Yoo Shin Choi

Peritrocal and intraperitoneal ropivacaine for laparoscopic cholecystectomy: a prospective, randomized, double-blind controlled trial.

BACKGROUND The goal of this study was to evaluate the effect of peritrocal, intraperitoneal, or combined peritrocal-intraperitoneal ropivacaine on the parietal, visceral, and shoulder tip pain after laparoscopic cholecystectomy. METHODS Eighty patients were randomly assigned to four groups. Group A received peritrocal and intraperitoneal saline. Group B received peritrocal saline and intraperitoneal ropivacaine. Group C received peritrocal ropivacaine and intraperitoneal saline. Group D received peritrocal and intraperitoneal ropivacaine. The parietal, visceral, and shoulder tip pain were assessed at 2, 4, 8, 12, 24, and 48 h postoperatively using a visual analog scale (VAS). The frequency of the patient pushing the button of the PCA and fentanyl use were also recorded. RESULTS In visceral pain, significantly lower VAS scores were observed in Group B from 2 to 4 h and in Group D from 2 to 8 h. In parietal pain, significantly lower VAS scores were observed in Group C from 4 to 24 h and in Group D from 2 to 12 h. In shoulder tip pain, significantly lower VAS scores were observed in Group B from 4 to 48 h and in Group D from 2 to 12 h. The fentanyl use and the frequency to push the button of the PCA were the highest in Group A and the lowest in Group D at every time point. CONCLUSIONS We conclude that peritrocal infiltration of ropivacaine significantly decreases parietal pain and intraperitoneal instillation of ropivacaine significantly decreases the visceral and shoulder tip pain. Their effects are additive with respect to the total pain.

An Assessment of the Effects of a Hyaluronan-Based Solution on Reduction of Postsurgical Adhesion Formation in Rats: A Comparative Study of Hyaluronan-Based Solution and Two Film Barriers

BACKGROUND Intra-abdominal application of anti-adhesive barriers may reduce the extent and severity of postoperative adhesions. This study was designed to compare the effectiveness of a sprayable liquid barrier (a mixed solution of sodium hyaluronate and carboxymethylcellulose) with two conventional sheets. METHODS Eighty male Sprague Dawley rats underwent laparotomy with subsequent multiple intestinal wall abrasions and abdominal wall injury. Afterwards, sodium hyaluronate and carboxymethylcellulose (HA-CMC) solutions were intraperitoneally sprayed or a film barrier of either oxidized regenerated cellulose (ORC) or polylactic acid (PA) was placed under the incision. At postoperative d 21, the rats underwent relaparotomy and complete adhesiolysis. Three investigators, who were blind to the group assignment, scored the extent of adhesion formation and resected specimens for histologic examination of fibrosis and inflammation. Expression profiles of parameters as mediators (macrophages [CD68]) in cellular inflammation response were analyzed. RESULTS Mean adhesion scores in rats that received HA-CMC solution (7.6±2.3) and ORC membrane (8.1±2.2) were lower than in rats that received PA film (10.7±2.5) and the control group (11.2±2.6) (P<0.05 for each comparison). In addition, there were significantly fewer adhesions located between large and small intestine in the HA-CMC solution group than in the control and each of the film barrier groups (P<0.05 for each comparison). CONCLUSIONS This study suggests that both HA-CMC solution and ORC membrane decrease the overall incidence of postoperative adhesions. However, the mixed solution of HA-CMC appeared to be superior to ORC membrane because this sprayable solution is easy to use and suitable for site-specific adhesion prevention after multifocal bowel trauma.

Pre- and intraoperative lidocaine injection for preemptive analgesics in laparoscopic gastrectomy: a prospective, randomized, double-blind, placebo-controlled study.

BACKGROUND The preemptive intravenous injection of local anesthetics is known to improve postoperative pains in abdominal surgery. The aim of this study is to assess the effect of intravenous lidocaine injection and analyze the precise amount of pain by computerized patient-controlled analgesia (PCA) in patients who had undergone laparoscopy-assisted distal gastrectomy (LADG). PATIENTS AND METHODS A double-blind placebo control study was designed, and 34 patients undergoing LADG for early gastric cancer were divided into two groups. Preoperatively and throughout the surgery, Group I received intravenous lidocaine injection, and Group C received normal saline injection for placebo. Postoperative outcomes, including the visual analog scale (VAS), the button hit counts (BHC) from PCA, and amount of fentanyl consumed, were measured. RESULTS The demographic data were similar between the groups. The VAS score, BHC, and fentanyl consumption were lower in Group I compared with Group C (P<.05). In particular, fentanyl consumption and BHC in Group I showed a significant decrease during the first 12 hours of the study (P<.05). Postoperative adverse events showed no difference except that nausea was more frequent in the placebo group (P=.039). CONCLUSIONS In this study, intravenous lidocaine injection showed a significant reduction in fentanyl consumption and pain during the earlier postoperative time with more favorable outcomes.

Efficacy of intraperitoneal and intravenous lidocaine on pain relief after laparoscopic cholecystectomy

Objectives This randomized, double-blind, placebo-controlled trial evaluated intraperitoneal (IP) lidocaine administration and intravenous (IV) lidocaine infusion for postoperative pain control after laparoscopic cholecystectomy (LC). Methods Patients who underwent LC were randomized to either group IV (intravenous lidocaine infusion), group IP (intraperitoneal lidocaine administration), or group C (control, IP and IV saline). Outcome measures were total postoperative pain severity (TPPS), total fentanyl consumption (TFC), frequency of administering patient-controlled analgesia (FPB), and a pain control satisfaction score (PCSS). Results Significantly reduced TPPS, TFC and FPB scores were observed in groups IP (n = 22) and IV (n = 26) compared with controls (n = 24). PCSS was higher in groups IP and IV than in controls. At 2 h postoperation, TPPS was significantly lower in group IP than group IV; at 0–2 h postoperation, FPB was lower in group IP than group IV. Conclusions The IP administration of lidocaine and IV lidocaine infusion significantly reduced postoperative pain and opioid consumption in LC patients, compared with control infusions. For convenience, IV lidocaine could be used for pain reduction following LC; IP administration places additional burden on the surgeon.

Single port laparoscopic appendectomy in children using glove port and conventional rigid instruments

Purpose To further improve the advantages of minimally invasive surgery, single port laparoscopic techniques continue to be developed. We report our initial experience with single port laparoscopic appendectomy (SPLA) in children and compare its outcomes to those of conventional laparoscopic appendectomy (CLA). Methods Clinical data were prospectively collected for SPLA cases performed at Chung-Ang University Hospital by a single surgeon between March 2011 and December 2011, including operative time, perioperative complications, conversion rate, and length of hospital stay. Each case of SPLA was performed using conventional laparoscopic instruments through Glove port placed into the single umbilical incision. To compare outcomes, a retrospective review was performed for those patients who underwent CLA between March 2010 and December 2010. Results Thirty-one patients underwent SPLA and 114 patients underwent CLA. Mean age (10.5 years vs. 11.1 years, P = 0.43), weight (48.2 kg vs. 42.9 kg, P = 0.27), and operation time (41.8 minutes vs. 37.9 minutes, P = 0.190) were comparable between both groups. Mean hospital stay was longer for CLA group (2.6 days vs. 3.7 days, P = 0.013). There was no conversion to conventional laparoscopic surgery in SPLA group. In CLA group, there were nine complications (7.9%) with 3 cases of postoperative ileuses and 6 cases wound problems. There was one complication (3.2%) of umbilical surgical site infection in SPLA group (P = 0.325). Conclusion The results of this study demonstrated that SPLA using conventional laparoscopic instruments is technically feasible and safe in children. SPLA using conventional laparoscopic instruments might be popularized by eliminating the need for specially designed instruments.

Accidental gallbladder perforation during laparoscopic cholecystectomy: does it have an effect on the clinical outcomes?

BACKGROUND Accidental gallbladder perforation during laparoscopic cholecystectomy (LC) is on the rise because of increased attempts at minimally invasive surgery. There have been a number of studies attempting to determine the influence of gallbladder perforation on the clinical outcomes, but the results are still conflicting. Therefore, we investigated the clinical outcomes and the risk factors in patients who sustained a gallbladder perforation during LC. METHODS We evaluated 198 patients who underwent LC between April 2009 and March 2010. Data were collected from a prospectively maintained database. RESULTS Thirty-three patients sustained a gallbladder perforation (16.7%) and it primarily occurred during dissection of the hepatic fossa in 21 patients (63.6%). The mean operative time and duration of postoperative hospitalization were longer in the perforated group (P=.015 and P=.001). Visual analog scale scores on the first and second postoperative days were higher in the perforated group (P=.009 and P=.034). Complications such as ileus and trocar site infection developed more frequently in patients with a gallbladder perforation (P=.001 and P=.004). There was no significant factor related to gallbladder perforation except for male gender (P=.017). CONCLUSION Accidental gallbladder perforation can cause more postoperative pain, ileus, and trocar site infection, which consequently increases the total duration of hospitalization, undermining the advantages of LC. Based on these interesting results, surgeons should make every effort to prevent gallbladder perforation by performing meticulous dissection during the operation.

Left paraduodenal hernia combined with acute cholecystitis

Paraduodenal hernia is a rare congenital malformation. Management consists of reduction of the herniated intestine and repair of the defect. A 74-year-old woman presented to the Emergency Department with persistent right upper quadrant pain that began 3 hours ago. Physical examination revealed tenderness at right upper quadrant of abdomen. Computed tomography revealed multiple gallstones with gallbladder wall thickening, marked dilatation of stomach and duodenum and a sac-like mass of small bowel loops to left of ligament of Treitz suggesting acute cholecystitis and left paraduodenal hernia. Laparoscopic exploration of abdomen was performed and cholecystectomy, bowel reduction, and closure of defect with intracorporeal interrupted suturing were performed. For left paraduodenal hernia without bowel necrosis, laparoscopic reduction of incarcerated bowel and closure of hernial orifice are technically feasible and may be the surgical method of choice because of its minimal invasiveness and aesthetic advantage.

Laparoscopy-assisted distal gastrectomy for gastric cancer patients with comorbid diseases: is it contraindicated for patients with systemic comorbidity?

Background This study was carried out to evaluate the safety and feasibility of laparoscopy-assisted distal gastrectomy (LADG) for gastric cancer patients with systemic comorbidity. Materials and Methods Two hundred and seventy-six patients who had undergone LADG by a single surgeon were given a physical status classification as defined by the American Society of Anesthesiologists (ASA class) and then divided into 2 criteria groups: criteria I group (ASA 1 vs ASA 2,3,4) and criteria II group (ASA 1,2 vs ASA 3,4). The clinicopathologic data of each patient were reviewed retrospectively and grouped by criteria. Results The percentage of patients with a comorbid disease was 8.1% (11 cases) in ASA class 1, 71.7% (86 cases) in class 2, 95.0% (19 cases) in class 3, and 100% (1 case) in class 4. No statistical difference was found between criteria I and II in terms of operative and postoperative results, operative time, estimated blood loss, transfusion rate, tumor size, total and positive number of dissected lymph nodes, proximal resection margin from lesion, the rate of open conversion, the duration of hospital stay, the time required before resuming a liquid diet, and the rate of complications, except the distal resection margin in criteria II (all P >0.05). There were no cases of mortality in any criteria group. Conclusions LADG would be a safe and feasible operation for patients with gastric cancer with systemic comorbidity, without reducing radicality, losing the advantages of minimally invasive surgery, or increasing operative risk.

Pancreaticoduodenectomy performed in a patient with situs ambiguous accompanied with isolated levocardia, malrotation, and normal spleen

We report a case of common bile duct (CBD) cancer, successfully managed with pancreaticoduodenectomy, in a patient with isolated levocardia, malrotation, and situs ambiguous (without splenic anomalies). A 59-year-old male patient was referred to Chung-Ang University Hospital with epigastric pain and jaundice. CT and MRI revealed distal CBD cancer without significant lymphadenopathy. Multiple abdominal anatomic anomalies were identified preoperatively, whereas no anatomic anomalies were detected within the chest. The patient had a right-sided stomach and spleen, liver at the midline, several vascular variations around the celiac axis, and intestinal malrotation, but the inferior vena cava and portal vein were normal. A pancreaticoduodenectomy was performed to treat the cancer. The postoperative course was favorable, and the patient was started on combined chemotherapy and radiotherapy 15 days after the surgery. In this case study, we report that pylorus preserving pancreaticoduodenectomy was successful for distal CBD cancer in a patient with rare situs anomalies.

Torsion of the gallbladder in pregnancy.

Torsion of the gallbladder is a rare condition that is difficult to diagnose preoperatively, but prompt surgical intervention is necessary to avoid possible sepsis and death. A 36-year-old pregnant woman presented to Emergency Department with a constant epigastric pain at 17 weeks of gestation. Abdominal ultrasonography and magnetic resonance imaging demonstrated a distended gallbladder that contained no stones but had mild wall thickening. Laparoscopic cholecystectomy using three ports was performed under the impression of an acalculous cholecystitis. The gallbladder was found to be rotated 180 degrees clockwise on gallbladder mesentery and to be gangrenous. The postoperative course was uneventful and the patient was discharged on the 4th day after surgery. It is important to keep in mind gallbladder torsion in the differential diagnosis from acute cholecystitis when the patient has an acute onset of abdominal pain and a severely distended gallbldder. Prompt cholecystectomy via a laparoscopic approach should be performed.