H. Troidl

Pain after laparoscopic cholecystectomy

It is postulated that laparoscopic cholecystectomy as “patient-friendly surgery” leads to more comfort and in particular to less pain. A prospective study on pain was performed on all patients undergoing the operation over the period of 1 year (n=382) out of a series of more than 1,000 patients who have undergone the operation in our clinic. Pain was measured by a 100-point visual analogue scale (VAS), by a five-point verbal rating scale, and by the consumption of analgesics. Pain was the most frequent symptom, both before and after the operation. The mean level of pain was 37 VAS points 5 h after the operation and declined to 16 points on the third day. In 106 patients (27.8%) the intensity of pain was higher than 50 VAS points. Analgesics were used by 282 patients (73.8%), opioids by 112 (29.3%). Pain was significantly higher in female than male patients (P<0.05), but consumption of analgesics was similar in both groups. The most severe pain was localized to the abdominal wall wounds by 157 (41.1%) and to the right upper abdomen by 138 patients (36.1%) on the first postoperative day. Patients who needed opioids and/or had a pain level of >50 VAS points (n=138) had higher preoperative pain levels (P=0.018) and preoperatively complained more frequently about nausea, vomiting, bloating, and a feeling of abdominal pressure (P=0.003–0.031). However, predictive values of these variables were too small to be of clinical benefit. The duration of operation, intraoperative events (loss of bile, blood, or gallstones), and additional laparoscopic procedures (adhesiolysis, lavage, extension of an incision, suture of fascia) did not influence the intensity of postoperative pain. We conclude that laparoscopic cholecystectomy did cause significant postoperative pain in one-third of our patients only up to the first postoperative day. As predictors for high intensity of pain were not identified, pain should be monitored and analgesics should be delivered liberally.

Laparoscopic antireflux surgery for gastroesophageal reflux disease (GERD): results of a consensus development conference

AbstractBackground: Laparoscopic antireflux surgery is currently a growing field in endoscopic surgery. The purpose of the Consensus Development Conference was to summarize the state of the art of laparoscopic antireflux operations in June 1996. Methods: Thirteen internationally known experts in gastroesophageal reflux disease were contacted by the conference organization team and asked to participate in a Consensus Development Conference. Selection of the experts was based on clinical expertise, academic activity, community influence, and geographical location. According to the criteria for technology assessment, the experts had to weigh the current evidence on the basis of published results in the literature. A preconsensus document was prepared and distributed by the conference organization team. During the E.A.E.S. conference, a consensus document was prepared in three phases: closed discussion in the expert group, public discussion during the conference, and final closed discussion by the experts. Results: Consensus statements were achieved on various aspects of gastroesophageal reflux disease and current laparoscopic treatment with respect to indication for operation, technical details of laparoscopic procedures, failure of operative treatment, and complete postoperative follow-up evaluation. The strength of evidence in favor of laparoscopic antireflux procedures was based mainly on type II studies. A majority of the experts (6/10) concluded in an overall assessment that laparoscopic antireflux procedures were better than open procedures. Conclusions: Further detailed studies in the future with careful outcome assessment are necessary to underline the consensus that laparoscopic antireflux operations can be recommended.

Laparoscopic antireflux surgery for gastroesophageal reflux disease (GERD)

In western countries, gastroesophageal reflux has a high prevalence and, in the USA and Europe in up to 44% of the adult population describe symptoms characteristic for GERD. Troublesome symptoms characteristic for GERD occur in 10–15% with equal frequency in men and women. Men, however, seem to develop reflux esophagitis and complications of esophagitis more frequently than women. Data from the literature indicate that 10–50% of these subjects will need long-term treatment of some kind for their symptoms and/or esophagitis.

Preincisional local anesthesia with bupivacaine and pain after laparoscopic cholecystectomy

SummaryThe aim of this study was to investigate whether local anesthesia of abdominal wall wounds prior to laparoscopic cholecystectomy leads to decreased pain beyond the immediate postoperative period and thus improves the comfort of the patient. In a randomized, double-blind study 50 patients scheduled for laparoscopic cholecystectomy were divided into two groups. In one group (n=25) the skin, subcutis, fascia, muscle, and preperitoneal space were infiltrated with 8 ml of bupivacaine 0.5% 5 min before each abdominal wall incision. The control group (n=25) received normal saline.The intensity of pain was assessed by a 100-point visual analogue scale (VAS) at rest and during movement and by the consumption of analgesics. Analgesic therapy was provided by on-demand analgesia with piritramid intravenously for 24 h and continued by ibuprofen orally on request.The mean intensity of pain at rest and during movement was lower but not statistically significant in patients who received bupivacaine compared to the control group up to the second postoperative day. The difference was between 4 and 9 VAS points and therefore of doubtful clinical relevance. Similar statistically nonsignificant results were found for the mean consumption of piritramid up to 16 h after the operation. Three patients (12%) in the bupivacaine group localized the most severe pain up to the second postoperative day to the right lower abdominal wall wound where the gallbladder had been extracted compared to 11 patients (44%) of the control group (P=0.012). These results indicate that bupivacaine was effective at the site where it was administered. However, preincisional local anesthesia of the abdominal wall wounds in laparoscopic cholecystectomy does not lead to a significant clinical benefit for the patient.

Laparoscopic and conventional closure of perforated peptic ulcer

AbstractBackground: After the first successful laparoscopic closure of a perforated peptic ulcer in 1990, 18 patients with laparoscopic closure were compared to 16 patients with conventional surgery. Methods: The endpoint adverse events (complications), pain intensity, operation time, fever, leucocytosis, and duration of hospital stay showed no clinically relevant differences. Results: Consumption of analgesics was lower in the laparoscopic group. Conclusions: Laparoscopic closure of perforated peptic ulcer is technically feasible. The safety of the method and the benefit for the patient need proof by means of a randomized controlled trial.

Port function after laparoscopic adjustable gastric banding for morbid obesity

Background: Laparoscopic adjustable gastric banding (LGB) has gained wide popularity, but information on port function is limited. Methods: In a prospective nonrandomized study, we analyzed port function and related symptoms in 50 consecutive patients with severe obesity. All patients underwent LGP in a five trocar technique. In 11 patients, the port was placed subcutaneously in the subxiphoid region. In 39 patients, the port was implanted in the left upper abdomen. Mean duration of follow-up was 2.8 years. Results: Patients (12 males and 38 females) had an initial body mass index (BMI) of 47.1 kg/m2. Puncturing the subxiphoidal port was without problems in all 11 patients. However, seven women reported pain and inconvenience when wearing a brassiere. Two underwent port reimplantation in the left upper abdomen (one due to infection; one due to pain). Among the 39 patients with abdominal port implantation, nine patients required port correction (two of them twice). The causes were port dislocation (four cases), difficult puncturing (three), tube leakage (three), and infection (one).Conclusion: The high number of complications suggests that the port is the Achilles’ heel of LGB. Ports at the subxiphoid site were easier to puncture, but frequently caused pain in female patients.

Organisation der Schmerztherapie in der Chirurgie

ZusammenfassungEin chirurgisch geleiteter Akutschmerzdienst ist eine der verschiedenen Möglichkeiten, die Schmerztherapie auf chirurgischen Stationen effektiv zu gestalten. Dabei sind einige personelle und organisatorische Voraussetzungen wie die 24-Stunden-Bereitschaft, integrierte Dokumentationssysteme und ein Team aus ärztlichen und pflegerischen Mitarbeitern notwendig. In Häusern der Grund- und Regelversorgung kann auch ohne einen Akutschmerzdienst eine effektive Schmerztherapie durchgeführt werden.In der Vergleichsstudie zwischen drei verschiedenen Modellen der Organisation der Schmerztherapie in der Chirurgie (mit und ohne Akutschmerzdienst) fand sich in allen drei Kliniken ein ähnlich hohes Maß an Zufriedenheit mit der Schmerztherapie bei den Patienten. Voraussetzung für eine effiziente Schmerztherapie in der Chirurgie ist, dass ein den Anforderungen des jeweiligen Hauses entsprechendes Konzept entwickelt und umgesetzt wird.AbstractAn acute pain service done by surgeons is one possibility for organizing pain therapy in surgical wards. To do this successfully, some preconditions must be kept in mind, such as 24-h presence, an integrated system of documentation, and teamwork between medical and nursing staff. Comparison of differently structured pain therapy in three different hospitals (with and without acute pain service) showed high levels of patient satisfaction with the pain therapies in all three hospitals. One of the preconditions for effective pain therapy in surgery is to formulate a concept which takes into account the specific situation of each hospital.

Laparoskopische colorectale Chirurgie – Versuch der Bewertung einer neuen Technologie

Summary. The aim of this study was to access the importance of the laparoscopic colorectal resection. Of 131 patients 80 were operated on laparoscopically. The conversion rate was 14 % (13/93). A total of 47 patients suffered from cancer. Curative resection was performed in 41 patients (87 %). For comparison, 48 patients who underwent open resection were used. The complication rate was lower after laparoscopy and no reoperation was performed. Patients recovered quicker and their first oral food intake and bowel movement were earlier. Hospital stay was shorter (15.3 vs. 8.1 days), and pain at rest and in motion was significantly reduced. Equal numbers of mesenteric lymph nodes were retrieved; adequate margins of resection could be obtained and the length of resected bowel did not differ. No port metastases were observed. Reduced morbidity, reduced hospital stay, reduced abdominal pain, quicker reconvalescence, and reduced overall health care costs are strong arguments in favor of laparoscopic colectomy.Zusammenfassung. Ziel der Untersuchung war, die Wertigkeit der laparoskopischen colorectalen Chirurgie zu untersuchen. Von 131 Patienten wurden 80 (61 %) laparoskopisch operiert. Bei 13/93 (14 %) wurde konvertiert. 47 (59 %) litten an einem Carcinom, 41 wurden kurativ operiert. Zum Vergleich dienten 48 offen operierte Patienten. Die Komplikationsrate war nach laparoskopischer Technik reduziert, Reoperationen waren nicht notwendig, die Rekonvaleszenz war rascher; erste Nahrungsaufnahme und erster Stuhlgang traten früher auf. Die Krankenhausverweildauer war verkürzt (15,3 vs. 8,1 Tage). Die Schmerzen waren in Ruhe und Bewegung signifikant geringer. Resektatlänge, Resektionsabstände und Anzahl der entfernten Lymphknoten waren gleich. Portmetastasen wurden nicht beobachtet. Eine verminderte Morbidität, ein verkürzter Krankenhausaufenthalt, verminderte Schmerzen, eine schnellere Rekonvaleszenz bei adäquater Radikalität und akzeptablen Kosten sprechen für die laparoskopische Technik.

Combined abdominal wall paresis and incisional hernia after laparoscopic cholecystectomy

Abstract. A case of combined abdominal wall paresis and incisional hernia after laparoscopic cholecystectomy is reported. The paresis possibly occurred by a lesion of the N. intercostalis when extending the incision for stone extraction. Possibly the paresis was a predisposing factor for the development of an incisional hernia. The causes of abdominal wall paresis are explored with a review of the literature. In spite of minimal trauma to the anterior abdominal wall in laparoscopic procedures, the risk of iatrogenic lesions remains.

Qualitätskontrolle in der Leistenhernienchirurgie

Summary. Quality assurance is a concept intended to ensure the quality of a surgical therapy on a defined level. But what is “quality” in surgical therapy? Quality can be described in a lot of different ways. Quality has something to do with taste, especially with individual preferences. The testing of the quality of wine is a good example. Even though this is quite difficult, it can still be done and has been done for hundreds of years. In surgery we are still at the beginning. Discussions regarding the definition of quality, the best method of quality assurance and, not least, who is responsibility for its measurement are well-known obstacles on the path to improvement. Quality has basically little to do with research. It is not a matter of finding the right technique, but of ensuring that the right technique, when found, is correctly used. Defined quality standards will allow this. Quality standards in inguinal hernia surgery are: outstanding comfort directly before and after the therapy, few or no side effects troubling the patient, most of all no disastrous side effects, disaster, low rate of relapse and, in our times, decent economy. The question: “Is the target to be oriented on the average or must the standard be brought nearer the best performance?” has to be answered. Surgery and average performance do not match; surgical performance cannot be oriented on the average. The next question is: “Which methods are suitable for this?”. The “tracer method” is one method, one aspect within quality assurance methods in general. It is designed for obtaining information on the quality of a clinic/department. The obtained data on complication rates, for example (10 %), and their striking points should above all give insight into the complete department, i. e., on complication rates of a surgical department in general. The same counts for infection rates or striking points. The essential question remains: “Who should carry it out?” Bureaucrats lacking expertise will buy it. The principle of autonomy, “expertise connected to competence” has to be kept when answering the question of who should do it and how. The tracer method, using hernia surgery as a tracer, is not necessarily suitable as a measure of the quality of inguinal hernia surgery. Even though it supplies – as a side effect – information about inguinal hernia surgery, like complication rates (10 %) and relapse operations (10 %), as well as the varying anaesthetic procedures, or the use for changes in therapeutic procedures, the tracer method is not suitable to sufficiently inform about the quality of inguinal hernia surgery in particular. A further essential aspect when analysing quality assurance – showing up clearly at the moment – is the fact, that “another” control will develop if this inactivity remains. In this case the “controllers” will certainly not be the surgeons. The nightmare vision of bureaucrats (insurance companies or other parties) as controllers is in sight. This would be the same situation as if Michael Schumachers Ferrari were checked by clerks and not by engineers.Zusammenfassung. Qualitätssicherung ist eine Konzeption, die die Qualität einer chirurgischen Therapie auf einem definierten Niveau sichern soll. Es besteht das Problem: „Was ist Qualität?“ in der chirurgischen Therapie. Es gibt viele unterschiedliche Wege Qualität zu beschreiben. Qualität hat etwas zu tun mit Geschmack, besonders mit individuellen Präferenzen. Die Prüfung der Qualität des Weines ist hierfür ein gutes Beispiel. Obwohl schwierig läßt sie sich hier bestimmen und dies seit Hunderten von Jahren. In der Chirurgie sind wir erst am Anfang. Die Diskussion über die Definition von Qualität, über die bessere Methode von Qualitätssicherung und nicht zuletzt über die Zuständigkeiten für diese Aktion sind die bekannten Hindernisse auf dem Weg zum Besseren. Qualität hat ganz grundsätzlich wenig mit Forschung zu tun. Es gilt nicht die richtige Technik zu finden, sondern zu sichern, daß die als richtig gefundene Technik richtig angewandt wird. Dies gelingt über festgelegte Qualitätsstandards. Qualitätsstandards in der Leistenhernienchirurgie sind: hervorragender Komfort unmittelbar vor und nach der Therapie, wenige oder keine den Patienten belästigenden Nebenwirkungen, vor allem keine Nebenwirkungen, die für den Patienten ein echtes Desaster darstellen, eine zumindest geringe Rezidivrate und trägt schließlich auch zur ökonomischen Transparenz bei. Es besteht die Frage: „Ist die Zielvorgabe am Durchschnitt orientiert, oder ist der Standard mehr in der Nähe der Bestleistung anzusiedeln?“ Chirurgie und Durchschnitt, das paßt nicht; Chirurgie, chirurgische Leistung kann sich nicht am Durchschnitt orientieren. Die nächste Frage ist: „Welche der Methoden ist hierfür geeignet?“. Die Tracer-Methode ist eine Methode, ein Aspekt, innerhalb der Qualitätssicherungsmethoden ganz allgemein. Sie ist konzipiert, um über die Qualität einer Abteilung Information zu bekommen. Die erhaltenen Daten über Komplikationsraten, z. B. (10 %), und deren Auffälligkeiten sollen vor allem Aufschluß geben über die gesamte Abteilung, also über Komplikationsraten einer chirurgischen Abteilung ganz allgemein. Ähnliches gilt für „Infektionsraten“ oder Auffälligkeiten. Es bleibt die entscheidende Frage: „Wer soll es machen?“. Bürokraten – ohne jegliche Fachkompetenz – werden sich diese kaufen, wenn sie ihnen fehlt. Das Prinzip der Selbstverwaltung, Kompetenz mit Entscheidungsbefugnis zu verbinden, muß auch bei der Beantwortung der Frage: „Wer soll es machen und wie?“ beibehalten werden. Die Tracer-Methode, die die Leistenhernienchirurgie als Tracer benutzt, ist also nur bedingt geeignet, über die Qualität der Leistenhernienchirurgie zu informieren. Wenn sie auch im Nebenschluß Informationen zur Leistenhernienchirurgie liefert, wie z. B. Komplikationsraten (10 %), Rezidivoperationen (10 %), sowie die unterschiedlich durchgeführten Anaesthesieverfahren oder die jeweils angewandten oder sich verändernden Therapieverfahren. Ein weiterer wesentlicher Aspekt, der bei der Analyse der Qualitätssicherung derzeit deutlich wird, ist die Tatsache, daß bei fortwährender Untätigkeit auf diesem Gebiet eine andere Kontrolle entstehen wird. Die Kontrolleure werden dann allerdings nicht mehr die Chirurgen sein. Die Horrorvision „Bürokraten als Kontrolleure (Krankenkassen oder andere Gruppierungen)“ steht vor uns. Dies wäre eine Situation, wie wenn Schumachers Ferrari von Buchhaltern und Bürokraten und nicht von Ingenieuren gecheckt würde.