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Laparoscopy papers


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Randomised trial of early versus delayed laparoscopic cholecystectomy for acute cholecystitis.  Lai P B S, Kwong K H, Leung K L et al.  Br J Surg 1998; 85: 764-767.

Laparoscopic cholecystectomy has become the 'gold standard' treatment for symptomatic gallstones and chronic cholecystitis. Its role in the management of acute cholecystitis is at present unclear. Some have suggested that in acute cholecystitis it is technically difficult, possibly unsafe and has a higher conversion rate than an open operation. The optimal time for laparoscopic cholecystectomy in acute cholecystitis remains to be determined. This study was performed as a randomised controlled trial in 104 patients with ultrasonic evidence of acute cholecystitis and no evidence of acute cholangitis or acute pancreatitis. Patients were randomised to either 'early' laparoscopic cholecystectomy within 24 hours of randomisation or 'delayed' operation at six to eight weeks. The conversion rate was high but similar (21% early vs. 24% late) in both groups. There was similar analgesic requirements in the two groups. The 'early' operation group had a longer operation time (123 min vs. 107 min) but a shorter overall hospital stay (8 vs. 12 days). It was concluded that laparoscopic cholecystectomy in acute cholecystitis is both feasible and safe and results in a reduced hospital stay.

Audit of methods of laparoscopic cholecystectomy.  Chitre V V, Studley J G N.  Br J Surg 1999; 86: 185-188.

The operation of laparoscopic cholecystectomy began the modern era of laparoscopic surgery. Refinements in technique continue to appear. The techniques favoured by British surgeons was reviewed. A simple questionnaire was sent to 396 members of the Association of Endoscopic Surgeons of Great Britain and Ireland enquiring into the their technique for laparoscopic cholecystectomy. A 66% response rate was achieved. The results showed that 50% did not use a nasogastric tube or urinary catheter. To induce the pneumoperitoneum 31% always used an open (Hasson) technique and 30% used a Veress needle. 75% used an intraperitoneal pressure of between 12 and 15 mmHg. 87% used four standard ports (umbilical, epigastric, right hypochondrium x2). 64% positioned the patient with a head up tilt and rolled to the left. 41% used blunt dissection of Calot's triangle. 65% used selective cholangiography. Most surgeons were not concerned with spilt stones. Only 12% performed no fascial repair at the end of the operation. It was concluded that practice within this country is variable. There appears to be a consensus against performing cholangiography in all cases. The dangers associated with the use of a Veress needle may not be well recognised.

Prospective randomised multicentre study of laparoscopic versus open appendicectomy.  Hellberg A,  Rudberg C,  Kullman E et alBr J Surg 1999;  86:  48-53.

Open appendicectomy is the 'gold standard' for the treatment of acute appendicitis.  Although it is a generally safe operation, postoperative complications occur in about 10% of patients.  Laparoscopic appendicectomy was first described in 1983.  Reports of early studies were equivocal with few studies evaluating analgesic requirements and the length of hospital stay.  The aim of this study was to compare laparoscopic with open appendicectomy with special emphasis on the postoperative recovery period.  A total of 523 patients were randomised but because of withdrawals the outcome in 500 patients was reported; 244 in the laparoscopic and 256 in the open group. Patients undergoing laparoscopic appendicectomy recovered quicker than those undergoing open surgery but there was no difference in the duration of sick leave taken (11 vs. 14 days).  Postoperative pain (at 24 hours, 7 and 14 days) was less after laparoscopic surgery and a functional index at one week after operation was more favourable in this group.  Operating time was longer in the laparoscopic group ( 60 vs. 35 mins.  p<0.01).  Hospital stay and complications did not differ between the two group.  In total 30 (12%) of laparoscopic procedures had to be converted to an open operation.  It was concluded that laparoscopic appendicectomy is as safe as open appendicectomy and has the advantage of a more rapid recovery.

Randomised clinical trial of laparoscopic versus open fundoplication:  blind evaluation of recovery and discharge period.  Nilsson G,  Larsson S,  Johnsson F.  Br J Surg 2000;  87:  873-878.

Gastro-oesophageal reflux disease (GORD) is the commonest upper gastrointestinal condition in the Western world.  For patients with severe symptoms, surgery offers the opportunity for a significant improvement in the quality of life.  The commonest procedure is the 360 degree fundoplication which can be performed via either an open or laparoscopic approach.  A number of publications have reported laparoscopic fundoplication to be effective, safe and to be associated with a higher patient acceptability than the conventional open procedure. Most of these studies have used historical control groups.   The aim of this study was to directly compare laparoscopic and open fundoplication in a prospective randomised trial with blind evaluation and with special reference to the postoperative recovery and discharge.  Sixty patients with GORD were randomised to either open or laparoscopic 360 degree fundoplication.  The type of operation was unknown to the patients and the evaluating nurses.  The median operating time was longer in the laparoscopy group (148 vs. 109 min p<0.0001).  The need for analgesia was less in the laparoscopic group (33.9 vs. 67.5 mg morphine. p<0.001).  There was no difference in the rate of postoperative nausea and vomiting.  The laparoscopic group had better respiratory function (improved FVC & FEV1) on the first postoperative day.  Postoperative stay was shorter in the laparoscopic group but there was no difference in the duration of sick leave.  It was concluded that laparoscopic fundoplication is associated with a longer operating time but better postoperative respiratory function, reduced analgesic requirements and shorted hospital stay.

Patterns of recurrence and survival after laparoscopic and conventional resections for colorectal carcinoma.  Hartley J E, Mehigan B J, MacDonald A W, Lee P W R, Monson J R T.  Ann Surg 2000;  232:  181-186.

Of patients with colorectal cancer, approximately 50% undergo resection with curative intent of whom 50% can be expected to be alive at 5 years.  The use of any new treatment modality, such a laparoscopic-assisted colectomy, should produce at least a similar recurrence and survival profile.  Laparoscopic colorectal surgery was introduced in 1991 but has not been widely adopted due concerns regarding oncological safety.  Evidence from non-randomised studies suggest that resection margins, recurrence rates and survival are similar after either laparoscopic or open procedures.  However, the reporting of port site metastases has lead to the suggestion that the pattern of recurrence following laparoscopic surgery might be different.  The aim of this study was to determine whether survival and recurrence after laparoscopic-assisted surgery for colorectal cancer was compromised by an initial laparoscopic approach.  Over a three year period, a prospective comparative trial of 114 patients undergoing laparoscopic-assisted surgery by one laparoscopic surgeon or a conventional open operation by a second specialist colorectal surgeon was performed.  A least two year follow up data was available on 109 patients.  Analysis was performed on an intention-to-treat basis.  Overall, recurrent disease developed in 27 (25%) of patients, 16 (28%) in the laparoscopic and 11 (21%) in the conventional surgery groups.  A crude death rate of 46% was seen in both groups.  No port-site metastases occurred in the laparoscopic group.  Stage-for-stage survival and recurrence figures were comparable.  It was concluded that outcome at a minimum of 2 years is not compromised by a laparoscopic approach

Prospective randomised trial of low-pressure pneumoperitoneum for reduction of shoulder-tip pain following laparoscopy.  Sarli L,  Costi R,  Sansebastiano G,  Trivelli M,  Roncoroni L.  Br J Surg 2000;  87:  1161-1165.

Shoulder-tip pain occurs in 30 to 50% of patients undergoing laparoscopic cholecystectomy, the aetiology of which remains unclear. Carbon dioxide insufflation is the commonest means of achieving a pneumoperitoneum and the use of this gas is widely considered to be the cause of this symptom.  Various methods have been used to reduce the severity of shoulder-tip pain, including the use of local anaesthesia, but none has proved to be practical and effective enough for routine clinical use. To test the hypothesis that shoulder-tip pain is secondary to peritoneal stretching and diaphragmatic irritation caused by carbon dioxide this study investigated the influence of low-pressure pneumoperitoneum on the frequency and intensity of shoulder-tip pain in patients undergoing laparoscopic cholecystectomy.  Ninety consecutive patients were randomised prospectively into low-pressure (9 mmHg) and normal pressure (13 mmHg) groups.  Shoulder-tip pain was recorded on a visual analogue pain scale at 1,3,6,12,24 and 48 hours after operation.  The low-pressure pneumoperitoneum did not increase the duration of surgery.  There was no significant intraoperative or postoperative complications in either group.  Fourteen (32%) patients in the normal pressure group and five (11%) patients in the low-pressure group complained of post-operative shoulder tip pain.  Both the mean shoulder-tip pain scores at 12 and 24 hours and post-operative analgesic requirements were significantly lower in the low-pressure group.  It was concluded that a carbon dioxide pneumoperitoneum pressure lower than that normally utilized to perform laparoscopic cholecystectomy reduces both the frequency and intensity of shoulder-tip pain.

Randomised clinical trial of laparoscopic versus open appendicectomy.  Pedersen A G,  Petersen O B,  Wara P,  Ronning H,  Qvist N,  Laurberg S.  Br J Surg 2001; 88:  200-205.

Previous randomised trials comparing laparoscopic versus open surgery have shown laparoscopic appendicectomy to be both feasible and safe.  In addition to improved diagnostic accuracy, it also been shown to confer advantages to the patient in terms of fewer wound infections, less pain and quicker recovery.  It is, however, time consuming and associated with increased hospital costs.  It has been argued that the benefits of laparoscopic appendicectomy achieved by experience laparoscopic surgeons are marginal compared with open appendicectomy.  The latter can be performed by surgeons-in-training through a short cosmetically acceptable incision with minimal complications and a short hospital stay.  The aim of this study was to compare the outcome of laparoscopic appendicectomy with that of open surgery performed, out of hours, by comparable surgical trainees, designated before randomisation. In total 828 of 583 consecutive patients with a clinical diagnosis of acute appendicitis consented to participate in the trial.  Of these patients 301 and 282 were allocated to open and laparoscopic surgery respectively.  In the latter group 65 patients required conversion to an open procedure.  The primary endpoint was hospital stay.  Secondary endpoints were operating time, postoperative morbidity, duration of convalescence and cosmesis.  On an intention to treat analysis hospital stay was equally short (median = 2 days) in both groups.  The median time to normal activity (7 vs. 10 days) and work (10 vs. 16 days) was significantly shorter in the laparoscopic group.  Laparoscopy was associated with fewer wound infections (p<0.03) and improved cosmesis (p<0.001).  Laparoscopy was associated with more intraperitoneal abscesses but when adjusted for the greater number of perforated appendices, the difference failed to reach statistical significance.  It was concluded that when comparing laparoscopic and open appendicectomy, hospital stay was equally short but that laparoscopic appendicectomy was associated with fewer wound infections, faster recovery, improved cosmesis and an earlier return to work.

A normal appendix found during diagnostic laparoscopy should not be removed.  van den Broek W T, Bijnen A B, De Ruiter P, Gouma D J. Br J Surg 2001; 88: 251-254.

Using clinical criteria for the diagnosis of acute appendicitis, a normal appendix will be removed in between 10 and 30% of open operations. With the use of ultrasonography or CT scanning both sensitivity and specificity for the diagnosis can be improved. Laparoscopy may also aide the diagnosis, being both specific and useful in confirming other diagnoses. During an open appendicectomy a normal looking appendix is invariable removed so as to prevent future diagnostic confusion in the presence of right iliac fossa scar. Since the introduction of diagnostic laparoscopy it has been suggested that a normal appendix should be left in place even if no other pathology is identified. This is especially so as an increased complication rate has been reported following the laparoscopic removal of a normal appendix. The aim of this study was to prospectively audit the outcome of a policy of not to remove a normal appendix during diagnostic laparoscopy for suspected acute appendicitis. Between 1994 and 1997, 109 diagnostic laparoscopies were performed. After a median follow-up of 4.4 years a questionnaire survey was performed. There were no false-negative laparoscopies. In 65 (60%) patients an alterative diagnosis was identified. In 44 (40%) patients no diagnosis was obtained. After a median follow up of 8 months, 15 patients represented with symptoms of possible appendicitis. Eight patients underwent surgery. In only one (<1%) patient was a histologically proven diagnosis of acute appendicitis obtained. Overall, 9% of patients still had recurrent abdominal pain. There was no difference between patients with or without another diagnosis obtained during the preceding laparoscopy. It was concluded that it is safe to leave a normal looking appendix during diagnostic laparoscopy for suspected acute appendicitis even if an alternative diagnosis can not be proven.

Short-term quality-of-life outcomes following laparoscopic-assisted colectomy vs. open colectomy for colon cancer.  Weeks J C,  Nelson H,  Gleber S et al.  JAMA 2002;  287:  321-328 .

Improvements in both technology and surgical skills have lead to an interest in extending the indications for laparoscopic surgery to include curative resection for colon cancer.  In laparoscopic-assisted colectomy (LAC), mobilisation of the bowel is performed laparoscopically and then the bowel is externalised for resection and anastomosis.  The safety and efficacy of LAC for colon cancer are unknown and the nature and magnitude of any quality-of-life (QOL) benefits resulting from LAC are unknown.  The aim of this study was to compare short-term QOL outcomes after LAC vs. open colectomy for colon cancer.  Between 1994 and 1999 a multicentre, randomised controlled trial of LAC vs. open colectomy was performed in 48 US hospitals.  Overall, 37 of the centres provided data on 429 patients for the QOL component of the study.  Scores on the Symptom Distress Scale, QOL index and single-item global rating scale were compared at 2 days, 2 weeks and 2 months post surgery.  Duration of of postoperative in-hospital analgesic use and length of hospital stay were also compared. In an intention-to treat analysis of the QOL scores the only significant difference observed between the two groups was for the global rating score at 2 weeks post surgery.  Whilst in the hospital, patients assigned to LAC required fewer days of both parenteral and oral analgesics.  It was concluded that only minimal short-term QOL benefits were found with LAC for colon cancer compared with standard open colectomy.  Until ongoing trials establish that LAC is as effective as open colectomy in preventing recurrence and death from colon cancer, this procedure should not be offered to patients with colon cancer.

Laparoscopy-assisted colectomy versus open colectomy for treatment of non-metastatic colon cancer:  a randomised trial.  Lacy A M, Garcia-Valdecasas J C, Delgado S et al.  Lancet 2002; 359:  2224-2229.

Colorectal cancer is the second leading cause of cancer-related death in Western countries.  Prognosis associated with the disease has improved due to earlier diagnosis and changes in medical therapy.  Adjuvant chemotherapy in colon cancer, radiotherapy and the introduction of mesorectal excision in rectal cancer have increased survival. Laparoscopic surgery has lead to great progress in the treatment of many gastrointestinal diseases.  Early reports on laparoscopy-assisted colectomy (LAC) in patients with colon cancer suggested that it reduces surgical trauma, decreases perioperative complications and leads to a more rapid recovery.  However, no previous studies have compared LAC with open colectomy (OC) in terms of tumour recurrence and survival.  The aim of this study was to assess whether there are differences in cancer-related survival between LAC and OC.  Between 1993 and 1998, all patients with adenocarcinoma of the colon were assessed for entry into this randomised trail.  Adjuvant therapy and postoperative follow-up were the same in both groups.  The primary endpoint was cancer-related survival.  Data were analysed according to the intention-to-treat principle.  Overall, 219 patients took part in the study (111 in the LAC and 108 in the OC groups).  Patients in the LAC group recovered faster than those in the OC group with shorter peristalsis detection (p=0.001), oral intake times (p=0.001) and hospital stay (p=0.005). Morbidity was lower in the LAC group (p=0.001) although LAC did not influence perioperative mortality.  Probability of cancer-related survival was higher in the LAC group (p=0.02).  A Cox model showed that LAC was independently associated with reduced risk of tumour recurrence, death from any cause and death form cancer-related causes.  The superiority of LAC was due to differences in patients with Stage III disease.  It was concluded that LAC is more effective than OC for the treatment of colon cancer in terms of morbidity, hospital stay, tumour recurrence and cancer-related survival.

Laparoscopic transperitoneal procedure for routine repair of groin hernia.  Laparoscopic transperitoneal procedure for routine repair of groin hernia.  Br J Surg 2002:  89:  1062-1066.

Laparoscopic techniques have have added a new dimension to groin hernia surgery and randomised studies have shown significant improvement in post-operative pain and rehabilitation rates compared with sutured repairs by either the Shouldice or Lichtenstein techniques.  However, these benefits come with higher costs, greater operative difficulty and corresponding longer operating times.  Laparoscopic transperitoneal hernia repair (TAPP) is thought to be a difficult techniques with a high complication rate.  This study was a prospective analysis of data from a large and unselected series of consecutive hernia repairs with the aim of assessing the feasibility of TAPP in the routine clinical setting.  It aimed to analyse the individual learning curve, comparing consultants with trainees. Secondary endpoints included postoperative morbidity, time of disability and recurrence rate.  Between 1993 and 2001, a total of 8050 TAPP repairs were performed in one hospital.  By the end of 2001, 99.9% of all hernia repairs were done by TAPP.  The median operating time dropped from 50 min in the first 600 cases to 42 min thereafter.  The morbidity rate dropped from 9.3% to 2.6% and the rate of recurrence from 4.4% to 0.4%.  Within the same interval the proportion of training procedure increased from 1.7 to 44.9%.  Morbidity and recurrence rates were similar for trainees and consultants.  It was concluded that TAPP was an effective and safe technique that can be performed in a standard way for all inguinal and femoral hernias.  The present results indicate that TAPP is possible in a routine clinical setting and is a safe training procedure.

Randomised clinical trial of laparoscopic cholecystectomy performed with mini-instruments.  Sarli L,  Lusco D,  Goby S et al.   Br J Surg 2003;  90: 1345-1348. 

Laparoscopic cholecystectomy has traditionally been undertaken with two 10-12 mm ports and two 5 mm ports.  There has been a recent drive to reduce port sizes, first with the introduction of 5 mm laparoscope and then with equipment designed for 3 mm and 2 mm port sizes.  Smaller surgical wounds might reduce tissue damage and improve the postoperative course and cosmetic outcome after laparoscopic cholecystectomy.  In this study, a randomised trial was conducted to assess the impact of reducing the size of three ports to 3 mm.  The study was a single-blind trial comparing laparoscopic cholecystectomy (LC) and mini-laparoscopic cholecystectomy (MLC).  Only elective patients were eligible for inclusion.  LC was a routine procedure at the institution whereas MLC was introduced after a short training period.  In total, 175 patients had elective minimal access cholecystectomy during the trial period of which 135 were entered into the trial.  68 and 67 patients underwent LC and MLC respectively.  The groups were well matched for age, sex and preoperative characteristics.  The median (range) operating time for LC and MLC were similar (45 min (20-120) and 50 min (20-170) respectively).  Intraoperative and postoperative complication rates, the time for patients to resume walking, eating and passing stool and the median hospital stay were similar in the two groups.  The level of postoperative pain within the first 24 hours was significantly lower in the MLC group.  MLC patients had a reduces analgesic requirement and expressed increased satisfaction with the cosmetic result.  It was concluded that MLC tool a similar time to perform and caused less postoperative pain than the standard laparoscopic procedure.  Reducing the port size enhanced the advantages of laparoscopic over open cholecystectomy.

Randomised clinical trial of open versus laparoscopic cholecystectomy for acute cholecystitis.  Johansson M,  Thume A,  Nelvin L et al.  Br J Surg 2005;  92:  44-49.

Surgical treatment of symptomatic gallstone disease has changed in the last decade since the introduction of laparoscopy.  Elective laparoscopic cholecystectomy has almost replaced the conventional open procedure and various studies have confirmed its safety and efficacy.  In the early years of minimally invasive surgery, acute cholecystitis was considered a relative contraindication to laparoscopic cholecystectomy because of the potential risk of severe complications owing to distorted anatomy caused by acute inflammation.  Randomised studies over the past few years have now proven this fear to be exaggerated.  Laparoscopic cholecystectomy for acute cholecystitis is safe, with mortality rates similar to those described in the era of open surgery.  The aim of this prospective trial was to determine whether the surgical approach (open vs. laparoscopic) had an impact on morbidity and postoperative recovery after cholecystectomy for acute cholecystitis.  Overall, 70 patients who met strict criteria for a diagnosis of acute cholecystitis were randomised to open or laparoscopic cholecystectomy.  The type of operation was unknown to the patient and all hospital staff involved in the postoperative care.  The two groups were similar with respect to demographic and clinical characteristics.  There was no significant differences in rate of postoperative complications, pain score at discharge and sick leave.  In eight patients a laparoscopic procedure was converted to an open cholecystectomy.  Median operating time was 90 m in (range 30-155) and 80 min (range 50-170) in the laparoscopic and open groups respectively (p=0.040).  The direct medical costs were equivalent in the two groups.  Although median postoperative hospital stay was 2 days in each group, it was significantly shorter in the laparoscopic group (p=0.01).  It was concluded that cholecystectomy for acute cholecystitis can be performed by either laparoscopic or open techniques without any major clinically relevant differences in postoperative outcome.  Both techniques offer low morbidity and rapid postoperative recovery.

Randomised clinical trial of day-care versus overnight-stay laparoscopic cholecystectomy.  Johansson M,  Thune A,  Nelvin L et al.  Br J Surg 2006;  93: 40-45. 

Since its introduction almost 20 years ago, laparoscopic cholecystectomy (LC) has become the treatment of choice for symptomatic gallstones.  Rapid recovery after LC and improved postoperative management have lead to progressively shorter hospital stays.  Economic incentives and anaesthetic and medical advances have encouraged healthcare providers to explore the option of carrying out a significant proportion of procedures on an outpatient basis.  Many studies have documented the safety and feasibility of outpatient LC in an ambulatory surgery unit in selected patients.  The aim of this study was to compare quality of life after LC performed as either a day case or overnight-stay procedure.  Data from 100 patients with symptomatic gallstones randomised to LC performed as either a day-case or overnight stay was analysed.  Complications, admissions and readmissions, quality of life and health economic aspects were assessed.  Two instruments were used to assess quality of life, The Hospital Anxiety and Depressions Scale (HADS) and the psychological General Well-Being Index (PGWB).  Overall, 48 (92%) of patients in the day-care group were discharged 4-8 hours after the operation.  42 (88%) of patients in the overnight-group went home on the first day after surgery.  The overall conversion rate was 2%.  Two patients had complications after surgery, both in the day-care group.  No patient in either group was readmitted.  There was no significant difference in total quality of life score between the two groups.  The mean direct medical cost per patient in the day-care group (3085 euros) was lower then in the overnight group (3394 euros).  It was concluded that LC can be performed as a day-case procedure with a low rate of complications and admission / readmissions.  Patient acceptance in terms of quality of life variables is similar or that for LC with an overnight stay.  The day-care strategy is associated with a reduction in costs.

Randomised clinical trial of the effect of preoperative dexamethasone on nausea and vomiting after laparoscopic cholecystectomy.  Feo C V,  Sortini D,  Ragazzi R et al.  Br J Surg 2006;  93:  295-299. 

Dexamethasone has been reported to reduce the incidence of vomiting in patients undergoing chemotherapy and surgical procedures including laparoscopic cholecystectomy.  Few randomised clinical trials have addressed the effect of the administration of a perioperative single dose of a glucocorticoid on surgical outcome.  The aim of this randomised, double-blind, placebo-controlled trial was to investigate whether a single dose of dexamethasone before surgery would improve nausea, vomiting and pain in patient undergoing laparoscopic cholecystectomy.  Between March and December 2004, 101patients undergoing laparoscopic cholecystectomy were randomised to receive 8mg dexamethasone (n=49) or placebo (n=52) intravenously before surgery.  Six patients were excluded from the study.  All patients received a standard anaesthetic, surgical and multimodal analgesic treatment.  The primary end-points were postoperative nausea, vomiting, postoperative antiemetic and analgesic requirements.  The pain scores and episodes of nausea and vomiting were recorded at 1, 3, 6 and 24 hours after the operation.  No apparent drug side-effects were noted.  Seven patients (14%) in the treatment group reported nausea and vomiting compared with 24 patients (46%) in the control group (p=0.001).  In the group of patients treated with dexamethasone, five (10%) required antiemetics compared with 23 (44%) of the receiving placebo (p<0.001).  No difference in postoperative pain scores and analgesic requirements were detected between the groups.  It was concluded that preoperative dexamethasone reduces postoperative nausea and vomiting in patients undergoing laparoscopic cholecystectomy, with no side-effects and may be recommended for routine use.

Analysis of stapling versus endoloops in appendiceal stump closure.  Beldi G,  Vorburger S A,  Bruegger L E et al.  Br J Surg 2006:  93:  1390-1393.

The laparoscopic approach for the treatment of appendicitis has gained wide clinical acceptance.  It offers fewer wound infections, faster recovery and an earlier return to work in comparison to open surgery.  The technical details are still being modified.  The base of the appendix is most frequently closed using staples or endoloop ligatures.  Staples have the advantage of relatively easy handling and a possible reduction in the incidence of leakage in advanced appendicitis owing to closure with a double row of staples.  An advantage of the endoloops is that they much cheaper than stapling devices.  To date there has been no systematic comparison of the efficacy of the two methods for treatment of the appendiceal stump.  The aim of this study was to compare morbidity of stump closure by stapling or the use of endoloops.  A non-concurrent cohort study of prospectively acquired data was performed.  The primary outcome variable was the rate of intra-abdominal surgical-site infection.  Secondary outcome measures were complications, duration of intervention, hospital stay, rate of readmission to hospital and the difference in direct costs of the operation.  Staples were used 60% and endoloops in 40% of 6486 patients operated on for suspected appendicitis between 1995 and 2003.  Among 4489 patients with acute appendicitis the rate of intra-abdominal surgical-site infection was 0.7% in the stapler group and 1.7% in the endoloop group (p=0.004).  The rate of readmission to hospital was 0.9% and 2.1% respectively (p=0.001).  It was concluded that the application of a stapler for transection and closure of the appendiceal stump in patients with acute appendicitis lowered the risk of postoperative intra-abdominal surgical-site infection and the need for re-admission to hospital.

Laparoscopic peritoneal lavage for generalised peritonitis due to perforated diverticulitis.  Myers E,  Hurley M,  O'Sullivan G C et al.  Br J Surg 2008;  95:  97-101

Hartmann's procedure became a 'gold standard' for perforated diverticulitis when resection was demonstrated to improve survival compared with defunctioning colostomy alone.  However, restoration of intestinal continuity involves a second procedure associated with considerable morbidity and mortality.  More than 30% of patients never have a reversal and adapt to living with a permanent colostomy.  Primary resection and anastomosis with or without a temporary defunctioning stoma emerged as an effective alternative to a Hartmann's procedure but the outcomes remain suboptimal.  Laparoscopic lavage for generalised peritonitis due to perforated diverticulitis was first described in 1996 all of whom made a complete recovery.  All previous studies were retrospective. The present study assessed prospectively the feasibility of laparoscopic peritoneal lavage due to perforated diverticulitis.  A prospective multi-institutional study of 100 patients was undertaken.  All consenting patients with perforated diverticulitis causing generalised peritonitis underwent attempted laparoscopic peritoneal lavage.  The degree of peritonitis (Hinchey grading system) was recorded.  Primary endpoints were operative success and resolution of symptoms.  Patients had a median age of 63 (range 39-95) years.  Male : female ratio was 2:1 and patients had a median ASA grade of III.  Eight patients with grade 4 diverticulitis were converted to an open procedure.  The remaining 92 were managed laparoscopically with morbidity and mortality rates of 4% and 3% respectively.  Two patients required postoperative intervention for a pelvic abscess.  Only 2 patients represented with diverticulitis at a median follow-up of 36 months.  It was concluded that laparoscopic management of perforated diverticulitis with generalised peritonitis is feasible with a low recurrence risk in the short term.

Warming and humidification of insufflation carbon dioxide in laparoscopic colonic surgery: A double-blinded randomized controlled trial.  Sammour T,  Kahokehr A,  Haynes J et al.  Ann Surg 2010;  251:  1024-1033

Warming and humidification of insufflation gas is thought be beneficial in laparoscopic surgery, but evidence in prolonged laparoscopic procedures is lacking.  The aim of this study was to test the hypothesis that warming and humidification of insufflation CO2 would lead to reduced postoperative pain and improved recovery by reducing peritoneal inflammation in laparoscopic colonic surgery. This was a multicentre, double-blinded, randomized controlled trial. The Study Group received warmed (37C), humidified (98% relative humidity) insufflation carbon dioxide, and the Control Group received standard gas (19C, 0% relative humidity).  Anaesthesia and analgesia were standardised. Intraoperative oesophageal temperature was measured at 15 minutes intervals. At the conclusion of surgery, the primary surgeon was asked to rate camera fogging on a Likert scale. Postoperative opiate usage was determined using Morphine Equivalent Daily Dose (MEDD), and pain was measured using visual analogue scores. Peritoneal and plasma cytokine concentrations were measured at 20 hours postoperatively. Postoperative recovery was measured using defined discharge and complication criteria, and the Surgical Recovery Score. Overall, eighty-two patients were randomized, with 41 in each arm. Groups were well matched at baseline. Intraoperative core temperature was similar in both groups. Median camera fogging score was significantly worse in the Study Group (4 vs. 2, P = 0.040). There were marginal differences in pain scores, but no significant differences were detected in MEDD usage, cytokine concentrations, or any recovery parameters measured. It was concluded that warming and humidification of insufflation CO2 does not attenuate the early inflammatory cytokine response, and confers no clinically significant benefit in laparoscopic colonic surgery.


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