Laparoscopic Gynecologic Procedures Research Articles

Fast-Track surgery protocol in perioperative care for gynecological laparoscopy.

This study aimed to compare fast-track surgery (FTS) and traditional perioperative care protocols in laparoscopic gynecological surgeries, assessing their impact on length of stay (LOS), recovery time, and postoperative complications. A case-control retrospective study was conducted at Suzhou Hospital of Integrated Chinese and Western Medicine, involving 167 patients undergoing laparoscopic gynecological surgery from June 2021 to June 2023. Of them, 81 patients underwent surgery based on the FTS protocol (FTS group) and 86 patients received a traditional perioperative management (control group). Patients in both groups underwent gynecologic laparoscopic procedures, including uterine, ovarian and tubal surgeries. Data were collected on general patients' characteristics, including age, BMI, surgery type and time, intestinal recovery and out-of-bed activity time, LOS, pain levels, and postoperative complications. Wilcoxon rank sum test with continuity correction was used to assess the difference in operative characteristics and postoperative pain levels. Fisher's exact test was used to assess the difference in overall frequency of postoperative complications between groups. Patients in the FTS group exhibited faster intestinal recovery, shorter mobilization time, and reduced LOS compared to the control group. Pain levels were significantly lower at one, six and twelve hours post-surgery in the FTS group. Overall, the proportion of postoperative complications was significantly lower in the FTS group than in the control group. Implementing the FTS protocol in laparoscopic gynecological surgeries for benign conditions can reduce LOS, accelerate recovery, and minimize pain without increasing postoperative complications. Further research with more diverse patient populations is warranted to validate these findings.

Insights Into Laparoscopic Port Site Complications: A Comprehensive Review.

Laparoscopic surgery has become a widely accepted standard of care for numerous procedures in the modern world. Nearly every major surgical procedure previously only possible by employing open techniques may now be completed laparoscopically, attributable to the quick advancement of technology and surgeons' abilities. There are several complications associated with the laparoscopic port site, either infective, non-infective, or neoplastic. This study aims to explore the morbidity associated with the port site following laparoscopic surgery and discuss the risk factors for complications. The umbilical port was most frequently associated with port-site hernia (PSH), followed by the epigastrium and the left and right hypochondrium. Prolonged port manipulation and reinsertion, longer surgical times, failure to effectively close the fascial defect, and wound infection are responsible for the development of PSH. Port-site infection (PSI) is one avoidable adverse effect of laparoscopic surgery. Patients who have a history of diabetes, malnourishment, prolonged preoperative hospital stays, preoperative Staphylococcus aureus colonization of the nares, perioperative blood transfusions, and tobacco or steroid use are more likely to have PSI. Port-site hydatid cyst (PSHC) and port-site tuberculosis (PST) are rare but possible. While uncommon, a doctor should rule out endometriosis if a painful mass in the surgical scar, such as the trocar site, is discovered in a reproductive-age woman who has had pelvic or obstetric surgery in the past. Port-site metastasis (PSM) is the term for tumor-cell implantation at the trocar insertion site after a malignant tumor is removed laparoscopically. PSM has been reported in 1-2% of laparoscopic gynecologic surgical procedures. A few potential mechanisms for cell implantation at the port site include embolization of exfoliated cells during tumor dissection or hematogenous spread, air turbulence during long laparoscopic operations, and direct implantation onto the wound during forced, unprotected organ/tissue retrieval or from contaminated surgical instruments during tumor dissection. Nonetheless, the triggering mechanism is likely essentially multifaceted.Prevention is better than cure. Port-site hernia can be prevented using smaller trocars and meticulous rectus sheath defect closure at the end of surgery. The rest of the port site complications can be prevented by employing autoclavable laparoscopic hand instruments, utilizing autoclaved water to clean the instruments following disassembly, adhering to the recommended concentration, contact duration, and usage cycles when sterilizing instruments with liquid sterilizers, preventing bile or gut content from spilling into the operating room or the port site, using non-porous specimen retrieval bags for recovering the specimen, and thoroughly cleaning and irrigating the port site before closing the wound.

Effect of continuous measurement and adjustment of endotracheal tube cuff pressure on postoperative sore throat in patients undergoing gynecological laparoscopic surgery: a randomized controlled trial.

Postoperative sore throat (POST) is a common complication following endotracheal tube removal, and effective preventive strategies remain elusive. This trial aimed to determine whether actively regulating intraoperative cuff pressure below the tracheal capillary perfusion pressure threshold could effectively reduce POST incidence in patients undergoing gynecological laparoscopic procedures. This single-center, randomized controlled superiority trial allocated 60 patients scheduled for elective gynecological laparoscopic procedures into two groups: one designated for cuff pressure measurement and adjustment (CPMA) group, and a control group where only cuff pressure measurement was conducted without any subsequent adjustments. The primary outcome was POST incidence at rest within 24h post-extubation. Secondary outcomes included cough, hoarseness, postoperative nausea and vomiting (PONV) incidence, and post-extubation pain severity. The incidence of sore throat at rest within 24h after extubation in the CPMA group was lower than in the control group, meeting the criteria for statistically significant superiority based on a one-sided test (3.3% vs. 26.7%, P < 0.025). No statistically significant differences were observed in cough, hoarseness, or pain scores within 24h post-extubation between the two groups. However, the CPMA group had a higher incidence of PONV compared to the control group. Additionally, the control group reported higher sore throat severity scores within 24h post-extubation. Continuous monitoring and maintenance of tracheal tube cuff pressure at 18 mmHg were superior to merely monitoring without adjustment, effectively reducing the incidence of POST during quiet within 24h after tracheal tube removal in gynecological laparoscopic surgery patients. The study was registered at www.chictr.org.cn (ChiCTR2200064792) on 18/10/2022.

Restoration of Pulmonary Compliance after Laparoscopic Gynecologic Surgery Using a Recruitment Maneuver.

This study aimed to investigate the hypothesis that an alveolar recruitment maneuver can restore lung compliance to initial values after laparoscopic gynecological surgery. A total of 31 patients who underwent laparoscopic gynecological surgery were enrolled. Protective mechanical ventilation was applied, and the radial artery was catheterized in all patients. An alveolar recruitment maneuver (incremental and decremental positive end-expiratory pressure) was applied ten minutes after the release of pneumoperitoneum. The respiratory mechanics and blood gas results were recorded at eight different time points: after induction of anesthesia (T1), in the lithotomy position (T2), in the Trendelenburg position (T3), 10 and 90 min after insufflation of carbon dioxide (T4 and T5), in the supine position (T6), after desufflation (T7), and 10 min after an alveolar recruitment maneuver at the end of surgery (T8). Pneumoperitoneum and the Trendelenburg position caused a decline of 15 units in compliance (T7 vs. T1; p < 0.05) compared to baseline. After the alveolar recruitment maneuver, compliance increased by 17.5% compared with the mean value of compliance at time T1 (T8 vs. T1; p < 0.05). The recruitment maneuver had favorable results in patients with low initial compliance (41.5 mL/cmH2O, IQR: 9.75 mL/cmH2O), high Body Mass Index 30.32 kg/m2 (IQR: 1.05 kg/m2), and high initial plateau airway pressure (16.5 cmH2O, IQR: 0.75 cmH2O). Lung compliance does not return to initial values after performing laparoscopic gynecological procedures. However, after the release of pneumoperitoneum, an alveolar recruitment maneuver is beneficial as it improves compliance and gas exchange.

Postoperative cognitive disorders and delirium in gynecologic surgery: Which surgery and anesthetic techniques to use to reduce the risk?

Despite their general good health, an increasing proportion of elderly individuals require surgery due to an increase in average lifespan. However, because of their increased vulnerability, these patients need to be handled carefully to make sure that surgery does not cause more harm than good. Age-related postoperative cognitive disorders (POCD) and postoperative delirium (POD), two serious consequences that are marked by adverse neuropsychologic alterations after surgery, are particularly dangerous for the elderly. In the context of gynecologic procedures, POCD and POD are examined in this narrative review. The main question is how to limit the rates of POCD and POD in older women undergoing gynecologic procedures by maximizing the risk-benefit balance. Three crucial endpoints are considered: (1) surgical procedures to lower the rates of POCD and POD, (2) anesthetic techniques to lessen the occurrence and (3) the identification of individuals at high risk for post-surgery cognitive impairments. Risks associated with laparoscopic gynecologic procedures include the Trendelenburg posture and CO2 exposure during pneumoperitoneum, despite statistical similarities in POD and POCD frequency between laparoscopic and laparotomy techniques. Numerous risk factors are associated with surgical interventions, such as blood loss, length of operation, and position holding, all of which reduce the chance of complications when they are minimized. In order to emphasize the essential role that anesthesia and surgery play in patient care, anesthesiologists are vital in making sure that anesthesia is given as sparingly and quickly as feasible. In addition, people who are genetically predisposed to POCD may be more susceptible to the disorder. The significance of a thorough strategy combining surgical and anesthetic concerns is highlighted in this article, in order to maximize results for senior patients having gynecologic surgery.

The Role of TAP/RS Block in Minor Gynecologic Laparoscopic Surgery: A Randomized Clinical Trial

Objectives: The aim of the study was to compare, in patients undergoing minor gynecological laparoscopic procedures, the effects of ultrasound (US)-guided transversus abdominis plane (TAP) + rectus sheath (RS) block versus no TAP/RS block in terms of post-surgical pain control using the numeric pain rating scale (NRS) and the degree of patient satisfaction, according to the main goals of Early Recovery After Surgery (ERAS) programs. The primary outcome is to value the postoperative abdominal pain using NRS in both groups. Secondary outcomes are to evaluate blood values, presence of postoperative nausea and vomiting (PONV), postoperative ileus, level of patient expected satisfaction, time of discharge, length of stay (LOS), and the amounts of additional analgesics required. Design: In this prospective randomized controlled trial, patients were randomly assigned to loco-regional anesthesia (LRA) group, who received TAP and RS block under US guidance, or no loco-regional anesthesia (N-LRA) group. Enrolled patients were randomized 1:1 to either receive bilateral TAP/RS block with ropivacaine or sham treatment (patches were applied on the abdominal wall of the patients under general anesthesia). Participants: All patients aged between 18 and 75 years, with ASA (American Society of Anesthesiologists) physical status 1-2, undergoing laparoscopic minor gynecological surgery, were enrolled. Setting: The study was conducted to the University of Campus Bio-Medico Hospital of Rome. Methods: Half an hour before surgery, all patients received gabapentin 300 mg per os. Once the patient underwent general anesthesia, US-guided bilateral TAP/RS block was performed by the anesthesiology team, while the uterine manipulator was positioned by a gynecology resident (not involved in the study). In the operative room, all patients received the same standardized anesthetic regimen. Postoperative abdominal pain was assessed at rest, after palpation, during movement, and after a cough by evaluating the patient at 6, 12, 18, 24, 36, 48, and 72 h after surgery, using the NRS from 0 to 10 in both groups. The amount of drug used for analgesia in the first 48 h after surgery was recorded. Moreover, hemoglobin, white blood cells, and c-reactive protein levels were recorded at 24, 48, and 72 h. The presence of PONV and the postoperative ileus was recorded throughout convalescence. The expected level of patient satisfaction at discharge and finally the LOS were assessed. Limitations: The major weakness of this study is that 60 mL of 0.5% ropivacaine was administered to each patient, without considering weight differences, yet contemporary literature rarely suggests volume/dose titration in fascial blocks. Results: A total of 104 women, undergoing gynecological minor laparoscopic surgery, were enrolled and assigned to LRA group (53 pts) and N-LRA group (51 pts). Postoperative pain was significantly reduced in patients who received TAP/RS block. A reduction in the intake of non-steroidal anti-inflammatory drugs after surgery was registered in LRA group (p < 0.01). Moreover, a significant reduction of LOS (45.97 ± 9.87 vs. 65.08 ± 17.32 h; p < 0.01) and PONV was observed in the LRA group, as well as a better level of patient satisfaction at discharge (9.43 ± 0.94 vs. 8.26 ± 1.19; p < 0.01), compared to the N-LRA group. Conclusions: US-guided TAP and RS block significantly reduces postoperative pain after minor gynecologic laparoscopic surgery and improves patients’ post-operative recovery.

Evaluation of the analgesic effect of Intraperitoneal instillation of lidocaine with and without meperidine versus non-steroidal anti-inflammatory drugs during and after gynecological laparoscopic procedures

Evaluation of the analgesic effect of Intraperitoneal instillation of lidocaine with and without meperidine versus non-steroidal anti-inflammatory drugs during and after gynecological laparoscopic procedures

Enhancing Women's Health: Advancing Gynecological Laparoscopy in Resource-Limited Eastern Sudan

The history of surgery has witnessed a remarkable evolution with the widespread adoption of minimally invasive techniques, notably operative video laparoscopy. This study aims to shed light on the laparoscopy experience in a rural hospital in Eastern Sudan and contribute to understanding its outcomes and challenges in low-resource settings. This study systematically collected and analyzed data encompassing patient demographics, preoperative assessments, postoperative complications, and gender. The purpose was to derive insights and draw meaningful conclusions from this information. Among the 124 laparoscopic procedures scrutinized, laparoscopic ovarian cystectomy emerged as the most frequently performed intervention. Diagnostic laparoscopy for tubal examination and ovarian drilling were also prominent procedures. The patient cohort spanned a wide age range, from 25 to 55 years, with an average age of 30.5 years. Preoperative ultrasound scans unveiled crucial findings such as polycystic ovaries and cysts of varying sizes. The analysis highlighted significant correlations between cyst size, wall thickness, operative duration, symptom duration, and conversion rates. The range of operative time spanned from 9 to 150 minutes, with an average of 40.1 minutes. While a few cases necessitated conversion from laparoscopy to open intervention, no instances of mortality were reported. The introduction of laparoscopic gynecological procedures in the Eastern Sudan regional hospital has ushered in enhanced surgical outcomes for specific conditions. However, to further elevate this practice, emphasis must be placed on augmenting medical staff training and optimizing infrastructure. Expanding the scope of laparoscopic procedures, particularly in emergency gynecology and major surgeries, is pivotal. These concerted efforts will not only facilitate the diffusion of laparoscopy but also contribute to elevated patient care standards and the overall advancement of surgical gynecology in the region.

Development and validation of GLVS (Generic Laparoscopic Video Scoring System), a tool for assessment of laparoscopic skills in gynaecology using videotaped procedures: Are edited videos representative of their full-length version?

Anonymized videotaped endoscopic procedures can be used for the assessment of surgical competence, but a reliable non-procedure-specific scoring system is needed for gynaecology. To design and evaluate the validity of the Generic Laparoscopic Video Scoring System (GLVS), a novel tool in the assessment of various gynaecological laparoscopic procedures. Seventeen anonymized unedited video recordings of various gynaecological laparoscopic procedures and the 4-minute-long edited versions of the same videos were independently scored by two experts, twice, using GLVS. Internal consistency reliability, test-retest, and inter-rater reliability of GLVS. We also compared the scored achieved by edited videos with those of the full-length version of the same videos. The mean score achieved by 4-minute-long edited videos was similar to that of the unedited version (p= 0.13 - 0.19). There was excellent correlation between the pooled scores for edited and unedited versions (intra-class correlation coefficient = 0.86). GLVS had excellent internal consistency reliability (Cronbach's alpha 0.92-0.97). Test-retest and inter-rater reliability were generally better for edited 4-minute-long videos compared to their full-length version. Test-retest reliability for edited videos was excellent for scorer 1 and good for scorer 2 with intra-class correlation coefficient (ICC) of 0.88 and 0.62 respectively. Inter-rater reliability was good for edited videos (ICC=0.64) but poor for full-length versions (ICC= -0.24). GLVS allows for objective surgical skills assessment using anonymized shortened self-edited videos of basic gynaecological laparoscopic procedures. Shortened video clips of procedures seem to be representative of their full-length version for the assessment of surgical skills. We devised and undertook a validation study for a novel tool to assess surgical skills using surgical video clips. We believe this addition clearly delineates the unique contributions of our study.

Development and validation of GLVS (Generic Laparoscopic Video Scoring System), a tool for assessment of laparoscopic skills in gynaecology using videotaped procedures: Are edited videos representative of their full-length version?

Background: Anonymized videotaped endoscopic procedures can be used for the assessment of surgical competence, but a reliable non-procedure-specific scoring system is needed for gynaecology. Objectives: To design and evaluate the validity of the Generic Laparoscopic Video Scoring System (GLVS), a novel tool in the assessment of various gynaecological laparoscopic procedures. Materials and methods: Seventeen anonymized unedited video recordings of various gynaecological laparoscopic procedures and the 4-minute-long edited versions of the same videos were independently scored by two experts, twice, using GLVS. Main outcome measures: Internal consistency reliability, test-retest, and inter-rater reliability of GLVS. We also compared the scored achieved by edited videos with those of the full-length version of the same videos. Results: The mean score achieved by 4-minute-long edited videos was similar to that of the unedited version (p= 0.13 - 0.19). There was excellent correlation between the pooled scores for edited and unedited versions (intra-class correlation coefficient = 0.86). GLVS had excellent internal consistency reliability (Cronbach’s alpha 0.92-0.97). Test-retest and inter-rater reliability were generally better for edited 4-minute-long videos compared to their full-length version. Test-retest reliability for edited videos was excellent for scorer 1 and good for scorer 2 with intra-class correlation coefficient (ICC) of 0.88 and 0.62 respectively. Inter-rater reliability was good for edited videos (ICC=0.64) but poor for full-length versions (ICC= -0.24). Conclusion: GLVS allows for objective surgical skills assessment using anonymized shortened self-edited videos of basic gynaecological laparoscopic procedures. Shortened video clips of procedures seem to be representative of their full-length version for the assessment of surgical skills. What’s new? We devised and undertook a validation study for a novel tool to assess surgical skills using surgical video clips. We believe this addition clearly delineates the unique contributions of our study.

The Effect of Postoperative Gum Chewing on Gastrointestinal Function Following Laparoscopic Gynecological Surgery. A Meta-analysis of Randomized Controlled Trials

To assess the effect of postoperative gum chewing on gastrointestinal function in women following laparoscopic gynecological surgery for benign indications. We screened 5 major databases (Medline, Scopus, Google Scholar, Cochrane Central Register of Controlled Trials, and Clinicaltrials.gov) from inception till February 2023. No language restrictions were applied. We included randomized controlled trials comparing the postoperative bowel function between patients who chewed and patients who did not chew gum postoperatively after laparoscopic gynecological procedures for benign indications. Data from 5 studies on 670 patients were extracted and analyzed by 3 independent reviewers. Meta-analysis was performed with RevMan 5.4 software (Copenhagen: The Nordic Cochrane Center, The Cochrane Collaboration, 2020), with mean differences (MDs), pooled risk ratios, and random-effects model. Postoperative gum chewing significantly reduced the time to first bowel sounds and the time to first passage of flatus (MD -2.58 hours 95% confidence interval (CI) -4.12 to -1.04 p=.001 and MD -3.97 hours 95% CI -6.26 to -1.68 p <.001, respectively). The time to first defecation, the time to first postoperative patients' mobilization, the length of hospital stay, and the risk of postoperative bowel obstruction showed no statistically significant difference between the 2 groups. When subgroup analysis was performed according to the type of the laparoscopic procedure, it failed to reveal a positive impact of postoperative gum chewing in both the times to first passage of flatus and first defecation following laparoscopic hysterectomies (MD -5.35 hours 95% CI -10.93 to 0.23 p=.06 and MD -15.93 hours 95% CI -40.13 to 8.28 p=.20, respectively). The results of the present meta-analysis support that postoperative gum chewing following laparoscopic gynecological procedures seems to have a positive effect on the early mobilization of the gastrointestinal tract. However, these results should be interpreted with caution due to the small number of the included randomized controlled clinical trials.

A prospective study of i-gel in elective laparoscopic gynecological procedures

Background: Many studies have been done to compare i-gel with other laryngeal mask airway. However, not many studies have been done to study the clinical uses of the supraglottic airway device, namely, i-gel. Aims and Objectives: The present study was undertaken to study of i-gel in elective laparoscopic gynecological procedures in tertiary health-care center. Materials and Methods: The present prospective observational study was conducted on patients admitted in OBGY ward for laparoscopic procedures during the period September 2019–2021. The study was undertaken after obtaining Ethical Committee Clearance. Informed consent was taken from each patient. Seventy patients, scheduled for various elective laparoscopic gynecological procedures under general anesthesia belonging to ASA class I and II, were included in the study. Results: Majority number of study participants belonged to age group of 50–59 years, that is, 52 (74.3%), while only 5 (7.1%) study participants belonged to age group of 30–39 years. I-gel insertion was successful in single attempt in 69 (98.6%) study participants, while two attempts were needed for 1 (1.4%) participant. In our study, there was no statistically significant difference of i-gel with regard to heart rate, systolic, diastolic and mean blood pressure, and arterial saturation, EtCO2. There was no post-operative complication after completion of procedure. Conclusion: The present study revealed that i-gel may be used safely and successfully in elective laparoscopic gynecological surgeries under general anesthesia with positive pressure ventilation. It offers excellent insertion conditions and adequate jaw relaxation for easy i-gel insertion on the first try.

First experiences with a diode laser in major gynecological laparoscopic procedures show lack of benefit and impaired feasibility

PurposeThe aim of this study is to evaluate feasibility and potential benefit of a diode laser in major laparoscopic procedures in gynecology.MethodsBetween 2018 and 2020, a total of 42 cases were enrolled in this study comparing standard electrosurgery with diode laser-supported therapy in laparoscopic supracervical hysterectomy (LASH), total laparoscopic hysterectomy (TLH), or laparoscopic myoma enucleation (LME). Dual wavelength 45 W diode laser light was used to cut and coagulate during laparoscopy in the prospective interventional arm consisting of 11 cases, while 31 matching patients who received conventional treatment with monopolar/bipolar current for the same interventions were retrospectively identified in our laparoscopy database. Recruitment in the prospective interventional laser diode arm was terminated after only 11 patients (instead of planned 50) due to intense hemorrhage and massive smoke development.ResultsA total of 42 cases were analyzed (11 LME, 19 LASH, and 12 TLH). Strong smoke development was evident in all 11 cases in the diode laser arm. It was necessary to convert to bipolar or monopolar current in all hysterectomies (n = 9) with initial diode laser implementation due to increased bleeding and smoke development. Conventional current sources had to be used in LMEs (n = 2) due to excessive bleeding and poor visibility during enucleation of the fibroid. A significant difference (p < 0.0001) was observed regarding smoke development when comparing the laser arm with the control arm.ConclusionWe found a 45-W diode laser to be inferior to electrosurgical techniques for major laparoscopic gynecologic surgeries regarding bleeding control and smoke development.

A study of menstrual cycle effects on pain perception, haemodynamic response to laryngoscopy, and postoperative outcome in gynaecological laparoscopy

ABSTRACT Background The physiological alterations that occur during the females’ reproductive age due to hormonal fluctuations throughout the menstrual cycle may affect the perioperative period and impact the postoperative outcome. This study evaluated the impact of menstrual cycle phases on pain perception, haemodynamic response to laryngoscopy, postoperative agitation, nausea, and vomiting in women undergoing laparoscopic gynaecological procedures. Methods This prospective observational study included 60 women who were randomly assigned to have diagnostic gynaecological laparoscopy during their menstrual cycle’s luteal or follicular phases. Patients were divided into two groups: follicular and luteal group. Preoperatively a blood sample was withdrawn for measurement of norepinephrine, estradiol, and progesterone levels. Anaesthetic techniques were standardized in both groups. In the postoperative period, another blood sample was withdrawn from all patients and sent for norepinephrine measurement. Before induction of anaesthesia, baseline HR, SBP, DBP, and MAP were measured. Then, following endotracheal intubation at 1, 3 and 5 minutes. Pain perception was assessed using Numerical Rating Scale (NRS); in response to IV cannulation, then postoperative abdominal pain and shoulder referred pain were assessed every 15 minutes till the end of 1st hour, then every 6 hours till discharge. The incidence of postoperative nausea and vomiting was recorded at the same time points of pain assessment. Postoperative agitation was assessed using Richmond Agitation-Sedation Scale (RASS). Results Women in the follicular phase showed higher postoperative pain, higher incidence of postoperative nausea, and more increase in HR and delayed return to baseline value post tracheal intubation as compared to luteal phase.

A Randomised Controlled Trial to Compare the Effect of Ramosetron and Ondansetron in Prevention of Postoperative Nausea and Vomiting in Patients Undergoing Laparoscopic Gynaecological Procedures.

Background and objectiveThe antiemetic drug is one of the most common armamentariums in an anaesthesiologist's pharmacopoeia to prevent postoperative nausea and vomiting (PONV). PONV is one of the usual side effects after general anaesthesia, especially in female patients (21%) and after laparoscopic surgery (60%). This study aimed to compare the efficacy of ondansetron with ramosetron.MethodologyAfter institutional ethical clearance and informed written consent, one hundred female patients scheduled for laparoscopic gynaecological surgeries were selected for this prospective, double-blinded, randomised interventional study. These patients were further subdivided into two equal groups (50 in groups R and O). Group R received ramosteron 0.3mg, and group O received ondansetron 8mg 30 minutes before the end of surgery. Patients were assessed between 0-2, 2-6, 6-12 and 12-24 hrs in the postoperative period. The primary objective of this study was to compare the effect of a single dose of ramosetron (0.3mg) with a single dose of ondansetron (8mg) for the prevention of PONV after general anaesthesia in laparoscopic surgeries. The secondary goal was to record the time of occurrence of the first episode of PONV, the need for rescue antiemetics, patient satisfaction scores, and to look for any side effects.ResultsThis study shows no significant difference in the reduction of PONV incidence between group O and group R in the first 24 hours of the postoperative period. The overall incidence of PONV was significantly higher in the early postoperative (0-6 hrs) than in the late postoperative period (6-24 hrs), i.e., 51% and 13%, respectively. The requirement of rescue antiemetic was higher in group O than in group R but not statistically significant. In our study, both groups had similar patient satisfaction scores. Headache was the most common side effect and was noted in 9% of the patient population.ConclusionWe conclude that ramosetron is as effective as ondansetron in preventing the incidence and severity of PONV up to 24 hours postoperatively.

An integrated method for contained laparoscopic specimen removal

Efforts at minimizing pain following minimally invasive (MIS) hysterectomy were hampered by the absence of simple, reliable methods to extract specimens following the 2014 FDA safety warning discouraging power morcellation. To address this gap, an integrated method intended to provide reliable specimen containment with a multi-layer bag, segmentation using bipolar energy, and tissue extraction during laparoscopic gynecological surgical procedures was developed. This report details the pre-clinical studies demonstrating specimen containment integrity, and thermal and electrical safety of the Eximis™ CS (Contained Segmentation) Procedure. All experiments were performed in pigs and approved by the research facility's institutional animal care committee and met USDA and AAALAC guidelines. The study design was composed of three experimental groups; Bovine tongue muscle to simulate normal uterine tissue, bovine tendon draped in a “sausage casing” to simulate hard-thick myoma tissues, and a polymer block wrapped with bacon strips to simulate a severely calcified fibroid. Additionally, there were two control groups: one negative and one positive (heat gun). Each experimental group was tested in four Eximis Capture Bags (8 cuts each) for a total of 24 electromechanical cuts. Thermal evaluation of the small bowel adjacent to the capture bag during device activation was performed with a Micronor FOTEMP4-PLUS-P0-V-B fiberoptic thermometry system. Specimens were then harvested for histology and graded by a blinded pathologist using the Histopathology Scoring Criteria (edema/necrosis/inflammation); 0-4; none to marked. Electrical testing evaluated high frequency electrical leakage current by an independent laboratory with the electrosurgical generator set to 200 W output power, the maximum output setting allowable. Finally, Eximis Capture Bags were tested after segmentation using a proprietary leak test that can detect leaks < a 1 μm hole size. The test group simulating normal uterine tissue (bovine tongue) had small bowel histopathology not different from the negative control group. The calcified fibroid and myoma test groups demonstrated statistically more mucosal edema than the negative control group, but differences were not observed in the submucosa or muscularis layers that were closer to the containment bag. The Eximis Capture Bag measured leakage current directly through the bag of 1.01 mA well below the maximum allowable standard of 150 mA. No evidence of leaks was detected. These studies demonstrate that the Eximis CS is thermally and electrically safe to surrounding tissues and that tissue segmentation and extraction do not impact Eximis Capture Bag’s integrity. Clinical evaluation during human and robotic gynecologic procedures for benign disease is warranted. Additionally, these results suggest the system may be beneficial in other MIS procedures where large specimens are removed.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

A comparative study of intrathecal morphine v/s nalbuphine along with bupivacaine in laparoscopic gynaecological procedures

: To compare the pain score of intrathecal morphine v/s nalbuphine along with bupivacaine in laparoscopic gynaecological procedures under general anaesthesia.: A prospective, comparative, randomized, double blinded, hospital based study was conducted among patients undergoing elective laparoscopic gynaecological procedures. After explaining the study to the selected patients, they were randomized into two groups of 30 each with the use of sealed envelope method i.e. group M (100 µg morphine + 2 ml bupivacaine) and group N (400 µg Nalbuphine + 2 ml bupivacaine). The primary objective of our study was to compare the pain intensity which was done by visual analogue scale (VAS). Any side-effects in the form of post-operative hypotension, bradycardia, respiratory depression, nausea, vomiting and pruritus were recorded and included as secondary objectives. With the help of SPSS version 24, difference between the continuous and categorical variables was analysed using t and chi square test respectively.: There was no significant difference among both groups with respect to motor blockade score. Mean VAS after extubation and 3 hour was comparable among both the groups, but at 6, 12 and 24 hour, it was comparatively more in group N as compared to group M, though statistically insignificant. Pruritus was revealed in 10% and 0% of the subjects among group M and N respectively. : Our results conclude that the analgesic efficacy of nalbuphine is comparable to morphine, but nalbuphine provides a better safety profile than morphine especially related to pruritus.

Respiratory Changes under Spinal Anaesthesia for Laparoscopic Gynaecological Procedures- a comparison with General Anaesthesia

Background: Laparoscopic surgery has become a frequently applied technique for a wide field ofindications. The procedure has become the gold standard for many procedures, with some of the mostcommon being gynecological procedures and appendectomy. Laparoscopic procedures that are widelyused in gynecological surgery are commonly applied under general anesthesia (GA). Now a days spinalanaesthesia (SAB) has become a routine technique for healthy patients. It is currently presumed thatspinal anaesthesia can compromise respiratory muscle function during carbon dioxide (CO2)pneumoperitoneum and causes some respiratory changes. Objective: This study was designed to compare the respiratory effects of CO2 pneumoperitoneumunder spinal anaesthesia with general anaesthesia for short duration (&lt;1hr) laparoscopicgynaecological procedures. Methods: A total number of sixty female patients, thirty in each group of ASA grade I &amp; II wereenrolled for the study. Group I patients received lumber SAB with 15 mg heavy bupivacaine and 25mcg fentanyl. Group II patients received standard general anaesthesia with propofol, halothane andfentanyl. Baseline heart rate, blood pressure, respiratory rate, ETCO2 &amp; SPO2 were noted in allpatients. Arterial blood gas analysis was done at time 0, 20 and 40 min after initiation ofpneumoperitoneum. Continuous ECG, pulse oximetry, noninvasive blood pressure, and ETCO2 weremonitored during the procedure. Any per operative and post-operative side effects were recorded andmanaged. Results: There were no observed changes in the respiratory rate. In group I, ETCO2 increased in astepwise manner over the first 10 min and reached a plateau between 15th and 30th min and declinedafter deflation of pneumoperitoneum. Arterial CO2 tension also increased at 20 min with significantchanges (p=0.000) in arterial to end tidal carbon dioxide tension. ETCO2 and arterial carbon dioxidetension changes were almost similar in both groups. Conclusion: Arterial and end-tidal CO2 tension changes during lower abdominal laparoscopicsurgery under SAB remain within physiological limits and comparable to the CO2 tension under GA.SAB may be adopted in ASA physical status I and II patients with proper preoperative counseling.Hence it is a safe alternative to GA with minimum respiratory alterations. JBSA 2021; 34 (2) : 10-15

PMU3 An Economic Model for Surgical Complication Treatment Costs Among Patients Undergoing Selected Major Surgeries Performed in Open Versus Laparoscopic Approach

To develop an economic model of surgical complication treatment costs for open versus laparoscopic colorectal, thoracic, hepatopancreatobiliary, and gynecological procedures. The economic model was developed to estimate costs incurred to treat complications from lower anterior resection, left and right colectomies, pancreatectomy, hepatectomy, thoracic lobectomy and wedge resection, and hysterectomy. Model inputs for complication rates and incremental costs of treating such complications were derived from literature published between 2008 and 2018. Complications examined include surgical site infection and bleeding as well as procedure-specific complications, such as anastomotic leak (colorectal surgeries), obstruction (hysterectomy), and air leak (thoracic surgeries); rates and costs associated with inpatient readmissions were also included. Expected per-patient cost to treat each complication for the open and laparoscopic groups was calculated by multiplying the complication incidence rate by estimated incremental cost associated with treating the complication; the sum of these values represented the total per-patient expected complication treatment costs. Complication treatment cost was up to 56 percent lower when the surgery was performed laparoscopically as compared with open for all procedures except for pancreatectomy. As compared with open surgeries, laparoscopic surgeries were associated with lower total complication treatment costs for the following procedures: inpatient hysterectomy ($1231.39 vs. $535.91), outpatient hysterectomy ($312.43 vs. $138.41), hepatectomy ($8966.37 vs. $4700.68), left colectomy ($4952.3 vs. $2852.46), right colectomy ($5016.71 vs. $3031.89), lower anterior resection ($5444.77 vs. $3235.85), thoracic wedge resection ($5246.62 vs. $3147.18), and thoracic lobectomy ($3833.88 vs. $2736.89). For pancreatectomy, complication treatment cost for open surgery was lower than that of laparoscopic surgery by 11 percent ($11710.27 vs. $13038.17). Compared to open surgery, laparoscopic surgery was associated with cost savings in complication treatments for hysterectomy, hepatectomy, colectomy, lower anterior resection, and thoracic lobectomy and wedge resection.

Effect of Local Anesthetics on Postoperative Pain in Patients Undergoing Gynecologic Laparoscopy: A Systematic Review and Meta-analysis of Randomized Trials

Pain remains a common complication after gynecologic laparoscopy. Use of local anesthesia may be beneficial in reducing postoperative pain. We performed a systematic review and meta-analysis to assess whether local anesthetic decreases postoperative pain after laparoscopic gynecologic procedures. We searched Cumulative Index to Nursing and Allied Health Literature, Embase, and Medline from inception to November 2020 using Medical Subject Headings and free text combinations. We included randomized controlled trials of patients undergoing gynecologic laparoscopy receiving port site subcutaneous, subfascial, or intraperitoneal local anesthetic compared with placebo or no intervention. We included 20 trials (1861 participants) with size varying between 28 and 164 participants. Meta-analysis was performed with RevMan 5.3 (Cochrane Collaboration, London, United Kingdom), with standard mean differences (SMDs) and random-effects model. Port site infiltration reduces postoperative pain at 4 hours (SMD -0.25; 95% confidence interval [CI], -0.44 to -0.06; 4 trials; 545 participants) and 6 hours (SMD -0.44; 95% CI, -0.82 to -0.06; 4 trials; 455 participants) after surgery. The administration of intraperitoneal local anesthetics reduces pain at 6 hours (-1.42; 95% CI, -3.22 to -0.30; 4 trials; 277 participants) after surgery. The use of port site and intraperitoneal local anesthetic decreases immediate postoperative pain in patients undergoing gynecologic laparoscopy, although its impact on analgesia requirements is unclear. Routine usage of local anesthetics should be considered for people undergoing gynecologic laparoscopy.