Laparoscopic Abdominal Procedures Research Articles

Alvimopan for postoperative ileus following abdominal surgery: a systematic review.

Postoperative ileus (POI) is a common complication following abdominal surgery, often leading to extended hospital stays and a higher risk of post-operative complications, leading to poorer patient outcomes. Alvimopan, a peripherally acting µ-opioid receptor antagonist, has been shown to aid in the recovery of normal bowel function after surgery. While its benefits are well-established in open abdominal surgeries, its efficacy in laparoscopic procedures had not been conclusively determined. However, recent clinical trials involving laparoscopic surgeries have since been conducted. This review aims to reassess the efficacy of Alvimopan by incorporating findings from these new studies, potentially providing further insight into its clinical benefits. A comprehensive search of PubMed, Google Scholar, EMBASE, and the Cochrane Library was conducted. Studies were included based on the PICO framework, focusing on Alvimopan's impact on postoperative gastrointestinal recovery. Primary outcomes were time to gastrointestinal function recovery (GI-3) and hospital stay duration. Ten studies met the inclusion criteria, with seven focusing on the use of Alvimopan in open abdominal surgeries and three in laparoscopic procedures. Collectively, these studies involved 18,822 patients undergoing various types of abdominal Administration of Alvimopan 6mg accelerated gastrointestinal function recovery by an average of 14h (Hazard ratio: 1.62, p = 0.002) and reduced hospital stays by 5.2h (Hazard ratio: 1.52, p = 0.04) compared to placebo. Similarly, Alvimopan 12mg reduced GI-3 recovery time by 13.5h (Hazard ratio: 1.58, p = 0.02) and hospital stay duration by 6.2h (Hazard ratio: 1.46, p = 0.018). Alvimopan shows promise in reducing POI and hospital stay durations following abdominal surgeries. The incorporation of the recent studies in laparoscopic abdominal procedures further supports these findings. Integrating Alvimopan into perioperative care protocols may enhance patient outcomes and help lower healthcare costs.

Benefits of Segmental Spinal Anaesthesia in Patients Undergoing Laproscopic Cholecystectomy: A Retrospective Study

Background: Segmental Spinal anaesthesia (SA) is reported to be having excellent results in terms of post-operative pain, analgesia requirement, relatively less complications and reduced hospital stay. General anaesthesia (GA) is the anaesthetic technique of choice for laparoscopic cholecystectomy (LC). The main reasons for selecting spinal anaesthesia (SA) as the first choice for laparoscopic cases were its advantages like total muscle relaxation, a conscious patient, economical, relatively uneventful recovery after, pain free early postoperative period and the protection from potential complications of general anaesthesia. Materials and Methods: It is a retrospective study conducted between October 2020 and September 2022. 160 Patients in study group undergoing laparoscopic abdominal procedures were operated under Spinal Anesthesia. In study group 45 patients had acute cholecystitis and 115 underwent elective cholecystectomy were included. 100 Patients who were operated under General anesthesia were kept as control. Results: Out of 160 patients, 105 patients were females, average age was 43.8 years and 55 male patients with average age was 39.2 years laparoscopic cholecystectomy was performed in all patients. Out of 160 patients 45(28.12%) of had acute cholecystitis. 32 (20%) patients HAD hypotension, 35 (21.88%) observed anxiety, neck or shoulder pain, and 1 (0.62%) patient required conversion because of anxiety, despite sedation where as one patient required conversion to general anaesthesia due to failure of SA effect. Conclusions: Laparoscopic surgery done with the patient under spinal anaesthesia has several advantages general anaesthesia. Laparoscopic cholecystectomy using spinal anaesthesia is a better alternative as there is no intubation related airway obstruction. There was excellent muscle relaxation; decreased surgical bed oozing, economical, pain free early post-operative period. A little risk of unrecognised hypoglycaemia was observed in a ..........

Pneumoperitoneum and Acute Kidney Injury-An Integrative Clinical Concept Review.

An increased intraabdominal pressure, particularly when occurring during periods of hemodynamic instability or fluid overload, is regarded as a major contributor to acute kidney injury (AKI) in intensive care units. During abdominal laparoscopic procedures, intraoperative insufflation pressures up to 15 mmHg are applied, to enable visualization and surgical manipulation but with the potential to compromise net renal perfusion. Despite the widely acknowledged renal arterial autoregulation, net arterial perfusion pressure is known to be narrow, and the effective renal medullary perfusion is disproportionately impacted by venous and lymphatic congestion. At present, the potential risk factors, mitigators and risk-stratification of AKI during surgical pneumoperitoneum formation received relatively limited attention among nephrologists and represent an opportunity to look beyond mere blood pressure and intake-output balances. Careful charting and reporting duration and extent of surgical pneumoperitoneum represents an opportunity for anesthesia teams to better communicate intraoperative factors affecting renal outcomes for the postoperative clinical teams. In this current article, the authors are integrating preclinical data and clinical experience to provide a better understanding to optimize renal perfusion during surgeries. Future studies should carefully consider intrabdominal insufflation pressure as a key variable when assessing outcomes and blood pressure goals in these settings.

Differences in risk factors for surgical site infection between laparotomy and laparoscopy in gastrointestinal surgery.

Extensive gastrointestinal surgery surveillance data in Japan were analyzed to examine the differences in the risk factors for surgical site infection (SSI) between laparotomy and laparoscopic abdominal procedures. Surgical procedures investigated in the study were gastrectomy, cholecystectomy, colectomy, rectal resection, and appendectomy. A total of 32,629 patients were included in the study. The study participants were divided into two groups according to the year of surgery, 2003–2009 (first study period) and 2010–2015 (second study period), due to the increase in the number of laparoscopic surgeries in the second study period. The incidence of SSI was stratified by three SSI classifications (superficial incisional, deep incisional, and organ/space SSI). Multiple logistic regression analysis was performed to predict the risk factors for SSI. The percentage of laparoscopic surgeries performed has increased linearly since 2010. Patients in the second study period were significantly older and had a higher prevalence of SSI risk factors compared with those in the first study period. In addition, the predictive factors changed substantially in most surgical procedures between the two study periods. Wound class ≥ 3 was a ubiquitous risk factor for superficial incisional SSI (SI-SSI) and organ/space SSI (OS-SSI) in both open (laparotomy) and laparoscopic procedures in the first study period. Meanwhile, in the second study period, operative duration was a ubiquitous risk factor in both procedures. The risk factors for SI-SSI differed from those for OS-SSI in the five abdominal surgeries investigated in the study. Periodic examination of risk factors for SSI is recommended in an aging society.

O047 Registry outcomes on gasless insufflation-less laparoscopic surgery in rural North-East India

Abstract Introduction Gasless insufflation-less laparoscopic surgery (GILLS) was introduced in rural northeast India as part of the NIHR Global Health Research Group - Surgical Technologies (GHRG-ST) project. The GILLS Registry aims to provide a reliable mechanism for monitoring the safe implementation of the GILLS technique in everyday clinical practice by the newly trained rural surgeons deemed competent in independent practice. Methods The GILLS Registry captured all gasless laparoscopic abdominal procedures for patients consenting to participate in the Registry and performed by trained rural surgeons. They attended the NIHR GHRG-ST TARGET training programme in March 2019 and proctorship in May 2019. Patients were recruited prospectively. Complications were reported using ISOS classification. The data were captured on REDCap from October 2019 to July 2020. Results Four rural surgeons from three regions of North-East India participated. Of 286 recorded procedures, 123 had general surgical and gynaecological GILLS procedures. Mean age was 34.51 (SD 11.17), 89% were female. Cholecystectomy (44%), tubal ligation (24%) and appendicectomy (16%) were the commonest procedures. More patients received regional (53%) over general anaesthesia (47%). Overall, 11% GILLS cases were converted to open and 9% to conventional laparoscopy. The intra and postoperative complication rates were both 5%. One patient died due to postoperative pancreatitis. Mean length of stay 3.02 (2.12) days. Conclusion GILLS procedure demonstrates favourable outcomes for patients in rural settings. This prospective Registry indicates that GILLS can be safely introduced in low resource settings and findings support wider adoption of GILLS technology in India. Take-home message Gas Insufflation-Less Laparoscopic Surgery (Gasless laparoscopy) can be safely introduced in low resource settings and the registry supports its wider adoption and implementation in India.

The Impact of Steep Trendelenburg Position on Intraocular Pressure.

Intraocular pressure occurring during the Trendelenburg position may be a risk for postoperative visual loss and other ocular complications. Intraocular pressure (IOP) higher than 21 mmHg poses a risk for ocular impairment causing several conditions such as glaucoma, detached retina, and postoperative vision loss. Many factors might play a role in IOP increase, like peak expiratory pressure (PIP), mean arterial blood pressure (MAP), end-tidal CO2 (ETCO2) and surgical duration and some others (anaesthetic and neuromuscular blockade depth) contribute by reducing IOP during procedures requiring both pneumoperitoneum and steep Trendelenburg position (25–45° head-down tilt). Despite transient visual field loss after surgery, no signs of ischemia or changes to the retinal nerve fibre layer (RNFL) have been shown after surgery. Over the years, several studies have been conducted to control and prevent IOPs intraoperative increase. Multiple strategies have been proposed by different authors over the years to reduce IOP during laparoscopic procedures, especially those involving steep Trendelenburg positions such as robot-assisted laparoscopic prostatectomy (RALP), and abdominal and pelvic procedures. These strategies included both positional and pharmacological strategies.

A comparative study on the surgical options for male rectal prolapse.

Purpose:Rectal prolapse is known to be a rare condition in males compared to females. This study aimed to analyse the frequency of male rectal prolapse and compare the results of different surgical approaches performed at a single centre.Patients and Methods:The authors included patients who underwent surgical treatment for rectal prolapse from March 2016 to February 2021. The proportion of males, mean age and recurrence rates were calculated. Patients were divided into two groups, transanal approach and laparoscopic abdominal approach group, to identify the para-operative parameters including functional tests.Results:A total of 56 males, comprising 23.7% (56/236) of all patients. The mean age was 60.8 years, with a recurrence rate of 7 cases (12.5%) during 7.2 months of follow-up. Forty patients underwent transanal procedures, and fifteen underwent laparoscopic abdominal procedures. The mean operative time was longer in the laparoscopic group (transanal vs. abdominal, 57.5 vs. 70.6 min, P < 0.003), and intra-operative bleeding was greater in the transanal group (12.4 vs. 3.4 ml, P < 0.001). Full-layer prolapse (36.8 vs. 81.2% P = 0.003) and longer length (5.6 vs. 7.8 cm, P = 0.048) were more common in laparoscopic group. Time to feeding resumption was shorter after the transanal group (1.2 vs. 1.7 days, P = 0.028). There was no difference between the groups in terms of post-operative complications and recurrence rates. Both Wexner's constipation and incontinence scores showed significant improvement postoperatively.Conclusion:The frequency of male rectal prolapse was 23.7%, and perioperative factors differed between transanal and abdominal approaches, but recurrence rates and functional test results did not differ significantly.

Laparoscopic versus Open Pediatric Surgery: Three Decades of Comparative Studies.

Despite its wide acceptance, the superiority of laparoscopic versus open pediatric surgery has remained controversial. There is still a call for well-founded evidence. We reviewed the literature on studies published in the last three decades and dealing with advantages and disadvantages of laparoscopy compared to open surgery. Studies comparing laparoscopic versus open abdominal procedures in children were searched in PubMed/MEDLINE. Reports on upper and lower gastrointestinal as hepatobiliary surgery and on surgery of pancreas and spleen were included. Advantages and disadvantages of laparoscopic surgery were analyzed for different types of procedures. Complications were categorized using the Clavien-Dindo classification. A total of 239 studies dealing with 19 types of procedures and outcomes in 929,157 patients were analyzed. We identified 26 randomized controlled trials (10.8%) and 213 comparative studies (89.2%). The most frequently reported advantage of laparoscopy was shorter hospital stay in 60.4% of studies. Longer operative time was the most frequently reported disadvantage of laparoscopy in 52.7% of studies. Clavien-Dindo grade I to III complications (mild-moderate) were less frequently identified in laparoscopic compared to open procedures (80.3% of studies). Grade-IV complications (severe) were less frequently reported after laparoscopic versus open appendectomy for perforated appendicitis and more frequently after laparoscopic Kasai's portoenterostomy. We identified a decreased frequency of reporting on advantages after laparoscopy and increased reporting on disadvantages for all surgery types over the decades. Laparoscopic compared with open pediatric surgery seems to be beneficial in most types of procedures. The number of randomized controlled trials (RCTs) remains limited. However, the number of reports on disadvantages increased during the past decades.

The role of Cushing’s reflex and the vasopressin-mediated oligoanuric response to intracranial hypertension in patients with abdominal compartment syndrome

BackgroundWe examined the link between increased intra-abdominal pressure, intracranial pressure, and vasopressin release as a potential mechanism. Intra-abdominal pressure, produced by abdominal-cavity insufflation with carbon dioxide (CO2) during laparoscopic abdominal procedures to facilitate visualization, is associated with various complications, including arterial hypertension and oliguria. MethodsMean arterial pressure, optic nerve sheath diameter, measured as a proxy for intracranial pressure, plasma vasopressin, serum and urine osmolarity, and urine output were measured 4 times during laparoscopic sleeve gastrectomy in 42 patients: before insufflation with CO2 (T0); after insufflation to 15 cm water (H2O) pressure, with 5 cm H2O positive end-expiratory pressure (T1); after positive end-expiratory pressure was raised to 10 cm H2O (T2); and after a return to the baseline state (T3). Mean values at T0 to T3 and the directional consistency of changes (increase/decrease/ unchanged) were compared among the 4 data-collection points. ResultsStatistically significant elevations (all P ≤ .001) were noted from T0 to T1 and from T0 to T2 in mean arterial pressure, optic nerve sheath diameter, and vasopressin, followed by decreases at T3. For optic nerve sheath diameter and vasopressin, the increases at T1 and T2 occurred in 98% and 100% of patients, ultimately exceeding normal levels in 88 and 97%, respectively. Conversely, urine output fell from T0 to T1 and T2 by 60.9 and 73.4%, decreasing in 88.1% of patients (all P < .001). Patients with class II obesity exhibited statistically greater increases in optic nerve sheath diameter and vasopressin, but statistically less impact on urine output, than patients with class III obesity. ConclusionIncreased mean arterial pressure, intracranial pressure, and vasopressin release appear to be intermediary steps between increased intra-abdominal pressure and oliguria. Further research is necessary to determine any causative links between these physiological changes.

Factors Affecting Blood Loss During Thoracoscopic Esophagectomy for Esophageal Carcinoma.

BackgroundMajor intraoperative hemorrhage reportedly predicts unfavorable survival outcomes following surgical resection for esophageal carcinoma (EC). However, the factors predicting the amount of blood lost during thoracoscopic esophagectomy have yet to be sufficiently studied. We sought to identify risk factors for excessive blood loss during video-assisted thoracoscopic surgery (VATS) for EC.MethodsUsing simple and multiple linear regression models, we performed retrospective analyses of the associations between clinicopathological/surgical factors and estimated hemorrhagic volume in 168 consecutive patients who underwent VATS-type esophagectomy for EC.ResultsThe median blood loss amount was 225 mL (interquartile range, 126–380 mL). Abdominal laparotomy (p<0.001), thoracic duct resection (p=0.014), and division of the azygos arch (p<0.001) were significantly related to high volumes of blood loss. Body mass index and operative duration, as continuous variables, were also correlated positively with blood loss volume in simple linear regression. The multiple linear regression analysis identified prolonged operative duration (p<0.001), open laparotomy approach (p=0.003), azygos arch division (p=0.005), and high body mass index (p=0.014) as independent predictors of higher hemorrhage amounts during VATS esophagectomy.ConclusionAs well as body mass index, operation-related factors such as operative duration, open laparotomy, and division of the azygos arch were independently predictive of estimated blood loss during VATS esophagectomy for EC. Laparoscopic abdominal procedures and azygos arch preservation might be minimally invasive options that would potentially reduce intraoperative hemorrhage, although oncological radicality remains an important consideration.

Update on Robotic Rectal Prolapse Treatment.

Rectal prolapse is a condition that can cause significant social impairment and negatively affects quality of life. Surgery is the mainstay of treatment, with the aim of restoring the anatomy and correcting the associated functional disorders. During recent decades, laparoscopic abdominal procedures have emerged as effective tools for the treatment of rectal prolapse, with the advantages of faster recovery, lower morbidity, and shorter length of stay. Robotic surgery represents the latest evolution in the field of minimally invasive surgery, with the benefits of enhanced dexterity in deep narrow fields such as the pelvis, and may potentially overcome the technical limitations of conventional laparoscopy. Robotic surgery for the treatment of rectal prolapse is feasible and safe. It could reduce complication rates and length of hospital stay, as well as shorten the learning curve, when compared to conventional laparoscopy. Further prospectively maintained or randomized data are still required on long-term functional outcomes and recurrence rates.

A meta-epidemiological study of bias in randomized clinical trials of open and laparoscopic surgery.

Blinding, random sequence generation, and allocation concealment are established strategies to minimize bias in RCTs. Meta-epidemiological studies of drug trials have demonstrated exaggerated treatment effects in RCTs where such methods were not employed. As blinding is more difficult in surgical trials it is important to determine whether this applies to them. The study aimed to investigate this using systematic meta-epidemiological methods. The Cochrane Database of Systematic Reviews was searched for systematic reviews of RCTs that compared laparoscopic and open abdominal surgical procedures. Each review was then scrutinized to determine whether at least one of the included trials was blinded. Eligible reviews were updated and individual RCTs retrieved. Extracted data included the primary outcomes of interest (length of stay and complications), secondary outcomes and a risk of bias assessment. A multistep meta-regression analysis was then performed to obtain an overall difference in the reported outcome differences between trials that employed each bias-minimization strategy, and those that did not. Some 316 RCTs were included, reporting on eight different procedures. Patient-blinded RCTs reported a smaller difference in length of stay between laparoscopic and open groups (difference of standardized mean differences -0·36 (95 per cent c.i. -0·73 to 0·00)) and complications (ratio of odds ratios 0·76 (95 per cent c.i. 0·61 to 0·93)). Blinding of postoperative carers and outcome assessors had similar effects. Lack of blinding significantly altered the treatment effect estimates of RCTs comparing laparoscopic and open surgery. Blinding should be implemented in surgical RCTs where possible to avoid systematic bias.

Education of pediatric surgery residents over time: Examining 15 years of case logs

Background/PurposeSurgical indications and techniques have changed over the last 15 years. The number of Pediatric Surgery training programs has also increased. We sought to examine the effect of these changes on resident education by examining case log data. MethodsAccreditation Council for Graduate Medical Education (ACGME) case logs for graduating Pediatric Surgery residents were examined from 2004 to 2018. Using the summary statistics provided, linear regression analysis was conducted on each case log code and category. ResultsIn 2004, there were 24 Pediatric Surgery training programs and 24 Pediatric Surgery residents graduating with an average of 979.8 total cases logged. In 2018, there were 36 programs with 38 residents graduating with an average of 1260.2 total cases logged. Total case volume of graduating residents significantly increased over the last 15 years (p < 0.001). Significant increases were demonstrated in skin/soft tissue/musculoskeletal (p < 0.01), abdominal (p < 0.001), hernia repair (p < 0.001), genitourinary (p < 0.01), and endoscopy (p < 0.001). No significant changes were seen in the head and neck, thoracic, cardiovascular, liver/biliary, and non-operative trauma categories. No categories significantly decreased over the time period. No significant changes were seen in the number of multiple index congenital cases, including tracheoesophageal fistula/esophageal atresia repair, omphalocele, gastroschisis, choledochal cyst excision, perineal procedure for imperforate anus, and major hepatic resections for tumors. Pertinent increases in specific procedures include diaphragmatic hernia repair (p < 0.01), ECMO cannulation/decannulation(p < 0.05), thyroidectomy (p < 0.001), parathyroidectomy (p < 0.001), biliary atresia (p < 0.001), and circumcision (p < 0.001) as well as most laparoscopic abdominal procedures. Specific procedure codes with significant decreases include tracheostomy (p < 0.05), minimally invasive decortication/pleurectomy/blebectomy (p < 0.001), laparoscopic splenectomy (p < 0.001), as well as most open abdominal procedures. ConclusionDespite increasing numbers of Pediatric Surgery residents and training programs, the number of cases performed by each graduating resident has increased. This increase is primarily fueled by increase in abdominal, skin/soft tissue/musculoskeletal, hernia repair, genitourinary, and endoscopic cases. Level of EvidenceLevel II.

The Impact of Navigation Grid Overlay on Performance of Camera Assistants during Laparoscopic Abdominal Procedures: A Randomized Controlled Trial

Camera assistance is important for proper visualization of the operative field in laparoscopic surgery. Navigation grid (NG) has been designed to help the camera assistants focus the camera on the target operative field. This is a randomized, controlled trial to study the effect of the NG on performance of camera assistants. Minimally invasive operations were randomized (1:1) to either with or without use of NG for the camera assistant. The operations were recorded and the time spent inside and outside of the target area were reported. A tertiary care teaching hospital. Fifty-eight operations (30 with and 28 without NG) were recorded. Sixteen camera assistants participated. Time spent outside the target area was significantly less with the use of NG (64.5 ± 63 seconds vs 396 ± 226.5 seconds; p < 0.0001). This impact of NG on performance of the camera assistants was significant regardless of their level of training. NG improved performance of the camera assistant during laparoscopic abdominal procedures. This is a feasible tool that can help camera holders better assist the operating surgeons.

Role of Prophylactic Dimenhydrinate Versus Ondansetron as an Adjunct to Dexamethasone on Post-Operative Nausea and Vomiting in Laparoscopic Abdominal Procedures

Introduction: Post-operative nausea and vomiting (PONV) is a common complication in patients undergoing surgery. Anti-emetic prophylaxis is recommended for all high risk patients. Combination therapy is considered superior to single dose prophylaxis however its efficacy in varied laparoscopic abdominal surgical situations has not been investigated. Aims &amp; Objectives: To compare the post-operative nausea and vomiting with Dimenhydrinate plus Dexamethasone versus Ondansetron plus Dexamethasone in patients following laparoscopic abdominal procedures. Place and duration of study: Operation Theatre, Shaikh Zayed Hospital Lahore, for one year (1st April 2015 – 31st March 2016). Material &amp; Methods: 464 patients were placed in two groups of 232 each. Group A received prophylaxis with Dexamethasone 8 mg I/V + Dimenhydrinate 50mg I/V and Group B received prophylaxis with Dexamethasone 8 mg I/V + Ondansetron 4 mg I/V. Efficacy was judged with absence of nausea and vomiting in first 24 hours after surgery. Data was analyzed in SPSS version 27. Results: The frequency of nausea was 6% with Dimenhydrinate while was 9% with ondansetron. Similarly, vomiting was 18% vs. 24% respectively. The efficacy of Dimenhydrinate was 88% while and Ondansetron achieved efficacy in 65% cases, which was statistically significant (p&lt;0.05). Conclusion: The combination Dexamethasone &amp; Dimenhydrinate was more efficacious in preventing PONV than the combination Dexamethasone &amp; Ondansetron

Direct trocar access: a safe method to create pneumo peritoneum, experience from GI and minimal access surgery unit, RIMS, Imphal

Background: The establishment of pneumoperitoneum is a prerequisite for all laparoscopic surgeries. The standard techniques of creating pneumoperitoneum are open and closed technique. Recent studies showed, complications associated with Veress needle insufflation such as gas embolism, sub cutaneous emphysema etc. Hasson’s method has shown to minimise vascular injuries but doesn’t reduce bowel injuries along with gas leak and port instability. The present study was conducted to assess the safety and efficacy of direct trocar insertion in patients undergoing elective laparoscopic procedures.Methods: The present study was conducted prospectively on 476 patients undergone various laparoscopic abdominal procedures using direct trocar access to create pneumo peritoneum during a period from May 2014 to July 2017 in unit 1 of Department of Surgery, RIMS, Imphal, India.Results: All patients age varying from 14 to 70 years are included. The average time taken from skin incision to create pneumoperitoneum was 1 mt. However, author is unable to use this technique in 4 patients having central obesity and switched on to conventional Veress needle for creating pneumoperitoneum. No injuries to bowel, vessels and other insufflation related complication were encountered.Conclusions: No technical difficulty was encountered while inserting trocar directly. No intra-abdominal injuries of bowel, mesentery or vessel were detected. Intra operatively all patients were found to be stable hemodynamically. Post-operatively and on follow up no port site complication such as infection, granuloma formation, induration and herniation were encountered.

Laparoscopic procedures in patients with cardiac ventricular assist devices.

Cardiac left ventricular assist device (LVAD) placement is a common therapy for heart failure. Non-cardiac surgical care of these patients can be complex given the need for anticoagulation, perioperative monitoring, comorbidities, and anatomical considerations due to the device itself. There are no guidelines or significant patient series reported to date for laparoscopic procedures in this population. We herein report the techniques and outcomes for commonly performed laparoscopic procedures in patients with LVADs at a high volume center. From our database of patients with ventricular assist devices, we retrospectively identified patients who underwent laparoscopic abdominal surgery. Intraoperative and perioperative data were collected, including anticoagulation management, transfusions and complications. Techniques and preoperative considerations from the surgeons were also compiled and described. Of 374 patients that had placement of LVADs, 17 had an elective laparoscopic procedure: enteral access placement (n = 7), cholecystectomy (n = 6), hernia repair (n = 2), small bowel resection (n = 1) and splenectomy (n = 1). Preoperative evaluation routinely included radiologic imaging to evaluate driveline location. The most common abdominal entry technique was a periumbilical open Hasson technique (11/17). No cases were converted to open. Overall, the average blood loss was 132 ± 64mL and the average operative time was 1.8 ± 0.3h. Five of the 17 patients required intraoperative blood transfusion. No patients suffered perioperative thrombotic events or LVAD complications secondary to holding anticoagulation. No patients required interventions or reoperation for bleeding complications. There were no mortalities related to these procedures. Laparoscopic abdominal procedures are safe and feasible in patients with LVADs. Although special consideration for bleeding and thrombotic risks, placement of ports and perioperative management is required, the presence of a LVAD itself should not be considered a contraindication for laparoscopic surgery and may in fact be the preferred method for access in these patients.

Chronic hyperglycemia with elevated glycated hemoglobin level and its association with postoperative acute kidney injury after a major laparoscopic abdominal surgery in diabetes patients.

The relationship between preoperative hyperglycemia and postoperative acute kidney injury (AKI) occurrence in non-cardiac surgery including laparoscopic surgery remains unclear. This study aimed to assess the relationship between preoperative chronic hyperglycemia and postoperative AKI occurrence after a major laparoscopic abdominal surgery. We retrospectively reviewed medical records of diabetic patients (≥ 20years old) who underwent elective major laparoscopic abdominal surgery procedures between 2010 and 2016. Patients were divided into two groups based on a cut-off value of hemoglobin A1c (HbA1c) at 6%. Serum creatinine value was used for the diagnosis of AKI, and all assessments and diagnoses of postoperative AKI were performed on 0-3 postoperative days (POD) using the criteria of Kidney Disease: Improving Global Outcomes. In all, 1885 patients were included in the final analysis, and patients were divided into the following groups: < 6.0% group with 1257 patients (66.7%), and ≥ 6.0% group with 628 patients (33.3%). Sixty-nine patients (3.7%) were diagnosed with postoperative AKI within 3 POD. Multivariable logistic regression analysis showed no significant difference in the incidence rate of postoperative AKI between the HbA1c ≥ 6.0% group and the < 6.0% group (odds ratio 1.10, 95% confidence interval 0.57-2.15; P = 0.770). In addition, there was no significant interaction between preoperative HbA1c group and exposure to acute hyperglycemia (serum glucose > 200mg/dL) for incidence of AKI on POD 0-3 (P = 0.181). In diabetic patients, preoperative chronic hyperglycemia is not associated with postoperative AKI occurrence within 3 POD after a major laparoscopic abdominal surgery.

Continuous intravenous perioperative lidocaine infusion for postoperative pain and recovery in adults.

Continuous intravenous perioperative lidocaine infusion for postoperative pain and recovery in adults.

Opioid Medication Use in the Surgical Patient: An Assessment of Prescribing Patterns and Use

With the epidemic of prescription opioid abuse in the US, rates of opioid-related unintentional deaths have risen dramatically. However, few data exist comparing postoperative opioid prescriptions with patient use. We sought to better elucidate this relationship in surgical patients. A prospective cohort study was conducted of narcotic-naïve patients undergoing open and laparoscopic abdominal procedures on a minimally invasive surgery service. During the first 14 post-discharge days and at their first postoperative clinic visit, patients recorded pain scores and number of opioid pills taken. Clinical data were extracted from the medical record. Descriptive statistics were used in data analysis. From 2014 through 2017, one hundred and seventy-six patients completed postoperative pain surveys. Mean age was 60.4 ± 14.9 years and sex was distributed equally. Most patients (69.9%) underwent laparoscopic procedures. Hydrocodone-acetaminophen was the most commonly prescribed postoperative pain medication (118 patients [67.0%]), followed by oxycodone-acetaminophen (26 patients [14.8%]). Patients were prescribed a median of 150 morphine milligram equivalents (MME) (interquartile range [IQR] 150 to 225 MME), equivalent to twenty 5-mg oral oxycodone pills (IQR 20 to 30 pills). However, by their first postoperative visit, they had only taken a median 30 MME (IQR 10 to 90 MME), or 4 pills (IQR 1.3 to 12 pills). Eight (4.5%) patients received a refill or an additional prescription for pain medications. At the first postoperative visit, 76.7% of respondents were satisfied or very satisfied with their overall postoperative pain management. Postoperative patients might consume less than half of the opioid pills they are prescribed. More research is needed to standardize opioid prescriptions for postoperative pain management while reducing opioid diversion.