Elective Open Cholecystectomy Research Articles

The Surgical outcomes of fundus-first technique in lowering the rate of bile duct injuries and bleeding during open cholecystectomy that facing intraoperative difficulties: A single-center prospective study

Background: The problem of difficult gallbladder is not clearly defined and associated with real missing of therapeutic approaches that decreased morbidity. Moreover, the difficult gallbladder was reported as a contributing risk factor for biliary injury due to raised difficulty in surgical dissection within Calot’s triangle. The aim of this study is to determine the surgical outcomes of the open fundus-first cholecystectomy in lowering the rate of lethal intraoperative risks.
 Subjects and Methods: Our prospective study conducted during the period of January 2019 to December 2022 at Ibn Sina specialized hospital, Khartoum, Sudan, for two hundred and fifty-three patients underwent elective open fundus-first cholecystectomy for intraoperative difficulties.
 Results: the majority of cases had long-standing cholelithiasis with intraoperative difficulties revealed by pre-operative TUS and MRCP which required open fundus-first cholecystectomy in 173 (68.4%) of patients, (P-value <0.05). The operative surgical time was 120 minutes in 103 patients (40.7%), (P-value <0.05). During open cholecystectomy, variable intraoperative difficulties were found in all patients, (P-value <0.05) and were divided into: (A) Contracted intra-hepatic gallbladder seen in 157 (62.1%) of cases; (B) Distorted anatomy within Calot's triangle seen in 135 (53.4%) of patients; and (C) Intraoperative bleeding from the liver bed was observed as bloody oozing form in 150 (59.3%) of cases. Our patients had minimal postoperative complications like mild wound infection in 8 (3.2%) of cases and mortality rate was zero. 
 Conclusions: There is a need for appropriate therapeutic and preventive strategies in healthcare systems for safe dealing with difficult cholecystectomy. Unclear anatomy due to severe inflammatory dense adhesions at Calot’s triangle and CBD stones needing difficult surgeries are the most important limiting factors for fundus-first laparoscopic cholecystectomy. Hence, we humbly recommend an open approach of fundus-first cholecystectomy as safe surgical option to reduce the incidence of bile duct injuries and intra-operative bleeding.

Thoracic spinal anaesthesia for abdominal surgery in a humanitarian military field hospital: a prospective observational study

BackgroundProviding safe and effective anaesthesia in the context of humanitarian medicine is always a challenging situation. Spinal anaesthesia, and in particular its thoracic approach, represents a promising technique for such...

Acute calculous cholecystitis complicated by a large anterior abdominal wall abscess

We present a 74-year-old male patient with a rare case of acute calculous cholecystitis that was complicated by formation of a large anterior abdominal wall abscess due to neglection. The primary management consisted of antibiotic therapy and two consequent procedures of abscess drainage. Cholecystectomy was postponed due to the massive volume of the abscess which posed a great risk for complications if the patient were to be operated on at that point, therefore an elective open cholecystectomy was performed 3 months later. This case is a good example for the management of such a rare and interesting complication.

Preoperative effects of magnesium sulfate on hemodynamics and muscle relaxation

Background/Aim: Although there are many studies on the effects of magnesium sulfate in the literature, there is no publication on the effects of low doses of magnesium sulfate, as we administered in our study. This prospective randomized study aimed to reveal that the use of low-dose magnesium sulfate (MgSO4) shortens the onset time and prolongs the block duration of neuromuscular blockers (NMBs) without changing the hemodynamics in patients monitored using the train-of-four (TOF) ratio. Methods: This is a prospective randomized study. A total of 60 cases aged between 18–65 years with American Society of Anesthesiologists classifications I–II who were scheduled for elective open cholecystectomy were randomly divided into 3 groups. Notably, 15 minutes before the anesthesia induction, 25 mg/kg MgSO4 in intravenous 0.9% saline (total volume, 100 mL) was administered to the MgSO4 group (MS group), 0.03 mg/kg midazolam was administered to the midazolam group (MD group), and the same volume of 0.9% saline solution was administered to the control group (PSS group). Nerve-muscle conduction monitoring was performed using TOF-Watch® SX (Organon, Ireland) and anesthesia depth was monitored with a BIS® monitor (A-2000; Aspect Medical Systems, USA). Results: NMB onset times were 83.95 (26.8), 111.15 (28.12), and 163.7 (34.16) seconds (P=0.001) in the MS, MD, and PSS groups, respectively. The times until additional rocuronium requirement after the intubation dose were 60.1 (4.19), 50.8 (4.99), and 38.25 (7.27) minutes in the MS, MD, and PSS groups, respectively, which was significantly longer in the MS group compared to the other groups (P 95% was longer in the MS group than in the other groups. No difference was found between the groups in terms of hemodynamic data. Conclusion: Low-dose MgSO4 administration before rocuronium injection significantly reduces neuromuscular agent consumption without altering hemodynamics and causing a residual neuromuscular block.

Open Cholecystectomy in Respiratory and Cardiovascular disease patients under Lumbar combined Spinal-Epidural Anesthesia

Background and Aims: Regional anesthesia gained popularity over the last three decades due to the technical advances across subdisciplines, better understanding of the physiology, the advances in the field of anesthetic drugs, and the better approach in training for such techniques. The technique is currently used in many anatomical levels and most surgical procedures can be performed using the combined spinal epidural type. The aim of this study is to evaluate the feasibility of the combined spinal-epidural anesthesia in patients with respiratory and cardiovascular diseases who underwent open cholecystectomy.  Patients and methods: This prospective cross sectional study which was done on patients undergoing elective open cholecystectomy (n=119) for whom the general anesthesia was contraindicated due to major cardiovascular and pulmonary diseases, under lumber combined spinal-epidural anesthesia. Results: The mean age of our patients was 64.33(SD: 12.085) years; females constituted 73 of them (61.3%) and males 46 (38.7%). Most patients (73) were complaining from the cardiovascular diseases (61.34%). In most patients the onset of the action of the anesthesia was between 10-12 minutes. In 55 patients (46.2%) no extra-drugs were required, and in the rest of patients intravenous mediations were given to relieve anxiety, pain, or both. In 81 patients (68.1%) no intraoperative complications were reported, the most common intraoperative complication was hypotension in 31 patients (26.1%), post-operatively no complications were reported in 86 patients (72%), and hypotension was reported in 12 patients (10.1%), nausea & vomiting in 11 patients (9.2%). The surgeon’s satisfaction was excellent in 73.11% of the surgeries, as was good in 23.53%. Most patients gained the lower limb movement within 2 hours. There was a significant correlation between the need for extra drugs and both comorbid diseases and the development of intraoperative complications (P values 0.022 & 0.000) respectively and no significant correlations with other parameters such as the gender, postoperative complications and the surgeon’s satisfaction (P values 0.707, 0.522, and 0.056) respectively. Conclusion: The technique of the combined spinal epidural anesthesia is safe and very effective when used for American Society of Anesthesiologist (ASA) patient classification class III and IV patients who need open cholecystectomy. This technique should be used by expert anesthetists who are well trained and gained skill in this technique, and it may be used in fields other than surgery such as trauma victims and for cancer patients.  

Undiagnosed hypothyroidism with delayed recovery: A case report.

Sir, We report a case of delayed recovery from general anesthesia, which was later on diagnosed as a case of hypothyroidism. A 60-year female patient was posted for elective open cholecystectomy with heart rate 47/min, blood pressure 140/80 mmHg, and normal electrocardiograph. Patient had no other comorbidities and was not any drugs. Her echocardiography revealed stage I left ventricular diastolic dysfunction with normal systolic functions. Medicine referral was done for bradycardia. On operating table (OT) table, her heart rate (HR) increased to 58/min after injecting atropine 0.6 mg intravenously (IV). Anesthesia was induced with intravenous morphine, thiopentone, and vecuronium with endotracheal intubation and maintained with isoflurane, nitrous oxide, and oxygen uneventfully. At the end, patient recovered well with adequate spontaneous respiration and neuromuscular blockade was reversed with injection neostigmine and glycopyrrolate. However, following extubation, patient became drowsy and apneic. Trachea was reintubated and intermittent positive pressure ventilation was restarted. Fresh reports revealed normal electrolytes and blood gas analysis. Patient was re-evaluated clinically and was observed to have very thick and rough skin (probably missed in preanesthetic evaluation), low body temperature, and bradycardia without thyroid swelling. Suspecting hypothyroidism, blood sample was sent for TSH estimation after 2.5 h of reintubation; and as injectable thyroxine was not available, two tablets of Thyroxin 100 μg each were given through Ryle's tube empirically on emergency basis. Patient recovered well after 4 h of elective postoperative ventilation. She became conscious with adequate spontaneous ventilation. Trachea was extubated. After surgery, corticosteroid replacement therapy was started as 100 mg three times a day and continued as oral therapy, since hypothyroidism is commonly associated with adrenal insufficiency. Her diagnosis was later confirmed as hypothyroidism after receiving reports of TSH level (TSH: 111 μIU/L). She was put on tablet Eltroxin 100 μg daily thereafter. Hypothyroidism may be present in subclinical form. The anesthetic requirement of hypothyroid patients has not been analyzed so far in any study; but clinically, they are found to be more sensitive to anesthetic drugs and sedatives affecting anesthetic management.[12] Clinical signs of hypothyroidism may range from cold intolerance to constipation, depression, lethargy, muscle weakness, slow movement, dry skin, slow gastric emptying, sleep apnea, depression of ventilatory response to hypoxia, and hypercarbia.[3] The normal range of TSH is 0.3–4.5 mU/L. Primary hypothyroidism is diagnosed through detection of a low free T4 and a high TSH level. A rising TSH level is the most sensitive indicator of failing thyroid function.[4] Hypothyroidism causes increased responsiveness to central nervous system depressants and neuromuscular blocking agents. Increased sensitivity may be secondary to reduced cardiac output and blood volume, abnormal baroreceptor function, slowing of drug metabolism, and excretion. Decreased neuromuscular excitability, decreased ventilatory response to hypoxia, and hypercarbia are enhanced by anesthetic agents.[14] Due to depression of vascular and respiratory reflexes, hypotension, cardiac arrest and delayed recovery of spontaneous ventilation is common in hypothyroid patients.[5] Such patients should be rendered euthyroid before the surgery. Regional anesthesia should be preferred, if the surgery cannot be delayed.[5] To conclude, a patient of persistent bradycardia may have other than cardiac cause. In cases of emergency, signs of hypothyroidism may be managed empirically with enteral thyroid hormone replacement state, if parenteral form of thyroxine is not available. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Cholecystitis in Situs Inversus with Dextrocardia

Background: Surgical problem known as Acute Cholecystitis is very common nowadays; however it may cause trouble in diagnosing when person has situs inversus, (i.e.) viscera situated on the opposite side of the body. Our case report discusses the history and physical exam findings, images of radiograph, diagnosis, and how we dealt with cholecystitis in situs inversus with dextrocardia.Case Presentation: An eighty-six yrs. old male having pain in the upper left hypochondrium region, presented in emergency department. He was later diagnosed to have acute cholecystitis (inflammation of the gallbladder) with cholelithiasis (presence of gallstones in gallbladder) in situs inversus totalis. Patient underwent elective open cholecystectomy within 24 h. Patient recovered well and was discharged on fourth postoperative day.Conclusion: Acute cholecystitis in Situs Inversus with Dextrocardia is very rare congenital anomaly and requires great expertise in the field of surgery to operate on these patients because of the reverse anatomy of the organs.

Open cholecystectomy: Exposure and confidence of surgical trainees and new fellows

BackgroundThe laparoscopic approach to cholecystectomy has overtaken open procedures in terms of frequency, despite open procedures playing an important role in certain clinical situations. This study explored exposure and confidence of Australasian surgical trainees and new fellows in performing an open versus laparoscopic cholecystectomy. Materials and methodsAn online survey was disseminated via the Royal Australasian College of Surgeons to senior general surgery trainees (years 3–5 of surgical training) and new fellows (fellowship within the previous 5 years). The survey included questions regarding level of experience and confidence in performing an open cholecystectomy and converting from a laparoscopic to an open approach. ResultsA total of 135 participants responded; 58 (43%) were surgical trainees, 58 (43%) were fellows and 19 (14%) did not specify their level of training. Respondents who were involved in more than 20 open cholecystectomy procedures as an assistant or independent operator compared with those less exposed were more likely to feel confident to independently perform an elective open cholecystectomy (87.8% vs. 57.3%, P = 0.001), independently convert from a laparoscopic to open cholecystectomy (87.8% vs. 58.7%, P = 0.001) and independently perform an open cholecystectomy as a surgical consultant based on their level of exposure as a trainee (73.2% vs. 45.3%, P = 0.004). ConclusionThis study suggests the need to ensure surgical trainees are exposed to sufficient open cholecystectomies to enable confidence and skill with performing these procedures when indicated. Greater recognition of the need for exposure during training, including meaningful simulation, may assist.

Low dose spinal anesthesia for open cholecystectomy: a feasibility and safety study

Background: Cholecystectomy is performed either open or a laparascopic route. the traditional and invasive open cholecystectomy is still in frequent practice for various reasons. Spinal anesthesia (SA) has been widely used as alternative to General Anesthesia (GA) for laparoscopic cholecystectomy. SA could be a safe and effective anaesthetic procedure for open cholecystectomy. This study was conducted to uncover feasibility and safety of low dose SA for conducting open cholecystectomy.Methods: All consented patients of ASA grade I and II of either sex scheduled for elective open cholecystectomy received SA using 2 ml of 0.5% hyperbaric Bupivacaine mixed with 100 µg Morphine. Peri-operative preparations and management were all standardized. Other drugs being only administered to manage anxiety, pain, nausea/vomiting, hypotension, and any adverse event. Open cholecystectomy by right oblique incision. Intra-operative events and post-operative events were observed for 48 hours, operative difficulty, post operative pain free interval, analgesia requirements, hospital stay and the surgeon and patient satisfaction were studied.Results: 20 patients were included in the study from 1st may 2016 to December 2016. Spinal anesthesia was adequate for surgery in all patients. Operative difficulty scores were minimal and surgery in one patient was converted to open cholecystectomy. Intraoperatively, five patients presented hypotension and Ephedrine was given. Four patients experienced pain and received Fentanyl and midazolam. Postoperatively, pain scores were minimal and paracetamol was not sufficient only in four patients who received ketoprofen and no patient received opioid. One patient required antiemetic for vomiting and two patients suffered urinary retention and one headache. 19 patients were discharged within 48 hours of surgery and patient satisfaction scores were very good.Conclusions: Spinal anesthesia is safe and effective anesthetic technic for uncomplicated open cholecystectomy in terms of peri-operative events and, in prolonged post-operative analgesia, as well as in terms of patient and surgeon’s satisfaction.

Hereditary Spherocytosis with Splenomegaly and Cholelithiasis in a Young Male of Western Region of Nepal - A Case Report.

Hereditary spherocytosis is an autosomal dominant congenital hemolytic anemia due to defect in RBC membrane protein that commonly presents with intermittent jaundice, anemia, abdominal pain, splenomegaly and sometimes cholelithiasis. Due to the membrane defect, there is increased fragility, hemolytic anemia, marked splenomegaly and hyperbilirubinemia. This is a report of an 11 years old male diagnosed case of hereditary spherocytosis who presented with jaundice, splenomegaly and cholelithiasis. He underwent elective open splenectomy and cholecystectomy after prophylactic immunization for capsulated organisms and was advised lifelong oral penicillin prophylaxis post-splenectomy.

Septic Shock from Cholecystitis in an Intrahepatic Gallbladder

Introduction: Intrahepatic gallbladders, a rare anatomical variant, usually have impaired functionality and do not empty completely. This stasis leads to the formation of gallstones which in turn leads to an increased risk of developing associated complications with increased morbidity and mortality. We illustrate this point with a case of a male with a history of partial cholecystectomy who presented with sepsis from cholecystitis within an intrahepatic gallbladder. Case Report: A 31-year-old male presented with complaints of right upper quadrant abdominal pain, nausea and vomiting. His past medical history included cholelithiasis with elective open partial cholecystectomy a few months prior for biliary cholic. His postoperative course had been complicated by stump leakage requiring an ERCP with stent placement. On this admission, the patient presented with hypotension and tachycardia, elevated WBC count of 12.6 K/mL, total bilirubin of 1.4, and direct bilirubin 0.56. Blood cultures were positive for gram-negative bacilli. CT scan was significant for a fluid collection in the gallbladder fossa (Figure 1). MRCP revealed an intrahepatic gallbladder with dark signal representing possible calculi (Figure 2). The patient was admitted to SICU on IV antibiotics and vasopressors. The patient had 15cc of purulence drained by interventional radiology. GI was then consulted for an ERCP. The prior stent was removed, sphincterotomy performed, a cholangiogram did not reveal any bile leaks or filling defects in the common bile duct, and a new stent was placed. The patient's vital signs improved and he no longer required vasopressors within 24 hours after the ERCP. Discussion: Intrahepatic gallbladders are predisposed to develop cholelithiasis, which presents a significant cause of morbidity. A delay in diagnosis leads to inappropriate management and increases in morbidity and mortality. In our case, the patient likely required earlier stent placement because the entirety of the gallbladder was not removed during his initial surgery. The remaining portion of the gallbladder remained at risk of developing further cholelithiasis due to its anatomical position if the original gallstone was not removed during the initial cholecystectomy. Intrahepatic gallbladders should be identified early as they have a higher propensity for developing gallstones, which can lead to other complications such as cholecystitis, cholangitis, perforation, abscess formation and even death.Figure 1Figure 2

Comparison between thoracic epidural anaesthesia & general anaesthesia for open cholecystectomy in adult patients

Background & Objectives: This study was done to assess the feasibility of thoracic epidural anaesthesia in open cholecystectomy. Laproscopic cholecystectomy is the standard now a days but in developing countries open cholecystectomy is still commonly performed. Methods: Our study was carried out on 60 adult, non-pregnant patients ASA grade I, II between 18 – 60 years of age for elective open cholecystectomy under thoracic epidural anaesthesia & general anaesthesia. Haemodynamic parameters(BP, heart rate), oxygenation were observed for 60 minutes. Sensory & motor blockade were observed in thoracic epidural group. Results: In our study both group T and group G were statistically comparable in terms of their gender, mean age and mean weight. Base line pulse rate, SBP, DBP, MAP was comparable in both groups. However, there was significant statistical difference in the two groups in hemodynamic parameters in the study period but it was not clinically significant. Interpretation & conclusions: Thoracic epidural anaesthesia can be used for open cholecystectomy in ASA 1, 2 patients. It provides hemodynamic stability, minimal respiratory distress (as per spo2 values). General anaesthesia still remains the anaesthetic technique of choice for open cholecystectomy. However, an experienced anaesthetist can use thoracic epidural anaesthesia for open cholecystectomy. Key words: Thoracic epidural, General anaesthesia, Open cholecystectomy

Ultrasound-guided thoracic epidural and paravertebral blocks for cholecystectomy in pediatric patients with a cyanotic heart disease: A randomized controlled study

BackgroundPerioperative pain treatment in pediatrics is often insufficient. This study aimed to compare between two different analgesic procedures used for open cholecystectomy in pediatrics with left (LT) to right (RT) shunt.Methods40 patients with age ranging from 2 to 5 years were submitted for elective open cholecystectomy procedures in congenital non-cyanotic heart diseases. After general anesthesia, they were randomized into two groups according to the type of analgesia given, 20 patients in each group. They were either epidural group (group A) or paravertebral group (group B). Hemodynamics including heart rate (HR), mean arterial blood pressure (MAP), and central venous pressure (CVP), were recorded. Pain score, arterial blood gases (ABG), first request for analgesic requirement, and total postoperative consumption of fentanyl (μg/kg) were detected.ResultsChildren’s Hospital Eastern Ontario Pain Scale (CHEOPS) pain score, total fentanyl requirement and the time for first request of analgesic requirement were comparable in both groups. Hemodynamic parameters (HR–MAP–CVP) and the oxygenation parameters in the form of arterial oxygen tension (PaO2) and arterial oxygen saturation (SaO2) were significantly decreased in the epidural group than paravertebral group as P < 0.05.ConclusionBoth blocks have the same analgesic efficacy but the paravertebral block is superior on epidural block in maintaining hemodynamic stability and improving the oxygenation in pediatrics with a cyanotic heart diseases.

Scoring System Development and Validation for Prediction Choledocholithiasis before Open Cholecystectomy.

Accurate precholecystectomy detection of concurrent asymptomatic common bile duct stones (CBDS) is key in the clinical decision-making process. The standard preoperative methods used to diagnose these patients are often not accurate enough. The aim of the study was to develop a scoring model that would predict CBDS before open cholecystectomy. We retrospectively collected preoperative (demographic, biochemical, ultrasonographic) and intraoperative (intraoperative cholangiography) data for 313 patients at the department of General Surgery at Gornji Milanovac from 2004 to 2007. The patients were divided into a derivation (213) and a validation set (100). Univariate and multivariate regression analysis was used to determine independent predictors of CBDS. These predictors were used to develop scoring model. Various measures for the assessment of risk prediction models were determined, such as predictive ability, accuracy, the area under the receiver operating characteristic curve (AUC), calibration and clinical utility using decision curve analysis. In a univariate analysis, seven risk factors displayed significant correlation with CBDS. Total bilirubin, alkaline phosphatase and bile duct dilation were identified as independent predictors of choledocholithiasis. The resultant total possible score in the derivation set ranged from 7.6 to 27.9. Scoring model shows good discriminatory ability in the derivation and validation set (AUC 94.3 and 89.9%, respectively), excellent accuracy (95.5%), satisfactory calibration in the derivation set, similar Brier scores and clinical utility in decision curve analysis. Developed scoring model might successfully estimate the presence of choledocholithiasis in patients planned for elective open cholecystectomy.

Preoperative sleep quality and inhalation anesthetic requirements: a sleep electroencephalography study

Background On the night before surgery, poor sleep quality due to anxiety is a frequently encountered problem. Objective This study aimed at determining the effect of preoperative sleep quality on intraoperative isoflurane requirements in patients undergoing elective surgeries and also offers an electroencephalography (EEG)-based classification of sleep quality. Patients and methods Twenty-seven adult male patients scheduled for elective open cholecystectomy with ages ranging from 20 to 40 years were included in this study. The night before the operation, the patients were subjected to an at least 8 h sleep EEG, which was scored for the following: total sleep time, percentage of slow wave sleep, and percentage of rapid eye movement sleep. Intraoperative isoflurane requirements were determined by recording the amount of inspired isoflurane concentration (every 2 min) needed to achieve an intraoperative bispectral index value between 40 and 60. Patients were classified according to sleep EEG into good sleepers and bad sleepers. Isoflurane requirements were first correlated with the EEG and then compared between the two groups. Results The inspired concentration of isoflurane in good sleepers was 1.15% (1.01-1.22%), whereas in bad sleepers it was significantly lower, at 0.99% (0.87-1.18%) ( P = 0.003). There was a positive correlation between isoflurane requirements and both slow wave sleep percentage ( r = 0.693; P = 0.003) and rapid eye movement sleep percentage ( r = 0.687; P = 0.005). Conclusion Patients suffering from poor sleep quality on the night before surgery need less intraoperatively inspired isoflurane concentration. This finding may have clinical importance in adjusting the isoflurane dose to meet patients' requirements, avoiding intraoperative complications. In addition, an EEG-based classification of sleep is offered.

Different local anesthetic technique for postoperative analgesia in open cholecystectomy

Background Paravertebral block is the technique of injecting a local anesthetic (LA) solution alongside the vertebral column close to the emergence of the spinal nerves. Infiltration of LAs into the surgical wound is a simple, safe, and low-cost technique for postoperative analgesia. Patients and methods Patients with physical status ASA I-II aged 20-45 years of both sexes and scheduled for an elective open cholecystectomy with subcostal incision were included in this study. Patients were classified randomly using sealed envelopes into three equal groups of 60 patients each. At the end of the surgical procedures, for all the patients of the study, a continuous wound catheter (CWC) and a continuous paravertebral catheter were inserted: group I (CWC), group II (continuous paravertebral catheter), and group III (control group). Anesthesia was induced with an intravenous fentanyl injection (1.5 µg/kg), propofol (1.5 mg/kg), followed by cis-atracurium (0.15 mg/kg), and then the patient was intubated after 3 min. Maintenance of anesthesia was by isoflurane with minimal alveolar concentration (1.5) with additional doses of cis-atracurium (0.04 mg/kg) when needed. Results A total of 120 patients were included in the study, with 40 patients randomized to each group. There were no significant differences in demographic data. For mean arterial blood pressure, heart rate, and respiratory rate, there were no significant differences between the groups, except 30 min after extubation, when there was a significant increase in group III compared with the other two groups. For SpO 2 , there was no significant difference between the three groups. In terms of pain assessment using visual analogue scale, there was a significant decrease at all time points in the values of group II compared with the other two groups and in group I compared with group III. Conclusion We conclude that paravertebral block with a continuous infusion is more effective than a CWC infusion in postoperative pain management after surgeries with subcostal incisions, although both techniques showed a significant improvement compared with the control group.

Cholecystectomy and Wound Complications: Smoking Worsens Risk

BackgroundIn the United States, approximately 800,000 cholecystectomies are performed annually. We sought to determine the influence of preoperative smoking on postcholecystectomy wound complication rates. Materials and methodsUsing the National Surgical Quality Improvement Program database (2005–2011), patients aged ≥18 y who underwent elective open or laparoscopic cholecystectomy (LC) for benign gallbladder disease were identified using current procedural terminology codes. Multivariate regression was performed to determine the association between smoking status and wound complications, by surgical approach. ResultsOf 143,753 identified patients, 128,692 (89.5%) underwent LC, 27,788 (19.3%) were active smokers, and 100,710 (70.2%) were females. Active smokers were younger than nonsmokers (mean + standard deviation age: 44.2 (14.9) versus 51.6 (17.9) years); P < 0.001) and had fewer comorbidities. Within 30-d postcholecystectomy, wound complications were reported in 2011 (1.4%) patients. Compared with nonsmokers, active smokers demonstrated increased odds of wound complications after both open cholecystectomy (odds ratio 1.28; P = 0.010) and LC (odds ratio 1.20; P = 0.020) after adjustment for demographic and clinical characteristics. Having wound complications increased the average postoperative length of stay by 2–4 d (P <0.001). ConclusionsActive smokers are more likely to develop wound complications after cholecystectomy, regardless of surgical approach. Occurrence of wound complications consequently increases postoperative length of stay. Smoking abstinence before cholecystectomy may reduce the burden associated with wound complications.

A comparative study of efficacy of epidural versus interpleural bupivacaine for post operative analgesia after open cholecystectomy

Background The conventional methods of administering the prescribed doses of intramuscular or intravenous analgesics at fixed time intervals results in widely fluctuating and inadequate plasma level leads to poor post operative pain relief. Despite all advances made in the field of medicine, this symptom called “Pain” has not been combated well. Objective The present study was carried out to compare the efficacy of epidural verses interpleural administration of bupivacaine(0.5%) with adrenaline for post operative pain relieve in patients undergoing open cholecystectomy. Methods We prospectively randomized and compared the post operative pain relieve with the reference of visual analog score (VAS) in patients undergoing elective open cholecystectomy in college of medical sciences-teaching hospital, Bharatpur, Chitwan. Forty adult patients undergoing elective cholecystectomy were divided into two groups. Twenty patients in each group were subjected to a different technique of post-operative analgesia, namely thoracic epidural and interpleural instillation of 0.5% bupivacaine. These two groups were then compared in relation to changes produced in the pain scores, vital parameters and complication and side effects associated with the two techniques. The study was conducted for 24 hour postoperatively. Observation: Both thoracic epidural and interpleural instillation of 0.5% bupivacaine compared favorably with regard to analgesia in the present study. In general, the pain relief following thoracic epidural was more complete compared to interpleural but this was not clinically significant. Conclusion The present study shows that both the techniques are equally effective in providing analgesia following cholecystectomy. However, neither technique rendered the patients completely pain free at all times during first 24 hours. Journal of College of Medical Sciences-Nepal, 2013, Vol-9, No-4, 15-23 DOI: http://dx.doi.org/10.3126/jcmsn.v9i4.10232

Effect of gabapentin premedication on preoperative anxiety and postoperative pain

Background: In addition to chronic pain and anxiety disorders, few studies have found promising role of gabapentin in relieving acute postoperative pain as well as acute anxiety too. Objectives: To evaluate the effect of gabapentin premedication on preoperative anxiety and postoperative pain in patients undergoing elective open cholecystectomy. Methods: A prospective, randomized, double blind and placebo controlled study. Eighty adult patients of ASA I and II were divided into 2 groups of 40 each. Patients in group 1 and group 2 received capsules Gabapentin (1200mg) or identical placebo capsules 2 hours prior to surgery respectively. Preoperative anxiety and 12 hours postoperative pain was assessed using Anxiety and Pain VAS score respectively along with the observation of side effects. Postoperatively, intravenous pethidine 0.5 mg/kg was given when pain VAS &gt; 40mm and time to first pethidine injection and total pethidine consumption in 12 hours was recorded. Results: Anxiety VAS scores after one hour of drug intake (35.75±20.11 versus 46.63±12.73) and just before induction of anaesthesia (45.75±30.27versus 68.13±29.84) along with postoperative Pain VAS scores were significantly lower in gabapentin group. Time to the first pethidine demand was significantly longer (145.34±194.54 min versus 26.30±51.02min) and cumulative pethidine consumption throughout study period was also significantly lower (35.91 ± 16.61 versus 57.84 ± 20.72mg) in gabapentin group. Conclusions: 1200 mg gabapentin premedication in open cholecystectomy patients significantly reduced preoperative anxiety, postoperative pain and total pethidine consumption with negligible side effects. DOI: http://dx.doi.org/10.3126/hren.v11i3.9642 Health Renaissance 2013;11(3):254-259

Stump cholecystitis: laparoscopic completion cholecystectomy with basic laparoscopic equipment in a resource poor setting.

Introduction. Stump cholecystitis is a recognised condition in which a large gallbladder remnant becomes inflamed after subtotal cholecystectomy. When this occurs, a completion cholecystectomy is indicated. Traditionally, these patients were subjected to open surgery because the laparoscopic approach was anticipated to be technically difficult. We present a case of completion cholecystectomy using basic laparoscopic equipment in a resource poor setting to demonstrate that the laparoscopic approach is feasible. Case Description. A 57-year-old woman presented with right upper quadrant pain and vomiting. She had an elective open cholecystectomy seven years before but reported remarkably similar symptoms. Abdominal ultrasound suggested calculous acute cholecystitis. MRCP confirmed the presence of a large gallbladder remnant with stones. Gastroduodenoscopy excluded other differentials. She had an uneventful laparoscopic completion cholecystectomy performed. Discussion. Although traditional dogma suggested that a completion cholecystectomy should be performed through the open approach, several small studies have demonstrated that laparoscopic completion cholecystectomy is feasible and safe. This report adds to the existing data in support of the laparoscopic approach.