) was associated with an increased risk of IAEs during surgery in both groups (BC:OR = 2.94, p = 0.049; AC:OR = 2.81, p = 0.35). The multivariate analyses showed no significant differences in IAEs or PCs when the residents performed surgeries compared to specialists. The average duration of surgery was significantly longer in the post-pandemic group (BC-102.4 min vs. AC-119.9 min, p = 0.024). Measurable determinants of surgical skills are the duration of surgery and the number of intraoperative adverse events. By defining this indicators, our study objectively shows that the reduction in the volume of surgeries during COVID-19 resulted in a phenomenon known as surgical skill decay.

A comparative evaluation of ultrasound guided dual transversus abdominis plane block versus erector spinae plane block for postoperative analgesia in patients undergoing laparoscopic cholecystectomy: A randomised prospective study

: Effective pain control after laparoscopic cholecystectomy (LC) is crucial for early patient mobilization, facilitating a speedy recovery and avoiding several complications. Ultrasound (USG) guided bilateral dual transversus abdominis plane block (DTAPB) and erector spinae plane block (ESPB) are effective for providing postoperative pain relief after LC.A prospective randomised, study comprising of 100 patients posted for elective LC. To compare the effectiveness of USG-guided DTAPB and ESPB for providing postoperative pain relief in patients undergoing LC. A total of 100 patients aged 18-70 years, were included in the study and divided into two groups of 50 patients each. Group DTAPB received bilateral DTAPB and group ESPB received bilateral ESPB, using 50 ml of 0.25% ropivacaine with 8 mgs of dexamethasone. Post operative visual analogue score (VAS) score, time to first analgesia request, total number of analgesic doses required in 24 hours (hrs) and complications if any were noted. VAS score was higher in DTAPB group than ESPB group at 1,2,6,8 and 14 hrs. In DTAPB group patients requested analgesia after an average of 8 ±2.0 hrs, whereas in ESPB group they requested after 12 ± 3.16 hrs. In ESPB group 45 patients needed single analgesic dose and only 5 needed second analgesic doses. However, in DTAPB group 35 patients received single and 15 patients received second analgesic dose. Side effects were comparable in both the groups.USG-guided bilateral ESPB with 50 ml of 0.25% ropivacaine plus dexamethasone is an effective approach in reducing postoperative pain following LC.

Cholecystocolonic Fistula (CCF) Case Report

Introduction: Gallbladder disease is one of the most common conditions affecting the digestive tract. Autopsy reports have shown a prevalence of gallstones ranging from 11-36%, with cholecystitis being one of the most prevalent complications. Although cholecystoenteric fistulas are rare, with an incidence of 0.15-0.5% among patients undergoing cholecystectomy, they can present significant diagnostic and therapeutic challenges. The transverse colon is the second most common site for these fistulas after the duodenum. A high degree of suspicion is required to diagnose it preoperatively. Here, we present a noteworthy case of a 65-year-old male patient with a fistula between the gallbladder and transverse colon, complicated by severe adhesions and a large stone, underscoring the complexities associated with this condition. Case Presentation: The patient had a history of hypertension and gallbladder stones when he was admitted during the COVID-19 pandemic with acute cholecystitis. Two years later, he had an elective laparoscopic cholecystectomy and, during surgery, the surgical team noticed significant adhesions around the gallbladder. Further inspection during dissection of the gallbladder bed revealed a fistula between the transverse colon and the gallbladder, and a single large stone was identified. The patient’s surgical procedure was successful, and his postoperative recovery was uncomplicated. Conclusion: A fistula between the gallbladder and transverse colon is a rare complication of gallbladder disease, and the transverse colon is the second most common cholecystoenteric fistula after the duodenum. The presence of a fistula is usually a late sequence of chronic gallstone disease that requires appropriate diagnosis and correct treatment. In this case, the surgery was complicated by extensive adhesions around the gallbladder with an adjacent colon and a large stone with a fistula noted between the transverse colon and the gallbladder. However, through careful planning, correct surgical procedures, and skilled surgical expertise, the patient’s condition after surgery lacked complications. This case focuses on the importance of addressing all possible complications of gallbladder disease and adjusting surgical procedures accordingly.

The incidences of nausea and vomiting after general anesthesia with remimazolam versus sevoflurane: a prospective randomized controlled trial.

Postoperative nausea and vomiting (PONV) refers to nausea and vomiting that occurs within 24-h after surgery or in the post-anesthesia care unit (PACU). Previous studies have reported that the use of remimazolam, a newer benzodiazepine (BDZ) hypnotic, for anesthesia results in less PONV. In this study, we compared the rate of PONV between sevoflurane and remimazolam after general anesthesia. In this prospective randomized controlled trial, participants aged 20-80 years who underwent elective laparoscopic cholecystectomy or hemicolectomy were randomized to either the remimazolam or sevoflurane group. The primary outcome was PONV incidence for 24-h after surgery. Secondary outcomes comprised of PONV at 30-min post-surgery, postoperative additional antiemetic use, and Quality of Recovery-15 (QOR-15) score at 24-h postoperatively. Forty patients were enrolled in the study. The remimazolam group exhibited significantly lower rates of PONV for 24-h after surgery than did the sevoflurane group (remimazolam group vs. sevoflurane group; 5% vs. 45%, P = 0.003, respectively). The use of dexamethasone, a rescue antiemetic administered within 24 h of surgery, was substantially lower in the remimazolam group than in the sevoflurane group (0% in remimazolam vs. 30% in sevoflurane, P = 0.020). The QOR-15 score at 24-h after surgery showed no significant difference between the two groups. Compared to sevoflurane, opting for remimazolam as an intraoperative hypnotic may decrease the incidence of PONV and reduce antiemetic use for 24 h after laparoscopic surgery.

Comparison of two different positions of an anaesthesiologist for ease of endotracheal intubation in adult patients: A randomised control trial

Background and aimsMaintaining the airway with a cuffed endotracheal tube (ETT) in the trachea remains one of the most essential anaesthesia skills. Many parameters were described to assess the difficulty of intubation in the preoperative period, but none allow the prediction of all difficult intubations. The correct posture of the anaesthesiologist is also an important factor for successful endotracheal intubation. The aim of this study was. This study aimed to compare the impact of two different positions of an anaesthesiologist (sitting vs. standing) at the time of endotracheal intubation. MethodsOne hundred ten American Society of Anaesthesiologists (ASA) Physical Status I/II patients, aged between 17 to 65 years, Mallampati grade I/II, mouth opening 39–70 mm, thyromental distance (TMD) 6–6.5 cm, and sternomental distance (SMD) >13 cm, scheduled for elective laparoscopic cholecystectomy, were recruited. Patients were divided into two groups; Group I consisted of patients who underwent endotracheal intubation by an anaesthesiologist in a sitting posture, while Group II encompassed patients who underwent endotracheal intubation by anaesthesiologists in a standing posture. Assessment parameters include ease of intubation (IDS score), intubation time, intubation success rate, number of attempts, grade of laryngoscopy (Cormack Lehane score, POGO score), and complications like tooth and soft tissue damage. ResultsThe ease of intubation was higher in group I, 1(0–1), than in group II, 1(1−2) (p = 0.02), and there was a significant difference between the two groups. The Cormack Lehane grade (CL) was I/IIa/IIb/III in 19/23/13/0 in group I and I/IIa/IIb/III in 13/21/18/3 in group II. The first-attempt intubation success rate for groups I and II was 94.54 % and 92.72 % respectively. ConclusionThe sitting posture of an anaesthesiologist at the time of laryngoscopy provides a better intubating condition when compared with the standing posture. RegistrationClinical Trial Registry - India (CTRI) CTRI/2023/03/050371.

The effect of dexamethasone and bupivacaine on postoperative pain and nausea and vomiting by preperitoneal nerve blocking in laparoscopic cholecystectomy: a randomized clinical trial

Background: This study aims to examine the effects of preperitoneal administration of dexamethasone and bupivacaine surrounding laparoscopic trocars on postoperative pain (POP) and nausea and vomiting (PONV) in patients undergoing laparoscopic cholecystectomy (LC). Method: In this randomized triple-blinded trial with a 1:1 randomization ratio, 104 patients with chronic cholecystitis were candidates for elective LC. A total of 40 mg (8 ml) of bupivacaine was mixed with 8 mg (2 ml) of dexamethasone or normal saline. The solution was injected preperitoneally via an 18G needle parallel and lateral to trocars until a bulge in the interior surface of the parietal peritoneum was observed by the camera. Primary outcomes were severity of POP based on 0-10 Likert visual analog scale (VAS) and rates of PONV and secondary outcomes were rate of postoperative opioid usage and any side-effects. Result: The mean VAS score was significantly lower in the dexamethasone group (3.5 vs. 6.2, P&lt;0.001). The dexamethasone group had 46.2% and 26.9% lower rate of nausea and vomiting after LC compared to the other group (P=0.001 and 0.015, respectively). Postoperative opioid use was lower in the dexamethasone group, but its difference was insignificant (P=0.3). Conclusions: Preperitoneal dexamethasone injection around laparoscopic trocars may lower the intensity of POP and PONV rates. Perioperative local corticosteroids can be used as an effective, available, and inexpensive analgesic and antiemetic prevention for laparoscopic procedures.

Low-pressure pneumoperitoneum with intraoperative dexmedetomidine infusion in laparoscopic cholecystectomy for enhanced recovery after surgery: A prospective randomised controlled clinical trial.

Enhanced Recovery After Surgery (ERAS) programs represent a shift in perioperative care, combining evidence-based interventions to reduce surgical stress to expedite recovery. ERAS requires cohesive team efforts to facilitate early discharge and reduce hospital stays. Anaesthesia and pneumoperitoneum management within ERAS play crucial roles in influencing postoperative outcomes. Laparoscopic cholecystectomy is widely acknowledged as the foremost approach for managing symptomatic gallstone disease due to its minimally invasive nature and favourable recovery. It has been demonstrated that increased abdominal pressures with prolonged CO2 exposure produce changes in cardio-vascular and pulmonary dynamics, which can be minimized by insufflating at minimum pressure required for adequate exposure, as advocated by European endoscopic guidelines. Dexmedetomidine, a highly selective alpha-2 adrenoreceptor agonist, has gained attention in anaesthesia armamentarium due to its sedative, analgesic, sympatholytic, and opioid-sparing properties. For multimodal opioid sparing postoperative pain management it's advantageous. To evaluate combined effect of low-pressure pneumoperitoneum and intra-operative dexmedetomidine infusion in laparoscopic cholecystectomy for ERAS. 160 patients of American Society of Anaesthesiologists (ASA) score 1 and 2, undergoing elective laparoscopic cholecystectomy were randomized into low pressure pneumoperitoneum (10-12 mmHg) and standard pressure pneumoperitoneum (13-15 mmHg) groups. Each group is subdivided into, no Dexmedetomidine (ND) and with Dexmedetomidine (WD) infusion (0.7 mcg/kg/hr) intra-operatively. Thus, 40 patients in each of the 4 study arms. Perioperative variables were collected and analysed. Low pressure pneumoperitoneum with intra-operative Dexmedetomidine infusion (0.7 mcg/kg/hr) resulted in stable hemodynamics, reduced post-operative pain, no requirement of additional analgesics and early discharge. Thus, synergistic impact of these interventions significantly improved postoperative outcomes when used as part of ERAS protocols.

Gall stones in children with sickle cell disease, management and outcomes

Background: It is rare to encounter a gall bladder stones in the paediatric age group. In Saudi Arabia, sickle cell disease (SCD) is common with incidence reach to 19.7%in some provinces. Cholecystitis is responsible for significant morbidity in SCD patients. Laparoscopic cholecystectomy (LC) is now considered as the procedure of choice for treating such cases. Over a period of 3 years, a total of 21 children with sickle cell anemia (SCA) had cholecystectomy. We exclude 3 patients who had splenectomy and cholecystectomy in the same time, the remaining 18 patients (6 males and 12 females) had LC only. Their age ranged from 4 years to 13 years (mean of 7.45±1.94 years). Methods: LC was the standard procedure performed in all the children in our study group. The mean duration of operation was 92.17±27.31 minutes (range from 62-167 minutes). Results: The mean post-operative stay after operation was 2.167±0.5 days (range from 1-3 days). One patient required conversion to open cholecystectomy (OC) because of severe adhesions, there were no immediate postoperative complications in the other 17 patients of our study group. Conclusions: In conclusion, elective LC in well prepared patients, is feasible and safe in children with SCA and should be the treatment of choice for both symptomatic and asymptomatic cholelithiasis. ERCP is a valuable diagnostic and therapeutic investigation both preoperatively and postoperatively.