Complications during the establishment of laparoscopic pneumoperitoneum.

BACKGROUND: A safe establishment of the laparoscopic pneumoperitoneum is of the utmost importance, as potentially fatal complications, such as vascular or visceral injury or gas embolism, may occur during the procedure. OBJECTIVE: We used the published studies and our own experience to evaluate the advantages and disadvantages of various techniques for the establishment of the laparoscopic pneumoperitoneum, thus aiming to contribute to the reduction in the rate of fatal complications. METHODS: We performed a retrospective review of 4940 medical charts of patients without prior history of abdominal surgeries who had the laparoscopic pneumoperitoneum established by using a modified closed method (i.e., the patient is in an anti-Trendelenburg's position 20-30 degrees and a left lateral tilt of 10-15 degrees, with the Veress needle and the first trocar introduced through the umbilicus and directed toward the intersection of the anterior axial line and the right costal arc). Additionally, we searched Medline, Embase, and the Cochrane libraries with a cut-off date of December 2006, using specific key-words (i.e., trocar injury, complication, laparoscopic surgery, Veress needle, open vs. closed pneumoperitoneum, prospective study). RESULTS: There were no reports of injuries to the major blood vessels or visceral organs. However, liver capsule injury was reported in 432 (8.2%) patients, pneumo-omentum in 55 (1.1%) patients, and subfascial insufflations in 45 (0.9%) patients. CONCLUSIONS: No reliable conclusions regarding advantages or disadvantages of different techniques for the laparoscopic pneumoperitoneum can be drawn in the absence of adequately powered, prospective, comparative studies. Based on the fact that no major blood vessel or visceral organ injuries were observed in our experience, we conclude that the modified closed method deserves further multicentric prospective evaluation.

Low fresh gas flow balanced anesthesia versus target controlled intravenous infusion anesthesia in laparoscopic cholecystectomy: a cost-minimization analysis.

BACKGROUND: Laparoscopic surgery is widely recognized as a well-tolerated and effective method for cholecystectomy. It is also considered cost saving because it has been associated with a decreased hospital length of stay. Variables that might lead to increased costs in laparoscopic surgery are the technique and drugs used in anesthesia. OBJECTIVE: The goal of this study was to compare the costs of 2 anesthetic techniques used in laparoscopic cholecystectomy (LC)--balanced versus IV anesthesia--from the standpoint of an outpatient surgical department, with a time horizon of 1 year. METHODS: Patients scheduled to undergo elective LC were enrolled in this prospective case study. Patients were randomly allocated to receive balanced anesthesia, administered as low fresh gas flow (LFGF) with inhalational sevoflurane and IV sufentanil in a target controlled infusion (LFGF SS group), or IV anesthesia, administered as IV propofol/sufentanil in a target controlled infusion (TCI group). We used a microcosting procedure to measure health care resource utilization in individual patients to detect treatment differences. The costs of medications used for the induction and maintenance of anesthesia during surgery were considered for LFGF SS and TCI. Other end points included duration of anesthesia; mean times to early emergence, tracheal extubation, orientation, and postanesthesia discharge (PAD); pain intensity before first analgesia; number of analgesics required in the first 24 hours after surgery; and prevalences of nausea, vomiting, and agitation. RESULTS: A total of 60 patients were included in this analysis (male/female ratios in the LFGF SS and TCI groups: 11/19 and 12/18, respectively; mean [SD] ages, 48 [7.9] and 47 [8.6] years; and mean [SD] body mass indexes, 26 [2.0] and 26 [3.0] kg/m2). The costs of anesthetics were significantly lower with LFGF SS compared with TCI (euro17.40 [euro2.66] vs euro22.01 [euro2.50] [2006 euros]). Times to early emergence and tracheal extubation were significantly shorter with LFGF SS than TCI (5.97 [1.16] vs 7.73 [1.48] minutes and 7.57 [1.07] vs 8.87 [1.45] minutes, respectively). There were no significant between-group differences in mean duration of anesthesia; times to orientation and PAD; pain intensity before first analgesia; number of analgesics required in the first 24 hours; or prevalences of nausea, vomiting, and agitation. Because no clinically significant differences in the anesthetic results were observed, a cost-minimization analysis was conducted and found that using LFGF SS, the outpatient surgical department could realize a budget savings of euro454 per 100 patients. For the nearly 1000 expected patients per year, the savings for the department was calculated as euro4540. CONCLUSION: The results from this cost analysis in these patients who underwent elective LC suggest that the use of sevoflurane through the LFGF technique would be cost saving in this outpatient surgical department.