Comparison of dexamethasone, metoclopramide, and their combination in the prevention of postoperative nausea and vomiting after laparoscopic cholecystectomy.

BACKGROUND: Postoperative nausea and vomiting (PONV) are one of the most common complaints following anesthesia and surgery. This study was designed to evaluate the efficacy of dexamethasone, metoclopramide, and their combination to prevent PONV in patients undergoing laparoscopic cholecystectomy. METHODS: A total of 160 ASA physical status I and II patients were included in this randomized, double blind, placebo-controlled study. Patients were randomly assigned to 4 groups (n = 40 each): group 1 consisting of control patients administered 0.9% NaCl; group 2 patients received metoclopramide 10 mg just before the end of anesthesia; group 3 patients received dexamethasone 8 mg after the induction of anesthesia; and group 4 patients received dexamethasone 8 mg after the induction of anesthesia and metoclopramide 10 mg before the end of anesthesia. The incidence of PONV, mean visual analog pain scores at rest and on movement, time to the first request for analgesia, side effects, and well-being score were recorded during the first 24 h postoperatively. RESULTS: Data were analyzed using one-way analysis of variance (ANOVA) and the chi2 test, with p < 0.05 considered statistically significant. The total incidence of PONV was 60% with placebo, 45% with metoclopramide, 23% with dexamethasone, and 13% with the combination of dexamethasone plus metoclopramide. None of the dexamethasone plus metoclopramide group patients (p < 0.05 versus groups 1 and 2) and one dexamethasone group patient (p < 0.05 versus group 1) required antiemetic rescue, as compared with four patients in the metoclopramide group and six patients in the placebo group. Pain scores, the time to the first request for analgesia, and side effects were similar across the study groups. CONCLUSIONS: Dexamethasone and the combination of dexamethasone plus metoclopramide were more effective in preventing PONV than metoclopramide and placebo.

A new bipolar hook for endoscopic surgery.

This article presents a new bipolar hook for endoscopic surgery. With this instrument monopolar and bipolar current can be used. The advantage of this new instrument is the possibility of using a bipolar current, which is safer than using the monopolar current. The technical details and usage instructions are discussed.

Laparoscopic cholecystectomy following abdominal surgery of the lower part of abdomen.

In this prospective study, laparoscopic cholecystectomy was performed in patients with previous abdominal surgery of the lower part of abdomen. According to authors experience, the usual method of 'blind' beginning of the laparoscopic procedure, with safety tests, is a safe and reliable method to start the laparoscopic procedure, even in these patients. This method does not carry a higher risk of intra-abdominal injury.

Laparoscopic cholecystectomy: results after 1000 procedures.

From May 1992, when the first laparoscopic cholecystectomy was performed at University Department of Surgery, Sveti Duh General Hospital, till October 1994, the authors performed more than 1000 procedures. Laparoscopic approach was successfully used in 965 (96.5%) patients. Thirty-five (3.5%) cases were converted to open surgery. Dangerous anatomy, some technical problems and perioperative bleeding were the most often reasons for conversion. Further, liver metastases and perioperatively recognized common bile duct lesion necessitated conversion in one case each. In total, there were 18 (1.8%) abdominal complications. Common bile duct lesion, postoperative common bile duct stricture and duodenal perforation occurred in one patient each. Major bleeding was present in eight and bile leak in seven patients. The mean duration of hospitalization was 2.8 days. Analyses of the results show laparoscopic cholecystectomy to be safe procedure with low perioperative and postoperative complications.

[Laparoscopic procedures in digestive surgery]. / Laparoskopski postupci u digestivnoj kirurgiji.

During last ten year laparoscopic procedures have become the part of digestive surgery. Almost all digestive surgery operations were also done laparoscopically. The number of these operations is increasing every day, but some of them are not accepted completely. Various laparoscopic procedures are reviewed, their indications, the advantages and disadvantages. While laparoscopic cholecystectomy is accepted as the treatment of choice for cholelithiasis, other laparoscopic procedures are still not. Appendectomy, endoscopic groin hernia repair, and some gastric procedures have the best chances to be accepted. For other operations it is important to find the best technique and compare the results of these operations with open procedures.

[5 years' laparoscopic surgery in Croatia]. / Pet godina laparoskopske kirurgije u Hrvatskoj.

Under the patronage of the Croatian Endoscopic Society, in October 1995 and October 1997, data from the Croatian surgery departments with laparoscopic surgery have been collected. The aim has been to evaluate the situation and development of endoscopic surgery in Croatia. The types and number of the procedures increased during the entire period. The total number of procedures is 29,349. The biggest part of that number, 25,889 (88.2%), were laparoscopic cholecystectomies. The next most frequent operations were laparoscopic hernioplasties and appendectomies. Many others laparoscopic operations were performed, too. The conversion and complication rate can be compared with the other authors' results. Endoscopic surgery in Croatia today is completely accepted and has become a part of digestive surgery in almost all surgical departments.

[Endoscopic hernioplasty]. / Endoskopska hernioplastika.

Development of the endoscopic surgery has made operations of the groin hernia by endoscopic technique possible. In spite of some dilemmas, the endoscopic hernioplasty takes place in the surgery. The advantages of this procedure are less recurrences, less postoperative pain, shorter hospital stay, quicker recovery and return to everyday activities, and better cosmetic effect. The benefit of this method is particularly visible after procedures on bilateral and recurrent hernias. In this review, we described surgical technique of endoscopic hernioplasty, possible complications, as well anatomical and pathophysiological basis important for the endoscopic approach.

[Bile duct injuries in laparoscopic cholecystectomy]. / Ozljede zucnih vodova pri laparoskopskoj kolecistektomiji.

Bile duct injuries are the most serious complications of laparoscopic cholecystectomy. Although the overall complications rate in laparoscopic cholecystectomy is significantly lower than in open cholecystectomy, bile duct injuries are more frequent. In this article we analyzed why and how they occur and if their prevention was possible. From May 1992 to May 1999, laparoscopic cholecystectomy was performed in 5651 patients by 17 surgeons and residents, with different experience but similar operative technique. In this period nine (0.16%) bile duct injuries occurred. Injuries were caused by seven operators. Number of operations by single surgeon before injury varied from 8 to 1477. Three patients with uncomplicated chronic cholecystitis had puncture or small bile duct laceration. Complete transection of main bile duct occurred in three patients and in one transection of right hepatic duct. The operative findings in two of them were acute cholecystitis, one had fibrosis in the triangle of Calot and one uncomplicated chronic cholecystitis. Bile duct strictures were found in two patients. Both had fibrosis in the triangle of Calot and in hepatic port. Dangerous pathologic findings were the main cause of injuries in 5 and inadequate surgical technique in 4 patients. In our opinion the education, critical state and experience are of main importance in avoidance and prevention of bile duct injures. We also plead for selective use of intraoperative cholangiography. In our opinion the intraoperative cholangiography has to be performed in all cases where the anatomy of the triangle of Calot is not clear.

[Comparison of the results of laparoscopic cholecystectomy preformed in the usual way and with a lesser number of trocars]. / Usporedba rezultata laparoskopskih kolecistektomija ucinjenih na uobicajeni nacin i onih s manjim brojem troakara.

Laparoscopic surgery is a part of the minimally invasive surgery. Its aim is to make on operation as valuable as the open one, or even more, with a smaller invasion or injury of the body. With the instruments improvement the operation would be possible without any remarkable organism injury. On the other hand, modifications of the operation techniques lead to progress. European technique of laparoscopic cholecystectomy using four trocars has changed. Procedures are performed with one trocar less. Two groups of two hundred patients each have undergone laparoscopic cholecystectomy. The operation in the first group was performed using four, and in the second group using three trocars. The aim of the investigation was to compare these two methods of laparoscopic cholecystectomy. The results analysis showed that laparoscopic cholecystectomy using three trocars did not cause either a higher complication rate, prolonged average operation time or longer duration of hospitalisation. The analgesics consumption was lower, sick-leaves were shorter, with smaller total costs, and cosmetic effect was better.

[High frequency current in endoscopic surgery and a new bipolar hook for endoscopic surgery]. / Visokofrekventna struja u endoskopskoj kirurgiji i nova bipolarna kukica za endoskopsku kirurgiju.

High frequency current is used in surgery for cutting the tissue and stopping bleeding. Its usage is more frequent in endoscopic than open surgery. "Polarity" (monopolar and bipolar) marks the number of the electrical poles on the application place. Monopolar current has been used more often. With its usage thermal injuries are possible: coagulation outside of the laparoscopic view, direct coupling, capacitive coupling, sparking, skin combustion, activity on the heart rhythm. Because of these complications, the bipolar current is more and more in usage, which reduces the number of complications or avoids them completely. Many bipolar instruments are available today. Bipolar hook for endoscopic surgery is a new instrument which unites the good characteristics of the hook and bipolar current.

[Less invasive laparoscopic cholecystectomy: initial experience and literature review]. / Manje invazivna laparoskopska kolecistektomija: nasa pocetna iskustva i pregled literature.

Laparoscopic cholecystectomy using the 5 and 10 mm caliber instrument is still a gold standard for surgical treatment of the gallstone disease. Today it is possible to perform this operation with a less invasive manner, using the fine caliber instruments, whose diameter is under 5 mm. According to published data, less invasive laparoscopic cholecystectomy does not have a higher complication rate, and other parameters are very similar or even better, specially the cosmetic outcome. In this article with small patient number we confirmed better cosmetic outcome, described different operation techniques and warned about the shortcomings. A greater number of patients and randomized study is indispensable for better technique analysis.

[Comparison of open and laparoscopic appendectomy]. / Usporedba otvorene i laparoskopske apendektomije.

The first laparoscopic appendectomy was performed by Senn in 1982. Since then, the dilemmas about the validity of this operation in relation to open operation have persisted. Many authors presented the technique modifications and results that are very different. The retrospective results, cost, duration of hospital stay and postoperative recovery analyses for fifty patients in each group were done in this study. Laparoscopic operations were done by "two-handed" technique and in different ways of appendix and mesoappendix closing and cutting. Endoscopic linear cutters were used in the second part of the study. When comparing parameters, laparoscopic operation in relation to open operation is equally safe; quicker; with less postoperative pain; with less wound infections rate; with shorter hospital stay; with less staff time involved; with faster recovery and return to work; more expensive; with better cosmetic effect. In conclusion, laparoscopic appendectomy is better, although more expensive, than open operation, so it should be recommended.

Laparoscopic treatment of nonparasitic cysts of spleen and liver.

Laparoscopic treatments of nonparasitic splenic and liver cysts in the period between March 1993 and April 1995 have been reported: partial decapsulation-fenestration and evacuation of a splenic pseudocyst in one patient, fenestration of large congenital liver cysts with total excision of a few smaller liver cysts in two patients and two unsuccessful treatments of splenic cysts. After successful laparoscopic procedures the patients experienced immediate and complete relief of the symptoms. Two years after the splenic cyst procedure and 6 months after the liver cyst operation, the patients remained free of the symptoms, and complete absence of the cysts was confirmed by computerized tomography scans. Laparoscopic fenestration of nonparasitic splenic and liver cysts with total excision of smaller liver cysts is a simple and safe surgical method with lower morbidity and a quick return to normal activity.