Elisabetta Marana

Postoperative pain after conventional laparoscopy and laparoendoscopic single site surgery (LESS) for benign adnexal disease: a randomized trial

OBJECTIVE To compare postoperative pain after laparoendoscopic single-site surgery (LESS) approach with conventional multiaccess laparoscopy (LPS). STUDY DESIGN Prospective randomized trial. SETTING University hospital. PATIENT(S) Benign adnexal disease. INTERVENTION(S) Postoperative pain was measured by using the visual analog scale (VAS) at 20 minutes, 2 hours, 4 hours, and 8 hours after surgery. The need for postoperative rescue doses of analgesia was also recorded. MAIN OUTCOME MEASURE(S) Pain after surgery. RESULT(S) A total of 60 patients were enrolled. Within 8 hours, patients who underwent conventional LPS complained of statistically significant greater postoperative pain at VAS evaluation than those undergoing LESS, both at rest and after Valsalva maneuver, with a higher need for rescue analgesia. CONCLUSION(S) LESS provides an advantage over conventional multiaccess LPS in terms of postoperative pain and need for rescue analgesia, with similar perioperative outcomes.

Neuroendocrine Stress Response in Patients Undergoing Benign Ovarian Cyst Surgery by Laparoscopy, Minilaparotomy, and Laparotomy

STUDY OBJECTIVE To quantify and compare neuroendocrine stress responses during and immediately after surgery by laparoscopy, minilaparotomy, and laparotomy for benign ovarian cysts. DESIGN Prospective study (Canadian Task Force classification II-1). SETTING Tertiary care university hospital. PATIENTS Thirty healthy women with no major diseases and without endocrine disorders. INTERVENTIONS Surgery for benign ovarian cysts performed by laparoscopy (10), minilaparotomy (10), or laparotomy (10). MEASUREMENTS AND MAIN RESULTS Venous blood samples were collected at fixed times as follows: at 8 A.M. in the ward before transferring the patient to the operating room (time 0), 30 minutes after the beginning of surgery (time 1), at the end of surgery after extubation with the patient awake (time 2), and 2 and 4 hours after the end of surgery (times 3 and 4). We evaluated intraoperative and postoperative variations of the following stress-related markers: norepinephrine (NE), epinephrine (E), adrenocorticotropic hormone (ACTH), human growth hormone (hGH), prolactin (PRL), and cortisol, and postoperative pain. No differences were present in demographic characteristics and operating times in the three groups. No anesthesiologic or surgical complications occurred. Postoperative pain was similar in the laparoscopy and minilaparotomy group but significantly higher in the laparotomy group (p <0.001). Serum levels of markers were not significantly different among the groups at baseline. In the laparoscopy group the increase of hGH was limited to intraoperative time (p <0.05); increases in NE, E, ACTH, and PRL were limited to intraoperative and early postoperative time after extubation (p <0.01), with only PRL persisting with significantly higher levels after the end of surgery (p <0.05). In the minilaparotomy group no increase was detected for hGH, a significant intraoperative increase in cortisol was present (p <0.05), and NE, E, ACTH, and PRL were significantly higher even after the end of surgery (p <0.01). In this group levels of NE, E, and hGH were significantly higher than in the laparoscopy group 2 and 4 hours after the end of surgery (p <0.05). In the laparotomy group significant intraoperative increases were present for all stress markers and persisted until after extubation for ACTH (p <0.01) and to the postoperative period for NE (p <0.01), E (p <0.01), cortisol (p <0.01), PRL (p <0.05), and hGH (p <0.01). In this group levels of NE, E, ACTH, and hGH were significantly higher than those in the laparoscopy group from the beginning (NE p <0.05, E p <0.01, ACTH p <0.05, hGH p <0.01) until after the end of surgery. Comparison of laparotomy and minilaparotomy groups showed the former to have significantly higher plasma levels of E, cortisol, and hGH in intraoperative and postoperative times (p <0.001); significantly higher NE at sampling times 1 and 2 (p <0.001) and time 4 (p <0.01), and no difference at sampling time 3; and ACTH significantly higher only during surgery (p <0.01). CONCLUSION Laparoscopic surgery causes minimal activation of stress hormones, which in some instances is confined to the intraoperative period. Minilaparotomy may be a valid alternative to laparoscopy in high-risk patients who cannot tolerate abdominal distention.

Evaluation of stress-related hormones after surgery by laparoscopy or laparotomy

STUDY OBJECTIVE To evaluate the stress hormone response after pelvic surgery performed by laparoscopy versus laparotomy. DESIGN Prospective study. SETTING A tertiary care university hospital. PATIENTS Ten women were scheduled to undergo laparoscopic surgery and 10 laparotomy for either tubal disease or endometriosis. INTERVENTIONS Surgical procedures were performed by laparoscopy or laparotomy for stage III-IV endometriosis, pelvic adhesions, or distal tubal occlusion. The following hormones were measured before the induction of anesthesia in the ward, 60 minutes after the beginning of surgery, at the end of surgery after extubation, and 2 hours and 6 hours after the end of the operation: norepinephrine (NE), epinephrine (E), dopamine (D), adrenocorticotropic hormone (ACTH), cortisol, prolactin (PRL), and GH. MEASUREMENTS AND MAIN RESULTS The mean duration of surgery was not significantly different between the two groups. Surgery-related adrenergic activation (E, NE, D) appears more pronounced in the laparotomy group (p<0.005) during surgery and in the postoperative period. More elevated values for laparotomy were observed also for the other stress hormones (ACTH, cortisol, PRL, GH), even though statistical significance was not always reached. CONCLUSIONS Compared with laparotomy, activation of stress-related factors during laparoscopy seems to be less intense and of shorter duration.

Neuroendocrine stress response in gynecological laparoscopy: TIVA with propofol versus sevoflurane anesthesia.

STUDY OBJECTIVE To compare intraoperative and postoperative neuroendocrine stress responses during total intravenous anesthesia (TIVA) using propofol and remifentanil versus sevoflurane anesthesia, during laparoscopic surgery. DESIGN Prospective, randomized study. SETTING Tertiary-care university hospital. PATIENTS 46 ASA physical status I patients undergoing laparoscopic surgery for benign ovarian cysts. INTERVENTION Patients were randomly allocated to two groups to receive either TIVA (Group A=23) or sevoflurane anesthesia (Group B=23). MEASUREMENTS Perioperative plasma levels of norepinephrine (NE), epinephrine (E), adrenocorticotropic hormone (ACTH), cortisol, growth hormone (GH), prolactin (PRL), and thyroid hormones (TSH, FT3, FT4) were measured. Blood samples were collected preoperatively, 30 minutes after the beginning of surgery, after extubation, and two and 4 hours after the end of surgery (times 0, 1, 2, 3, and 4). MAIN RESULTS In Group A, perioperative levels of NE, E, ACTH, cortisol, and GH compared with preoperative values significantly decreased; in Group B they increased (Groups A vs. B: time 1, P<0.001 for all markers; time 2, P<0.001 for E, ACTH, cortisol, and GH; time 3, P<0.01 for cortisol, NE, and E, and P<0.05 for ACTH and GH). Perioperative PRL levels were significantly enhanced in both groups versus preoperative values. In both groups, TSH levels increased while FT3 levels decreased significantly relative to basal values. In both groups, perioperative FT4 levels significantly increased compared with preoperative values. CONCLUSIONS TIVA inhibited the ACTH-cortisol axis and reduced NE, E, and GH levels, but it enhanced PRL and had a weak effect on thyroid hormone concentrations as compared to sevoflurane anesthesia.

Stress responses to endoscopic surgery.

Growing evidence in the literature suggests that laparoscopic surgery should be performed instead of laparotomy for the treatment of pelvic benign diseases whenever feasible, as it results in a lower stress response on the part of the patient and possibly a shorter recovery time.

Laparoscopic Excision of Adnexal Masses

STUDY OBJECTIVE The purpose of the present study was to evaluate a prospective series of consecutive patients with adnexal masses selected with strict preoperative clinical and ultrasonographic criteria. DESIGN Prospective series of consecutive patients (Canadian Task Force classification II-2). SETTING Tertiary care university hospitals. PATIENTS Six hundred and eighty-three consecutive patients under 40 years of age with ultrasonographic evidence of an adnexal cystic mass without thick septa, internal wall papillation, or solid components, except for sonographic pattern suggestive of dermoid. INTERVENTIONS Operative laparoscopy and follow-up. MEASUREMENTS AND MAIN RESULTS After initial diagnostic laparoscopy in 13 patients with stage 4 endometriosis and extensive bowel adhesions, in 2 patients with large-volume dermoids, and in 1 patient with suspect ovarian and peritoneal implants, the procedure was converted to laparotomy. Therefore, 667 patients were completely managed by laparoscopy. There were 1069 cysts excised. Histologic diagnosis was endometrioma in 57% of the excised cysts, serous cyst in 13%, dermoid in 12%, paratubal in 8%, mucinous cysts in 5.3%, functional cyst in 2.8%, other benign histotypes in 1.1%, and ovarian malignancies (seven borderline tumors and one endometrioma with a microfocus of G1 endometrioid carcinoma) in 0.7% of the cysts and 1.2% of the patients. These last patients are alive with no evidence of disease after a mean follow-up of 62 months. CONCLUSIONS In the present series, with accurate preoperative and intraoperative selection, the rate of unexpected borderline or focally invasive malignancies was 1.2% of the patients, and the laparoscopic management of these adnexal masses did not adversely impact on prognosis.

Diastolic function: the influence of pneumoperitoneum and Trendelenburg positioning during laparoscopic hysterectomy

Background and objective Several reports concerning the haemodynamic changes during gynaecologic laparoscopy have been published so far, and the effects of head-down tilt and pneumoperitoneum have not been clearly separated. However, its main effect seems to be an increase in systemic vascular resistance. We investigated how the augmented afterload can affect diastolic function. Methods : Our study involved 20 healthy women, classified as having ASA status I: 10 undergoing laparoscopic hysterectomy and 10 undergoing conventional open hysterectomy. Measurements were made in awake patients and after induction of anaesthesia and then repeated after carbon dioxide insufflation and head-down positioning and at the end of surgery. Diastolic function was primarily studied by transthoracic echocardiography. Results We observed that pneumoperitoneum caused a significant reduction in stroke volume, cardiac output and left ventricular end-diastolic volume; the diastolic filling times showed a progressive reduction in the E-velocity (the velocity of early mitral inflow, corresponding to the ventricular passive filling phase, measured by pulsed-wave Doppler), a prolonged deceleration time and an augmented isovolumetric relaxation time. After head-down tilting, stroke volume, cardiac output and left ventricular end-diastolic volume increased in both laparoscopic hysterectomy and conventional open hysterectomy groups. Conclusion We have found that pneumoperitoneum has important effects on left ventricular volumes, causing a drop in left ventricular end-diastolic volume; it also affects diastolic function with a delay in deceleration time and isovolumetric relaxation time without any effects on intracavitary pressures.

Current practical application of office endoscopy.

Outpatient hysteroscopy has shown good correlation of findings compared with inpatient hysteroscopy, but one limitation is pain and discomfort in some women, and vasovagal reaction. Various forms of local anaesthesia have been evaluated in the past year, with controversial results, and a narrow 3.5 mm sheath hysteroscope has been introduced. Transvaginal hydrolaparoscopy as an outpatient procedure has been further investigated.

Positive end-expiratory pressure during laparoscopy: cardiac and respiratory effects☆☆☆

STUDY OBJECTIVE To determine the effect of positive end-expiratory pressure (PEEP) on the respiratory system and on cardiac function. DESIGN Prospective randomized study. SETTING Operating room. PATIENTS 60 ASA physical status 1 women scheduled for pelvic laparoscopic surgery. INTERVENTIONS Patients were ventilated normally during surgery; PEEP was modified depending on patient group allocation. Group A was the control group and did not receive PEEP. Group B received PEEP 5 cmH2O and Group C received PEEP 10 cmH2O. MEASUREMENTS Respiratory parameters measured were partial pressure of arterial oxygen (PaO2), partial pressure of carbon dioxide (PaCO2), and end-tidal carbon dioxide tension (ETCO2). Cardiac parameters measured were left ventricular end-diastolic volume index (LVEDVI), ie, ratio of LVEDV/body surface area (BSA; [LVEDVI = end-diastolic volume [EDV]/BSA); left ventricular (LV) systolic function, tricuspid annular plane systolic excursion (TAPSE), right ventricular (RV) fractional area change (FAC), RV dimensions in the apical 4-chamber view, tracing basal and mid-cavity minor dimensions and longitudinal dimension, cardiac index, systolic pulmonary artery pressure (PASP), and systolic RV pressure (RVSP). Respiratory and cardiac measurements were recorded at T0 (baseline); T1 (after anesthesia induction, before pneumoperitoneum induction); at 10 (T2), 20 (T3), and 30 (T4) minutes after CO2 insufflation; and at the end of surgery (T5). MAIN RESULTS Ventilation with PEEP at 10 cm H2O led to significant improvement in both respiratory and cardiac parameters. A reduction in pulmonary vascular resistance and enhanced washout of expiratory CO2 occurred. Ten and, to a lesser extent, 5 cm H2O of PEEP decreased LV stroke work. CONCLUSIONS Ventilation with PEEP (up to 10 cm H2O) recruits the hypoventilated areas of the lungs and reduces cardiac afterload.

Benign cystic peritoneal mesothelioma incorrectly diagnosed as an ovarian borderline mucinous tumor of intestinal type at transvaginal preoperative ultrasound evaluation

A 42-year-old sexually inactive woman presented to our emergency department with worsening abdominal pain and high fever of 1 day’s duration. During the previous month, she had had occasional mild lower abdominal pain, but without other symptoms. Her past medical history was unremarkable except for a myomectomy 10 years previously. Physical examination revealed diffuse abdominal tenderness with rebound. Laboratory data were notable for a leukocyte count of 42 880 per mm3 with a left shift. Pelvic sonography showed a large unilocular cystic structure in the upper pelvis measuring 9.0 × 8.0 × 6.5 cm that demonstrated internal debris and a hyperechoic thick wall (Figure 1a). Contrast-enhanced computed tomography revealed a large cystic mass with a thick wall, which was posterior to and superior to the uterus (Figures 2a and c). Bilateral ovarian cysts were also noted (Figure 2b). Even in the absence of risk factors for ascending genital-tract infection, tubo-ovarian abscess was still the primary consideration based on the laboratory results and imaging findings. Antibiotic therapy was started immediately, but the patient’s symptoms persisted. The following day an exploratory laparotomy revealed purulent material in the peritoneal cavity and a thick-walled pelvic mass containing purulent material. The mass was found to originate from the posterior wall of the uterus. Myomectomy could not be performed because the mass had severe adhesions. Instead, a tumor incision, marsupialization and drainage were performed. Microscopically, the mass consisted of fibrous tissue and smooth muscle cells, along with granulation tissue and chronic inflammation. No evidence of malignancy was noted. The patient had an uneventful recovery and was discharged within a week after surgery. Pelvic ultrasound 4 months after surgery showed that the size of the mass had decreased to 3 cm (Figure 1b). She remained well at the 12-month follow-up visit. Pyomyoma, or a suppurative leiomyoma, is a rare and potentially fatal complication of uterine leiomyoma. Only 21 cases have been reported since 19451–10. Most cases occur during pregnancy or after menopause, and are caused by ascending genitaltract infection. To our knowledge, this is the first case of pyomyoma described in a healthy premenopausal female and unrelated to any focus of infection. Figure 1 (a) Preoperative ultrasound image showing a large unilocular cystic structure in the upper pelvis that demonstrated internal debris and a hyperechoic thick wall. (b) Pelvic ultrasound image 4 months after surgery showed that the size of the subserosal fibroid had decreased to 3 cm. M, tumor mass; U, uterus.