Background Pain management in patients undergoing laparoscopy is still a matter of debate as several techniques have been proposed to reduce postoperative analgesic consumption and improve recovery. Among these, transversus abdominis plane (TAP) block is considered as safe, effective, and easy to perform under ultrasound guidance; even so, recently laparoscopically guided trocar site anesthetic infiltration has been proposed as a “surgeon-dependent alternative to TAP block.” The aim of this evaluation is to compare these analgesic techniques in the setting of laparoscopic adrenalectomy. Methods This is a retrospective evaluation of a prospectively maintained database. Patients were divided into two groups: Group A patients received laparoscopic-assisted trocar site infiltration of ropivacaine; Group B patients received bilateral ultrasound-guided TAP block with ropivacaine. All patients received 24 h infusion of 20 mg morphine postoperatively; pain was checked at 6, 24 and 48 h after surgery. A rescue analgesia was given if numerical rating scale (NRS) score was > 4 or on patient request. Results One hundred and three patients were enrolled in the evaluation (57 in group A and 46 in group B). There were no differences in operative time, complications and postoperative stay, and no complications related to trocar site infiltration. There were no differences in NRS at 6, 24, and 48 hours as well as in patients requiring further analgesic administration. Conclusions Laparoscopic-guided trocar site ropivacaine infiltration has similar pain outcomes compared to ultrasound-guided TAP block in the management of postoperative pain in patients undergoing laparoscopic adrenalectomy. Since there is no difference among these techniques, the decision can be based on surgeon or anesthesiologist preference.
Purpose: This retrospective study aimed to evaluate the clinical outcomes (mortality rate, operative time, complications) of elective LC when performed by a surgical resident in the backdrop of Italian academic centers.Methods: A retrospective review of all patients undergoing elective LC between January 2016 and January 2022 at six teaching hospitals across Italy was performed. Cases were identified using the Current Procedural Terminology (CPT) code 5123 (LC without cholangiogram). All cases of emergency surgery, ASA score > 3, or when cholecystectomy was performed with another surgical procedure, were excluded. All suitable cases were divided into 2 groups based on primary surgeon: consultant (group A) or senior resident (group B).Results: A total of 2331 cases (1425 females) were included, of which, consultants performed 1683 LCs, while the residents performed 648 surgeries. The groups were statistically comparable regarding demographics, history of previous abdominal surgery, operative time, or intraoperative complications (p > 0.05). The rate of conversion to open cholecystectomy was 1.42% for group A and none for Group B. However, a statistically significant difference was observed between groups A and B regarding the average length of stay and postoperative complications (2.2 ± 3 versus 1.6 ± 1.3 days, and 1.7% versus 0.5%, respectively; p < 0.05 each). Conclusions: Our study demonstrates that in selected patients, senior residents can safely perform LC when supervised by senior staff surgeons.
BaCKgrOuND: hiatal hernia repair (hhr) is still controversial during bariatric procedures, especially in case of laparoscopic sleeve gastrectomy (LSg). aims: to report the long-term results of concomitant hhr, evaluating the safety and efficacy of posterior cruroplasty (PC), simple or reinforced with biosynthetic, absorbable Bio-a ® mesh (gore, Flagstaff, aZ, uSa). Primary endpoint: PC's failure, defined as symptomatic hh recurrence, nonresponding to medical treatment and requiring revisional surgery. MeThODS: The prospective database of 1876 bariatric operations performed in a center of excellence between 2011-2019 was searched for concomitant hhr. intraoperative measurement of the hiatal surface area (hSa) was performed routinely. reSuLTS: a total of 250 patients undergone bariatric surgery and concomitant hhr (13%). Simple PC (group a, 151 patients) was performed during 130 LSg, 5 re-sleeves and 16 gastric bypasses; mean BMi 43.4±5.8 kg/m 2 , hSa mean size 3.4±2 cm 2 . reinforced PC (group B) was performed in 99 cases: 62 primary LSg, 22 LgB and 15 revisions of LSg; mean BMi 44.6±7.7 kg/m2, hSa mean size 6.7±2 cm 2 . PC's failure, with intrathoracic migration (iTM) of the LSg was encountered in 12 cases (8%) of simple vs. only 4 cases (4%) of reinforced PC (P=0.23); hence, a repeat, reinforced PC and r-en-Y gastric bypass (LrYgB) was performed laparoscopically in all cases. No mesh-related complications were registered perioperatively or after long-term follow-up (mean 50 months). One case of cardiac metaplasia without goblet cells was detected 4 years postoperatively; conversion to LrYgB, with reinforced redo of the PC was performed. The Cox hazard analysis showed that the use of more than four stitches for cruroplasty represents a negative factor on recurrence (hr=8; P<0.05). CONCLuSiONS: an aggressive search for and repair of hh during any bariatric procedure seems advisable, allowing a low hh recurrence rates. additional measures, like mesh reinforcement of crural closure with biosynthetic, absorbable mesh, seem to improve results on long term follow-up, especially in case of larger hiatal defects. in our experience, reinforcement of even smaller defects seems advisable in obese population.
Background The present study was conducted to evaluate the impact of enhanced recovery after surgery (ERAS) pathway in patients undergoing laparoscopic adrenalectomy (LA) for primary and secondary adrenal disease, in reducing the length of primary hospital stay and return to daily activities. Materials and Methods: This retrospective study was carried out on 61 patients who underwent LA. A total of 32 patients formed the ERAS group. A total of 29 patients received conventional perioperative care and were assigned as the control group. Groups were compared in terms of patient’s characteristics (sex, age, pre-operative diagnosis, side of tumour, tumour size and co-morbidities), post-operative compliance (anaesthesia time, operative time, post-operative stay, post-operative numeric rating scale (NRS) score, analgesic assumption and days to return to daily activities) and post-operative complications. Results: No significant differences in anaesthesia time (P = 0.4) and operative time (P = 0.6) were reported. NRS score 24 h postoperatively was significantly lower in the ERAS group (P < 0.05). The analgesic assumption in post-operative period in the ERAS group was lower (P < 0.05). ERAS protocol led to a significantly shorter length of post-operative stay (P < 0.05) and to return to daily activities (P < 0.05). No differences in peri-operative complications were reported. Discussion ERAS protocols seem safe and feasible, potentially improving perioperative outcomes of patients undergoing LA, mainly improving pain control, hospital stay and return to daily activities. Further studies are needed to investigate overall compliance with ERAS protocols and their impact on clinical outcomes.
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