Terms Of Postoperative Pain Research Articles

Stapled haemorrhoidectomy versus openhaemorrhoidectomy: a prospective comparative study

Open haemorrhoidectomy (OH) treatment has been reserved for prolapsing haemorrhoidal disease (third and fourth grade) and comprehends excision of haemorrhoidal tissue and is associated with significant postoperative pain. As an alternative approach, many randomized controlled trials have shown consistent advantage with haemorrhoidopexy (SH) in terms of postoperative pain, analgesic requirement, length of surgical procedure, short recovery time and early return to normal activities. This study has been conducted to compare the short-term outcome of SH with OH. A prospective comparative study, which included grade 3 and 4 haemorrhoids and comparing short Term outcomes between SH and OH was conducted in the Surgical Gastroenterology units of University Teaching Hospital. A total 44 patients, 22 in each group were compared. Age (SH 42±10.80 Vs. OH 45±13.30) and sex (SH, M:F-9:13 Vs. OH, M:F-14:8) distribution was comparable. Also, the groups were comparable in terms of symptom duration in years (SH, 3.20±2.26 Vs. OH, 2.31±2.47) and distribution of haemorrhoid grades. The SH group showed significant advantage in terms of postoperative pain (Average pain score SH, 2.73±1.20 Vs. OH, 5.20±1.91) and analgesic use (SH 2.32±0.94 Vs. OH 9.32±2.62). Similarly the operating time (time in minutes SH, 42±7.34 Vs. OH, 57.50±8.27), hospitals stay (days of stay SH, 2.90±0.68 Vs. OH, 3.77±0.86) and return to preoperative activity (days to return SH, 7.9±4.90 Vs. OH, 13.6±5.60) were also significantly shorter in the SH group than the OH group. The short-term complications were similar in both groups (P value >0.05). In conclusion, SH has better short-term outcome compared with OH and SH is a viable addition to the therapy options available for haemorrhoids.DOI: http://dx.doi.org/10.3126/jcmc.v4i4.11956

English

INTRODUCTION: Shoulder arthroscopy is a common orthopedics procedure performed on day-case basis. Adequate pain relief reduces surgical stress response, patient's morbidity and improves postoperative recovery and rehabilitation. Various drugs have been tried intra-articularly to provide postoperative analgesia. PURPOSE: We studied analgesic effect of dexamethasone 16mg (4ml) with ropivacaine and compared it with ropivacaine intra-articularly in shoulder arthroscopic procedures in search of the ideal analgesic combination. METHODS: A Prospective Multicenter Double Blind study on 60 patients undergoing arthroscopic shoulder surgery from July'13- April'14. Patients were assigned into 3 groups randomly - Group I (20 ml normal saline),Group II (20 ml 0.2% ropivacaine) and Group III (16 ml 0.2% of ropivacaine & dexamethasone- 4 ml containing 16 mg. VARIABLES ASSESSED: Analgesic effect (VAS Score), time to first postoperative analgesic request, Analgesic used during first 24 hours. RESULTS: Group III had significant low pain scores for 1 st 20 hours as compared to Group II and Group I. Time to first analgesic requirement was longest in Group III (1356.2±193.10mins) (p<0.01). Intensity of pain &Total analgesic requirement was significantly less in Group III (38.2±27.83 mg)(p<0.01) in comparison to Group II and I. No significant side-effects were noted. CONCLUSION: A16 mg (4ml) dosage of Dexamethasone is safe, cost effective and free from relative side effects, has a better patient compliance in terms of post-operative pain, need for analgesia and should be used routinely in arthroscopic shoulder surgeries. Helps in the recovery of patients to the pre-operative level.

Comparative study between the conventional laparoscopic cholecystectomy and clipless cholecystectomy using a harmonic scalpel

Objective This was a comparative study between laparoscopic conventional cholecystectomy and clipless cholecystectomy using a harmonic scalpel. Background This study aimed to compare the laparoscopic conventional cholecystectomy and clipless cholecystectomy using a harmonic scalpel in terms of the duration of the operation, intraoperative blood loss, postoperative complications, postoperative pain, and hospital stay. Patients and methods This study included 80 patients who were classified into two groups: group A (40 patients) was subjected to laparoscopic cholecystectomy by clipping of the cystic duct and cystic artery and dissection of the gall bladder from the gall bladder fossa by electrocautery and group B (40 patients) was subjected to laparoscopic cholecystectomy by a harmonic scalpel, closure and division of both the cystic duct and artery and dissection of the gall bladder from the liver bed by a harmonic scalpel. The intraoperative and postoperative parameters were determined including duration of operation, intraoperative blood loss, postoperative drainage, postoperative pain, complications, and hospital stay. Results The harmonic scalpel provided a shorter operative duration than the conventional method (34.21 ± 9.6 vs. 41.7 ± 13.79, respectively, P = 0.006), and the difference was statistically significant. A statistically significantly lower volume of intraoperative blood loss was observed in group B than group A (64.20 ± 44.01 vs. 96.62 ± 53.33, respectively, P = 0.004) and fewer incidences of gall bladder perforation in group B (7.5 vs. 17%, respectively, P = 0.176), but this was not statistically insignificance, and a lower rate of conversion to open cholecystectomy in group B than group A (0 vs. 5%, respectively, P = 0.246), but this was not statistically significant. The amount of postoperative drainage was significantly less in group B than group A (60.30 ± 11.48 vs. 79.0 ± 36.95, respectively, P = 0.004). Three patients in group B with dilated cystic duct discovered intraoperative and clip technique used for closure; otherwise, no postoperative bile leak was encountered in group B, but it occurred in 5% of patients in group A as a minor biliary leak. In terms of postoperative pain, it was less in group B than group A at 12 and 24 h (45 vs. 70%, P = 0.024, and 37.5 vs. 60%, P = 0.044, respectively), which was statistically significant and insignificant at 48 h and 1 week. Visual analogue scale in group B was lower than that in group A at 12 and 24 h (3.12 ± 0.33 vs. 3.49 ± 0.49, P = 0.01, and 2.5 ± 0.34 vs. 3.34 ± 0.47, P = 0.01, respectively) and statistically significant and insignificant at 48 h and 1 week; the hospital stay was shorter in group B than in group A (20.15 ± 5.65 vs. 24.65 ± 6.22, P = 0.006) and the difference was statistically significant. Conclusion The harmonic scalpel can be used safely for sealing of the cystic artery and cystic duct less than 6 mm in size in laparoscopic cholecystectomy without a risk of major injuries or leak; if the diameter is more than 6 mm, the clips technique should be used. It is better than electrocautery in terms of not just a faster and safer surgery, but also less intraoperative blood loss and less postoperative drainage, with decreased associated morbidity and pain and early return home; however, it is very costly.

Comparison of Subcuticular Suture Materials in Cesarean Skin Closure.

Aim. Comparison of the rate of wound complications, pain, and patient satisfaction based on used subcuticular suture material. Methods. A total of 250 consecutive women undergoing primary and repeat cesarean section with low transverse incision were prospectively included. The primary outcome was wound complication rate including infection, dehiscence, hematoma, and hypertrophic scar formation within a 6-week period after operation. Secondary outcomes were skin closure time, the need for use of additional analgesic agent, pain score on numeric rating scale, cosmetic score, and patient scar satisfaction scale. Results. Absorbable polyglactin was used in 108 patients and nonabsorbable polypropylene was used in 142 patients. Wound complication rates were similar in primary and repeat cesarean groups based on the type of suture material. Skin closure time is longer in nonabsorbable suture material group in both primary and repeat cesarean groups. There was no difference between groups in terms of postoperative pain, need for additional analgesic use, late phase pain, and itching at the scar. Although the cosmetic results tended to be better in the nonabsorbable group in primary surgery patients, there was no significant difference in the visual satisfaction of the patients. Conclusions. Absorbable and nonabsorbable suture materials are comparable in cesarean section operation skin closure.

A Comparative Study of Laparoscopic vs. Open Cholecystectomy in a Suburban Teaching Hospital

Background: Gallstones are common in Indian population and its treatment has shown a decisive shift from open to minimally invasive route. There is no doubt that laparoscopy require longer and steeper learning curve and incur higher cost, especially in the absence of health insurance to majority of suburban and rural Indian population. However, preferences of patients are changing rapidly due to better level of awareness and availability of healthcare facility. The guidelines issued by Medical Council of India on laparoscopic training for postgraduate surgical residents has shown favorable results for patients, junior faculties and residents. Aims: To study safety and efficacy of laparoscopic cholecystectomy in patients of cholelithiasis by comparing with results of open cholecystectomy by comparing use of Post-operative analgesia, Operative Time, Post-operative hospital stay, morbidity and mortality. Material and Method: It is a prospective randomized study of 100 Patients of cholelithiasis aged between 25 years to 65 years operated during 2011-2012 at a suburban teaching hospital. They were divided into open and laparoscopic cholecystectomy group by draw a lot method. Patient’s written valid informed consent for the particular procedure was taken and the pros and cons of both the procedure were explained in detail to the patient. This study was done after due clearance of Ethical committee. Results: The median (range) operation time for laparoscopic cholecystectomy was 50-175 min (mean=103.98 min) and 35-95 min (mean=70 min) for open cholecystectomy (p<0.001). During the study period operation time for laparoscopic cholecystectomy showed a tendency to become shorter. The use of Injectable analgesics in case of laparoscopic cholecystectomy (Mean no. of days=1.5) is considerably less than open cholecystectomy (Mean no. of days=3.36). Conversion rate in literature in laparoscopic cholecystectomy ranges from 3% to 15% in well trained hands. In our series it is 6% in spite of being a teaching and training institution. Conclusion: Minimally invasive surgery is better than open cholecystectomy in terms of post-operative pain, analgesic requirement and early return to work. However, open cholecystectomy is preferred method for Surgeons in the beginning of their career and in case of difficult cholecystectomy.

Reduced patellofemoral and walking pain with mobile-bearing vs. fixed-bearing total knee replacements: a mid-term prospective analytic study

Total knee replacement (TKR) is the standard treatment for advanced stage knee osteoarthritis. The introduction of the mobile-bearing (MB) design has given rise to a series of theoretical advantages compared to fixed-bearing (FB) implants, although current literature does not reveal significant differences between the designs. The aim of this study was to estimate the clinical results of 2 cemented total knee prosthetic designs: an MB and an FB design. A series of patients with similar clinical and radiographic characteristics were treated consecutively with 100 FB followed by 94 MB implants. Patients were evaluated radiographically and clinically. Statistically significant differences were found in terms of pain at 5 years in favor of MB prostheses (p=0.006). The "pain on ascending/descending stairs" category on the KSS score showed improvement at 5 years for the MB design (p=0.003). MB implants showed better results in terms of ability to ascend/descend stairs at five years (p=0.002). With regards to the patients' ability to walk, there were differences at 1 year (p=0.020) and at 5 years (p=0.021) in favor of MB implants. At a mean follow-up of 5 years, significant differences were observed in the MB prosthesis in terms of postoperative pain, ability to ascend/descend stairs, and patellofemoral pain.

Anterior vs. Posterior Approach for Total Hip Arthroplasty, a Systematic Review and Meta-analysis

The objective of this study is to compare the clinical, radiographic and surgical outcomes among patients undergoing primary THA performed via the anterior versus posterior approach. We searched numerous sources and eventually included 17 studies, totaling 2302 participants. In terms of post-operative pain and function, the anterior approach was significantly favored in 4 studies at short-term follow-up. Pooled estimates showed a significant difference in favor of the anterior approach in terms of length of stay and dislocations. Current evidence comparing outcomes following anterior versus posterior THA does not demonstrate clear superiority of either approach. Until more rigorous, randomized evidence is available, we recommend choice of surgical approach for THA be based on patient characteristics, surgeon experience and surgeon and patient preference.

Single-Incision Sleeve Gastrectomy Versus Laparoscopic Sleeve Gastrectomy. A 2-Year Comparative Analysis of 600 Patients

This is a 2-year study to evaluate the feasibility; outcomes in terms of postoperative pain, weight loss, and complication rates; and cosmesis of the single-incision sleeve gastrectomy versus the conventional multiport sleeve gastrectomy. A prospective comparative analysis was done in 300 patients in each arm who underwent laparoscopic sleeve gastrectomy and single-incision sleeve gastrectomy from September 2009 till January 2012. Both groups were matched for age and BMI. Postoperative pain scoring was done using visual analogue scale. Outcomes in terms of pain score, scar satisfaction score, excess weight loss, resolution of co-morbidities, and complications were compared in both groups at the end of 6 months, 1 year, and 2 years. Female patients preferred to undergo single-incision sleeve gastrectomy. Operating time and intraoperative blood loss were comparable in both groups. Visual analogue scale (VAS) scoring revealed lesser postoperative pain in the single-incision group. Excess weight loss and resolution of co-morbidities were also comparable in both groups at 6 months, 1 year, and 2 years. Incisional hernia was seen in 3 patients (1%) in the single-incision group. Leak rate was comparable. Cosmetic satisfaction was superior in patients who underwent single-incision surgery. Surgical outcomes are comparable in both groups at the end of 2 years. The myth of high long-term incisional hernia rate after single-incision surgery has been dispelled. Single-incision surgery is less painful with better cosmesis. It has come of age and should no longer be considered as an experimental procedure.

Comparison between two thoracotomy closure techniques: postoperative pain and pulmonary function.

OBJECTIVE: To compare two thoracotomy closure techniques (pericostal and transcostal suture) in terms of postoperative pain and pulmonary function. METHODS: This was a prospective, randomized, double-blind study carried out in the Department of Thoracic Surgery of the Luzia de Pinho Melo Hospital das Clínicas and at the University of Mogi das Cruzes, both located in the city of Mogi das Cruzes, Brazil. We included 30 patients (18-75 years of age) undergoing posterolateral or anterolateral thoracotomy. The patients were randomized into two groups by the type of thoracotomy closure: pericostal suture (PS; n = 16) and transcostal suture (TS; n = 14). Pain intensity during the immediate and late postoperative periods was assessed by a visual analogic scale and the McGill Pain Questionnaire. Spirometry variables (FEV1, FVC, FEV1/FVC ratio, and PEF) were determined in the preoperative period and on postoperative days 21 and 60. RESULTS: Pain intensity was significantly greater in the PS group than in the TS group. Between the preoperative and postoperative periods, there were decreases in the spirometry variables studied. Those decreases were significant in the PS group but not in the TS group. CONCLUSIONS: The patients in the TS group experienced less immediate and late post-thoracotomy pain than did those in the PS group, as well as showing smaller reductions in the spirometry parameters. Therefore, transcostal suture is recommended over pericostal suture as the thoracotomy closure technique of choice.

Robotic lung segmentectomy for malignant and benign lesions.

Surgical use of robots has evolved over the last 10 years. However, the academic experience with robotic lung segmentectomy remains limited. We aimed to analyze our lung segmentectomy experience with robot-assisted thoracoscopic surgery. Prospectively recorded clinical data of 21 patients who underwent robotic lung anatomic segmentectomy with robot-assisted thoracoscopic surgery were retrospectively reviewed. All cases were done using the da Vinci System. A three incision portal technique with a 3 cm utility incision in the posterior 10(th) to 11(th) intercostal space was performed. Individual dissection, ligation and division of the hilar structures were performed. Systematic mediastinal lymph node dissection or sampling was performed in 15 patients either with primary or secondary metastatic cancers. Fifteen patients (75%) were operated on for malignant lung diseases. Conversion to open surgery was not necessary. Postoperative complications occurred in four patients. Mean console robotic operating time was 84±26 (range, 40-150) minutes. Mean duration of chest tube drainage and mean postoperative hospital stay were 3±2.1 (range, 1-10) and 4±1.4 (range, 2-7) days respectively. The mean number of mediastinal stations and number of dissected lymph nodes were 4.2 and 14.3 (range, 2-21) from mediastinal and 8.1 (range, 2-19) nodes from hilar and interlobar stations respectively. Robot-assisted thoracoscopic segmentectomy for malignant and benign lesions appears to be practical, safe, and associated with few complications and short postoperative hospitalization. Lymph node removal also appears oncologically acceptable for early lung cancer patients. Benefits in terms of postoperative pain, respiratory function, and quality of life needs a comparative, prospective series particularly with video-assisted thoracoscopic surgery.

Pure Single-Port Laparoscopic Distal Gastrectomy for Early Gastric Cancer: Comparative Study with Multi-Port Laparoscopic Distal Gastrectomy

The purpose of this study was to show the feasibility and safety of pure single-port laparoscopic distal gastrectomy (SDG) by comparing its short-term outcomes with those of conventional multiport totally laparoscopic distal gastrectomy (TLDG). Prospectively collected data of 50 gastric cancer patients who underwent pure SDG from November 2011 through October 2013 were compared with the matched data of 50 TLDG patients. Mean operation time (144.5 vs 140.3 minutes; p= 0.561) and number of harvested lymph nodes (51.7 ± 16.3 vs 52.4 ± 17.9; p= 0.836) were comparable. Estimated blood loss was lower in the SDG patients (50.5 ± 31.5 mL vs 87.5 ± 79.6 mL; p= 0.007). Postoperative recovery was faster in the SDG patients in terms of lower maximum pain score on the operative day (6.1 ± 1.4 vs 6.9 ± 1.5; p= 0.015) and postoperative day 1 (4.6 ± 1.0 vs 5.5 ± 1.4; p < 0.001), less use of parenteral analgesics (0.8 ± 1.0 vs 1.4 ± 1.0; p= 0.020), and less increase in C-reactive protein level on postoperative day 5 (4.57 ± 6.26 mg/L vs 8.51 ± 5.25 mg/L; p= 0.008). Postoperative morbidity occurred in 6 (12%) and 5 (10%) patients in the SDG and TLDG group, respectively. This study showed that pure SDG is both safe and feasible for early gastric cancer, with similar operation time and better short-term outcomes than TLDG in terms of postoperative pain, estimated blood loss, inflammatory reaction, and cosmetic result.

Outcome of Displaced Metacarpal and Proximal Phalangeal Fractures Treated with Intramedullary κ-Wire and Cross κ-wires: A Prospective Study of 105 Patients

AIM: Kirschner wire (κ-wire) fixation is one of the most commonly used methods for fixation of metacarpal and phalangeal fractures.Two commonly used surgical techniques are intramedullary κ-wire fixation and cross κ-wires fixation. The aim of our study was to evaluate and compare the functional results and complications in closed displaced metacarpal and phalangeal fractures treated with κ-wires using above two techniques. MATERIALS AND METHODS: 105 patients of closed displaced metacarpal and phalangeal fractures were randomized to receive fracture fixation with one of the two methods, 54 patients stabilized with intramedullary κ-wires (group A) and rest 51 patients with cross κ-wires (group B). The operative time, pain scale, success of union, time of union, total active range of motion (ROM), total active motion (TAM) and complications were assessed.The Student’s t-test was used to analyze the difference of mean for different parameters. RESULTS: Both groups showed no statistical difference in term of age (p=0.82), gender (p=0.64), the time from injury to operation (p=0.62). After surgical fixation with above two techniques, there were no significant difference found in terms of postoperative pain, rate of union, union time, total active range of motion (ROM), total active motion (TAM) and complications except postoperative loss of reduction which was found significantly more common in group A (p=0.04). There was insignificant difference found in terms of outcomes and complications between patients of both the groups treated with both techniques. CONCLUSION: Transverse and short oblique closed metacarpal and proximal phalangeal fractures treated with intramedullary κ-wire and cross κ-wires had produced favourable and comparable outcomes in long term.

A beneficial effect of purse-string skin closure after ileostomy takedown: A retrospective cohort study

ObjectivesThe aim of this study was to investigate the clinical benefits of purse-string skin closure (PS) in daily practice compared with conventional linear skin closure (CL) after ileostomy takedown in Korean population. MethodsThese retrospectively collected data were based on 157 consecutive patients who underwent ileostomy takedown between November 2010 and September 2011. Before March, 2011, CL was performed in 79 patients. Thereafter, PS was performed in 78 patients. The medical records including pain score recorded daily were reviewed and the postoperative outcomes, including SSI, were analyzed. ResultsPS group had a significantly lower overall complication rate than the CL group (8.97% vs. 25.32%, p = 0.010). Among complications, PS group had a significantly lower SSI rate than the CL group (0% vs. 11.39%, p = 0.003). After adjusted for other risk factors (smoking, body mass index, anastomosis method), PS method was associated significantly and independently with a lower SSI rate than CL method (adjusted odds ratio: 26.63, 95% confidence interval: 3.02–267.70, p = 0.001). And the two groups did not differ in terms of postoperative pain (p = 0.323) or pain pattern (p = 0.548). ConclusionIn daily practice, PS had a beneficial effect on SSI in patients who underwent ileostomy takedown in the Korean population.

Tips for single-port laparoscopic cholecystectomy.

Single-port laparoscopic cholecystectomy (SPLC) is an emerging technique and gaining increased attention by its superiority in cosmesis. A 1.5-cm vertical transumbilical incision is used for the single port, followed by the glove method. Indications for SPLC are the same as those for standard 4-port laparoscopic cholecystectomy, including patients with morbid obesity, previous upper abdominal surgery, severe acute cholecystitis, or suspected presence of common bile duct stones. Some randomized controlled trials have shown negative results of SPLC regarding operative time, wound-related complications, and postoperative pain. However, our retrospective analysis shows equivalent clinical outcomes among the two approaches in terms of postoperative pain and complications. In this context, SPLC can be a good option for gallbladder pathologies.

Systematic Review and Meta-Analysis of Randomized Controlled Trials Comparing Single Incision versus Conventional Laparoscopic Appendectomy

Single incision laparoscopic appendectomy (SILA) has been proposed as an alternative to conventional laparoscopic appendectomy (CLA). The aim of this study was to evaluate the safety and efficacy of SILA when compared with CLA through a systematic review. We performed an electronic search of EMBASE, PubMed, MEDLINE, and Cochrane Central Register of Controlled Trials. Randomized controlled trials (RCTs) that compared SILA with CLA were included. Six RCTs met eligibility criteria, which included a total of 800 patients, 401 in the SILA group and 399 in the CLA group. There were no significant differences in terms of overall complications (odds ratio [OR] 0.93; 95% confidence interval [CI] 0.59-1.47; p = 0.77). SILA had a higher technical failure rate (OR 3.30; 95% CI 1.26-8.65; p = 0.01) and required a longer operative time (mean difference [MD] 4.67; 95% CI 1.76-7.57; p = 0.002). SILA was associated with better cosmetic results (standardized MD -0.4; 95% CI -0.64 to -0.16; p = 0.001) and earlier return to normal activity (MD -0.64; 95% CI -1.09 to -0.20; p = 0.005), although these advantages should be taken with caution due to the small number of studies reporting these two items and the short follow-up in the evaluation of cosmetic results. There were no significant differences in terms of postoperative pain or length of hospital stay between groups. SILA is comparable to CLA in selected patients, although it is associated with a higher technical failure rate and longer operative time. Further randomized trials are needed to determine if SILA really offers benefits over CLA.

Clipping the (tongue) tie

Ankyloglossia is an uncommon congenital oral anomaly that can cause difficulty with breast-feeding and speech articulation. For many years, the subject of ankyloglossia has been controversial with practitioners of many specialties having widely different views regarding its significance and management. This study is about a series of five cases of ankyloglossia subjected to surgical correction by frenectomy procedure. Three cases were treated with electrocautery, one case with diode laser and one case with conventional scalpel technique. 1 week and 1 month post-operative follow-ups were done and healing was compared with the available literature. Manipulation of tissues was better in laser and electrocautery techniques when compared with scalpel. Post-operative complication of swelling and pain was seen in scalpel technique whereas it was largely uneventful in other techniques. Though, there was no difference in healing at the end of first month clinically, scalpel technique has shown better results in organization of muscle fibers. This clinical study indicates that laser and electrocautery treatment used for frenectomy operations provides better patient perception in terms of postoperative pain and function than that obtained by the scalpel technique. Considering the above advantages, when used correctly, the laser and electrocautery offers a safe, effective, acceptable and impressive alternative for frenectomy operations.

Robotic single-site surgery for female-to-male transsexuals: preliminary experience.

Hysterectomy with bilateral salpingo-oophorectomy is a part of gender reassignment surgery for the treatment of female-to-male transsexualism. Over the last years many efforts were made in order to reduce invasiveness of laparoscopic and robotic surgery such as the introduction of single-site approach. We report our preliminary experience on single-site robotic hysterectomy for cross-sex reassignment surgery. Our data suggest that single-site robotic hysterectomy is feasible and safe in female-to-male transsexualism with some benefits in terms of postoperative pain and aesthetic results.

Reply to: Long-term cosmetic results after minimally invasive video-assisted thyroidectomy

Dear Dr. Mangano, We have read your very interesting article about the important evolution in endocrine surgery over the last few years, especially regarding video-assisted technology in thyroid surgery. The aim of the constant development of all procedures is to increase the patients’ satisfaction. The advantages of minimally invasive video-assisted thyroidectomy (MIVAT) over conventional thyroidectomy are described in terms of postoperative pain and cosmetic results [1, 2]. Improved patient satisfaction in having a smaller neck scar has been the main argument for implementation of this approach. The small incision is the major difference, as well as the measuring criterion in comparison between minimally invasive and conventional thyroid surgery. I completely agree that the standardized operative technique is an important step for successful results. The procedure of skin closure is of the same importance comparing minimally invasive surgery versus conventional thyroid surgery. In this regard, it might be highly interesting to become familiar with your unpublished data relating to the influence of the kind of surgical technique and the type and diameter of the suturing wire on the cosmetic results. In our study, a standardized procedure was shown by using an absorbable suture (Dexon 4x0; Dexon; B. Braun Melsungen AG, Germany) [3]. In this regard, I would like to add that we performed an inverting suture. Your idea that skin closures are done by the same surgeon seems hardly realizable in the present supply situation. Your remarks concerning the use of an ultrasonic scalpel with intraoperative cooling of the tip of the instruments in physiologic water are very important. Thermal injuries on the skin incision due to the increased temperature of the tip of the instruments during the surgical procedures are a well-known problem. We cover the lower edge of the wound by an operation cloth to avoid thermal injuries of the skin. Also in this regard, it is worthwhile to find out the influence of the different procedures. Furthermore, it is important to impose the cosmetic results of thyroid surgery by a standardized evaluation. Only that way are results really comparable. The Patient and Observer Scar Assessment Scale we used is a complete scar evaluation tool developed by plastic surgeons [4]. In this regard, it is important to gather the results by follow-up examination. Using this method we have been able to compare our results with a Canadian study referring to the comparison of minimal access and conventional access [5]. Another fact is the time at which the post-surgery examination is performed. The scar analysis needs longterm follow-up at a minimum of 6 months because the healing and remodeling process is a long procedure [6]. In our study, the average follow-up period was 22.4 months. Another issue associated with the use of the MIVAT technique is the problem of keloid. In our study, we showed that ten women (with an average age of 38 years), who make up 10.4 % of all MIVAT patients, experienced keloid [3]. Furthermore, these results can only be shown by using long-term follow-up examination. Further exaltations are necessary in this regard. In your article you mentioned the genetic influence and interpersonal variability among patients, such as age, skin or phototype, as being influential M. Sahm (&) M. Pross Department of Surgery, DRK Kliniken Berlin Kopenick, Berlin, Germany e-mail: m.sahm@drk-kliniken-berlin.de

Scheduled Analgesic Regimen Improves Rehabilitation After Hip Fracture Surgery

BackgroundPostoperative pain often is the limiting factor in the rehabilitation of patients after hip fracture surgery.Questions/purposesWe compared an approach using scheduled analgesic dosing with as-needed analgesic dosing in patients after hip fracture surgery, to compare these approaches in terms of (1) resting and dynamic pain intensity, (2) postoperative patient mobility, and (3) functional end points.MethodsWe conducted a prospective cohort study of 400 patients who underwent surgical treatment of hip fractures at our hospital. The groups were formed sequentially, such that the first 200 patients formed the intervention group (treated with scheduled analgesic intake for the first 3 weeks after surgery), and the next 200 patients were the control group (treated using a protocol of analgesic administration on request). Resting and dynamic pain intensity, mobility, and functional performance were compared between the two analgesic protocols.ResultsAs expected, analgesic consumption was lower in the control group (tramadol doses, 27 versus 63; paracetamol doses, 29 versus 63). Despite the large difference in the amounts of analgesics consumed, resting and dynamic pain intensity showed improvement in each group and there was no difference between groups in terms of postoperative pain. However, there was a positive correlation between functional outcomes and analgesic consumption in the control group. The intervention group achieved higher functional performance on discharge (elderly mobility scale, 11 versus 8; functional independence measure, 88 versus 79). On discharge, fewer patients in the intervention group were wheelchair ambulators (3 versus 32), meaning more patients in the intervention group were able to walk.ConclusionsThe study showed that a scheduled analgesic intake can improve the functional outcomes of patients with geriatric hip fractures after surgery.Level of EvidenceLevel II, therapeutic study. See the guidelines for authors for a complete description of levels of evidence.

A Comparison of Postoperative Pain After Conventional Open Thyroidectomy and Transaxillary Single-Incision Robotic Thyroidectomy: A Prospective Study

The aim of this study was to compare conventional open thyroidectomy with robotic thyroidectomy in terms of postoperative pain. We compared the intensity of postoperative pain experienced by patients who received conventional open thyroidectomy (n = 45) versus those who underwent robotic thyroidectomy (n = 45). During surgery, we carefully controlled the anesthetic conditions. All the patients underwent a total thyroidectomy with ipsilateral central compartment node dissection. Postoperative pain in the 2 groups was compared using a visual analog scale and the amount of rescue analgesic at 30 min, 4 h, 1, 2, 3, and 10 days after surgery. The postoperative pain at 30 min and 4 h after surgery were 3.0 ± 0.9 and 2.6 ± 0.9 (p = .066) and 4.9 ± 1.3 and 4.4 ± 1.3 (p = .055) in the conventional open group and the robotic group, respectively. The mean pain scores at 1, 2, 3, and 10 days after surgery were 3.8 ± 1.3 and 3.0 ± 1.3 (p = .001), 2.6 ± 1.2 and 2.0 ± 0.9 (p = .005), 1.7 ± 0.9 and 1.3 ± 0.6 (p = .034), and 0.9 ± 0.7 and 1.2 ± 1.1 (p = .093), respectively. No significant differences were observed between the 2 groups in terms of postoperative rescue analgesic use (1.1 ± 1.1 and 0.8 ± 0.9, p = .264). Even though robotic thyroidectomy using the transaxillary technique requires a more extensive subcutaneous dissection than conventional open thyroidectomy, robotic thyroidectomy does not result in more postoperative pain or use of analgesic when compared with open thyroidectomy.