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:
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 al. Br J Surg 1999;
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
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:
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
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:
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;
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:
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:
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:
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;
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:
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 (37°C), humidified (98% relative humidity) insufflation
carbon dioxide, and the Control Group received standard gas (19°C, 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.