Laparoscopic splenectomy: learning curve comparison between benign and malignant disease.

BACKGROUND: New surgical techniques should be formally evaluated for feasibility and safety. As a model for this evaluation, this study examines the authors' institution's experience with splenectomy for benign and malignant hematologic disease since the introduction of laparoscopic splenectomy (LS) in 1996. The authors present the evaluation of the recognized surgeon/institutional learning curve using CUSUM (cumulative sum) analysis. METHODS: This is a single institution retrospective chart review of consecutive splenectomies for hematologic disease performed between 1996 and 2008. The primary outcome was conversion to open splenectomy. The learning curve for LS was evaluated using CUSUM analysis. RESULTS: A total of 123 splenectomies were performed for benign (51.2%) or malignant (48.7%) hematologic disease. 58% of patients underwent planned LS, with a 21% conversion rate. The surgeon's overall learning curves for LS, as well as that for malignant disease, were maintained within acceptable conversion thresholds. However, the learning curve for benign disease did cross the unacceptable conversion threshold at case 29. With additional experience, the curve again approached the acceptable conversion threshold. Patients with malignant disease were significantly older (P = .0004), had larger spleens (P = .0004), were more likely to undergo open splenectomy (P = .001), and had longer lengths of stay (P = .01). However, there was no significant difference in operative time, transfusion requirements, morbidity rates, or mortality rates between patients with benign and malignant disease. CONCLUSION: LS, for benign or for malignant hematologic disease, is associated with a significant learning curve. This evaluation model illustrates that careful patient selection and ongoing quality assessment is essential when introducing a new technique.

Ketorolac analgesia for inguinal hernia repair is not improved by peripheral administration.

PURPOSE: It has been suggested that ketorolac, a non-steroidal anti-inflammatory drug (NSAID) available for parenteral use, may result in prolonged (24 hr) postoperative analgesia through a peripheral mechanism when added to local anesthetic infiltration. Our objective was to assess this effect by controlling for systemic absorption of the drug. METHODS: This randomized, double-blind trial studied 40 men undergoing elective inguinal hernia repair under spinal anesthesia. All patients received 19 mL of lidocaine 1% infiltrated in the operative field before incision. Patients were randomized into two groups of 20. The surgical site group received ketorolac 30 mg added to the lidocaine infiltration. In the control group, ketorolac 30 mg was injected subcutaneously in the contralateral abdominal wall. Numeric rating scores (0-10) of pain at rest and with movement were recorded at the time of discharge from the recovery room and at 24 hr postoperatively. Time to first analgesia, postoperative iv morphine use, total time in the recovery room, and total oral analgesic use in the first 24 hr were also compared. RESULTS: There were no significant differences between groups with respect to any of the measured variables. In both groups, pain scores were low at rest (1.9 +/- 1.4 vs 2.2 +/- 1.8, surgical site and systemic groups, respectively) and moderate with movement (5.3 +/- 2.2, 5.0 +/- 1.8) after anesthetic recovery. Pain scores were similar at 24 hr (1.1 +/- 1.3, 1.9 +/- 1.6 at rest; 5.7 +/- 2.0, 6.2 +/- 2.2 with movement). CONCLUSION: Adding ketorolac to lidocaine infiltration for hernia repair does not improve or prolong postoperative analgesia compared to systemic administration.